4.1 Epilepsy and other seizure disorders

4.1 Epilepsy

Epilepsy

• NICE Quality Standard 211. Epilepsy in children and young people
• Please see guidance from MHRA on prescribing of antiepileptics (when used for seizure control) by brand/specific manufacturer’s product. 
• Lamotrigine is considered to be in Category 1 by Consultants locally and therefore patients should be maintained on a specific manufacturer’s product when prescribed for seizure control. Consultants would like to be consulted before any change is made to the patients lamotrigine brand/manufacturer prescribing.
• When used for pain syndromes, generic medicines are appropriate to use
• Pharmacists and medicines management technicians when reconciling medications should confirm with the patient if they normally receive branded medicines and endorse the details on the drug chart. Requests to dispense anti-epileptics should be done by brand

Sodium valproate (oral) (TLS Amber 3 months)

• Shared Care Protocol
• Valproate must only be considered for epilepsy where there is no suitable alternative treatment.
• Not for routine use in women of childbearing potential - use in exceptional circumstances only - see MHRA Drug Safety Update and MHRA guidance 
• See NHSE Decision support tool: is valproate the right epilepsy treatment for me?
• Very easy read (VERA) leaflets for valproate are available
• Original pack dispensing of valproate exceptions risk assessment form

Sodium valproate injection (TLS Red)

• Not for routine use in women of childbearing potential - see MHRA Drug Safety Update Use in exceptional circumstances only

Lamotrigine (TLS Amber 3 months)

• Click here for Lamotrigine shared care protocol

Carbamazepine (TLS Amber 3 months)

• Prescribe by brand
• Click here for Carbamazepine shared care protocol

Alternatives:

Gabapentin (TLS Amber)

Specific Indications:

Acetazolamide (TLS Amber)

Clonazepam (TLS Amber 3 months)

• Click here for Clonazepam shared care protocol

Ethosuximide (TLS Amber 3 months)

• Click here for Ethosuximide shared care protocol

Oxcarbazepine (TLS Amber)

Tiagabine (TLS Amber)

Topiramate (TLS Amber 3 months)

• Click here for Topiramate shared care protocol
• Initiation by Consultant in Neurology and Neuropsychiatry only for patients with intractable epilepsy
• Note Topiramate is also licensed for migraine prophylaxis (indication included in shared care protocol)

• Topiramate should not be used:

  • in pregnancy for prophylaxis of migraine

  • in pregnancy for epilepsy unless there is no other suitable treatment

  • in women of childbearing potential unless the conditions of the Pregnancy Prevention Programme are fulfilled.

  The use of topiramate during pregnancy is associated with significant harm to the unborn child. Harms included a higher risk of congenital malformation, low birth weight and a potential increased risk of intellectual disability, autistic spectrum disorder and attention deficit hyperactivity disorder in children of mothers taking topiramate during pregnancy - see MHRA Drug Safety Update for information (June 2024).

Phenobarbital (oral) (TLS Amber 3 months SCP)

• Prescribe by brand
• Click here for shared care protocol

Phenobarbital (parenteral) (TLS Red)

• Patients on phenobarbital and primidone should only have medication withdrawn with extreme caution and preferably with specialist advice as withdrawal seizures can be problematic.

Primidone (TLS Amber)

Levetiracetam (TLS Amber 3 months SCP)

• Click here for shared care protocol

Eslicarbazepine (TLS Amber 3 months)

• Click here for Eslicarbazepine shared care protocol

Clobazam (TLS Amber 3 months)

• Click here for Clobazam shared care protocol
• Where a liquid preparation is required, the 10mg/5ml strength liquid is the recommended formulation in BNSSG to reduce risk of errors with changes in formulation strength.

Fenfluramine (TLS Red)

• NICE TA808 Fenfluramine for treating seizures associated with Dravet syndrome

Cannabidiol (TLS Red)

• NICE TA873 Cannabidiol for treating seizures caused by tuberous sclerosis complex

Alternatives:

These agents are indicated when symptoms have not been controlled with other anti-epileptics. They may only be prescribed on the recommendation of a specialist:

Phenytoin (oral) (TLS Amber)

• Prescribe by brand

Phenytoin (parenteral) (TLS Red)

Phenytoin (slow intravenous injection) (TLS Red)

• In accordance with BNF

Pregabalin (TLS Amber 1 month)

• Initiation by Consultant in Neurology and Neuropsychiatry only for patients with intractable epilepsy
• N.B. TLS Green for neuropathic pain and generalised anxiety disorder

Zonisamide (TLS Amber 3 months)

• Click here for Zonisamide shared care protocol
• Initiation by Consultant in Neurology and Neuropsychiatry only for patients with intractable epilepsy

Vigabatrin (TLS Red)

• Initiated and supervised by a specialist

Brivaracetam (TLS Amber 3 months SCP)

• Click here for shared care protocol

Rufinamide (TLS Amber 3 months SCP)

• Initiated by a specialist for the treatment of Lennox-Gastaut syndrome (licensed) or as an option in the adjunctive treatment of tonic or atonic seizures (unlicensed)
• Click here for shared care protocol

Perampanel (TLS Amber 3 months SCP)

• Initiated by a specialist for the adjunctive treatment of partial-onset seizures with or without secondarily generalised seizures in patients with epilepsy aged 12 years and older who have failed on treatment with all first and second line agents.
• Click here for Perampanel shared care protocol

Stiripentol (TLS Amber)

Tetracosactide (TLS Amber)

Lacosamide (TLS Amber 3 months)

• Click here for Lacosamide shared care protocol

Febrile Convulsions

Paracetamol (oral) (TLS Green)

Alternatives:

Levetiracetam intravenous injection (TLS Blue)

Diazepam rectal tubes (TLS Blue)

4.1.2 Status epilepticus

Prednisolone (TLS Amber)

Pyridoxine (TLS Blue)

• Pyridoxine deficiency See Chapter 9.10

Sodium thiopentone (TLS Red)

• Specialist use

Lorazepam (TLS Red)

Thiopental (TLS Red)

Paraldehyde (TLS Red)

• Specialist use only

Specific indications:

Midazolam (buccal) (TLS Green)

• For Status epilepticus

Diazepam rectal tubes (TLS Blue)

• Prolonged or recurrent seizures

Infantile Spasms:

Clomethiazole (TLS Red)

Sulthiame (TLS Red)

• After other anti-epileptics have failed

Tetracosactide  (TLS Red)

• 1mg/mL to treat infantile spasms