THERAPEUTICS

Brands

• Trileptal
• see index for additional brand names

Generic?

• Yes

Class

• Anticonvulsant, voltage-sensitive sodium channel antagonist

Commonly Prescribed For

• (bold for FDA approved)
• Partial seizures in adults with epilepsy (monotherapy or adjunctive)
• Partial seizures in children ages 4–16 with epilepsy (monotherapy or adjunctive)
• Bipolar disorder

How The Drug Works

• Acts as a use-dependent blocker of voltage-sensitive sodium channels
• Interacts with the open channel conformation of voltage-sensitive sodium channels
• Interacts at a specific site of the alpha pore-forming subunit of voltage-sensitive sodium channels
• Inhibits release of glutamate

How Long Until It Works

• For acute mania, effects should occur within a few weeks
• May take several weeks to months to optimize an effect on mood stabilization
• Should reduce seizures by 2 weeks

If It Works

• The goal of treatment is complete remission of symptoms (e.g., seizures, mania)
• Continue treatment until all symptoms are gone or until improvement is stable and then continue treating indefinitely as long as improvement persists
• Continue treatment indefinitely to avoid recurrence of mania and seizures

If It Doesn’t Work (for bipolar disorder)

• Many patients only have a partial response where some symptoms are improved but others persist or continue to wax and wane without stabilization of mood
• Other patients may be nonresponders, sometimes called treatment-resistant or treatment-refractory
• Consider increasing dose, switching to another agent or adding an appropriate augmenting agent
• Consider adding psychotherapy
• For bipolar disorder, consider the presence of noncompliance and counsel patient
• Switch to another mood stabilizer with fewer side effects
• Consider evaluation for another diagnosis or for a comorbid condition (e.g., medical illness, substance abuse, etc.)

Best Augmenting Combos for Partial Response or Treatment-Resistance

• Oxcarbazepine is itself a second-line augmenting agent for numerous other anticonvulsants, lithium, and atypical antipsychotics in treating bipolar disorder, although its use in bipolar disorder is not yet well-studied
• Oxcarbazepine may be a second or third-line augmenting agent for antipsychotics in treating schizophrenia, although its use in schizophrenia is also not yet well-studied

Tests

• Consider monitoring sodium levels because of possibility of hyponatremia, especially during the first 3 months