Renal tubular acidosis simplified

Diuretics in heart failure

Antiepileptic drugs (AEDs) in pediatric epilepsy

1. Initial Evaluation and Classification:
- Accurate seizure classification is crucial (focal vs. generalized)
- Consider EEG findings
- Age of patient
- Comorbidities
- Access to medications and monitoring

2. First-line Monotherapy Selection:

For Focal Seizures:
- First choices: Oxcarbazepine, Levetiracetam, Carbamazepine
- Alternative: Lamotrigine
- Special considerations:
* Avoid carbamazepine in patients with cardiac conduction issues
* Levetiracetam preferred if liver dysfunction
* Oxcarbazepine may worsen hyponatremia

For Generalized Seizures:
- First choices: Valproate (not in females of childbearing potential), Levetiracetam
- Alternative: Lamotrigine
- Special considerations:
* Avoid valproate in liver disease
* Avoid valproate in mitochondrial disorders
* Consider lamotrigine in mood disorders

For Absence Seizures:
- First choices: Ethosuximide, Valproate
- Avoid: Carbamazepine, Oxcarbazepine, Phenytoin (may worsen absences)

3. When to Add Second Drug:

Consider add-on therapy when:
- Failed adequate trial of first drug at maximum tolerated dose
- Persistent seizures after 6-8 weeks of optimal dose
- Intolerable side effects preventing dose optimization

4. Choice of Second Drug:

For Focal Seizures:
- If on Levetiracetam → Add Oxcarbazepine/Lamotrigine
- If on Oxcarbazepine → Add Levetiracetam/Topiramate
- If on Carbamazepine → Add Levetiracetam/Lamotrigine

For Generalized Seizures:
- If on Valproate → Add Levetiracetam/Lamotrigine
- If on Levetiracetam → Add Valproate/Topiramate
- If on Lamotrigine → Add Levetiracetam/Valproate

5. Special Populations and Considerations:

Liver Disease:
- Prefer: Levetiracetam, Gabapentin, Pregabalin
- Avoid: Valproate, Carbamazepine

Kidney Disease:
- Dose adjustment needed for: Levetiracetam, Gabapentin, Pregabalin
- Prefer: Carbamazepine, Oxcarbazepine

Behavioral/Psychiatric Comorbidity:
- Prefer: Lamotrigine (mood stabilizing)
- Use caution with: Levetiracetam (may worsen behavior)
- Consider: Oxcarbazepine

6. When to Substitute Instead of Add:

Consider substitution when:
- Severe adverse effects to first drug
- Drug interactions making current therapy unsuitable
- Compliance issues due to dosing schedule
- Cost/availability issues
- Teratogenic concerns (e.g., switching from valproate in adolescent females)

7. Monitoring:

Before Starting:
- Baseline CBC, LFTs, electrolytes
- Consider EKG if starting carbamazepine
- Pregnancy test in adolescent females

During Treatment:
- Regular monitoring of drug levels
- CBC and LFTs as needed
- Monitor for specific drug-related adverse effects
- Growth monitoring
- Academic/behavioral monitoring