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

20 common pediatric epilepsy scenarios with treatment approaches.

1. Typical Absence Epilepsy (7-year-old)
- First: Ethosuximide
- Second add-on: Valproate
- Third add-on: Lamotrigine
- Replacement options: Levetiracetam if both fail

2. Juvenile Myoclonic Epilepsy (14-year-old male)
- First: Valproate
- Second add-on: Levetiracetam
- Third add-on: Topiramate
- Replacement: Lamotrigine, Zonisamide

3. Juvenile Myoclonic Epilepsy (13-year-old female)
- First: Levetiracetam
- Second add-on: Lamotrigine or valproate
- Third add-on: Topiramate
- Replacement: Zonisamide

4. Benign Rolandic Epilepsy (8-year-old)
- First: Oxcarbazepine or valproate if there is paradoxical worsening
- Second add-on: Levetiracetam
- Third add-on: Carbamazepine
- Replacement: Gabapentin

5. West Syndrome (6-month-old)
- First: ACTH/Vigabatrin
- Second add-on: Topiramate
- Third add-on: Levetiracetam
- Replacement: Valproate, clobazam

6. Lennox-Gastaut Syndrome (5-year-old)
- First: Valproate
- Second add-on: Clobazam
- Third add-on: Rufinamide
- Replacement: Lamotrigine

7. Focal Epilepsy with Normal MRI (10-year-old)
- First: Oxcarbazepine
- Second add-on: Levetiracetam
- Third add-on: Lamotrigine
- Replacement: Carbamazepine

8. Focal Epilepsy with Cortical Dysplasia (4-year-old)
- First: Levetiracetam
- Second add-on: Oxcarbazepine
- Third add-on: Topiramate
- Replacement: Lacosamide

9. Dravet Syndrome (2-year-old)
- First: Valproate
- Second add-on: Clobazam
- Third add-on: Stiripentol
- Replacement: Topiramate, Fenfluramine

10. Childhood Absence Epilepsy with Myoclonic Components (8-year-old)
- First: Valproate
- Second add-on: Levetiracetam
- Third add-on: Lamotrigine
- Replacement: Topiramate

11. Post-traumatic Epilepsy (12-year-old)
- First: Levetiracetam
- Second add-on: Carbamazepine
- Third add-on: Lacosamide
- Replacement: Oxcarbazepine

12. Tuberous Sclerosis with Focal Seizures (3-year-old)
- First: Vigabatrin
- Second add-on: Levetiracetam
- Third add-on: Topiramate
- Replacement: Oxcarbazepine

13. GLUT-1 Deficiency Syndrome (2-year-old)
- First: Ketogenic Diet
- Second add-on: Levetiracetam
- Third add-on: Zonisamide
- Replacement: Topiramate

14. Juvenile Absence Epilepsy (12-year-old)
- First: Valproate
- Second add-on: Lamotrigine
- Third add-on: Levetiracetam
- Replacement: Topiramate

15. Focal Epilepsy with Language Dysfunction (6-year-old)
- First: Levetiracetam
- Second add-on: Lamotrigine
- Third add-on: Oxcarbazepine
- Replacement: Topiramate (avoid phenytoin/phenobarbital)

16. Myoclonic-Atonic Epilepsy (Doose Syndrome) (4-year-old)
- First: Valproate
- Second add-on: Lamotrigine
- Third add-on: Clobazam
- Replacement: Levetiracetam

17. Early Myoclonic Encephalopathy (2-month-old)
- First: Phenobarbital
- Second add-on: Levetiracetam
- Third add-on: Topiramate
- Replacement: Valproate

18. KCNQ2 Encephalopathy (neonate)
- First: Carbamazepine/Oxcarbazepine
- Second add-on: Levetiracetam
- Third add-on: Topiramate
- Replacement: Phenobarbital

19. Rasmussen Encephalitis (7-year-old)
- First: Levetiracetam
- Second add-on: Carbamazepine
- Third add-on: Clobazam
- Replacement: Consider immunotherapy/surgery

20. Focal Epilepsy with Autism (5-year-old)
- First: Levetiracetam (though may need to monitor behavior)
- Second add-on: Oxcarbazepine
- Third add-on: Lamotrigine
- Replacement: Valproate (if no behavioral worsening)

Key Considerations for All Cases:
- Monitor side effects closely
- Consider drug interactions
- Adjust based on comorbidities
- Consider ketogenic diet in refractory cases
- Evaluate for surgical candidacy in focal cases
- Regular EEG monitoring
- Growth monitoring
- Development/cognitive monitoring
- Quality of life assessment

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