4.8. Antiepileptic drugs
4.8.1. Control of the epilepsies
Where it is essential in all cases to maintain a patient on a specific brand or manufacturer’s preparation, this is indicated in the relevant Formulary entry. For all other antiepileptic medicines, when being used to treat epilepsy, there is no requirement to be maintained on a specific brand or manufacturer’s preparation, unless the prescriber considers, following a discussion with each individual patient at the next review, that an individual patient's circumstances require the need for continuity of supply of a particular specific manufacturer or brand (e.g. seizure risk, treatment history or other concerns, such as patient anxiety, risk of confusion or dosing errors).
Restrictions:
Restricted to adjunctive treatment of partial-onset seizures with or without secondary generalisation in adults and adolescents from 16 years of age with epilepsy. Treatment should be initiated by physicians who have appropriate experience in the treatment of epilepsy.
Restrictions:
Restricted to specialist use for the following indications:
- in combination with clobazam for the adjunctive therapy of seizures associated with Dravet syndrome and Lennox-Gastaut syndrome in accordance with local protocol (requires access to StaffNet).
- Use as an adjunctive therapy of seizures associated with tuberous sclerosis complex (TSC)
Prescribing Notes:
When used for epilepsy, Patients should be maintained on a specific brand/preparation and prescribing by brand name should be followed where possible.
Restrictions:
Restricted to specialist initiation in patients with drug-resistant epilepsy as a second-line adjunctive anti-seizure medicine, after the failure of the first adjunctive anti-seizure medicine.
Restrictions:
Restricted to initiation by specialists in epilepsy.
Prescribing Notes:
Use as monotherapy in the treatment of partial-onset seizures, with or without generalisation, in adults with newly diagnosed epilepsy is not recommended for use in NHSScotland by the SMC and is non-Formulary.
Restrictions:
Restricted to specialist use in the treatment of seizures associated with Dravet syndrome as an add-on to other anti-epileptic medicines for patients 2 years of age and older after trying two or more anti-seizure medicines.
Restrictions:
Restricted to specialist initiation only. Restricted to patients with refractory epilepsy.
Prescribing Notes:
Use as monotherapy for partial-onset seizures with or without secondary generalisation is not recommended by SMC and is non-Formulary.
Restrictions:
Restricted to specialist initiation only. Monotherapy for partial onset seizures (with or without secondary generalisation) in newly diagnosed patients is further restricted to second line treatment when usual first line treatment are ineffective or not tolerated. The infusion is restricted to specialist use only.
Restrictions:
Restricted to speialist initiation only. The liquid formulation remains non-formulary.
Restrictions:
Restricted to specialist initiation for the indications listed below. Adjunctive treatment of partial-onset seizures with or without secondarily generalised seizures in patients with epilepsy aged 12 years and older is restricted to initiation by specialists in epilepsy.
Prescribing Notes:
For the relevant SMC advice click here
Restrictions:
Restricted to specialist initiation for the second-line adjunctive treatment in patients with refractory partial onset epilepsy who are unable to swallow perampanel tablets.
Prescribing Notes:
Non-Formulary indication:
- Adjunctive treatment of primary generalised tonic-clonic seizures in adult and adolescent patients from 12 years of age with idiopathic generalised epilepsy is not recoomended by SMC.
Restrictions:
Restricted to specialist initiation only.
Prescribing Notes:
Patients should be maintained on a specific manufacturer’s preparation. Prescriptions should detail the manufacturer of the generic preparation.
Restrictions:
Restricted to specialist initiation only.
Prescribing Notes:
When used for epilepsy, Patients should be maintained on a specific brand/preparation and prescribing by brand name should be followed where possible.
Restrictions:
Restricted to initiation only by physicians who have appropriate experience in the treatment of epilepsy and should be used principally in patients who have not benefited from treatment with older anti-convulsants or for whom these drugs are unsuitable because of contraindications, interactions or poor tolerance. Pregabalin has not been accepted by the SMC for use in the treatment of central neuropathic pain and generalised anxiety disorder and is non-Formulary for these indications. The oral solution is also further restricted to those patients who find it difficult to or are unable to swallow tablets.
Restrictions:
Restricted to specialist initiation only.
Prescribing Notes:
When used for epilepsy, Patients should be maintained on a specific brand/preparation and prescribing by brand name should be followed where possible.
Restrictions:
Restricted to specialist initiation only in patients who have failed treatment with or are intolerant of other antiepileptic drugs.
Restrictions:
Restricted to specialist initiation only.
Prescribing Notes:
Prescribe by brand name.
Children exposed to valproate in utero are at high risk of developmental disorder and congenital malformations. For further information and communication materials for prescribers to use in their discussions with patients, see MHRA guidance here (latest update January 2024)
Valproate should NOT be used routinely in women of child-bearing age for the treatment of Bipolar Disorder. If it is deemed clinically necessary, then all aspects of the prevent programme MUST be followed and documented.
Restrictions:
Restricted to specialist initiation only.
Prescribing Notes:
- In June 2024, the MHRA advised that topiramate is contraindicated in pregnancy and in women of childbearing potential unless the conditions of a Pregnancy Prevention Programme are fulfilled.
Restrictions:
Restricted to initiation by physicians who have appropriate experience in the treatment of epilepsy for use in patients who have not responded to established anticonvulsants or for whom these drugs are unsuitable or not tolerated.
Use as monotherapy for partial seizure (with or without secondary generalisation) in adults with newly diagnosed epilepsy is not recommended by SMC and remains non-Formulary.
4.8.2. Drugs used in status epilepticus
Restrictions:
Buccal midazolam should only be initiated on the advice of a specialist in accordance with agreed local guidelines and following appropriate training of the parent or carer. It may, however, be continued to be prescribed in primary care.
Prescribing Notes:
Buccal midazolam is available as Buccolam® or Epistatus®. The two preparations are different strengths and may have different doses, therefore are not considered interchangeable. In light of these differences and the associated risks, any agreed change of preparation in existing patients would require careful management by all involved.
4.8.3. Febrile convulsions
Restrictions:
The infusion should be only be used when the IV route can be clinically justified over other routes of administration. The dose of the IV preparation may need to be reduced in the presence of risk factors (e.g. low weight or renal impairment).