These are the FDA-Approved anti-epileptic drugs for monotherapy, the list is small:
- Felbamate for newly diagnosed and refractory focal.
- Lamotrigine for refractory focal and conversion to monotherapy.
- The next group consists of oxcarbazepine, topiramate, lacosamide, eslicarbazepine. These are all approved as monotherapy for newly diagnosed and refractory focal.
Note that levetiracetam is widely used as initial monotherapy for focal and generalized seizures although it is not FDA-approved for any monotherapy indication. This also holds for gabapentin, pregabalin, and zonisamide, although they are widely used as initial monotherapy.
Other than efficacy for a certain epilepsy syndrome, the type of adverse effects often guides choices. Drugs that may cause weight gain are valproic acid, gabapentin, pregabalin, carbamazepine, ezogabine, and perampanel. By contrast, topiramate, zonisamide, and felbamate may decrease weight. Lamotrigine and felbamate tend to be “alerting.” Pregabalin, lamotrigine, valproic acid, and carbamazepine may reduce anxiety. Zonisamide tends to be sedating. The sodium-channel blockers, such as carbamazepine and lacosamide, may cause imbalance and blurred vision. There are many other factors in choosing, such as enzyme induction and risks to the fetus. Those considered “safer in pregnancy” are levetiracetam, carbamazepine, oxcarbazepine, zonisamide, lamotrigine, and surprisingly phenytoin.
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