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alized and partial seizures (see Table 16-5 for typical initial dosages) Valproate is probably less effective in the treatment of complex partial seizures The rst two of these drugs putatively act by blocking sodium channels, thus preventing abnormal neuronal ring and seizure spread Since carbamazepine has somewhat fewer side effects, it is preferred as the initial drug by many neurologists, but phenytoin and valproate have very similar therapeutic and side-effect pro les Carbamazepine and valproate are probably preferable to phenytoin for epileptic children because they do not coarsen facial features and do not produce gum hypertrophy or breast enlargement In many cases, phenytoin or carbamazepine alone will control the seizures If not, the use of valproate (which facilitates GABA activity) alone or the combined use of phenytoin and carbamazepine produces better control In others, the addition of valproate to carbamazepine may prove effective Because of the high incidence of myoclonic epilepsy in adolescence, it has been our practice to use valproate as the rst drug in this age group Weight gain and menstrual irregularities (see below) during the period of initiation of valproate may also gure into the decision regarding the choice of initial drug for otherwise uncomplicated seizures in women Finally, it should be said that most of the commonly used antiepileptic drugs cause, to varying degrees, a decrease in bone density and an increased risk of fracture from osteoporosis in older patients, particularly in women Several mechanisms are probably active, among them, induction of the cytochrome P450 system, which enzymatically degrades vitamin D No speci c recommendations have been offered to counteract this effect of bone loss Calcium supplements or one of the bisphosphonates are advised if there is no contraindication Phenytoin Both oral and intravenous forms are available Rash, fever, lymphadenopathy, eosinophilia and other blood dyscrasias, and polyarteritis are manifestations of an idiosyncratic phenytoin hypersensitivity; their occurrence calls for discontinuation of the medication Overdose with phenytoin causes ataxia, diplopia, and stupor The prolonged use of phenytoin often leads to hirsutism (mainly in young girls), hypertrophy of gums, and coarsening of facial features in children Chronic phenytoin use over several decades may occasionally be associated with peripheral neuropathy and probably with a form of cerebellar degeneration (Lindvall and Nilsson); it is not clear if these are strictly dose-related effects or if there is an idiosyncratic reaction An antifolate effect on blood and interference with vitamin K metabolism have also been reported, for which reason pregnant women taking phenytoin should be given vitamin K before delivery and the newborn infant should receive vitamin K as well to prevent bleeding Phenytoin should not be used together with disul ram (Antabuse), chloramphenicol, sulfamethizole, phenylbutazone, or cyclophosphamide, and the use of either phenobarbital or phenytoin is not advisable in patients receiving warfarin (Coumadin) because of the undesirable interactions already described Choreoathetosis is a rare idiosyncratic side effect Carbamazepine This drug causes many of the same side effects as phenytoin, but to a slightly lesser degree Leukopenia is common, and there have been rare instances of pancytopenia, hyponatremia, and diabetes insipidus as idiosyncratic reactions It is essential, therefore, that a complete blood count be done before treatment is instituted and that the white cell count be checked regularly A more recently introduced analogue of carbamazepine oxcarbazepine is said to have even fewer of these side effects than the parent drug, but its long-term therapeutic value still has to be. birt barcode free BIRT barcode fonts - InterPro Solutions
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