Abstract and Introduction
Seizures and chronic kidney disease are both common and often coexist. Treating seizures in patients with renal failure, including those on dialysis, is a challenge that is frequently encountered, especially in the inpatient setting. For the newer antiepileptic drugs, there are limited data available, so an understanding of how each drug is affected by kidney disease and dialysis is critical in order to make rational choices qualitatively (which drug) and quantitatively (dosing). Generally, newer (second-generation) antiepileptic drugs are associated with fewer systemic side effects and drug–drug interactions, so they tend to be preferred in this population. The landscape of antiepileptic drugs is constantly evolving, with new compounds being released on a regular basis. Thus, several new agents have become available since the last review of this topic (in 2006) and these are the ones discussed here. Most require dosage adjustment according to the degree of renal failure, and most require extra doses after dialysis.
Epilepsy has a prevalence of 1%, the lifetime prevalence of a single seizure is approximately 9%, and seizures are also common in renal failure. Seizures occur in approximately 30% of patients with uremic encephalopathy. Therefore, the use of antiepileptic drugs (AEDs) in patients with chronic kidney disease (CKD) is a common problem in neurological practice, to which the clinical neurologist is sure to be confronted, in both inpatient and outpatient settings. There are few data and systematic reviews on the use of AEDs in patients with renal failure, including patients on dialysis. In addition, the landscape of available AEDs is constantly evolving, with new drugs being added to the market on a regular basis. In the absence of data, often the management will rely on a good understanding of the drug's metabolism or 'dialysability'.
This article will focus on the agents that have become available since the last review of this topic, which include vigabatrin, rufinamide, lacosamide, pregabalin, ezogabine, eslicarbazepine, brivaracetam, perampanel and clobazam.
This review is meant as a practical guide to help clinicians (internists, nephrologists and neurologists) in this relatively common situation. We will first review the general principles of drug treatments in patients with CKD, and then turn to individual AEDs (summarized in Table 1), with an emphasis on recently released and soon to be available compounds. Many AEDs are indicated for conditions other than seizures (e.g., gabapentin and pregabalin for chronic pain, topiramate and valproate for migraine, and lamotrigine for bipolar disease), but these indications are less 'acute' than seizures, so the main focus here will be for the purpose of seizure control.
Expert Rev Neurother. 2012;12(1):99-105. © 2012 Expert Reviews Ltd.