Drugs are listed in order of approval in the USA, from oldest to newest. FELBAMATE
Felbamate is a broad-spectrum anti-epileptic drug. It is not considered to be a first-line drug because of its potential for serious idiosyncratic side-effects, including potentially fatal aplastic anaemia (incidence of 1 in 3000) and hepatic failure (incidence of 1 in 10 000) . Recent analyses indicate that aplastic anaemia and liver failure occur almost exclusively within the first year of therapy. During this period, safety monitoring consisting of liver function tests and blood counts is recommended with a frequency of up to twice monthly, despite lack of evidence that early detection of changes will prevent serious health problems, even if the drug is discontinued. Yet, felbamate may still be an important drug in the armamentarium for refractory patients, because it may control seizures when other drugs fail, and tends to be alerting rather than sedating. It has been found to be particularly effective in patients with Lennox-Gastaut syndrome . Felbamate should be started at 300-600 mg twice daily, and increased as necessary over several weeks, up to 3600 mg, or higher in some cases. Drug levels may be useful, and serum concentrations of 30-80 mg/l are recommended . Three-times-a-day dosing may improve tolerability. Dose-related side-effects include insomnia, decreased appetite and weight loss, ataxia, GI upset and headache. Other serious idiosyncratic adverse events include rash and Stevens-Johnson syndrome. Felbamate has a complex metabolism and elimination, by both the hepatic and renal routes, and inhibits the metabolism of some drugs while inducing others (see Tables 1.1 and 1.2). Adjustments in these medications may be necessary.
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