Pharm
Carbamazepine
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Carbamazepine
, Tegretol
Indication
Simple Partial Seizure
s
Complex Partial Seizure
s
Generalized Tonic Clonic Seizure
s
Trigeminal Neuralgia
Bipolar Disorder
Frequently reserved for use as a second agent
Resistant
Schizophrenia
Restless Leg Syndrome
Psychosis in Dementia
Post-Traumatic Stress Disorder
Contraindications
MAO inhibitor
use within last 14 days
Bone Marrow
suppression
Pregnancy
Tricyclic compound sensitivity
Asian patients who are positive for HLA-B1502
Risk of Steven's Johnson: 5% if HLA-B1502 positive
Also associated with
Toxic Epidermal Necrolysis
FDA has issued a black box warning
Man (2007) Epilepsia 48(5):1015-8 [PubMed]
Adverse Effects
Dose related
Gradual tolerance to side effects (slowly titrate)
Headache
Lethargy,
Fatigue
or
Somnolence
Nausea
and
Vomiting
Tremor
Nystagmus
Dizziness
Ataxia
or altered coordination
Diplopia
Adverse Effects
Other
Morbilli
form rash
Gingival Hyperplasia
Blood dyscrasias
Agranulocytosis
Aplastic Anemia
Leukopenia
Cardiac conduction abnormality (increases A-V delay)
Hyponatremia
Occurs in up to 40% of patients
Elderly are at higher risk of
SIADH
Liver
failure
Osteoporosis
Serum Sickness
Stevens-Johnson Syndrome
Toxic Epidermal Necrolysis
Drug Interactions (Numerous)
Substrate of
Cytochrome P450
2C8/9
Substrate of
Cytochrome P450
3A4
Induces
Cytochrome P450
1A2
Induces
Cytochrome P450
2B6
Induces
Cytochrome P450
2C8/9
Induces
Cytochrome P450
2C19
Induces
Cytochrome P450
3A4
Dose
Gene
ral
Titrate dose to serum concentration and effect
Target serum concentration: 4-12 mcg/ml
Observe closely for concentration 8 mcg/ml or higher
Toxic serum concentration: >15 mcg/ml
Dose
Adults
Seizure Disorder
Initial: 200 mg orally twice daily
Increase by 200 mg/day increments weekly
Typically up to 800-1200 mg/day (max: 2400 mg/day) in divided dosing
Target concentration: 4 to 12 mcg/ml
Trigeminal Neuralgia
Initial: 100 mg orally twice daily
Increase by 100 mg/day increments weekly
Target: 400-800 mg/day divided twice daily
Bipolar Disorder
Initial: 200 mg twice daily
Increase by 200 mg as often as daily in acute mania as tolerated
Slower titration results in fewer side effects
Target: 200-1600 mg per day
Target serum level: 4 to 12 mcg/ml
Dose
Elderly
Initial: 100 mg orally twice daily
Increase by 100 mg/day increments weekly
Target: 400-1000 mg/day divided three to four times daily
Monitoring
Routine labs
Obtain monthly for first 2 months, then every 3 to 12 months
Complete Blood Count
with
Platelet Count
Liver Function Test
s
HLA-B1502
Indicated before starting in asian patients
See contraindications above
Serum Carbamazepine level
Initial: Every 1-2 weeks
Later: Every 3-6 months
Also check before and after dose changes
Other tests previously monitored with Carbamazepine use
Serum Iron
Urinalysis
Serum Sodium
Blood Urea Nitrogen
Thyroid Stimulating Hormone
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