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Content Update

April 29, 2018

Risk of Hemophagocytic Lymphohistiocytosis with Lamotrigine Use: Lamotrigine is an antiepileptic medication used for management of epilepsy and mood disorders such as bipolar disorder. The U.S. Food and Drug Administration issued a new warning regarding the risk for hemophagocytic lymphohistiocytosis (HLH), which is a rare immune system reaction.


For the chapter in the Wells Handbook, please go to Chapter 53. Epilepsy.



  • Image not available. Accurate classification and diagnosis of seizure type/epilepsy syndrome, including mode of seizure onset, is critical to selection of appropriate pharmacotherapy.

  • Image not available. The goal of pharmacotherapy is seizure freedom with minimal side effects, and two-thirds to 80% percent of patients can achieve this.

  • Image not available. Patients who do not respond to drug therapy should be referred to a comprehensive epilepsy center to determine if nonpharmacologic treatments such as surgery are potential options.

  • Image not available. Patient specific treatment goals should be identified as early as possible, and patient characteristics such as age, comorbid conditions, ability to adhere with the prescribed regimen, presence or absence of insurance coverage, gender, child-bearing ability, and ethnicity should be considered.

  • Image not available. If the therapeutic goal is not achieved with monotherapy, a second antiseizure drug (ASD), preferably with a different mechanism of action, can be added, or a switch to an alternative single ASD can be made.

  • Image not available. Pharmacotherapy of epilepsy is highly individualized and requires titration of the dose to optimize ASD therapy (maximal seizure control with minimal or no side effects).

  • Image not available. Newer ASDs appear to have comparable efficacy to older ASDs and are perhaps better tolerated.

  • Image not available. Despite numerous drug trials, 20% to 35% of patients will have unsatisfactory control with ASDs.

Epilepsy is a common neurologic condition in which a person is prone to recurrent epileptic seizures. There are many types of epilepsies characterized by different seizure types, ranging in severity and etiologies. While the specific pathophysiologic mechanisms behind different epilepsies are complex, the underlying general pathophysiologic process at the heart of all epilepsies is disturbed regulation of electrical activity in the brain resulting in synchronized and excessive neuronal discharge.

Beyond seizures, people with epilepsy face many challenges. It is important to recognize the coexisting health conditions and psychosocial effects of epilepsy. Patients with epilepsy may display neurodevelopmental delay, cognitive impairment, and often suffer from comorbid depression and anxiety.1 Furthermore, patients with epilepsy may face educational and vocational challenges, have difficulties with independent living, and be victims of stigma and common public misunderstanding.2 Such comorbid and psychosocial issues must be taken into account when treating and caring for patients with epilepsy. Indeed, the International League Against Epilepsy (ILAE) defines epilepsy not only as “a chronic condition of the brain characterized by an enduring propensity to generate epileptic seizures” but also by “the neurobiological, cognitive, psychological, and social consequences of this condition.”3 Clinicians treating epilepsy must try to address these ...

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