AED(% protein-bound) Kidney Liver Bone marrow Heart Comment
Carbamazepine
(65-80%)
Hyponatremia   Leukopenia Anemia   Monitor cyclosporine level
Gabapentin
(3%)
300 mg q.o.d. for severe renal failure300 mg after ~4 hrs hemodialysis   Useful during engraftment    
Lamotrigine
(55%)
T1/2 ~48 hrs during severe renal failureT1/2 ~12 hrs during hemodialysis T1/2 ~110 hrs during severe hepatic failure     Serious rashes:~3/1000 adults~1/100 children
Levetiracetam
(
Reduce dose during renal failure
Supplemental dose after hemodialysis
  Useful during engraftment    
Oxcarbazepine
(MHD is ~40%)
Hyponatremia Liver converts to active MHD
Not studied in severe failure
Avoid during engraftment   Both an inhibitor and inducer of CYP450
Monitor cyclosporine level
Phenobarbital
(40-60%)
Sedating Sedating Useful during engraftment   Monitor cyclosporine level
Steroid metabolism altered
Phenytoin
(80-90%)
Use free phenytoin levels Use free phenytoin levels Avoid during engraftment Use free phenytoin levels Monitor cyclosporine level
Steroid metabolism altered
Topiramate
(~15%)
Clearance reduced ~50% in renal failure
Need to adjust dose during hemodialysis
      Kidney stone: ~1% incidence
Valproic acid
(~95%)
Useful during hemodialysis because little is removed Avoid during hepatic failure Avoid during engraftment
Thrombocytopenia at high concentrations
  Severe hepatotoxicity or pancreatitis are rare
Avoid in patients
Zonisamide
(~40%)
Avoid in renal failure Not studied in hepatic failure Avoid during engraftment   A sulfonamide
Kidney stone: ~4% incidence

MHD = monohydroxy derivative (active metabolite); T1/2 = terminal half-life.

Adapted from: Cruz-Martinez E and Gilmore RL. Transplantation and seizures. In: Ettinger AB and Devinsky O, eds. Managing epilepsy and co-existing disorders. Boston: Butterworth-Heinemann; 2002;75-82.
With permission from Elsevier (www.elsevier.com).

Authored By: 
E Cruz-Martinez and RL Gilmore
Reviewed By: 
Steven C. Schachter MD
on: 
Monday, March 1, 2004