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