Carbamazepine

How to take:

Take carbamazepine exactly as your health care provider prescribes it. Do not change your dose without talking to your provider first. Stopping a seizure medicine suddenly can cause seizures that will not stop (status epilepticus). 

• Check the number of tablets and the strength of the pills you get from the pharmacy. If your provider changes your dose the strength of the pills may be different. 
• The immediate-release tablets, chewable tablets and liquid are usually given 3 or 4 times a day.
• The extended-release tablets and controlled-release capsules can be given 2 times a day.
• The tablets should be swallowed whole with a glass of water - do not chew them. 
• The chewable tablets can be swallowed whole or chewed. Drink some liquid after chewing the tablets so all the medicine is swallowed. 
• Taking carbamazepine with food may help avoid an upset stomach. Because food affects the way medicine is used by the body, it’s important to take it the same way every day. 
• For the liquid form, always check the bottle for the amount to take and the strength. Carbamazepine liquid is given as 100 mg per 5 ml, which means there is 20 mg in every ml.
  • Shake the bottle well before measuring a dose.
  • Always use an accurate measuring spoon or syringe to make sure the amount is correct. Do not use a regular teaspoon.  
  • Do not mix the liquid carbamazepine with any other liquid. Try not to take it at the same time as another liquid medicine.
• Don't drink grapefruit juice with carbamazepine. The juice can affect how the medicine works in your body. 
• Take only the amount that your provider tells you to take. If you take an extra dose, call your provider for advice. If you take a larger number of pills or overdose, call the poison control center (800-222-1222) or call your hospital emergency room. 

How to store:

• Store carbamazepine at room temperature (below 86^oF, 30^oC).
• Keep them away from heat and moisture. 
• Keep all medicines out of reach of children. 
• Keep the bottle of liquid in a cabinet or place where it will not get too much light. 

Taking the right amount of seizure medicine on time every day is the most important way to control seizures. Try these steps to help you remember when to take carbamazepine. 

• If you miss a dose, take it as soon as you remember it. 
• If it is almost time for the next dose, skip the missed dose and take the next dose at the regular time. If you are not sure what to do, call your doctor's office for more advice. 
• Avoid taking two doses at the same time or taking extra doses, unless your provider has asked you to do this. 
• To avoid missed doses, use a pillbox or set an alarm on your watch or phone.
• Send reminders to yourself with an online seizure diary or text message system like Texting 4 Control.
• Ask your pharmacist to prefill the medicine in blisterpaks.
• Write down any missed doses in your seizure calendar. Share this with your provider at each visit. 

• Brain cells work and talk with each other by generating electrical discharges. These discharges must be sent or fire at a certain rate to function normally. During a seizure, brain cells are forced to work much harder and faster than normal.
• Carbamazepine helps stop seizures by slowing down the electrical discharges that cause seizures. 
  • This medicine is thought to work by slowly turning off sodium channels in brain cells. The sodium channels are like gates on brain cells that help spread electrical activity from one cell to another. If the gate is turned off, the electrical activity can not spread as fast and the brain cells can recover. 

How the body absorbs, digests, and gets rid of a medicine or food is called metabolism. The way the body breaks down a medicine affects how often it should be taken and if it will interact other medicines or food. Some medical conditions such as liver disease can also affect a drug's metabolism.  

Some important points about carbamazepine:

• After taking carbamazepine immediate release tablets, the highest blood levels are reached in about 4 hours. When the chewable tablets or liquid are taken, the highest levels are reached quicker. 
• When a long-acting carbamazepine is taken, it may take up to 12 hours for the highest blood levels to be reached.
• Immediate release tablets do not last as long in the body as extended release tablets, so they need to be taken more often.
• Carbamazepine is broken down in the liver. This means it could interact or be affected by other medicines that are broken down in the liver. Talk to your provider and pharmacist about potential drug interactions, what to avoid, and how this may affect the dose of carbamazepine taken. 

Carbamazepine has been used to treat seizures for many years. Most studies suggest that carbamazepine may control seizures in about 7 out of 10 people taking this drug. These promising results are not always seen in everyday life. 

• How well a medicine works will depend on if it is taken the same way every day. 
• Not everyone's seizures can be controlled at a dose that can be taken without side effects. 
• Everyone is different - there is no best dose that will work for everyone. 

Many studies have compared carbamazepine with other seizure medicines to see which works best.

• When carbamazepine is used in people newly diagnosed with epilepsy, it works as well as many other seizure medicines. Side effects are important in deciding which medicine is best for each person. In one study, people who took carbamazepine had fewer problems with side effects.
• If carbamazepine doesn't control seizures when taken alone, another medicine may be added to it.

Some side effects may include:

• Blurry or double vision   
• Dizziness
• Headache
• Nausea or upset stomach
• Sleepiness or feeling tired
• Unsteady walking 

If you notice any of these problems, call your health care provider. Changing the amount or way it is taken may help. Do not stop taking carbamazepine or change the way it is taken without your doctor's advice. 

Some tips:

• Avoid dangerous activities when first starting this medicine or if taking a larger dose until you see if any side effects happen.
• Talk to your health care provider about driving. People who are first starting this medicine or having side effects may be advised not to drive. People also must be seizure free for a period of time to drive. See your state driving laws for more information. 
• Blood tests may be needed at times to check how much medicine is in your body and how your body is reacting. For example, liver function tests, blood cell counts and sodium or salt levels may be checked. 
  • Some people may see a slight change in white blood cells that is not a serious problem. If white blood cells went lower, a person could be prone to infections. 
  • Some people may have a slight drop in the sodium or salt levels in their blood. Usually this is not a problem. If sodium levels fall too low, other symptoms may be seen, including a change in seizures. 
  • Tell your doctor or provider if any of these symptoms happen. 
  • Ask how often blood tests should be done and what else to look for. 

Serious side effects of carbamazepine are rare. It is important to be aware of possible reactions and what to do if they happen. Only a very small number of people have died from them.

• Read the package insert for a complete list of all reactions to carbamazepine. 
• Call your provider's office right away if any of these problems occur. 

Allergic reactions: About 5 to 10% of people who take carbamazepine have a red rash within in the first month of taking it. If this happens, tell your health care provider to be sure that it's not the beginning of a serious problem.

• Tell your provider if you have had a rash to oxcarbazepine or eslicarbazepine or any similar medications in the past. You could have a similar reaction to carbamazepine.

Severe skin reactions: Carbamazepine can cause rare but serious skin reactions, such as Stevens-Johnson Syndrome (SJS) and toxic epidermal necrolysis (TEN). These conditions may start with a fever and flu-like symptoms. Then a rash develops. Ulcers or lesions of the mucous membranes may be seen and develop into painful blisters. 

• Report any fever or rash to a health care provider as this can be a life-threatening condition. 
• These types of skin reactions happen most commonly in the second or third week after starting the medicine. Though it can happen at other times too. 
• Serious skin rashes are more common in people with a particular gene called “HLA-B*1502.” (An allele is a form of a gene that is found on a chromosome. Alleles are involved in deciding whether certain traits passed on from a parent to a child will occur. The tendency to severe drug reactions can be one of these traits.) 
  • This gene is found in ancestry or family lines from broad areas of Asia including South Asian Indians. People who are Chinese, Thai, Filipino, Malaysian, and Korean may have an increased risk for these skin reactions with carbamazepine.
  • People at risk should be tested for the HLA-B*1502 allele before starting carbamazepine. If you test positive, you should avoid using this medicine unless your provider and you decide the benefits are worth the risks. 

Blood disorders: Certain changes in blood cells may happen and lead to serious problems. Only 1 in 30,000 people who take carbamazepine will develop one of these blood disorders. This risk is higher than the risk for people who do not take carbamazepine. Some symptoms of a blood disorder may include:

• Bruising easily
• Fever
• Nosebleeds or other unusual bleeding
• Sore throat
• Sores in the mouth
• Tiny red spots on the skin

Blood tests are usually done before starting carbamazepine and again while taking it. These tests look for any changes that happen while on this medicine. Some people may have some small changes in their blood that go away on their own. 

If you notice any of these symptoms, call your health care provider right away. Do not stop taking carbamazepine without your doctor's advice. 

Liver problems: Liver problems are another serious disorder that occurs in a few people who take carbamazepine. Some symptoms may include: 

• Black or pale color of bowel movements
• Loss of appetite
• Nausea, upset stomach, vomiting
• Stomach pain
• Yellow eyes or skin

Tell your health care provider right away if you notice any of these problems. Do not stop taking carbamazepine without your doctor's advice. 

Suicidal thoughts and behavior: In 2008, the Food and Drug Administration (FDA) reviewed data from drug studies that showed a possible relationship between many seizure medicines and suicidal thoughts and behavior. Together, these thoughts and behavior are called suicidality. According to the FDA’s Alert, among the patients with epilepsy in these drug studies, more had symptoms of suicidality than people taking a placebo or inactive substance - 3.5 of 1,000 people taking a seizure medicine had suicidality compared to 1 of 1,000 people taking a placebo.

• Taking seizure medicines may increase the risk of having suicidal thoughts or actions.
•  Do not make any changes to the medicines without first talking to your prescribing health care provider.
•  Pay close attention to any day-to-day changes in mood, behavior and actions. These changes can happen very quickly so it is important to be mindful of any sudden differences.
• Be aware of common warning signs that might be a signal for risk of suicide. Some of these are:
  • Talking or thinking about wanting to hurt yourself or end your life
  • Withdrawing from friends and family
  • Becoming depressed or having your depression get worse
  • Becoming preoccupied with death and dying
  • Giving away prized possessions
• Contact your health care provider before stopping any seizure meicine. This could possibly lead to worsening of seizure and mood. 

Thinning of the bones (osteopenia) or bone loss (osteoporosis) has been seen in some men and women taking carbamazepine. People using this medicine should talk to their health care provider about their bone health.

• Vitamin D and calcium may be recommended to help strengthen bones.
• Blood tests and a test to check the strength of your bones may be needed. 

Besides epilepsy, carbamazepine is also approved by the FDA for use with: 

• Trigeminal neuralgia, a type of facial pain
• Certain mental health problems

Often medicines are used for more than one purpose. It is legal for a prescribing health care provider to recommend medicines for "off-label uses" even though the FDA has not formally approved a medicine for that reason. Other conditions where carbamazepine has been used "off-label" include:

• Aggression
• Glossopharyngeal neuralgia
• Idiopathic muscle cramps
• Painful peripheral neuropathy (particularly due to diabetes)
• Restless leg syndrome
• Schizophrenia
• Seizures caused by a traumatic brain injury

People who have certain genes: People with the genes called “HLA-B*1502” or HLA-A*3101 should not use carbamazepine. Rashes that may be very serious are more likely to occur in people with these genes.

• The HLA-B*1502 gene ioccurs almost exclusively in people with ancestry or family lines across broad areas of Asia, including South Asian Indians.
• The HLA-A*3101 gene is reported in people of European descent.

People with a history of severe skin rashes: People who have had severe skin rashes with carbamazepine should not take it again. People have had had severe skin reactions to other seizure medicines should be careful about taking carbamazepine.

People with absence seizures or myoclonic seizures: Carbamazepine may worsen absence and myoclonic seizures. 

People with liver disease and who take certain medicines: People with liver disease or who take certain types of medicine should be careful taking carbamazepine. Work closely with your health care provider about how much carbamazepine to take and what to look for. Tell your doctor about any liver problems and about all medicines you take.  

Sometimes one kind of medicine changes the way another kind of medicine works in the body. This can happen with prescription and over-the-counter medicines, herbal products, vitamins, some foods, and even cigarettes. Tell your health care team any time a new medicine is given to you or any time you take other products or substances. 

Carbamazepine can affect other medicines: This usually happens because of the way medicines are broken down by the liver. Some examples include:

• Hormonal birth control pills, injections, implants
• Some seizure medicines
  • Clobazam (Onfi)
  • Clonazepam (Clonopin)
  • Lamotrigine (Lamictal)
  • Perampanel (Fycompa)
  • Phenytoin (Dilantin, Phenytek)
  • Sodium valproate/valproic acid (Depakote, Depakene)
  • Topiramate (Topamax)
• Some blood pressure medicines, such as felodipine
• Cholesterol medicines (statins)
• Coumadin
• Some antidepressant medicines

Medicines that may increase carbamazepine levels: Some medicines can cause carbamazepine to build up in the blood by slowing down its metabolism. Higher amounts of carbamazepine in the blood makes people feel dizzy, unsteady, or sleepy. Some medicines and other things that may increase carbamazepine include: 

• Sodium valproate or valproic acid (Depakote, Depakene)
• Some medicines for high blood pressure, such as diltiazem (Cardizem) and verapamil
• Fluoxetine (Prozac) 
• Certain antibiotics, such as erythromycin 
• Cimetidine or Tagamet
• Several types of anti-fungus medications
• Darvon and Darvocet
• Grapefruit juice

Medicines that may lower carbamazepine levels: Some medicines reduce the amount of carbamazepine in the blood, which can lead to more seizures. The dose of carbamazepine may need to be adjusted. 

• Felbamate (Felbatol)
• Phenobarbital
• Phenytoin (Dilantin or Phenytek)
• Primidone (Mysoline)
• Oxcarbazepine (Trileptal)

• Carbamazepine is used to treat many kinds of seizures in children. Yet some seizure types in children, such as absence seizures, can be worse when carbamzepine is used. Knowing the correct diagnosis is very important when choosing a seizure medicine. 
• Children’s bodies break down carbamazepine faster than adult's bodies do. This means that young children need to take a larger amount than adults. By the time children are teenagers, their bodies handle medicines similar to adults.
• The dose of a seizure medicine like carbamazepine needs to be carefully checked as a child or teen grows. 
• Side effects like sleepiness, double vision, or dizziness can be a problem for children. A child's thinking, behavior, and mood should be watched too. These problems are uncommon, but they can affect a child's development and school performance if they occur.  

Effects of carbamazepine during pregnancy: The FDA classifies this medicine in Pregnancy Category D. This means that there is a risk of birth defects in children who are born to mothers taking carbamazepine during pregnancy. Yet, the benefits to the mother using this medicine may be acceptable despite this risk.  

• Research studies suggest that there may be an association between the use of carbamazepine during pregnancy and birth defects called congenital malformations, including spina bifida. Spina bifida is a neural tube defect in which the spinal cord is not completely enclosed.
• All women who take carbamazepine and are able to become pregnant should take at least 0.4 mg (400 mcg) of folic acid or folate daily to help prevent neural tube defects in a child.
• Women at high risk of having a child with a birth defect (such as those with a history of a birth defect in a prior pregnancy or taking certain seizure medicines) may be asked to take a higher dose, for example 4 mg (4,000 mcg) of folic acid daily before and during pregnancy. 

Carbamazepine may also be associated in some children with develomental disorders and other congenital problems (such as facial malformations, cardiovascular malformations, and problems affecting other body systems).

• Talk to your doctor about possible risks of carbamazepine on your unborn child. Ask about the risks of using the medicine during pregnancy and the risks of seizures.
• Ask about other options to treat seizures during pregnancy and the risks and benefits in your situation. 

Seizures during pregnancy: Some women may have more seizures during pregnancy, because of hormone changes and how seizure medicine is handled by your body. Blood levels of carbamazepine may need to be checked more regularly during pregnancy so the dose can be adjusted if needed. 

Breastfeeding: Carbamazepine is present in breastmilk in small amounts. Yet, the amount of medicine the baby is exposed to while breastfeeding is less than during pregnancy. If you want to breastfeed your baby, check with your health care team about the best approach. 

Contraception: Carbamazepine can lower the amount of some hormonal forms of birth control. This may make the birth control less effective. A woman taking carbamazepine and some forms of hormonal birth control may be at greater risk for pregnancy. 

• Tell your health care team and pharmacist if you are taking hormonal birth control such as the pill, injection, or patch. 

• The best amount of any seizure medicine is the amount that completely controls seizures without causing troublesome side effects. It depends on many factors and will be different for each person. 
• The usual dose range for carbamazepine is 600 to 1,200 mg daily. Higher doses may be used in some situations. 
• No one should stop taking carbamazepine or change the amount they take without talking to the doctor first. Stopping any seizure medicine all at once can cause seizure emergencies that can be life-threatening.

As people get older, their bodies and how they metabolize and handle medicines change. Liver function may also change in older people. Some tips to consider:

• Seniors may do better with lower doses of carbamazepine then younger adults. 
• Older adults may be more sensitive to side effects of carbamazepine. For example, unsteady walking or blurry vision may lead to falls. 
• Some of the common side effects, like sleepiness, dizziness, unsteady walking and upset stomach, may worsen problems they had before taking carbamazepine.
• Starting carbamazepine at a lower dose and making changes more slowly may be needed to avoid problems with side effects and to find the best dose.
• Carbamazepine may interact or affect other medicines a person may take. Review all your medicines (including over-the-counter medicines, supplements, and vitamins) with your health care team to avoid any drug interactions. 

In the United States, companies that manufacture medicines are required to publish certain kinds of information about each product. This document is commonly known as a “package insert” because it is usually included with each package of the medicine.

You can also read these documents (also called "prescribing information") online. The U.S. package insert for Tegretol (carbamazepine) is found at:

• http://www.pharma.us.novartis.com/product/pi/pdf/tegretol.pdf

Some of the information may differ in other countries.

Learn how to read a package insert here.