Special situations
A medicine that looks ideal on a seizure-type table may become a poor choice once pregnancy potential, age, mood, cognition, organ function or comorbidity is considered.
Pregnancy and pregnancy planning
Do not stop antiseizure medicines abruptly. Pre-pregnancy review should balance seizure-control risk against fetal risk, simplify therapy where possible, review folate, and establish a monitoring plan. Lamotrigine concentrations can fall substantially during pregnancy.
Reproductive safety
Valproate has major known teratogenic and neurodevelopmental risks and requires strict, current safety counselling. Australian TGA advice should be checked whenever prescribing to people who may conceive or are planning a family.
Older adults
Prioritise tolerability, falls risk, cognition, bone health, polypharmacy and interactions. Start low and titrate thoughtfully; renal clearance can become increasingly important.
Renal and hepatic disease
Levetiracetam, gabapentin and pregabalin are heavily renal-cleared; many older agents depend on hepatic metabolism. Dose and interaction decisions should follow organ function and product information.
Mood, behaviour and cognition
Behavioural vulnerability may make levetiracetam or perampanel less attractive for some people; topiramate and phenobarbital may impair cognition. Conversely, lamotrigine may be advantageous when mood profile matters.
Weight, bone and metabolic factors
Valproate and pregabalin can promote weight gain; topiramate and zonisamide can reduce weight but increase stone/acidosis risk. Enzyme-inducing older drugs can adversely affect bone health and interactions.
Pregnancy safety is not a reason to leave epilepsy untreated
Uncontrolled seizures can also harm the pregnant person and fetus. The aim is planned, informed treatment with the safest effective regimen — not abrupt withdrawal after a positive pregnancy test.
Australian reproductive-safety information should be checked against current TGA medicine safety communications and product information because regulatory advice evolves.