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Listen now!
This March episode might be a day late, but it's definitely not short on content.
In addition to last month's heartburn and gastric reflux discussion, Chris's provider friend/friend of the show wanted to hear an episode devoted to anticonvulsants. Anticonvulsants sit at the intersection of several challenging issues in the corrections environment, including medical necessity, mental health, and diversion risk. And though Chris was a bit wary of this topic, he stepped up and delivered a sprawling but practical discussion that any correctional provider could benefit from.
Chris breaks down the essentials of antiepileptic drugs: how they work, when to use them, and the critical safety risks that can’t be overlooked. He also looks at lab monitoring, drug interactions, cost considerations, and their use as mood stabilizers.
Chris also spends some time on gabapentin misuse in correctional settings and a common clinical pitfall: why anticonvulsants don’t work for functional (non-epileptic) seizures—and what actually does.
To follow up on this heavy meal of anticonvulsant information, we finish with a light, airy dessert of fun anticonvulsant trivia.
As usual, we get started with indispensable medication news with the Into the Clinic segment, including:
-New drug approvals for schizophrenia and atopic dermatitis
-New AHA/ACC guideline for acute pulmonary embolism severity
-Follow-up info on SMART efficacy
-Updated labeling for menopausal hormone therapy products
Sponsor Links:
Music in this Episode:
The Retro Synth by Art Haiz
Vitals & Headlines (Suno AI)
Breezy Thoughts (Suno AI)
Trivia Time Ticker (Suno AI)
References/Further Reading:
Into the Clinic:
Manalac T. Vanda rebounds from jet lag rejection with FDA nod for bipolar, schizophrenia drug. Reuters. February 20, 2026. https://www.reuters.com/business/healthcare-pharmaceuticals/us-fda-approves-vandas-psychiatric-drug-2026-02-20
MedPageToday Staff. New topical PDE4 inhibitor gets FDA green light for chronic skin disease. MedPageToday. February 17, 2026. https://www.medpagetoday.com/dermatology/atopy/119913
Writing Committee Members. 2026 AHA/ACC/ACCP/ACEP/CHEST/SCAI/SHM/SIR/SVM/SVN Guideline for the Evaluation and Management of Acute Pulmonary Embolism in Adults: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. J Am Coll Cardiol. 2026.doi:10.1016/j.jacc.2025.11.005
MedPageToday Staff. SMART asthma treatment saves healthcare dollars. MedPageToday. February 3, 2026. https://www.medpagetoday.com/pulmonology/asthma/119681
U.S. Food and Drug Administration. FDA approves labeling changes to menopausal hormone therapy products. FDA News Release. February 12, 2026. https://www.fda.gov/news-events/press-announcements/fda-approves-labeling-changes-menopausal-hormone-therapy-products
Main Discussion:
Stahl SM.*Stahl's Essential Psychopharmacology: Neuroscientific Basis and Practical Applications*. 5th ed. Cambridge University Press; 2021.
Rogawski MA, Löscher W. The neurobiology of antiepileptic drugs. *Nat Rev Neurosci*. 2004;5(7):553-564. doi:10.1038/nrn1430.
Bialer M, White HS. Key factors in the discovery and development of new antiepileptic drugs. *Nat Rev Drug Discov*. 2010;9(1):68-82. doi:10.1038/nrd2997.
Fazel S, Vassos E, Danesh J. Prevalence of epilepsy in prisoners: systematic review.*BMJ*. 2002;324(7352):1495. doi:10.1136/bmj.324.7352.1495.
Whitman S, Coleman TE, Patmon C, Desai BT, Cohen R, King LN. Epilepsy in prison: elevated prevalence and no relationship to violence. *Neurology*. 1984;34(6):775-782.doi:10.1212/WNL.34.6.775.
Harding TW, Curran WJ. Mental disorder and the practice of law: problems in prisons.*Int J Law Psychiatry*. 1979;2(1):47-66.
Favril L, Yu R, Sharpe M, et al. Prevalence of mental and physical health conditions in prison: umbrella review. *BJ Psych Open*. 2025;11(1):e9.doi:10.1192/bjo.2024.764.
Fard ME, Sharifi A, Dehkordi AS. Drug formularies in correctional settings. *J Am AcadPsychiatry Law*. 2020;48(1):2-10.
Perucca E. Clinically relevant drug interactions with antiepileptic drugs. *Br J Clin Pharmacol*. 2006;61(3):246-255. doi:10.1111/j.1365-2125.2005.02529.x.
Johannessen SI, Landmark CJ. Antiepileptic drug interactions: principles and clinical implications. *Curr Neuropharmacol*. 2010;8(3):254-267.doi:10.2174/157015910792246254.
Wilfred PM, Mathew S, Chacko B, Prabha R, Mathew BS. Estimation of free phenytoin concentration in critically ill patients with hypoalbuminemia: direct-measurement vs traditional equations. *Indian J Crit Care Med*.2022;26(6):682-687. doi:10.5005/jp-journals-10071-24235.
Ghimire S, Castelino RL, Lam G, et al. A novel correction equation avoids high-magnitude errors in interpreting therapeutic drug monitoring of phenytoin among critically ill patients. *Pharmacotherapy*. 2020;40(7):668-676.doi:10.1002/phar.2418. PMC7377971.
Hong JM, Choi YC, Kim WJ. Differences between the measured and calculated free serum phenytoin concentrations in epileptic patients. *Yonsei Med J*.2009;50(4):517-520. doi:10.3349/ymj.2009.50.4.517. PMC2730613.
Ferrell PB Jr, McLeod HL. Carbamazepine, HLA-B*1502 and risk of Stevens-Johnson syndrome and toxic epidermal necrolysis: US FDA recommendations. *Pharmacogenomics*.2008;9(10):1543-1546. doi:10.2217/14622416.9.10.1543. PMC2586963.
Dean L. Carbamazepine therapy and HLA genotype. In: Pratt VM, Scott SA, Pirmohamed M,et al., eds. *Medical Genetics Summaries*. NCBI Bookshelf; updated 2018.NBK321445.
Lheureux PE, Penaloza A, Zahir S, Gris M. Science review: carnitine in the treatment of valproic acid-induced toxicity: what is the evidence? *Crit Care*. 2005;9(5):431-440. doi:10.1186/cc3742.
Ornoy A. Valproic acid in pregnancy: how much are we endangering the embryo and fetus? *Reprod Toxicol*. 2009;28(1):1-10. doi:10.1016/j.reprotox.2009.02.014.
Schaefer C, Koch-Gromus U, editors. *Drugs During Pregnancy and Lactation*. 3rd ed. Academic Press; 2015. [Chapter: Antiepileptics]
U.S. Food and Drug Administration. FDA Drug Safety Communication: Children born to mothers who took valproate products while pregnant may have impaired cognitive development. December 2009; updated June 2011. [FDA.gov]
Marchetti A, Magar R, Fischer J, et al. Impact of maternal first trimester treatment regimen on the outcome of valproate exposed pregnancies: an observational Embryo tox cohort study. *Sci Rep*. 2024;14(1):329.doi:10.1038/s41598-023-50669-1.
Evoy KE, Morrison MD, Saklad SR. Abuse and misuse of pregabalin and gabapentin. *Drugs*.2017;77(4):403-426. doi:10.1007/s40265-017-0700-x. PMC5573873.
Reccoppa L, Malcolm R, Ware M. Gabapentin abuse in inmates with prior history of cocaine dependence. *Am J Addict*. 2004;13(4):321-323. doi:10.1080/10550490490468778.
Nahar LK, Murphy KG, Paterson S. Misuse and mortality related to gabapentin and pregabalin are being under-appreciated: a two-year post-mortem study. *J Anal Toxicol*. 2019;43(7):564-568. doi:10.1093/jat/bkz036.
Wilens TE,Morrison NR, Prince J. An update on the pharmacotherapy of attention-deficit/hyperactivity disorder in adults. *Expert Rev Neurother*.2011;11(10):1443-1465.
Drug Formularies in Correctional Settings. *J Am Acad Psychiatry Law*.2020;48(1):2-10.
Caulkins JP, Reuter P. Illicit drug markets and policy interventions. *Ann Rev Law Soc Sci*. 2010;6:61-77.
Anno BJ.*Prison Health Care: Guidelines for the Management of an Adequate Delivery System*. National Institute of Corrections; 2001.
Fard ME,Sharifi A, Dehkordi AS. Drug formularies in correctional settings. *J Am Acad Psychiatry Law*. 2020;48(1):2-10. doi:10.29158/JAAPL.003905-20.
National Commission on Correctional Health Care (NCCHC). *Standards for Health Services in Prisons*. Chicago, IL: NCCHC; 2018.
Estelle v.Gamble, 429 U.S. 97 (1976).
Nuwer MR, Browne TR, Dodson WE, et al. Generic substitutions for antiepileptic drugs.*Neurology*. 1990;40(11):1647-1651. doi:10.1212/WNL.40.11.1647.
Bowden CL,Brugger AM, Swann AC, et al. Efficacy of divalproex vs lithium and placebo inthe treatment of mania. *JAMA*. 1994;271(12):918-924.doi:10.1001/jama.1994.03510360024028.
Weisler RH, Kalali AH, Ketter TA; SPD417 Study Group. A multicenter, randomized, double-blind, placebo-controlled trial of extended-release carbamazepine capsules as monotherapy for bipolar disorder patients with manic or mixed episodes. *J Clin Psychiatry*. 2004;65(4):478-484. doi:10.4088/JCP.v65n0404.
Calabrese JR, Bowden CL, Sachs GS, et al. A double-blind placebo-controlled study of lamotrigine monotherapy in outpatients with bipolar I depression. *J Clin Psychiatry*. 1999;60(2):79-88. doi:10.4088/JCP.v60n0203.
Goodwin GM, Bowden CL, Calabrese JR, et al. A pooled analysis of 2 placebo-controlled 18-month trials of lamotrigine and lithium maintenance in bipolar I disorder.*J Clin Psychiatry*. 2004;65(3):432-441. doi:10.4088/JCP.v65n0321.
Johnson BA, Ait-Daoud N, Bowden CL, et al. Oral topiramate for treatment of alcohol dependence: a randomised controlled trial. *Lancet*. 2003;361(9370):1677-1685.doi:10.1016/S0140-6736(03)13370-3.
Morley KC, Luquin N, Baillie A, et al. Topiramate versus naltrexone for alcohol use disorder: a genotype-stratified double-blind randomised controlled trial. *Am J Psychiatry*. 2024;181(5):415-424. doi:10.1176/appi.ajp.20230666.
Dworkin RH, O'Connor AB, Backonja M, et al. Pharmacologic management of neuropathic pain: evidence-based recommendations. *Pain*. 2007;132(3):237-251.doi:10.1016/j.pain.2007.08.033.
Goldstein LH, Robinson EJ, Mellers JDC, et al.; CODES study group. Cognitive behavioural therapy for adults with dissociative seizures (CODES): a pragmatic, multicentre, randomised controlled trial. *Lancet Psychiatry*.2020;7(6):491-505. doi:10.1016/S2215-0366(20)30128-0. PMC7242906.
Goldstein LH, Chalder T, Chigwedere C, et al. Cognitive-behavioral therapy for psychogenic nonepileptic seizures: a pilot RCT. *Neurology*.2010;74(24):1986-1994. doi:10.1212/WNL.0b013e3181e39658. PMC2905892.
LaFrance WC Jr, Baird GL, Barry JJ, et al. Multicenter pilot treatment trial for psychogenic nonepileptic seizures: a randomized clinical trial. *JAMA Psychiatry*. 2014;71(9):997-1005. doi:10.1001/jamapsychiatry.2014.817.
Moro P, Lattanzi S, Beier CP, Di Bonaventura C, Cerulli Irelli E. Cognitive behavioral therapy in adults with functional seizures: a systematic review and meta-analysis of randomized controlled trials. *Epilepsy Behav*.2024;159:109981. doi:10.1016/j.yebeh.2024.109981.
Carlson P, Nicholson Perry K. Psychological interventions for psychogenic non-epileptic seizures: a meta-analysis. *Seizure*. 2017;45:142-150.doi:10.1016/j.seizure.2016.12.007.
Hall-Patch L, Brown R, House A, et al. Acceptability and effectiveness of a strategy for the communication of the diagnosis of psychogenic nonepileptic seizures.*Epilepsia*. 2010;51(1):70-78. doi:10.1111/j.1528-1167.2009.02099.x.
Reuber M. Psychogenic nonepileptic seizures: answers and questions. *Epilepsy Behav*. 2008;12(4):622-635. doi:10.1016/j.yebeh.2007.11.009.
Trivia Capsule:
Anderson GD, Pak C, Doane KW, et al. Revised Winter-Tozer equation for normalized phenytoin concentrations in trauma and elderly patients with hypoalbuminemia.*Ann Pharmacother*. 1997;31(3):279-284. doi:10.1177/106002809703100302.
Mula M, Trimble MR, Yuen A, Liu RS, Sander JW. Psychiatric adverse events during levetiracetam therapy. *Neurology*. 2003;61(5):704-706.doi:10.1212/01.WNL.0000078031.32935.FE.
Pimental PA, Taber KH. Pseudoseizures and pseudo-toxicity syndrome for secondary gain.*J Correctional Health Care*. 1996;3(1):39-48. doi:10.1177/107834589600300103.
Löscher W, Schmidt D. Modern antiepileptic drug development has failed to deliver: ways out of the current dilemma. Epilepsia. 2011;52(4):657-678.doi:10.1111/j.1528-1167.2011.03024.x. PMID 21426333.
Yasiry Z, Shorvon SD. How phenobarbital revolutionized epilepsy therapy: the story of phenobarbital therapy in epilepsy in the last 100 years. Epilepsia.2012;53(Suppl 8):26-39. doi:10.1111/epi.12026. PMID 23205960.
Shank RP, Gardocki JF, Streeter AJ, Maryanoff BE. An overview of the preclinical aspects of topiramate: pharmacology, pharmacokinetics, and mechanism of action. Epilepsia.2000;41(Suppl 1):S3-9. doi:10.1111/j.1528-1157.2000.tb01524.x. PMC6494007.
Bialer M. The discovery of valproate. In: Bialer M, Yagen B, Mechoulam R, eds. Antiepileptic Drugs. Springer; 1995. doi:10.1007/978-3-0348-8759-5_1.
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