Dosing & Uses
Dosage Forms & Strengths
tablet, chewable (Epitol)
- 100mg
tablet, immediate-release (Tegretol)
- 200mg
tablet, extended-release (Tegretol XR)
- 100mg
- 200mg
- 400mg
capsule, extended-release (Equetro, Carbatrol)
- 100mg
- 200mg
- 300mg
oral suspension (Teril)
- 100mg/5mL
IV solution (Carnexiv)
- 10mg/mL (200mg/20mL single-dose vial)
Epilepsy
Indicated for the treatment of partial seizures with complex symptomatology (eg, psychomotor, temporal lobe), generalized tonic-clonic seizures (grand mal), and mixed seizure patterns, which include the seizure types listed here or other partial or generalized seizures
Maintenance dose range: 800-1200 mg/day PO in divided doses
Therapeutic range: 4-12 mg/L (16.9-50.8 micromoles/L)
Maximum dose of 1600 mg/day recommended (rarely, some patients have required 1.6-2.4 g/day)
Tablet (immediate-release)
- Initial: 200 mg PO q12hr
- Increase qWeek by 200 mg/day divided PO q6-8hr
Tablet/capsule (extended-release)
- Initial: 200 mg PO q12hr
- Increase qWeek by 200 mg/day PO divided q12hr
Oral suspension
- Initial: 10 mL (200 mg) PO q6hr
- Increase qWeek by up to 200 mg/day PO divided q6-8hr
IV solution
- Indicated as replacement therapy in adults for PO carbamazepine formulations, when PO administration is temporarily not feasible
- Approved as temporary use (ie, ≤7 days) for the following seizure types
- Partial seizures with complex symptomatology
- Generalized tonic-clonic seizures
- Mixed seizure patterns which include the above, or other partial or generalized seizures
- Dose
- The total daily dose of carbamazepine IV is 70% of the total daily PO dose from which patients are being
- Equally divide the total daily dose of the IV in four 30-minute infusions, separated by 6 hr
- Patients should be switched back to oral carbamazepine administration at their previous total daily oral dose and frequency of administration as soon as clinically appropriate
- IV administration has not been studies for >7 days
Limitations of use
- Not indicated for absence seizures (including atypical absence); carbamazepine has been associated with increased frequency of generalized convulsions in these patients
Trigeminal Neuralgia
Indicated for pain associated with trigeminal neuralgia; beneficial results have also been reported in glossopharyngeal neuralgia; carbamazepine is not a simple analgesic and should not be used for the relief of trivial aches or pains
Maintenance dose range: 400-800 mg/day PO in divided doses; attempts to reduce or discontinue the drug should be made at least every 3 months throughout the treatment period
Maximum dose of 1200 mg/day recommended
Tablet (immediate-release)
- Initial: 200 mg/day on day 1 divided q12hr
- Increase by up to 200 mg/day in increments of 100 mg q12hr, to dose range of 400-800 mg/day divided twice daily; not to exceed 1200 mg/day
Tablet/capsule (extended-release)
- Initial (XR tablet): 200 mg/day PO on day 1 divided q12hr
- Initial (XR capsules): 200 mg PO once on the first day; may increase dose by up to 200 mg/day using increments of 100 mg q12hr to reach an effective/tolerated dose; not to exceed 1200 mg/day
- Increase by up to 200 mg/day in increments of 100 mg q12hr, to dose range of 400-800 mg/day divided twice daily; not to exceed 1200 mg/day
Oral suspension
- Initial: 200 mg PO on day 1 divided q6hr
- Increase by up to 200 mg/day in increments of 50 mg q6hr, to dose range of 400-800 mg/day divided twice daily; not to exceed 1200 mg/day
Bipolar Mania
Equetro
- Indicated for treatment of patients with acute manic or mixed episodes associated with bipolar I disorder
- Initial: 200 mg PO q12hr
- Increase by increments of 200 mg/day; not to exceed 1600 mg/day
Dosage Modifications
Renal impairment
- Glomerular filtration rate <10 mL/min: Administer 75% of dose and monitor
- Peritoneal dialysis and hemodialysis: Administer 75% of dose and monitor
Hepatic impairment
- Use caution; drug is metabolized primarily in the liver
Restless Legs Syndrome (Off-label)
100-600 mg PO qHS for up to 5 weeks
Schizophrenia (Off-label)
200-1300 mg/day for 2.5-8 weeks
Postherpatic Neuralgia
100-200 mg PO qDay; may increase slowly to 1200 mg/day
Intravenous Carbamazepine (Orphan)
Orphan designation for treatment of epilepsy patients who cannot take anything by mouth
Orphan sponsor
- Lundbeck, LLC; Four Parkway North; Deerfield, IL 60015
Dosage Forms & Strengths
tablet, chewable (Epitol)
- 100mg
tablet, immediate-release (Tegretol)
- 200mg
tablet, extended-release (Tegretol XR)
- 100mg
- 200mg
- 400mg
capsule, extended-release (Equetro, Carbatrol)
- 100mg
- 200mg
- 300mg
oral suspension (Teril)
- 100mg/5mL
Epilepsy
Indicated for the treatment of partial seizures with complex symptomatology (eg, psychomotor, temporal lobe), generalized tonic-clonic seizures (grand mal), and mixed seizure patterns, which include the seizure types listed here or other partial or generalized seizures
<6 Years
6-12 Years
- Initial (oral suspension): 50 mg PO q6hr
- Initial (tablet, immediate- or extended-release): 100 mg PO q12hr; may increase qWeek by 100 mg/day
- Maintenance: 400-800 mg/day PO q6-8hr (immediate-release); q12hr (extended-release)
- Not to exceed 1000 mg/day
>12 Years
- Initial (oral suspension): 10 mL (200 mg) PO q6hr
- Initial (tablet, immediate- or extended-release tab/cap): 200 mg PO q12hr
- May increase by up to 200 mg/day qWeek; q12hr (extended-release tablet); q6-8hr (other formulations)
- 12-15 years: Dose not to exceed 1000 mg/day
- >15 years: Dose not to exceed 1200 mg/day
Dosage Modifications
Renal impairment
- Glomerular filtration rate <10 mL/min: Administer 75% of dose and monitor
- Peritoneal dialysis and hemodialysis: Administer 75% of dose and monitor
Hepatic impairment
- Use caution; drug is metabolized primarily in the liver
Dosing Considerations
Important to initiate slowly by advancing dose every 5-7 days to minimize GI upset and allow autoinduction of liver enzymes to occur (autoinduction is complete at 3-5 weeks)
Children <12 years who receive >400 mg/day may be converted to Carbatrol ER at the same dose, q12hr PO
Monitor: CBC, LFTs
Interactions
Interaction Checker
No Results
Contraindicated
Serious - Use Alternative
Significant - Monitor Closely
Minor
Adverse Effects
>10%
Ataxia (15%)
Dizziness (44%)
Drowsiness (32%)
Nausea (29%)
Vomiting (18%)
1-10%
Dry mouth (8%)
Rare
MI
Stevens-Johnson syndrome
Hepatic failure
Punctate cortical lens opacities
Syndrome of inappropriate antidiuretic hormone secretion (SIADH)
Frequency Not Defined
Hemopoietic system: Aplastic anemia, agranulocytosis, pancytopenia, bone marrow depression, thrombocytopenia, leukopenia, leukocytosis, eosinophilia, anemia, acute intermittent porphyria, variegate porphyria, porphyria cutanea tarda
Skin: Toxic epidermal necrolysis (TEN) and Stevens-Johnson syndrome (SJS) (see Black Box Warnings), pruritic and erythematous rashes, urticaria, photosensitivity reactions, alterations in skin pigmentation, exfoliative dermatitis, erythema multiforme and nodosum, purpura, aggravation of disseminated lupus erythematosus, alopecia, diaphoresis, generalized exanthematous pustulosis, and onychomadesis
Cardiovascular system: Congestive heart failure, edema, aggravation of hypertension, hypotension, syncope and collapse, aggravation of coronary artery disease, arrhythmias and AV block, thrombophlebitis, thromboembolism, and adenopathy or lymphadenopathy
Liver: Abnormalities in liver function tests, cholestatic and hepatocellular jaundice, hepatitis; very rare cases of hepatic failure
Pancreatic: Pancreatitis
Respiratory System: Pulmonary hypersensitivity characterized by fever, dyspnea, pneumonitis, or pneumonia
Genitourinary System: Urinary frequency, acute urinary retention, oliguria with elevated blood pressure, azotemia, renal failure, and impotence (rare reports of impaired male fertility and/or abnormal spermatogenesis)
Laboratory: Albuminuria, glycosuria, elevated BUN, decreased plasma calcium, and microscopic deposits in the urine, decreased values of thyroid function tests
Nervous system: Dizziness, drowsiness, disturbances of coordination, confusion, headache, fatigue, blurred vision, visual hallucinations, transient diplopia, oculomotor disturbances, nystagmus, speech disturbances, abnormal involuntary movements, peripheral neuritis and paresthesias, depression with agitation, talkativeness, tinnitus, hyperacusis, isolated cases of neuroleptic malignant syndrome
Digestive system: Nausea, vomiting, gastric distress and abdominal pain, diarrhea, constipation, anorexia, and dryness of the mouth and pharynx, including glossitis, and stomatitis, liver damage
Eyes: Scattered punctate cortical lens opacities, increased intraocular pressure as well as conjunctivitis
Musculoskeletal system: Aching joints and muscles, and leg cramps
Metabolism: Fever and chills; SIADH; cases of frank water intoxication, with decreased serum sodium (hyponatremia) and confusion; decreased levels of plasma calcium leading to osteoporosis
Immune system disorders: Hypogammaglobulinemia
Other: Multiorgan hypersensitivity reactions occurring days to weeks or months after initiating treatment have been reported in rare cases, signs or symptoms may include fever, skin rashes, vasculitis, lymphadenopathy, disorders mimicking lymphoma, arthralgia, leukopenia, eosinophilia, hepatosplenomegaly and abnormal liver function tests
Warnings
Black Box Warnings
Serious and sometimes fatal dermatologic reactions, including toxic epidermal necrolysis (TEN) and Stevens-Johnson syndrome (SJS), have been reported during treatment with carbamazepine; studies in patients of Chinese ancestry found a strong association between the risk of developing SJS/TEN and the presence of HLA-B*1502, an inherited allelic variant of the HLA-B gene; HLA-B*1502 is found almost exclusively in patients of Asian ancestry, with populations across broad areas of Asia producing such descendants; patients testing positive for the allele should not be treated with carbamazepine unless the benefit clearly outweighs the risk; patients with ancestry in genetically at-risk populations should be screened for the presence of HLA-B*1502 prior to initiation of treatment with carbamazepine
Aplastic anemia and agranulocytosis reported; patients with a previous history of adverse hematologic reaction to any drug may be at increased risk
Complete pretreatment hematological testing should be obtained as a baseline; if a patient in the course of treatment exhibits low or decreased white blood cell or platelet counts, the patient should be monitored closely; consider discontinuation of therapy if significant bone marrow depression develops
Contraindications
Documented hypersensitivity
History of bone marrow suppression
Administration of MAO inhibitors within last 14 days
Coadministration with nefazodone; carbamazepine decreases plasma levels of nefazodone and its active metabolite
Coadministration with NNRTIs (eg, delavirdine, efavirenz, etravirine, nevirapine, rilpivirine); carbamazepine induces CYP3A4 and may substantially reduce NNRTI serum concentration
Jaundice, hepatitis
Pregnancy (especially first trimester: risk of fetal carbamazepine syndrome)
Cautions
Monitor for notable changes in behavior that might indicate suicidal thoughts or depression and notify healthcare provider immediately if behavioral changes observed
Discontinue if significant bone marrow depression occurs
Withdraw gradually
Increased risk of agranulocytosis and aplastic anemia
May cause ECG abnormalities; use caution in patients with conduction abnormalities; AV heart block, including second and third degree block, reported following carbamazepine treatment; effect occurred generally, but not solely, in patients with underlying EKG abnormalities or risk factors for conduction disturbances
May exacerbate absence seizures; in the event of allergic or hypersensitivity reaction, more rapid substitution of alternative therapy may be necessary
Bipolar mania: Efficacy inconsistent; APA recommends use after failure of or if there is resistance to lithium and valproate
May cause psychosis/confusion/agitation; elderly patients are at greater risk
May render oral contraceptives ineffective
Higher risk of potentially fatal skin reactions (SJS/TEN) in patients of Asian ancestry (genetic testing recommended); increased risk of developing hypersensitivity reactions with presence of HLAA*3101 or HLA-B*1502, inherited allelic variants of the HLA-A and HLA-B gene (see Pharmacogenomics in the Pharmacology section);
Hyponatremia may occur and appears to be a result of SIADH; may be dose-related and elderly individuals are at greater risk
Associated with hypotension, bradycardia, AV block, and signs and symptoms of HF
Fatal dermatologic reactions, including toxic epidermal necrolysis (TEN) and Stevens-Johnson syndrome (SJS), reported
Not a simple analgesic; do not use to relieve minor aches and pains
Suspension formulation contains sorbitol; not for administration to patients with rare hereditary problems of fructose intolerance
AV heart block, including second and third degree block, reported following carbamazepine treatment; effect occurred generally, but not solely, in patients with underlying EKG abnormalities or risk factors for conduction disturbances
Rare cases of anaphylaxis and angioedema involving larynx, glottis, lips, and eyelids reported with first or subsequent doses; angioedema associated with laryngeal edema can be fatal; if a patient develops reactions after treatment discontinue therapy and start alternative treatment; patients should not be rechallenged with drug
Mild anticholinergic activity; use caution in patients with snesitivity to anticholinergic effects
Hepatic effects
- Hepatic effects reported ranging from slight elevations in liver enzymes to rare cases of hepatic failure
- In some cases, hepatic effects may progress despite discontinuation
- Rare instances of vanishing bile duct syndrome reported; consists of a variable clinical course ranging from fulminant to indolent, involving the destruction and disappearance of the intrahepatic bile ducts
- Some cases associated other immunoallergenic syndromes (eg, multiorgan hypersensitivity [DRESS syndrome], serious dermatologic reactions)
- As an example there has been a report of vanishing bile duct syndrome associated with Stevens-Johnson syndrome, and in another case an association with fever and eosinophilia
- Baseline and periodic evaluations of liver function, particularly in patients with history of liver disease, must be performed during treatment with this drug since liver damage may occur; drug should be discontinued immediately in cases of aggravated liver dysfunction or active liver disease
Pregnancy & Lactation
Pregnancy category: D
Lactation: Enters breast milk; not recommended (AAP states compatible with nursing; however, adverse reactions in breastfeeding infant are possible; take into account the importance of the drug to the mother before deciding to discontinue breastfeeding or the drug)
Pregnancy Categories
A:Generally acceptable. Controlled studies in pregnant women show no evidence of fetal risk.
B:May be acceptable. Either animal studies show no risk but human studies not available or animal studies showed minor risks and human studies done and showed no risk.
C:Use with caution if benefits outweigh risks. Animal studies show risk and human studies not available or neither animal nor human studies done.
D:Use in LIFE-THREATENING emergencies when no safer drug available. Positive evidence of human fetal risk.
X:Do not use in pregnancy. Risks involved outweigh potential benefits. Safer alternatives exist.
NA:Information not available.
Pharmacology
Mechanism of Action
Stabilizes inactivated state of sodium channels, thereby making neurons less excitable
May reduce activity of nucleus ventralis of the thalamus or decrease synaptic transmission or summation of temporal stimulation leading to neuronal discharge
Absorption
Bioavailability: 85% (oral suspension)
Peak serum time: 4.5 hr (immediate-release tablets); 3-12 hr (extended-release tablets); 1.5 hr (oral suspension)
Distribution
Protein bound: 75-90%
Vd: 1.5 L/kg (neonates); 1.9 L/kg (children); 0.59-2 L/kg (adults)
Metabolism
Via hepatic CYP3A4
Metabolites: Carbamazepine 10,11-epoxide
Enzymes induced: CYP1A2, CYP2C9, CYP3A4
Elimination
Half-life: 25-65 hr (initial dosing); decreases to 10-20 hr after autoinduction; 35-40 hr (extended release)
Excretion: Urine (72%); feces (28%)
Pharmacogenomics
HLA-B*1502
- It is estimated that 1 in 20 patients with HLA-B*1502 will have a severe dermatologic reaction (eg, TEN, SJS) when taking carbamazepine
- This allele occurs almost exclusively in patients with ancestry across broad areas of Asia, including Han Chinese, Filipinos, Malaysians, South Asian Indians, and Thais
HLA-A*3101
- Retrospective case-control studies in patients of European, Korean, and Japanese ancestry have found a moderate association between the risk of developing hypersensitivity reactions and the presence of HLAA*3101, an inherited allelic variant of the HLA-A gene, in patients using carbamazepine; these hypersensitivity reactions include Stevens Johnson syndrome and toxic epidermal necrolysis
- HLA-A*3101 is expected to be carried by more than 15% of patients of Japanese, Native American, Southern Indian (eg, Tamil Nadu) and some Arabic ancestry; up to about 10% in patients of Han Chinese, Korean, European, Latin American, and other Indian ancestry; and up to about 5% in African-Americans and patients of Thai, Taiwanese, and Chinese (Hong Kong) ancestry
Genetic testing laboratories
- The following companies provide genetic testing for HLA variants
- Kashi Clinical Laboratories (www.kashilab.com)
- LabCorp (http://www.labcorp.com/)
- Specialty Laboratories (http://www.specialtylabs.com)
- Quest (http://www.questdiagnostics.com)
Administration
Oral Administration
Take with food
Do not chew, crush, or cut extended-release tablets
IV Preparation
For IV use only
Must be diluted with 100 mL of a compatible diluent before infusion (ie, 0.9% NaCl, lactated Ringer’s solution, or D%W)
Transfer measured dose to 100 mL bag of compatible solution
Inspected visually for particulate matter, cloudiness, or discoloration prior to administration; if any of these are present, discard the solution
IV Administration
Administer IV over 30 minutes
Storage
IV (before dilution)
- Store at 20-25°C (68-77°F); excursions permitted to 15-30°C (59-86°F)
IV (after dilution)
- Controlled room temperature (20-25°C [68-77°F]): Maximum of 4 hr
- Refrigerated (2-8°C [36-46°F]): Maximum of 24 hr
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Patient Handout
Formulary
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