Anti-seizure medications in patients with renal failure undergoing dialysis: how to manage?

Introduction: Managing epilepsy in patients with end-stage kidney disease presents unique challenges due to altered pharmacokinetics of anti-seizure medications (ASMs) and the effects of dialysis treatments. Dialysis can significantly affect ASM clearance, requiring careful dosing adjustments to maintain therapeutic efficacy while avoiding toxicity. This review aims to provide an up-to-date overview of the current knowledge and to offer practical clinical guidance on the use of ASMs in patients undergoing hemodialysis and peritoneal dialysis. Areas covered: Relevant literature on ASMs in dialysis patients was searched in MEDLINE and Google Scholar. Additional information was retrieved from the summary of product characteristics for each ASM. Expert opinion: Evidence on the management of ASMs in patients receiving dialysis is still limited, mainly based on small observational studies and case reports. Currently, no official guidelines are available. Effective treatment strategies require individualized approaches. ASMs with low protein binding and predominant renal elimination generally require post-dialysis dose adjustments. Therapeutic drug monitoring may be indicated in some cases. Data regarding the impact of different dialysis filter types on ASM clearance are sparse. The paucity of data, especially for newer ASMs, underscores the urgent need for further research to establish comprehensive, evidence-based recommendations for this vulnerable patient population.