Perampanel

How it works

It is a selective, non-competitive antagonist of the AMPA glutamate receptor on postsynaptic neurons, reducing excitatory neurotransmission and seizure propagation.

Prescribing in practice

• It carries an MHRA warning for serious neuropsychiatric reactions including aggression, hostility, irritability and suicidal ideation, which warrant prompt review and possible withdrawal.
• It is taken once daily at bedtime because of dose-related dizziness and somnolence, and is titrated slowly.
• Enzyme-inducing antiepileptics can lower its concentration, and it may reduce the effectiveness of some hormonal contraceptives at higher doses.

Monitoring

Monitor for behavioural and mood changes, dizziness, somnolence, gait disturbance and falls, particularly during titration.

Counselling the patient

• Take it once a day at bedtime to limit dizziness and drowsiness.
• Tell your team or family carers urgently about any new aggression, anger, low mood or thoughts of self-harm.
• Avoid alcohol and use alternative or additional contraception if advised, as it can affect the pill at higher doses.

Evidence & guidelines

Pivotal randomised controlled trials supported its licensing as adjunctive therapy, and the MHRA has issued specific guidance on its neuropsychiatric and behavioural risks.