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Chapter 4 - Nervous System > 2. Epilepsy > Flashcards

2. Epilepsy Flashcards

1
Q

What is epilepsy

A

Seizure caused by hyperexcitable neurons that fire electrical impulses rapidly.

Epilepsy is not the only cause of seizures, e.g hyperglycaemia

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2
Q

Epilepsy and driving

A

Patient has established epilepsy, has had NO unprovoked seizures AND

  • Seizure free for 1 year
  • Seizure Pattern AND No effect on consciousness
  • Seizure due to prescribed change or withdrawal (earlier if treatment was replaced for 6 months and no further seizures)
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3
Q

Epilepsy driving AND exceptions

A

If a patient has a seizure while asleep, they cannot drive for 1 year

EXCEPT:
they ONLY have sleep seizures and it has been 1 year since their first sleep seizure
OR
if it has been 3 years since their last awake seizure

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4
Q

When can a patient start driving after 6 months

A

If its only a single isolated seizure OR first unprovoked seizure

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5
Q

Focal Seizures

A

When a seizure begins in a localised area at one side of the brain

Focal seizures can also develop into a generalised tonic-clonic seizure

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6
Q

Focal seizures treatment

A

first line: Lamotrigine OR levitiracetam

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7
Q

myoclonic seizures treatment

A

Offer sodium valproate as first-line treatment for myoclonic seizures in:

  • boys and men
  • girls aged under 10 years and who are unlikely to need treatment when they are old enough to have children
  • women who are unable to have children.

Offer levetiracetam as first-line treatment for myoclonic seizures in women and girls able to have children (including young girls who are likely to need treatment when they are old enough to have children).

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8
Q

Tonic or atonic seizures

A

Offer sodium valproate as first-line treatment for tonic or atonic seizures in:

  • boys and men
  • girls aged under 10 years and who are unlikely to need treatment when they are old enough to have children
  • women who are unable to have children.

Consider lamotrigine as first-line treatment for tonic or atonic seizures in women and girls able to have children (including young girls who are likely to need treatment when they are old enough to have children).

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9
Q

Generalised seizures

A

When seizure activity affects both sides of the brain at the same time.
Can cause patients to lose consciousness, EXCEPT in myoclonic seizures

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10
Q

Generalised seizures types

A

Tonic-clonic: when muscle become tense and jerk violently

Myoclonic: brief muscle twicthes

Atonic: Muscles go weak or limp

Tonic: Muscles tense up

Absence: Staring into space

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11
Q

Generalised seizures treatment

A

For tonic-clonic, myoclonic, atonic, tonic:
First line: Sodium Valproate

*Second line: *Lamotrigine OR Levitracetam
GO FOR THIS if female is of child bearing age

For absence seizures:
First line: Ethosuximide

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12
Q

Treatment for men with established tonic-clonic seizures only
(men)

A

1st line: Sodium valproate

For men, women who are unable to have children, girls aged under 10 years and who are unlikely to need treatment when they are old enough to have children

Alternatively: lamotrigine

If first-line add-on treatments tried are unsuccessful in people with generalised tonic-clonic seizures, consider 1 of the following second-line add-on treatment options:

lamotrigine

levetiracetam

perampanel

sodium valproate, except in women and girls able to have children

topiramate

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13
Q

Treatment for women with established tonic-clonic seizures only
(women)

A

1st line: lamotrigine or leviteracetam

If first-line add-on treatments tried are unsuccessful in people with generalised tonic-clonic seizures, consider 1 of the following second-line add-on treatment options:
clobazam

lamotrigine

levetiracetam

perampanel

sodium valproate, except in women and girls able to have children

topiramate

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14
Q

Epilepsy treatment regimen

A

First: monotherapy

Second: If monotherapy does not control seizures, change the AED

Third: Combine at least TWO AED’s for seizure control

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15
Q

Importance of staying on the same brand of AED

A

Switching brands of AED can cause a worsening of side effects

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16
Q

AED’s which must be maintained on the same brand:

A

C-3P

Carbamazepine
Phenytoin
Phenobarbital
Primodone

With generics, make sure the manufacturer is specified

This does not apply when AED’s are being used in other conditions, e.g antipscyhosis

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17
Q

AED’s which are up to the clinical judgement of the doctor when/if being prescribed by brand

A

Valproate, Lamotrigine, Clonezepam, Topiramate

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18
Q

AED’s that do not need to be prescribed by brand

A

Gabapentin, Levitiracetam, Pregablin, Ethosuximide

19
Q

Examples of AED’s

A

Carbamazepine
Gabapentin, Pregablin
Lamotrigine
Phenytoin
Sodium valproate
Levitiracetam
Phenytoin

Barbiturates: Phenobarbital

Benzodiazepine: Clobazam, Clonazepam, Diazepam, Midazolam

20
Q

AED’s and pregnancy

A

Highly teratogenic: valproate

Carbamazepine, Phenytoin, Phenobarbital, Pregablin, Topiramate also increase teratogenic risk —->

Must use highly effective contraception. *Though some AED’s reduce effectiveness of contraceptives

21
Q

AED’s and pregnancy planing

A
  • Must not stop taking AED
  • Must be referred to a specialist
  • Must be offered high dose folic acid
  • Join UK epilepsy and pregnancy register
  • If unplanned –> seek urgent medical advice
22
Q

AED’s and breastfeeding

A

Patients taking a single AED should be encouraged to breastfeed

Monitor infants

Must monitor for drowsiness and withdrawal effects

23
Q

Which AED’s appear in high amounts in breastmilk

A

zelp:

  • Zosinamide
  • Ethosuximide
  • Lamotrigine
  • Primidone
24
Q

AED side effects

A
  • Dizziness - resolves overtime
  • Anti-epileptic hypersensitivity syndrome -> patients must report signs of a fever, rash or swollen lymph nodes that appear as painful lumps in neck, armpits or groin
    More common with CL-3P (Carbamazepine, Lamotrigine, Phenytoin, Phenobarbital, Primidone). Hypersensitivities may also cross over
  • Suicidal behaiviour. Patients must changes in mood or suicidal thoughts
  • Blood dyscrasias
    More commonly caused by phenytoin, sodium valproate, carbamazepine, lamotrigine
    Patients must report signs of fever, sore throat, mouth ulcer, bleeding or bruising
25
Q

Gabapentin can cause severe respiratory depression, high-risk groups at risk of this:

A

Patients taking CNS depressants (barbiturates, benzodiazepines, Z drugs, opioids, ALOCHOL)

Respiratory diseases: Asthna, COPD, impaired respiratory function

Neurological disease: renal impairment, elderly

26
Q

Warnings surrounding topiramate

A

Increased risk of neurodevelopmental disabilities

Highly effective contraception should be used

27
Q

AED interactions

A

Carbamazepine, Phenytoin, Phenobarbital are enzyme inducers
Can reduce the effectiveness of hormonal contraceptives
Can reduce the effectiveness of warfarin

Sodium valporate is an enzyme inhibitor

28
Q

Phenytoin mechanism of action

A

Makes neurones in the brain less excitable

A Narrow therapeutic index drug

29
Q

Phenytoin therapeutic drug monitoring

A

Therapeutic index: 10-20mg/L
A small increase in dose largely increases blood phenytoin levels

Phenytoin is most protein bround - inactive. When it is free it is active

Free-drug levels are monitored in pregnancy, patients less than 3 months old, elderely, in liver failure as free-drug is higher in these patients = increases likelihood of toxicity.
Even if phenytoin blood levels are within the therapeutic range.

30
Q

Phenytoin uses

A

phenytoin should be avoided in absence and myoclonic seizures -as can worsen them

31
Q

Signs of Phenytoin toxicity

A

Hands

H - hyperglycaemia
A - ataxia (affects co-ordination, balance and speech)
N - nystagmus (eye rolling)
D - dipolopia
S - slurred speech and confusion

32
Q

Phenytoin side effects

A

Appearance
coarse facial features
acne
hirsutism
gingival hyerplasia

AED hypersensitivty syndrome
patients must report signs of fever, rash, lumphadenopathy

Skin reactions, from mild to Stevon Johnson syndrome
Han chinese & thai patients are at an increased risk, must undergo pre-screening HLA-B*1502

Blood dyscrasias e.g agrunolocytosis. Patients must report signs of infection, e.g fever, sore throat, mouth ulcers, and bruising, bleeding

Bone disorders
Phenytoin induces vitamin D metabolism
Patients should be offered vitamin D, if they are immobile, have no sun exposure or have low calcium

33
Q

Phenytoin interactions

A

Phenytoin is metabolised by cytochrome P450 enzymes.

  • Phenytoin interacts with cytochrome inhibitors to increase its levels: amiodarone, azole antifungals, rate-limiting CCB’s SSRI’s, Valproate, Cimetidine, Erythromycin
  • Phenytoin interacts with cytochroe inducers to reduce its levels:
    Carbamazepine, Phenobarbital, Rifampicin, St John’s Wort
  • NSAIDs and Warfarin can displace protein-bound phenytoin

Phenytoin interacts with oral contraceptives and HRT to reduce efficacy

Phenytoin interacts with drugs that lower seizure threshold: antipsychotic, quinolone, SSRI, TCA, tramadol

Interacts with theophylline and digoxin

34
Q

Carbamazepine therapeutic range

A

4-12 mg/L

(Always treat patient and not level, patient not experience toxicity, even above level)

Therapeutic range is measured after 1-2 weeks of starting treatment

35
Q

Signs of carbamazepine toxicity

A

Handbag

H - hyPOnatraemia and Hallucinations
A - Ataxia and anuria
N - Nystagmus
D - Drowsy, Dizzy, Slurred speech
B - Blurred or double vision
A - arrhythmias
G - Gastro-intestinal effects (N +V)

Also a risk category 1 medicine (C-3P)*

36
Q

Carbamazepine side effects

A
  • AED hypersensitivty syndrome
    patients must report signs of fever, rash, lumphadenopathy
  • Skin reactions, from mild to Stevon Johnson syndrome
    Han chinese & thai patients are at an increased risk, must undergo pre-screening HLA-B*1502
  • Blood dyscrasias e.g agrunolocytosis. Patients must report signs of infection, e.g fever, sore throat, mouth ulcers, and bruising, bleeding
  • Bone disorders
    Phenytoin induces vitamin D metabolism
    Patients should be offered vitamin D, if they are immobile, have no sun exposure or have low calcium
  • Hepatotoxicity
    Patinets must report signs of abdominal pain, persistent vomiting, dark urine, jaundice
  • HyPOnatraemia
  • Dose-limiting nausea and vomiting, headache, dizziness
    To manage this, start with low dose and increase gradually OR use modified release preparations
37
Q

Carbamazepine interactions

A
  • Carbamazepine interacts with enzyme inhibitors to increase carbamazepine metabolism thus lowering its levels :
    azole antifungals, cimetidine, ciprofloxacin, clarithromycin, erythromcyin, rate-limiting CCB’sm Fluoxteine, Fluvoxamine, Grapefruit juice, isoniazid
  • phenobarbital, phenytoin, St John’s wort lower carbamazepine levels in the blood
  • Carbamazepine is an an enzyme inducer, classically affecting oestrogen and progestogen (reducing efficacy) and warfarin.
38
Q

Carbamazepine interactions (more)

A
  • Interacts with drugs that lower seizure threshold = carbamazepine’s anticonvulsant effect is lowered
    Antipsychotics, quinolones, SSRI’s, TCA, tramadol
  • Interacts with drugs that are also HypOnatraemic:
    SSRI’s, TCA’s, MAOI, desmopressin, diuretics, NSAID
  • Interacts with drugs that are also Hepatotoxic:
    co-amoxiclav, flucloxacillin, tetracycline, fluconazole, isoniazis, methotrexate, statin, sulfasalazine
  • Interacts with drugs that also cause blood dyscrasias:
    Clozapine
39
Q

Sodium valproate and pregnancy

A
  • Sodium valproate has a high risk of birth defects, abnormal limbs, mental disorders = TERATOGENIC
  • Should only be offered to women of childbearing potential if there are no other suitable alternatives and they are part of the pregnancy prevention programme
  • Should be given at the lowest effective dose, in divided doses, as modified release preparations
  • Patients that find out they are pregnant must be reffered to specalist. They must not stop medicine or contraception.
40
Q

Valproate pregnancy prevention programme

A
  • No other suitable alternative
  • Patients must be supervised by specialist
  • patient must have a negative pregnancy test before starting treatment
  • Patient must be on a highly effective form of contraception
    1. IUD or implant
    OR
    2. Combined oral contraceptive AND barrier method
  • Patients must be provided with a patient guide, patient card and an annual risk acknowledgment form
41
Q

Sodium valproate side effects

A
  • Blood dyscrasias e.g agrunolocytosis. Patients must report signs of infection, e.g fever, sore throat, mouth ulcers, and bruising, bleeding
  • Bone disorders
    Phenytoin induces vitamin D metabolism
    Patients should be offered vitamin D, if they are immobile, have no sun exposure or have low calcium
  • Hepatotoxicity
    Must monitor LFTS
    Prolonged prothrombin time due to insufficient platelat factors
    Patients must report signs of dark urine, abdominal pain, jaundice, vomiting persistent
  • Pancreatitis
    Patients must report abdominal pain, nausea, vomiting
42
Q

Sodium valproate drug interactions

A
  • Sodium valproate is a cytochrome P450 enzyme inhibitor. Interacts with drugs which are substrates for this enzyme, hence raising their blood levels
  • Interacts with drugs that lower seizure threshold = carbamazepine’s anticonvulsant effect is lowered
    Antipsychotics, quinolones, SSRI’s, TCA, tramadol
  • Interacts with drugs that are also Hepatotoxic:
    co-amoxiclav, flucloxacillin, tetracycline, fluconazole, isoniazis, methotrexate, statin, sulfasalazine
43
Q

What is status epilepticus

A

When a single seizure lasts longer than 5 minutes, or when multiple seizures occur within 5 minutes

A MEDICAL EMERGENCY - can lead to brain damage/death

44
Q

Status epilepticus treatment

A

Rectal Diazepam

OR

Midazolam oromucosal solution

Can be repeated once more after 5-10 minutes if necessary

Chapter 4 - Nervous System (8 decks)

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