AEDs General Uses HY Flashcards
General questions
Medications or conditions associated with interictal spikes on EEG.
Cefepime; lithium; tramadol; bupropion; clozapine (CeLia Transfer Busy Clothes). Thyrotoxicosis and Uremia are also associated with interictal spikes on EEG.
BZD vs Phenobarb
BZD increase the frequency of opening of Cl channels and barbiturates prolong the opening time
Antiepileptic drugs that are inducers of the hepatic cytochrome P450 enzyme system and are associated with bone loss
phenytoin; phenobarbital; primidone; carbamazepine
Note- Valproic acid is an inhibitor of the cytochrome P450 system but is also associated with altered bone metabolism and decreased bone mass.
Antiepileptic drugs that can exacerbate depression
phenobarbital; primidone; tiagabine; vigabatrin; benzodiazepines; felbamate; levetiracetam; topiramate and zonisamide
AEDs commonly recognized for their mood-stabilizing properties
carbamazepine; lamotrigine; and valproic acid
Antidepressants best avoided in epilepsy
amoxapine; clomipramine; maprotiline; and bupropion; particularly at higher doses.
For depression: first-line pharmacologic therapy
SSRIs with minimal effects on CYP450 isoenzymes;such as citalopram; escitalopram; and sertraline
Iatrogenic psychosis has been described with the use of some AEDs
topiramate; levetiracetam; and zonisamide; and may also potentially occur when discontinuing an AED; particularly one with mood-stabilizing properties
Medication that can cause PLEDS
Teophylline
AED combination that ususally results in diplopia and dizziness
Phosphenytoin and CBZ
Drugs that aggravate myoclonic or absence seizures
CBZ; gabapentin; Oxcarb; Pregabalin; Tiagabine. (Lamotrigine can aggravate myoclonic jerks)
AEDs to be avoided in Dravet syndrome as they may worsen seizures
Lamotrigine and CBZ
AEDs with high cognitive side effects
BZD; phenobarb; TPM; Zonisamide;
AEDs with less cognitive side effects
LVT; Gabapentin; LMT; tiagabine
Diagnosis of SUDEP if
(1) person had epilepsy; (2) death occurred suddenly; (3) death occurred unexpectedly while the person was in a reasonable state of health; (4) death occurred during normal activity; often while sleeping; (5) there was no determinable cause of death after autopsy; and (6) death was not due to SE nor accidental injury; such as falls or asphyxiation from aspiration.
Highest risk of SUDEP
Uncontrolled generalized convulsive seizures (not medication non-compliance)
Syncopes
The two main causes of syncope are changes in vasovagal tone and cardiac arrhythmia. Most cases of vaso-vagal syncope (91%) are associated with some type of physiologic sign or symptom; including sweating; nausea; vomiting; visual dimming; motor weakness; and palpitations. These signs and symptoms may occur in isolation or in combination. By comparison; syncopal events resulting from cardiac arrhythmia are not accompanied by prodromal symptoms in 50% of cases. When symptoms are present; diffuse weakness and dizziness are the most common symptoms. Vasovagal syncope is more common in younger patients (mean age of 40); while syncope resulting from cardiac arrhythmia is more common in older patients (mean age of 68).
Ketogenic diet contraindications
Contraindicated in patients with: pancreatitis; hepatic failure; carnitine deficiency; porphyria; pyruvate carboxylase deficiency and beta-oxidation defects.
Ketogenic diet -first line for:
It is the first line of treatment for GLUT1 deficiency or pyruvate dehydrogenase deficiency.
Ketogenic diet and ICU
In the intensive care setting; KD is contraindicated in patients receiving proposal as it may lead to propofol infusion syndrome.
Ketogenic diet: chances of resposding:
The approximate percent chance that a child will respond with a greater than 50% seizure reduction is 50%.
Ketogenic diet ratios
Typically ration of 4:1 or 3:1 fat:carbohydrate.
Ketogenic diet : ketosis
Ketosis is measured by the urinary ketones: 80-160mg/dl.
Ketogenic diet: types of fat
Fats are usually long chain fatty acids or medium chain tryglicerides (which are better absorbed and produce more ketones).
Ketogenic diet vs MADE
The effectiveness of the the MADE is comparable to the KD in children and adults.
Ketogenic diet correlated with ketosis?
Seizure reduction is not correlated with the degree of acidosis or ketosis.
NEE predictors of poor outcome
Predictors of poor outcome: older age; prominent motor features; lower education achievement.
NEE predictors of good outcome
Predictors of good outcome: shorter duration of illness.
Most likely to have NEEs misdiagnosed?
Veterans are most likely to have their psychogenic nonepileptic events mischaracterized as epileptic seizures
Best initial choice for young female with JME
LVT
Predictors of poor surgical neuropsychological outcome
Higher pre surgical cognitive performance; older age; lack of hippocampal atrophy on MRI; surgery on the dominant side.
VNS and bradycardia
Fibers from the right vagus nerve innervate the sinoatrial node; while fibers from the left nerve innervate the atrioventricular. Stimulation of the right side is postulated to cause bradycardia; but with higher settings bradycardia can be seem with stimulation of either nerve.
VNS baseline frequency
1- 20-30Hz frequency (lowering to 20Hz decreases the risk of OSA)
VNS baseline pulse width
2- 200-500_s pulse width
VNS baseline current
3- 0.25-0.5mA current (more current leads to cough or hoarseness; less than 0.25mA not effective)
VNS baseline on and off times
4- 7-30s on-time and 5min off-time
VNS baseline magnet settings
5- magnet 0.25-0.5mA current and 30-60s on-time.
DBS - best responders?
Temporal lobe epilepsy
DBS side effects
Memory problems; depression; hemorrhage and infection (in this order)
Suicidaltiy
Increased risk of suicide is higher in patients with coexisting depression. Other risk factors; including low reported quality of life; seizure type and seizure control are not associated with higher risks.
Medications or products that lower AEDs concentrations
St Johns Wort
Medications or products that increase AEDs concentrations
Macrolide antibiotics; calcium channel blockers (diltiazem; verapamil); antifungals (fluconazole; ketoconazole); antivirals (indinavir; ritonavir); antidepressants (fluvoxamine; nefazodone); propoxyphene and grapefruit juice.
Muito Calor Fuja vire depressa proponha grande isolamento
AEDS that lower OCP efficiency:
Phenobarbital Phenytoin CBZ Oxcarbazepine Eslicarbazepine Felbamate Topiramate
Mnemonic : Pepe coerced Felipa today.
Note: Lamotrigine is not metabolized by the hepatic enzymes, but OCPs may significantly reduce the level of lamotrigine. The dose of lamotrigine may need to be adjusted if OCPs are started or stopped during the course of AED treatment.
AEDs that are known to have no effect on OCP efficiency
VPA Benzodiazepines LVT LMT Gabapentin ZNS Tiagabine
AEDS with lowest risk of cognitive effects
LMT; LVT; Gabapentin
Risk of congenital malformations
Carbamazepine; lamotrigine; levetiracetam; and oxcarbazepine have low overall risk of major congenital malformations. Carbamazepine has a slight risk of spina bifida; but its overall risk for malformations is low. Lamotrigine has been implicated in cleft defects; but this has not been substantiated; and its overall risk of malformations is low. Valproate has the highest risk and phenobarbital probably the next highest. Topiramate has a higher risk than several antiepileptic drugs; especially for cleft defects. Data are inadequate to determine the risks for many antiepileptic drugs (e.g.; gabapentin; lacosamide; and zonisamide).
Drug whose levels fluctuates the most during pregnancy
Lamotrigine
Medications associated with spikes on EEG
Cefepime; lithium; tramadol; bupropion; clozapine (CeLia Transfer Busy Clothes). Thyrotoxicosis and Uremia are also associated with interictal spikes on EEG.
GLUT1 defficiency (De Vivo disease)
GLUT1 deficiency syndrome is caused by mutations in the SLC2A1 gene -protein: glucose transporter protein type 1 (GLUT1).
Autosomal dominant - usually de novo.
90% of patients have seizures, which begin in the first month of life.
In newborns, first sign may be irregular eye movements.
Microcephaly, spasticity, complex movement disorders and developmental delay are common.
Diagnosis: low CSF lactate and glucse concentrations + genetic testing.
Ketogenic diet is very efficient
Nonketotic Hyperglycinemia
Glycine encephalopathy
Mutations in the AMT and GLDC genes (which code for glycine cleavage enzyme complex) cause glycine encephalopathy.
Autosomal recessive pattern,
Appears shortly after birth with lethargy, feeding difficulties, hypotonia, abnormal jerking movements, and life-threatening problems with breathing.
Profound intellectual disability and seizures that are difficult to treat follow.
EEG: “suppression-burst” pattern in the neonatal period, changing to hypsarrhythmia during early or mid-infancy
Occipital epilepsies
The association between occipital seizures and coeliac disease, with or without bilateral occipital calcifications, has been well documented.
Lafora body disease is frequently associated with occipital seizures. The diagnosis should be suspected when myoclonus and progressive mental decline are present.
Tuberous sclerosis
Caused by a mutation of either of two genes, TSC1 and TSC2, which code for the proteins hamartin and tuberin respectively.
These proteins act as tumor growth suppressors.
50% have learning difficulties; 25% and 61% of affected individuals meet the diagnostic criteria for autism.
Three types of brain tumors may be associated with TSC:
1) Giant cell astrocytoma: (grows and blocks the CSF flow leading to dilatation of ventricles causing headache and vomiting)
2) Cortical tubers (are thought to represent foci of abnormal neuronal migration)
3) Sub-ependymal nodules: form in the walls of ventricles.
Some form of dermatological sign will be present in 96% of individuals with TSC:
1) Facial angiofibromas (“adenoma sebaceum”)
2) Periungual fibromas
3) Hypomelanic macules (“ash leaf spots”) - noted by UV light (Wood’s lamp)
4) Forehead plaques
5) Shagreen patches
