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Cpt > Anti Epileptic > Flashcards

Anti Epileptic Flashcards

1
Q

What is a seizure

A

sudden irregular discharge of electrical activity in the brain causing a physical manifestation such as sensory disturbance, unconsciousness or convulsions

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2
Q

What is a convulsion

A

uncontrolled shaking movements of the body due to rapid and repeated contraction and relaxation of muscles

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3
Q

What is an aura

A

a perceptual disturbance experienced by some prior to a seizure, e.g. strange light, unpleasant smell, confusing thoughts

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4
Q

What is epilepsy

A

neurological disorder marked by sudden recurrent episodes of sensory disturbance, LOC or convulsions, associated with abnormal electrical activity in the brain

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5
Q

What is status epilepticus

A

epileptic seizures occurring continuously without recovery of consciousness in between

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6
Q

How can seizures be classified

A

-

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7
Q

Compare partial vs generalised seizures

A

Partial happens in a single focus - one part of the brain. Generalised - seizure all over the brain - might start as a focus nd the spread uncontrolled throughout the brain

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8
Q

What are partia lseizures

A

PARTIAL SEIZURES β€’ Part of the brain
β€’ Simple or complex – Simple = Same consciousness - no loc
– Complex β€”> COnsciousness is iMPaired - loc

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9
Q

What are common types of partial seizures

A

β€’ Temporal lobe epilepsy
– 1st/2nd decade in most people, following seizure with fever or an early injury to the brain
– auras –e.g. auditory hallucination, rush of memories
β€’ Frontal lobe epilepsy – next most common
- Abnormal movements when motor areas affected (contralateral side)

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10
Q

What are types of generalised seizures

A
  • Tonic-clonic: 2 parts - 1st tonic (muscles Tense), 2nd clonic (Convulsions)
  • Absence:β€˜daydreaming’
  • Statusepilepticus:medicalemergency
  • Myoclonic:briefshock-likemusclejerks
  • Atonic:β€˜without tone’ – drop attack
  • Tonic:increasedtone
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11
Q

What are the vestigatins to confirm/exclude diagnosis

A

INVESTIGATIONS
β€’ Clinical history β€’ EEG
β€’ MRI
β€’ (ECG,bloods)

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12
Q

What should be asked about when asking a history abt seizure

A

Before

  • pmh, fh
  • triggers
  • auras
  • first sign/symptoms

During

  • description of seizure
  • duration
  • abrupt or gradual Ed

After

  • post-coal state
  • tongue biting
  • incontnence
  • neurological defecit

Vial to take collateral history where possible

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13
Q

What are causes of epilepsy

A 
β€’ Can be primary or secondary
β€’ Primary (idiopathic) 
– No apparent cause 
– May be inherited
β€’ Secondary (symptomatic)
– Known cause for epilepsy
  • Vascular:Stroke,TIA
  • Infection: Abscess, Meningitis
  • Trauma:Intracerebralhaemorrhage
  • Autoimmune:SLE
  • Metabolic:Hypoxia,Electrolyteimbalance, Hypoglycaemia,Thyroid dysfunction
  • Iatrogenic: Drugs, Alcohol Withdrawal
  • Neoplastic:Intracerebralmass
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14
Q

What is an eeg

A

EEG
β€’ EEG not diagnostic - supports diagnosis
β€’ In first unprovoked seizure – assess risk of seizure recurrence (unequivocal epileptiform
activity on EEG)
β€’ Standard EEG assessment involves photic stimulation and hyperventilation - patient warned that it may induce a seizure
β€’ Do NOT use if:
– Probable syncope (risk of false positive result)
– Clinical presentation supports diagnosis of non-epileptic event – In isolation to make a diagnosis of epilepsy
β€’ Ifunclear,consider:
– Repeated standard EEGs
– Sleep EEGs (sleep deprivation or melatonin in children/young people) – Long-term video or ambulatory EEG

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15
Q

What are other investigations

A

OTHER INVESTIGATIONS
β€’ To exclude other suspected causes of seizure β€’ ECG as standard in adults
β€’ MRI – in all patients with new-onset seizures

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16
Q

What are some classes of anti epileptic drugs

A
  • Na channel blockers β€’ GABA potentiators β€’ Ca channel blockers
  • Other drugs affecting GABA β€’ Levetiracetam
17
Q

How to Na+ channels work and what are some examples

A 
β€’ Cause Na channels to remain in an inactive state
β€’ Prevent axons from firing repetitively
β€’ Examples
– Carbamazepine
– Phenytoin
– Lamotrigine
– Sodium valproate – Topiramate
18
Q

What are ccbs and how do they work

A 
CALCIUM CHANNEL BLOCKERS
β€’ Prevent activity of Ca channels
β€’ Prevent depolarisation causing β€œspike and wave” discharge 
β€’ Used in absence seizures
β€’ Examples
– Ethosuximide
– Sodium valproate
19
Q

What are gaba potentiators and gaba

A 
β€’ GABA = inhibitory neurotransmitter, so rapidly alters excitability
β€’ Involved with neurotransmitter modulation in a third of brain impulses
β€’ GABA potentiators enhance the effect of GABA at the synaptic junction
– Examples
β€’ Barbiturates (Phenobarbital)
β€’ Benzodiazepines (Midazolam)
β€’ GABA-transaminase inhibitors 
– Prevent breakdown of GABA 
– Vigabatrin
β€’ Increased GABA production
– Improve utilisation of glutamate 
– Gabapentin
20
Q

What is levetiracetam

A

β€’ Trade name Keppra
β€’ Binds to synaptic vesicles (SV2A glycoprotein)
to inhibit pre-synaptic calcium channel activity
β€’ Therefore, inhibiting neurotransmitterrelease from the pre-synaptic neuron

21
Q

When would antiepileptic be considered for use

A

β€’ Epilepsy specialist/neurologist once diagnosis confirmed
β€’ Considered if first unprovoked seizure and…
– Neurological deficit
– EEG shows unequivocal epileptic activity
– Risk of a further seizure is unacceptable
– Imaging reveals a structural abnormality
β€’ Take into account the seizure type, patient’s age, lifestyle and preferences

22
Q

How are antiepileptics initiated

A

β€’ Start with monotherapy and if ineffective change to monotherapy with different AED
β€’ First-line for generalised or tonic-clonic seizures – sodium valproate (or lamotrigine)
– If ineffective, other adjuncts considered (e.g. Levetiracetam, topiramate or sodium valproate AND lamotrigine)
β€’ Titrate up to achieve a balance of therapeutic effect vs adverse side effects

23
Q

What are ways anti epileptics can interact with other drugs

A 
β€’ Beware of interactions
– Liver enzyme inducers 
β€’ Carbamazepine
β€’ Phenyotin
– Liver enzyme inhibitors
β€’ Sodium valproate
24
Q

What are some side effects of aeds

A

Ss

25
Q

Why may aeds be changed

A

β€’ Change if unacceptable side effects, failure of treatment or on inappropriate drug
β€’ Start at initial dose and slowly increase to middle of recommended therapeutic range
β€’ Then slowly withdraw old drug over about 6 weeks
Keep patient on the drug, start a new one, slowly titrations up until middle of therapeutic range, then take the old one away. Want them to overlap - initial one may have had some kind of effect

26
Q

When might aeds be stopped

A

β€’ Consider if patient seizure free for at least 2 years
– 60% will have no further seizure when medication withdrawn
β€’ However, bear in mind the increased risk of seizure compared to those who continue on treatment
– Epilepsy since childhood
– Patients on more than one drug
– Myoclonic or tonic-clonic seizures – Abnormal EEG in last year
– Known underlying brain damage
β€’ Need to think about patient’s livelihood
β€’ DVLA recommends no driving for 6 months after stopping medication

27
Q

How are aeds stopped

A

CESSATION OF ANTIEPILEPTICS
β€’ Gradually taper off
β€’ Aim is to avoid withdrawal features – Recurrent seizures
– Anxiety and restlessness
β€’ Lamotrigine, carbamazepine, phenytoin, sodiumvalproate, vigabatrin – Reduce dose by 10% every 2-4 weeks
β€’ Ethosuximide, barbiturates, benzodiazepines – Reduce dose by 10% every 4-8 weeks
β€’ If on more than one drug, withdraw from one drug at a time
– 1 month between complete withdrawal from one drug and starting withdrawal from another

28
Q

What are the effects of some aeds in pregancy

A

β€’ Risk of congenital malformations
– E.g.neuraltubedefects, hypospadias, cardiacdefects

β€’ Carbamazepine
– Generally perceived as safe in pregnancy, although still carries risks

β€’ Sodium Valproate
– Thought to cause decreased serum folate -> neural tube defects
– Craniofacial and skeletal abnormalities
– Developmental disorders after birth (mental and physical)

β€’ Try not to prescribe sodium valproate to females of childbearing age
β€’ Prescribe lowest effective dose
– Divided over the day
– Controlled-release tablets
β€’ Start folate supplementation before pregnancy
β€’ If no suitable alternative, counsel on risks and appropriate contraception
β€’ Specialist prenatal monitoring

29
Q

What are the effects of phenytoin

A 
PHENYTOIN
β€’ Common congenital malformations
– Cleft lip and palate
– Congenital heart defects (septal defects)
β€’ Anticonvulsant (epilepsy)
β€’ Cardiac depressant (arrhythmias)
β€’ Levels peak at 3 – 9 hours post dose
β€’ Therapeuticlevels:10mg/l–20mg/l
  β€’ Toxicity οƒ  nausea, CNS dysfunction (confusion, nystagmus, ataxia), decreased consciousness, coma!
30
Q

Describe teh pk of phenytoin

A

β€’ Narrow therapeutic window
β€’ Non-linear pharmacokinetics
β€’ Therapeutic drug monitoring to:
– Establish individual therapeutic concentration
– Aid diagnosis of clinical toxicity
– Assess compliance
– Guide dose adjustments in patients with greater pharmacokinetic variability
β€’ Following loading dose, checked at 3-4 days, then 3-12 monthly if stable

31
Q

What are treatments for partial seizures

A

Treatment of partial seizures (simple & complex)
β€’ Lamb
– Lamotrigine
β€’ Top
– Topiramate: can’t be explained off the Top a Ma Head
– Also used in migraines
β€’ Gave
– Gabapentin: wishes it worked like GABA but has pent up frustration
β€’ Funny
– Phenytoin: can’t be funny for too long, so use in Status Epilepticus
β€’ Carbs
– Carbamazepine: keeps Na channels inactive like phenytoin

32
Q

What are the treatment of general seizures

A

eneral seizures:
β€’ Barbara
– PheNObarbitol: NO barb means don’t use unless desperate
β€’ Valiantly
– Sodium valproate: valiantly tries to do many things (including β€œattacking the liver enzymes”)
β€’ Sux
– Ethosuximide: Sucks to learn it, but make sure it doesn’t go absent from revision
β€’ Good-Pam
– Ends in Pam, so it’s a benzo
– Acts quickly, so it’s good 1st line for status epilepticus

33
Q

Describe the initial management of seizures

A

ABCDE -> lorazepam or midazolam benzodiazepines)

Pre-hospital: PR or buccal Hospital: IV

34
Q

What is status epilepticus

A

= epileptic seizures occurring continuously without recovery of consciousness in between
Neither Funny nor Good
So use Phenytoin or Benzodiazepines

35
Q

What is first fit c.liic

A

β€’ Following first seizure, patient deemed safe for discharge β€’ Referral to First Fit Clinic follows
β€’ Advise patient of lifestyle changes in the meantime
β€’ If treatment initiated:
AIM = CONTROL of seizures on FEWEST drugs with LOWEST dose and LEAST side effects

36
Q

What are daily living considerations

A

β€’ Driving:
– Epilepsy when awake, licence is taken away until 1 year seizure-free
– If due to medication change: 6 months seizure-free
– Seizures whilst asleep or don’t affect driving or consciousness – assessment of case by DVLA
– If one-off seizure then can apply when 6 months seizure-free and assessment by DVLA
β€’ Do not operate dangerous machinery
β€’ Avoid potentially dangerous work or activities, e.g. swimming, climbing ladders
β€’ Bathe with supervision or leave bathroom door unlocked
β€’ Do not bathe babies alone
β€’ Do not cycle on busy roads
β€’ Avoid consuming alcohol

37
Q

What are the long term considerations

A

β€’ Annual review
– Check seizure control and if any precipitants
– Compliance
– Consider advice on contraception, pregnancy, employment issues and benefits
β€’ SUDEP (sudden unexpected death in epilepsy)
– Increased risk in patient with uncontrolled seizures
– Risk increases to 1 in 150 with poorly controlled seizures
β€’ Increased risk of mental health illness
– Abnormal activity of neurotransmitters – Structural abnormalities
– Functional abnormalities

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