Brainscape's Knowledge GenomeTM

Browse over 1 million classes created by top students, professors, publishers, and experts.


See full index

Seizures > Anti-seizure Medications > Flashcards

Anti-seizure Medications Flashcards

1
Q

AE’s are common and contribute to…

A

Treatment failure in up to 40% of patients, due to non-adherence

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

Most common AE’s with ASM’s are…

A

Dose-dependent, predictable, and reversible

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

Common CNS AE’s include…

A

Sedation, dizziness
Blurred or double vision
Ataxia
Difficulty concentrating

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

Common GI AE’s include…

A

Nausea, vomiting

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

Idiosyncratic reactions from ASM’s usually develop…

A

Within the first few weeks of treatment; unpredictable, but uncommon/rare

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

An example of a hypersensitivity reaction is…

A

SJS, TENS

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

SJS/TENS is most likely to occur with…

A

Phenytoin
Carbamazepine
Lamotrigine

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

Cross-sensitvity of hypersensitivity between agents…

A

Is possible, due to aromatic hydrocarbon ring

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

Drugs with an aromatic hydrocarbon ring include…

A

Carbamazepine + its derivatives
Phenobarbital
Primidone
Phenytoin
Lamotrigine

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

ASM exposure during pregnancy has been associated with…

A

Major congenital malformations and neurodevelopmental delay in offspring

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

General measures to consider for women taking ASM’s include…

A

Discussing pregnancy plans prior to conception
Ensure adequate folic acid supplementation
Aim for seizure-freedom for 9-12 months prior to pregnancy

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

Prevention of teratogenicity may include…

A

Avoiding valproic acid in women of childbearing potential
Avoid polytherapy + use lowest effective dose of ASM
Avoid stopping ASM’s or switching medications during pregnancy

Be mindful of risk to baby + mom with uncontrolled seizures

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

Adding a new ASM will often interfere…

A

With the levels of an existing ASM - strong CYP inducers + inhibitors are common

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

Hormonal contraceptives are involved with drug interactions via…

A

Enzyme inducing ASM’s reduce efficacy of COC (phenytoin, carbamazepine, phenobarb, primidone). Estrogen containing contraception will reduce lamotrigene levels

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

Preferred contraceptives for someone on ASM is…

A

LGN-IUD, copper IUD, or progesterone implant
Depot-medroxyprogesterone
COC with >30mcg EE taken continuously

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

Therapeutic drug monitoring is available for many older ASM’s, but…

A

There is a poor correlation between levels and clinical efficacy

Variability in patient response + seizure type

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
17
Q

A drug level could be drawn when…

A

Desired clinical response - establish individual therapeutic range
Determining magnitude of dose increase, esp. with dose-dependent PK
Signs/sx’s suggestive of ASM toxicity
Assess if alteration in PK/formulation change drug level

Unexpected change in clinical response/poor compliance expected

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
18
Q

1st line options for focal seizures as per AAN guidelines include…

A

Carbamazepine + Lamotrigine

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
19
Q

2nd line options for focal seizures as per AAN guidelines include…

A

Levetiracetam
VPA
Oxcarbamazepine
Zonisamide

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
20
Q

3rd line agents for generalized motor seizures (tonic-clonic) as per NICE guidelines include…

There are no 1st/2nd line agents listed in AAN due to lack of evidence

A

Carbamazepine
Lamotrigine
Valproate
Topiramate
Levetiracetam

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
21
Q

1st and 2nd line agents for generalized motor myoclonic seizures as per NICE guidelines include…

A

1st line: Valproate
2nd line: Levetiracetam, topiramate

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
22
Q

Medications that NEED to be avoided in generalized motor myoclonic + absence seizures include…

A

Carbamazepine + derivatves
Gabapentin
Phenytoin
Tiagabine
Vigabatrin
Lamotrigine in myoclonic only

May precipitate or aggravate seizures - importance of an accurate diagnosis

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
23
Q

1st and 2nd line medications for absence seizures as per AAN guidelines include…

A

1st line: ethosuximide, valproate
2nd line: lamotrigine

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
24
Q

Most common MOA of ASM is…

A

Sodium channel blockers - blocking sodium ion flow in neurons alters signal transduction

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
25
Q

ASM’s that are sodium channel blockers are…

A

Phenytoin
Carbamazepine + derivatives
Lamotrigine
Lacosamide
Rufinamide

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
26
Q

Phenytoin is a ____ spectrum ASM.

A

Narrow

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
27
Q

Phenytoin place in therapy is…

A

Treating status epilepticus
Last line for focal seizures, NOT for absence/myoclonic seizures

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
28
Q

Advantages to phenytoin include…

A

OD/BID dosing, many dosage forms
Cheap
Extensive experience
Defined therapeutic serum concentration range

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
29
Q

Disadvantages to phenytoin include…

A

Substrate + broad spectrum inducer of CYP and glucuronidation - MANY drug interactions
Complicated PK, saturable kinetics (therapeutic drug monitoring necessary)
Lots of AE’s

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
30
Q

Dose-related toxicities of phenytoin may involve…

A

Mainly CNS: Drowsiness, confusion, nystagmus, ataxia, slurred speech, unusual behaviour, mental changes, coma
Nausea

(Levels > 200 umol/L)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
31
Q

Non-dose related toxicities of phenytoin may involve…

A

Hirsutism, acne, gingival hyperplasia, folate deficiency, osteomalacia, hypersensitivity reactions (SJS), lupus

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
32
Q

Carbamazepine place in therapy for seizures is…

A

1st line for focal onset seizures
3rd line for generalized tonic-clonic

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
33
Q

Carbamazepine is a ____ spectrum ASM.

A

Narrow

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
34
Q

Advantages of carbamazepine include…

A

CR/XR tablets - BID dosing
Can be used for other indications such as bipolar or neuropathic pain

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
35
Q

Disadvantages of carbamazepine include…

A

Significant DI’s
Lots of AE’s
Risk of SJS + TENS

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
36
Q

Carbamazepine has a lot of drug interactions due to…

A

Substrate + broad-spectrum inducer of CYP enzymes and induces its own metabolism, resulting in increased clearance and decreased half-life with continued dosing

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
37
Q

Carbamazepine CYP inducing effect starts within ____ and ends in…

A

Within 24 hours, ends in 1-5 weeks. Applies to every dose increase

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
38
Q

Dose related AE’s with carbamazepine include…

A

GI - N/V, constipation, dry mouth
CNS - lethargy, sedation, dizziness, blurred vision, ataxia
CV - tachycardia, hypotension, conduction abnormalities

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
39
Q

Some idiosyncratic AE’s with carbamazepine include…

A

Hyponatremia
Blood dyscrasias
Rash + hypersensitivity rxns
Weight gain
Hepatic and thyroid issues
Menstrual disturbances

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
40
Q

These lab values should be monitored with carbamazepine usage…

A

LFT’s + Thyroid
Renal fx
CBC with diff + platelets
Electroytes
ECG
Bone mineral density

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
41
Q

These patients have increased risk of rash + hypersensitivity reactions with carbamazepine:

A

Asian ancestry + HLA-B1502
Caucasian + HLA-A3101

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
42
Q

Chronic usage of carbamazepine may lead to…

A

Osteomalacia
Vitamin D deficiency

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
43
Q

Notable drugs that will increase carbamazepine levels include…

A

Macrolides
Antifungals
CCB’s
Other ASM’s - valproic acid + lamotrigine

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
44
Q

Common drugs that may decrease carbamazepine levels include…

A

Other ASM’s - phenytoin, phenobarbital, primidone

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
45
Q

Notable drugs that have their serum levels decreased by carbamazepine include…

A LOT

A

Antipsychotics
Antidepressants
Anticoagulants
Antifungals
Estrogen/progesterone
Other ASM’s - phenytoin, valproic acid, lamotrigine

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
46
Q

Eslicarbazepine MOA is ____, and is approved for…

A

Inhibition of voltage gated sodium channels - mono or adjunctive tx for focal seizures

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
47
Q

Eslicarbazepine DI’s compared to carbamazepine is…

A

Less severe - still induces 3A4, but no autoinduction

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
48
Q

Eslicarbazepine AE’s compared to carbamazepine is…

A

Similar, but frequency is less for all sx’s.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
49
Q

Eslicarbazepine severe AE includes ____ and cannot be used if…

A

Prolongation of PR interval - CI if 2nd/3rd degree AV block

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
50
Q

Oxcarbazepine is a prodrug structurally related to carbamazepine, and its difference is…

A

Adjusted to try and reduce frequency of AE’s and severity DI’s

51
Q

Lamotrigine MOA is…

A

Blockage of sodium channels + reducing glutamate release
Weak serotonin receptor inhibitory effect

52
Q

Lamotrigine is a ____ spectrum ASM

A

Broad

53
Q

Lamotrigine place in therapy includes…

A

1st line for focal seizures
3rd line for generalized motor seizures
2nd line for absence seizures

Not for myoclonic

54
Q

Advantages of lamotrigine include…

A

Well-tolerated
Broad spectrum activity
One of the safest in pregnancy
Fewer DI’s
Good for bipolar depression

55
Q

Disadvantages of lamotrigine include…

A

Does have clinically important DI’s
Slow titration required, not good if therapeutic levels are required quickly - risk of life-threatening rashes

56
Q

Lamotrigine DI’s that are important to note include…

A

Other ASM’s - VPA, other enzyme-inducing ASM’s
Estrogen products

All decrease lamotrigine levels

57
Q

Lamotrigine titration is usually as follows…

A

Week 1-2: 25mg once daily
Week 3-4: 50mg once daily
Week 5: 100mg once daily
Then increase dose by 50mg-200mg every 1-2 weeks

58
Q

Common AE’s that occur with lamotrigine include…

A

Sedation/insomnia, headaches, nausea, dizziness

59
Q

Serious but rare AE that we must monitor in lamotrigene usage includes…

A

Life-threatening SJS/TENS
Blood dyscrasias

60
Q

85% patients on lamotrigene who experience SJS rash have prodromal symptoms, which involve…

A

Flu-like symptoms

61
Q

The following needs to be monitored while on lamotrigine…

A

Baseline hepatic + renal function
Monitor for rash
CBC, LFT, SCr

62
Q

Lamotrigine titration needs to be restarted if ____ days are missed, to avoid…

A

5 days - avoid increased risk of skin rash

63
Q

Lacosamide is a newer ASM that is a ____ spectrum ASM, and is approved for ____ seizures.

A

Narrow, but maybe broad spectrum - approvaed for focal seizures

64
Q

MOA of lacosamide is also…

A

Slow inactivation of voltage-gated sodium channels, inhibiting repetitive neuronal firing

65
Q

Lacosamide has few DI’s, but notably…

A

Has no contraceptive interactions

66
Q

Lacosamide AE’s are similar to other sodium channel blockers, which include…

A

CNS - dizziness, headache, ataxia, fatigue, diplopia, nystagmus, tremor
GI - nausea, vomiting, diarrhea

67
Q

Serious AE’s with lacosamide include…

A

Hypersensitivity skin reactions
Dose-dependent prolongation in PR interval, 1st degree AV block, afib/flutter

Skin rxn thought to be cross-reactive with other agents

68
Q

Clobazam’s MOA is…

This is a BZD

A

Bind to GABA receptors to facilitate increased endogenous GABA binding activity

69
Q

Clobazam is a ____ spectrum ASM

A

Broad

70
Q

Clobazam place in therapy is…

A

3rd/4th line, or adjunct tx. for most seizure types. (both focal + generalized - including myoclonic, atonic)

71
Q

Compared to other BZD’s, clobazam is less likely…

A

To develop tolerance

BZD’s are usually not well-suited for chronic management due to rapid development of tolerance - this one is less likely

72
Q

Advantages of clobazam include…

A

Broad-spectrum
Rapid onset
OD/BID dosing, cheap
Few DI’s

73
Q

Disadvantages of clobazam include…

A

Possible tolerance (but less likely than other BZD’s)
Potential for abuse + dependence
Needs to be weaned off to avoid withdrawal, if stopping

74
Q

In general, if we are stopping ASM’s, we should ____, because…

A

Taper - stopping immediately may worsen seizures

Going from “seizure protective” to “no protection”

75
Q

Primary AE’s with clobazam include…

A

CNS effects - drowsiness, dizziness, ataxia, reduced concentration

Some people develop tolerance

76
Q

With clobazam, we should monitor…

A

Level of sedation
Respiratory depression (especially with concurrent opioids)

77
Q

MOA of phenobarbital is…

A

Bind to GABA receptors to prolong the activity of GABA

78
Q

Phenobarbital is a ____ spectrum ASM

A

Narrow

79
Q

Phenobarbital place in therapy is…

A

Not listed in AAN.
4th line for focal seizures and 3rd line for generalized TC seizures as per ILAE

Declining use due to AE’s and DI’s

80
Q

Advantages with phenobarbital include…

A

OD dosing, due to long half-life
Cheap

81
Q

Disadvantages with phenobarbital include…

A

Substrate + broad-spectrum inducer of various CYP enzymes and glucuronidation = many DI’s
Prominent sedation
Lethality in overdose

82
Q

Notable AE’s with phenobarbital include…

A

CNs effects - sedation
Rash
Decreased vitamin D, folic acid
Hepatotoxicity

83
Q

If someone were to take phenobarbital, we would monitor…

A

Serum levels (target therapeutic range available)
LFT’s + renal function
CBC’s

84
Q

MOA of topiramate is…

Combination

A

Blocks sodium channels
Enhances GABA
Antagonizes AMPA glutamate receptors
Weakly inhibits carbonic anhydrase

85
Q

Topiramate is a ____ spectrum ASM

A

Broad

86
Q

Topiramate place in therapy is…

A

4th line for focal seizures (AAN)
3rd line for generalized tonic-clonic seizures (AAN)
2nd line for myoclonic seizures (NICE)
3rd line for absence seizures (NICE)

87
Q

GABA is the major ____ neurotransmitter, involved in seizure activity

A

Inhibitory

88
Q

One advantage with topiramate is that it may assist with…

A

Migraine prophylaxis
Weight loss
Alcohol dependence

89
Q

Topiramate is generally not well tolerated due to the multitude of AE’s, such as…

A

CNS - drowsiness, dizziness, paresthesias, decreased concentration + cognition
Nausea, diarrhea
Renal stones, metabolic acidosis
Weight loss

90
Q

Glutamate is the major ____ neurotransmitter, thought to increase seizure activity

A

Excitatory

91
Q

MOA of perampanel is…

A

AMPA (Glutamate) receptor antagonist

92
Q

Place in therapy of perampanel is…

A

Adjunctive tx of generalized tonic-clonic seizures, may also help with adjunctive tx with focal seizures

93
Q

Perampanel is a ____ spectrum ASM

A

Broad

94
Q

Common AE’s with perampanel include…

A

CNS - dizziness, drowsiness, fatigue, ataxia, abnormal gait, irritability
GI - vomiting, nausea
Skin rash
Pain (MSK, arthralgia, myalgia, back pain)

95
Q

Black box warning on perampanel is…

CNS + Irritability AE’s may lead to…

A

Psychiatric and behavioural reactions - aggressive behaviour and homicidal thoughts

Appears to be dose-dependent

96
Q

Valproic acid MOA is…

A

Increasing GABA activity through several mechanisms
Modulates sodium, calcium, and potassium channels

97
Q

Divalproex compared to valproic acid…

A

Has better GI tolerance

98
Q

VPA is a ____ spectrum ASM

A

Broad - option for practically all seizure types

99
Q

Divalproex place in therapy includes…

A

2nd line - focal seizures
3rd line - generalized tonic-clonic
3rd line - myoclonic
1st line - absence

100
Q

Advantages with divalproex include…

A

Very broad spectrum - useful for other psychiatric + neurologic conditions
Low risk of rash, no cross-reactivity

101
Q

Disadvantages with divalproex include…

A

Inhibition of CYP enzymes - many potential DI’s
Well known teratogen
May contribute to metabolic syndrome

102
Q

Lamotrigine and valproic acid have a key drug interaction in that…

A

Lamotrigine concentrations are increased by ~50%, so we have to decrease lamotrigene dose by 50%

103
Q

Notable side effects of valproic acid include…

A

GI: N/V/D, constipation, anorexia
CNS: Tremor, sedation, ataxia, dizziness
Thrombocytopenia
Hair loss/thinning, weight gain, amenorrhea

104
Q

Some serious adverse effects of valproic acid include…

A

Increased transanimases, LDH; hepatotoxicity
Pancreatitis
Hyperammonemia
Leukopenia
Skin rash (increased with lamotrigene usage)

105
Q

With chronic usage of valproic acid, the following may occur…

A

Weight gain (up to 8-14kg)
Menstrual disturbances; PCOS
Alopecia

106
Q

The following should be monitored with valproic acid usage…

A

Sedation
Rash
CBC, platelets, and LFT’s
Ammonia levels (unexplained lethargy, confusion, vomiting)
Valproate levels

107
Q

How often should valproate levels be tested?

A

2-4 days after a dose change or an interacting drug is started, then in 1-2 weeks to ensure stability

Then PRN

108
Q

Therapeutic range of valproic acid is…

A

350-700 micromol/L of total valproic acid; guideline only and needs to be individualized

109
Q

Valproic acid levels should be taken…

A

At a steady state trough level; 3-4 days after initial therapy

Or at suspected s/sx’s of valproic acid toxicity

110
Q

MOA of levetiracetam is…

A

Full mechanism unclear - binds to synpatic vesicle protein SV2A in presynaptic terminal to modulate NT release

111
Q

Levetiracetam is a ____ spectrum ASM.

A

Broad

112
Q

Levetiracetam’s place in therapy for seizure management is…

A

2nd line for focal
3rd line for generalized TC seizures
2nd line or adjunct tx for myoclonic seizures

113
Q

Advantages of levetiracetam include…

A

Different MOA, easy to be added
No significant DI’s (COC still affected)
Very-well tolerated, low risk of rash
Can be titrated rapidly with loading doses

114
Q

Disadvantages of levetiracetam include…

A

Psychiatric/behavioural prbolems may limit therapy
Renal dosing adjustments necessary

115
Q

Common AE’s with levetiracetam include…

A

CNS - sedation most common
GI
Behavioural/psychiatric symptoms

Mood swings - agitation, aggression, anxiety, depression

116
Q

Rare AE’s with levetiracetam include…

A

Decrease in WBC’s
SJS, TEN

117
Q

Monitoring with levetiracetam can include…

A

CBC’s, if clinically indicated
Renal function

118
Q

Brivaracetam’s MOA is…

A

Same as levetiracetam - binds to SVA2 protein

119
Q

Brivaracetam is considered a ____ spectrum ASM.

A

Broad

120
Q

So far, brivaracetam is approved for…

A

Adjunctive tx for focal seizres, not controlled with 1st line ASM’s

121
Q

Brivaracetam AE’s are similar to levetiracetam, except for…

A

Lower risk of psychiatric disturbance (clinically, may still be similar)
Low risk of bronchospasm or angioedema

122
Q

IN GENERAL, broad-spectrum ASM’s are…

A

Often effective at treating focal AND generalized seizures

123
Q

IN GENERAL, narrow-spectrum ASM’s are…

A

Used primarily for focal seizures

Seizures (3 decks)

Brainscape helps you reach your goals faster, through stronger study habits.
© 2024 Bold Learning Solutions. Terms and Conditions