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BNF > CHAPTER 4: CNS: Epilepsy > Flashcards

CHAPTER 4: CNS: Epilepsy Flashcards

1
Q

Most anti-epileptics are given twice daily. Which can be given once daily at bedtime due to long half life? (4)

A
  1. Lamotrigine
  2. Perampanel
  3. Phenobarbital
  4. Phenytoin
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2
Q

The recommended management for epilepsy is monotherapy with a first-line anti-epileptic. What is the next option and the one after that?

A
  1. Monotherapy - alternative anti-epileptic

3. Combination therapy - 2 or more drugs

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3
Q

When switching from one drug to the other, how is the old drug withdrawn?

A

Start the new drug THEN begin withdrawing the old drug

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4
Q

What is the MHRA warning associated with anti-epileptic drugs in general?

A

Potential harm can result from switching between brands, including loss of seizure control

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5
Q

What are the category 1 anti-epileptics that should never be brand-switched? (4)

A
  1. Phenytoin
  2. Phenobarbital
  3. Primidone
  4. Carbamazepine
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6
Q

What are the category 3 anti-epileptics where it is unnecessary to maintain the same brand? (7)

A
  1. Levetiracetam
  2. Lacosamide
  3. Tigabine
  4. Ethosuximide
  5. Vigabatrin
  6. Gabapentin
  7. Pregabalin
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7
Q

What are the initial symptoms of anti-epileptic hypersensitivity syndrome? (3)

A
  1. Fever
  2. Rash
  3. Lymphadenopathy
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8
Q

As well as fever, rash and lymphadenopathy, what are the other systemic signs of anti-epileptic hypersensitivity syndrome? (6)

A
  1. Liver dysfunction
  2. Renal
  3. Haematological
  4. Pulmonary
  5. Vasculitis
  6. Multi-organ failure
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9
Q

Give 4 examples of anti-epileptics that have been associated with anti-epileptic hypersensitivity syndrome

A
  1. Carbamazepine
  2. Lamotrigine
  3. Phenytoin
  4. Phenobarbital
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10
Q

If a patient experiences anti-epileptic hypersensitivity syndrome, can they be re-exposed to that drug at a later time?

A

No

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11
Q

As well as brand, what is another MHRA alert for all anti-epileptics?

A

Suicidal thoughts and behaviour

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12
Q

Which symptoms, related to suicidal thoughts and behaviour, should patients seek medical advice if they experience?(4)

A
  1. Mood changes
  2. Distressing thoughts
  3. Feelings about suicide
  4. Self-harm
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13
Q

Anti-epileptics have many drug interactions which can be complex, variable and unpredictable. They can lead to both toxicity or treatment failure. What are interactions usually caused by?

A

Enzyme induction or inhibition

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14
Q

Give 3 anti-epileptics with an enzyme INDUCING effect

A
  1. Carbapmazepine
  2. Phenytoin
  3. Phenobarbital
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15
Q

Give 1 anti-epileptic with an enzyme INHIBITING effect

A

Sodium Valproate

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16
Q

Should anti-epileptics be stopped suddenly?

A

No, gradual withdrawal

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17
Q

How long can withdrawal of anti-epileptic drugs take?

A

Months

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18
Q

Which agency must all people with epilepsy alert?

A

The DVLA

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19
Q

If a patient has their first, single/isolated unprovoked seizure, how long are they unable to drive?

A

6 months

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20
Q

If a patient has established epilepsy, is compliant with follow-ups and treatment, how long must they remain seizure-free for them to be able to drive?

A

1 year

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21
Q

If a patient only gets seizures while they are asleep, how long after this is diagnosed are they able to drive? Must be able to prove that seizures only happen at night

A

1 year

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22
Q

What is the DVLA’s recommendation regarding driving while changes to anti-epileptic medications are being made?

A

Not to drive during that period

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23
Q

If a patient is withdrawn on anti-epileptic medicines, how long after their last dose are they unable to drive?

A

6 months

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24
Q

Which anti-epileptic has the highest risk of teratogenicity?

A

Sodium Valproate

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25
Q

Which congenital malformation is sodium valproate most associated with?

A

Neural tube defects

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26
Q

At which point in the pregnancy is teratogenicity of highest risk?

A

First trimester

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27
Q

Which anti-epileptic is associated with a risk of cleft palate in the first trimester?

A

Topiramate

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28
Q

As well as Valproate, all anti-epileptics carry a risk of teratogenicity including phenytoin, primidone, phenobarbital, lamotrigine and carbamazepine. What is the advice for all women of child-bearing age?

A

Effective contraception to avoid unplanned pregnancy

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29
Q

Related to pregnancy, which class of drugs do anti-epileptics interact with?

A

Hormonal contraception, decreases the efficacy

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30
Q

If pregnancy is discovered in a woman taking anti-epileptics, what is the chance that the baby will have no malformations at all?

A

90%

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31
Q

If pregnancy is discovered in a woman taking anti-epileptics, should she be advised to stop taking treatment?

A

NO

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32
Q

Which supplement should a pregnant woman taking anti-epileptics take?

A

Folate

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33
Q

If a woman taking anti-epileptics wishes to become pregnant, who do we refer them to?

A

Specialist

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34
Q

If an epileptic woman experiences seizures during pregnancy, what else could be the cause?

A

Eclampsia

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35
Q

Routine injection of which drug minimises the risk of neonatal haemorrhage associated with anti-epileptics?

A

Vitamin K

36
Q

Which register should all pregnant women with epilepsy be encouraged to notify?

A

The UK epilepsy and pregnancy register

37
Q

What should a breastfed infant be monitored for? (4)

A
  1. Sedation
    2, Feeding difficulties
  2. Weight gain
  3. Developmental milestones
38
Q

What is an option for breastfed infants unable to tolerate mother taking anti-epileptics?

A

Formula - breastmilk must be weaned off to avoid withdrawal

39
Q

What are the first line options for focal seizures? (2)

A
  1. Carbamazepine

2. Lamotrigine

40
Q

What is the first line treatment option for generalised tonic-clonic seizures?

A
  1. Sodium Valproate
41
Q

In which population is sodium valproate contra-indicated?

A

Women of childbearing age

42
Q

What is an alternative to sodium valproate in generalised tonic-clonic seizures?

A

Lamotrigine

43
Q

As well a sodium valproate and lamotrgine, which other drugs can also be considered in generalised tonic-clonic seizures? (2)

A
  1. Carbamazepine

2. Oxacrbazepine

44
Q

What are the first line options for absence seizures? (2)

A
  1. Ethosuximide

2. Sodium Valproate

45
Q

As well as ethosuximide and sodium valproate, which other drug is a suitable alternative for absence seizures?

A

Lamotrigine

46
Q

What is the drug of choice for newly diagnosed myoclonic seizures?

A

Sodium valproate

47
Q

What are the other options for newly diagnosed myoclonic seizures? (2)

A
  1. Topiramate

2. Levetiracetam

48
Q

Usually seen in childhood, specific epilepsy syndromes, cerebral damage and mental retardation, what is the first line treatment option for atonic and tonic attacks?

A

Sodium Valproate

49
Q

Which side effect is ethosuximide associated with?

A

Blood disorders

50
Q

Due to its narrow therapeutic window, which anti-epileptic is started at a low dose and gradually titrated up?

A

Carbamazepine

51
Q

As well as being used in focal seizures, which 2 anti-epileptics are now more associated with neuropathic pain?

A

1, Pregabalin

2. Gabapentin

52
Q

As well as foal seizures and neuropathic pain, what else is pregabalin licensed for?

A

Generalised anxiety disorder

53
Q

Which anti-epileptic is effective in migraine prophylaxis but is not licensed?

A

Gabapenint

54
Q

Which anti-epileptic is a CD3?

A

Phenobarbital

55
Q

What is special about the pharmacokinetics of phenytoin?

A

They are non-linear, a small increase in dose could result in a large increase in plasma concentration

56
Q

What are the 3 main side effects of phenytoin?

A
  1. Liver toxicity
  2. Rash - discontinue if it occurs more than once
  3. Adolescents - coarsening face, acne, swelling gums
57
Q

Which seizure type can pheytoin exacerbate? (2)

A
  1. Myoclonic

2. Absence

58
Q

Phenytoin cannot be given via the intramuscular route. Which drug related to it can?

A

Fosphenytoin

59
Q

Which side effect of Topiramate must be reported to a specialist?

A

Raised intra-occular pressure: glaucoma reported

60
Q

What must be monitored if a patient is taking sodium valproate?

A
  1. LFTs

2. FBC

61
Q

During the first 6 months of use, toxicity to which organ can occur with sodium valproate?

A

Liver

62
Q

Sodium valproate should be withdrawn immediately if the patient experiences which side effects associated with hepatotoxicity?

A
  1. Persistent vomiting
  2. Abdominal pain
  3. Anorexia
  4. Jaundice
  5. Oedema
  6. Malaise
  7. Drowsiness
63
Q

What is the risk of serious developmental disorders if infants are exposed to sodium valproate?

A

30-40%

64
Q

What is the risk of congential malformations if infants are exposed to sodium valproate?

A

11%

65
Q

Sodium valproate must not be used in females of child-bearing potential. If one has to take sodium valproate, what measures must she take?

A

Effective contraception, Pregnancy Prevention Programme

66
Q

Before starting sodium valproate in a female of child-bearing age, what must be excluded?

A

Pregnancy

67
Q

What are the precautions that must be taken if sodium valproate is to be used during pregnancy? (3)

A
  1. Lowest possible dose
  2. Divided doses
  3. Modified-release tablets
68
Q

In status epilepticus, what is administered if seizures last longer than 5 minutes?

A

IV lorazepam, repeated once after 10mins if does not repond

69
Q

In status epilepticus, what is the alternative to IV lorazapem if seizures last longer than 5 minutes? It is more unfavourable due to the risk of thrombophlebitis

A

IV diazepam

70
Q

In status epilepticus, what is administered if seizures last longer than 25 minutes? (3)

A
  1. Phenytoin
  2. Fosphenytoin
    3, Phenobarbital
71
Q

In status epilepticus, what is administered if seizures last longer than 45 minutes?

A

Anaesthesia with midazolam or propofol

72
Q

Why is intramuscular administration or using suppositories not recommended in status epilepticus?

A

Absorption from them is too slow

73
Q

If alcohol abuse is suspected in a person having seizures, what must be considered?

A

Parenteral thiamine (B1)

74
Q

As well as thiamine, deficiency of which vitamin B can also cause seizures?

A

Pyridoxine (B6)

75
Q

If a patient experiences brief, febrile convulsions, what is the recommended treatment?

A

Anti-pyretic (e.g. Paracetamol)

76
Q

Supplementation with which vitamin should be considered in patients taking certain anti-epileptics including Carbamazepine and Phenytoin

A

Vitamin D

77
Q

Which disorders can carbamazepine cause, calling for its discontinuation?

A
  1. Blood
  2. Liver
  3. Skin
78
Q

Which anti-epileptic can cause leucopenia?

A

Carbamazepine

79
Q

Patients experiencing which side effects with carbamazepine should be offered modified release preparations? (5)

A
  1. Headache
  2. Ataxia
  3. Blurred vision
  4. Drowsiness
  5. Allergic skin reactions
80
Q

What is the pre-treatment screening for carbamazepine due to the risk of Steven-Johnson Syndrom?

A

Test for HLA-B* allele in Chinese or Thai people -

81
Q

What should the plasma concentration of carbamazepine be?

A

4-12 mg/L measured after 1-2 weeks

82
Q

What is the NHS improvement patient safety alert associated with phenytoin?

A

Risk of death and severe harm resulting from error with injectible phenytoin

83
Q

Is the use of intramuscular phenytoin recommended?

A

No, absorption is slow and erratic

84
Q

As well as hepatoxicity, rash and effects on adolescents, what is a cardiac side effect of phenytoin?

A

Bradycardia and hypotension

85
Q

What should the plasma concentration of phenytoin be?

A

10-20mg/L

86
Q

What are the symptoms of phenytoin overdose? (6)

A
  1. Ataxia
  2. Slurred speeh
  3. Confusion
  4. Hyperglycaemia
  5. Nystagmus
  6. Diplopia

BNF (28 decks)

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