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Pharmacy Pre-Reg 2020/2021 > Chapter 4 - Epilepsy > Flashcards

Chapter 4 - Epilepsy Flashcards

1
Q

What does the ILAE define epilepsy as?

A

> 2 unprovoked seizures >24h apart

Or

One unprovoked seizure and a 60% probability of having another within 10 years

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2
Q

What is seizure freedom?

A

12 months without a seizure

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3
Q

What is a good therapeutic effect of an AED?

A

3 times the longest previous interval between seizures

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4
Q

Does glutamate cause an excitatory or inhibitory response?

A

Excitatory

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5
Q

Does GABA cause an excitatory or inhibitory response?

A

Inhibitory

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6
Q

What are the two types of focal seizures?

A

Simple - remain aware

Complex - lose consciousness

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7
Q

What are the five main types of motor generalised seizures?

A 
Tonic-clonic 
Tonic
Clonic 
Myoclonic 
Atonic
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8
Q

What are some signs and symptoms that may be seen in a focal seizure?

A 
Kicking
Rocking
Altered vision
Numbness or tingling
Muscles stiffening in one area
Smelling, tasting, hearing or seeing things
Behavioural changes

There may be an aura

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9
Q

What is an example of a non-motor generalised seizure?

A

Absence

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10
Q

What happens during a tonic-clonic seizure?

A

Muscles contract and the body becomes rigid

Loss of consciousness and falling to the floor

Violent muscle contractions

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11
Q

How long to tonic-clonic seizures last for?

A

Usually 1-3 mins

>5 mins is a medical emergency

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12
Q

Do people always recover straight away after a tonic-clonic seizure?

A

No, it can take a while to recover

The person may feel confused, tired, agitated etc

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13
Q

If a person has bitten their tongue/cheek during a seizure, what type of seizure does this usually indicate?

A

Generalised tonic-clonic

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14
Q

What is a myoclonic seizure?

A

Brief jerks of a muscle/group of muscles

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15
Q

Does a person usually lose consciousness during a myoclonic seizure?

A

No, they are usually too short to affect consciousness

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16
Q

What age group do absence seizures usually occur in?

A

Children

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17
Q

How long do absence seizures usually last?

A

A few seconds

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18
Q

What is an absence seizure?

A

A brief seizure that causes a lapse in awareness, e.g. the child may stare at something

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19
Q

What groups of people are atonic and tonic seizures seen in?

A

Children

Epilepsy syndromes

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20
Q

What are tonic and atonic seizures?

A

Tonic - rigidity/stiffness, usually happens I’m in sleep

Atonic - the body goes limp e.g. head may drop, eyelids mag drop, the person may drop items that they are holding

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21
Q

What is a febrile seizure?

A

A seizure in a child caused by a high fever

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22
Q

How are febrile seizures managed?

A

Usually with antipyretics e.g. paracetamol

> 5 mins is a medical emergency (status epilepticus)

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23
Q

What is reflex epilepsy?

A

Seizures triggered by the environment

E.g. due to noises, chewing, flashing lights, sleep deprivation

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24
Q

How is epilepsy diagnosed?

A

Speak to the patient and any witnesses (especially if they were unconscious)

ECG - but don’t use this alone to diagnose epilepsy

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25
Q

Why isn’t an ECG used alone to diagnose epilepsy?

A

It can sometimes give false positive or false negative results

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26
Q

What is status epilepticus?

A

A seizure lasting >5 mins

Or

Multiple seizures where the person doesn’t regain consciousness in between

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27
Q

In a person with status epilepticus, what should also be given if alcohol abuse is suspected?

A

Thiamine

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28
Q

What would you give for status epilepticus in the community?

A

Rectal diazepam

Buccal midazolam

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29
Q

What is the first treatment for status epilepticus in hospital?

When should this be repeated if it fails or if seizures reoccur?

A 
IV lorazepam 
IV diazepam (carries a high risk of thromboplebitis)

Repeat after 10mins if necessary

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30
Q

In status epilepticus, if seizures are still occur 25mins after giving IV lorazepam/diazepam, what would you do?

A

Either:
IV phenytoin
IV fosphenytoin
IV phenobarbital

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31
Q

In status epilepticus, if seizures are still occur 45 mins after giving IV lorazepam/diazepam, what would you do?

A

Refer to ICU

Give thiopental sodium, midazolam, or propofol

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32
Q

What are the indications of lorazepam?

A

Status epilepticus
Febrile convulsions
Convulsions due to poisoning

Anxiety
Panic attacks
Sedation

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33
Q

If lorazepam is used for sedation, how long shouldn’t the patient drive for afterwards?

A

Minimum 24h

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34
Q

Why shouldn’t people have benzodiazepines and alcohol?

A

Both are CNS depressants

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35
Q

What are the indications of midazolam?

A

Status epilepticus
Febrile convulsions

Convulsions in palliative care
Sedation

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36
Q

Does midazolam have a short or long duration of action compared to other benzodiazepines?

A

Shorter duration of action

And so faster recovery time

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37
Q

After a first unprovoked seizure, how long can’t a person drive for?

When can they start driving again?

A

6 months

Can restart if they have been assessed by a specialist and have been declared fit to drive at a low risk of another seizure

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38
Q

After an AED has been changed or stopped, how long can’t someone drive for?

A

Minimum 6 months (as long as there have been no seizures within this time)

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39
Q

What are the first line and alternative options for focal seizures?

A

First line
Lamotrigine
Carbamazepine

Alternatives
Sodium valproate
Levetiracetam
Oxcarbazine

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40
Q

What are the first line and alternative options for generalised tonic-clonic seizures?

A

First line
Sodium valproate

Alternatives
Lamotrigine
Carbamazepine or oxcarbazine (may worsen myoclonic or absence seizures)

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41
Q

When is adjunct therapy used in focal seizures?

A

When two first line AEDs haven’t worked

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42
Q

What are the first line and alternative options for absence seizures?

A

First line
Ethosuximide
Sodium valproate

Alternatives
Lamotrigine

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43
Q

What are the first line and alternative options for myoclonic seizures?

A

First line
Sodium valproate

Alternatives
Lecetiracetam
Topirmate (consider poor side effect profile)

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44
Q

What are the first line and alternative options for tonic and atonic seizures?

A

First line
Sodium valproate

Alternatives
Lamotrigine

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45
Q

What AEDs can worsen myoclonic, absence, tonic and atonic seizures?

A 
Carbamazepine 
Oxcarbazine 
Gabapentin
Phenytoin 
Pregabalin 
Tiagabine
Vigabatrin
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46
Q

What are the first line and alternative options for Dravet Syndrome?

A

First line
Sodium valproate
Topiramate

Alternatives
Cannabinol and clobazam

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47
Q

What are the first line and alternative options for Lennox-Gastaut syndrome?

A

First line
Sodium valproate

Alternatives
Sodium valproate + lamotrigine
Cannabidol + clobazam

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48
Q

How effective do cannabidol and clobazam need to be in order to be continued in epilepsy syndromes?

A

Need to reduce seizure frequency by 30% in 6 months

49
Q

When are antiepileptic drugs usually initiated?

A

After the second unprovoked seizure

50
Q

How are AEDs initiated?

A
  1. Monotherapy - titration to the lowest effective dose/maximum tolerated dose
  2. Monotherapy with an alternative AED
  3. Combination therapy
51
Q

What is the MRHA advice regarding AEDs and suicidal thoughts/behaviour

A

All AEDs are associated with a small increase in suicidal thoughts or behaviour

52
Q

How soon can suicidal thoughts or behaviour occur as a result of AEDs?

A

Within 1 week

53
Q

How frequently are most AEDs usually taken?

What are the exceptions?

A

Twice a day

Exceptions include lamotrigine, phenytoin and phenobarbital - these have a longer half life

54
Q

What is an advantage of giving AEDs more frequently?

A

Peak drug concentration will be reduced, which will reduce the adverse effects

55
Q

Why interactions do many AEDs have in common?

A

Most are hepatic

enzyme inhibitors or inducers

56
Q

If a patient is on multiple AEDs, how should these be withdrawn?

A

Gradually and one at a time

57
Q

Why should AEDs be withdrawn gradually?

Which AEDs is this particularly important for?

A

Because withdrawing them quickly increases the risk of rebound seizures, which may be severe

Take particular care with benzodiazepines and barbiturates

58
Q

What is refractory epilepsy?

A

When two AED schedules have failed to achieve seizure freedom

59
Q

Which AEDs do you do routine TDM for?

A

Phenytoin

Carbamazepine

60
Q

When is the risk of teratogenicity increased with the use of AEDs?

A

When AEDs are used in the first trimester

When multiple AEDs are being taken

61
Q

What are the implications of using sodium valproate in pregnancy?

A 
Congenital malformations (10%)
Neurodevelopmental disorders (30-40%)
Increased risk of intra-uterine growth restriction
62
Q

When used in pregnancy, which AEDs can cause:

Congenital malformations
Neurodevelopmental disorders
Increased risk of intra-uterine growth restriction?

A

Sodium valproate
Phenytoin
Phenobarbital

63
Q

When used in pregnancy, which AEDs can cause:

Congenital malformations

A

Carbamazepine
Topiramate

Sodium valproate
Phenytoin
Phenobarbital

64
Q

When used in pregnancy, which AEDs can cause:

Increased risk of intra-uterine growth restriction?

A

Topiramate
Zonisamide

Sodium valproate
Phenytoin
Phenobarbital

65
Q

When can sodium valproate be given to females of a child bearing potential?

A

When they have met the conditions of the pregnancy prevention programme

When alternative treatments are not effective or not tolerated

66
Q

Which AEDs are safest in pregnancy?

A

Lamotrigine

Levetiracetam

67
Q

If a patient on sodium valproate finds out she’s pregnant, should she stop taking her sodium valproate?

A

No - seek urgent medical advice first

68
Q

Which AEDs are hepatic inducers?

A

Carbamazepine
Phenytoin
Phenobarbital

69
Q

Which AEDs are hepatic inhibitors?

A

Sodium valproate

70
Q

Why is folate supplementation given in pregnancy when a person is also taking AEDs?

A

To prevent neural tube defects

71
Q

Pregnancy can change the concentrations of AEDs, which two AEDs can be particularly affected?

A

Lamotrigine

Phenytoin

72
Q

When switching between AEDs, what drugs are in category 1?

A

Carbamazepine
Phenytoin
Phenobarbital

73
Q

When switching between AEDs, what drugs are in category 2?

A 
Clobazam
Clonazepam
Lamotrigine 
Oxcarbazepine
Topiramate 
Valproate 
Zonisamide
74
Q

When switching between AEDs, what drugs are in category 3?

A

Pregabalin
Gabapentin
Levetiracetam
Ethosuximide

75
Q

What is antiepileptic hypersensitivity syndrome?

A

A rare but potentially fatal type of anaphylactic reaction

76
Q

What AEDs is antiepileptic hypersensitivity syndrome associated with?

A 
Carbamazepine 
Lamotrigine 
Oxcarbazine 
Phenytoin 
Phenobarbital
77
Q

How soon does antiepileptic hypersensitivity syndrome usually occur after exposure to an AED?

A

1-8 weeks

78
Q

What are some signs and symptoms of antiepileptic hypersensitivity syndrome?

A 
Rash
Fever
Hepatic dysfunction 
Renal dysfunction 
Pulmonary abnormalities 
Multi organ failure
79
Q

What is sudden unexpected death in epilepsy?

A

A non traumatic death
With or without evidence of a seizure
In the absence of status epilepticus

80
Q

What are some risk factors for sudden unexpected death in epilepsy?

A 
Young age
Refractory epilepsy 
Nocturnal seizures 
Long duration of epilepsy 
Frequent convulsions
81
Q

When should an ambulance be called if a person is having a seizure?

A 
Duration >5 minutes 
First seizure 
Difficult to wake up afterwards 
Difficulty breathing 
Person is injured
82
Q

How can you prevent injury duri bf a seizure?

A

Remove glasses/anything that could cause harm

Put something soft under the persons head

Don’t restrain them

83
Q

What should you do once a persons seizure has stopped?

A

Check their airways
Put them in the recovery position
Monitor for injuries and manage as appropriate

84
Q

When does liver dysfunction occur with use of sodium valproate?

A

Within the first 6 months

85
Q

If sodium valproate is used in pregnancy, how should it be used?

A

Lowest dose possible
Prescribe m/r
Prescribe less than 1g - doses higher than this are associated with an increased risk of teratogenicity

86
Q

When dispensing sodium valproate to women of a child bearing potential, what should you do if you can’t dispense in whole packs?

A

Ensure that a pregnancy warning label is either on the box or as a sticker

87
Q

If a patient on lamotrigine develops a rash, what could this be?

A

Stevens-Johnson syndrome

Antiepileptic hypersensitivity syndrome

88
Q

If a patient on lamotrigine develops a rash, what should be done?

A

Discontinue lamotrigine

89
Q

If a patient on lamotrigine develops a rash, factors increase the risk of a serious skin reaction?

A

Concomitant use of valproate
Starting at high doses
Titrating quickly

90
Q

Can lamotrigine be given in pregnancy and breastfeeding?

A

Yes

91
Q

What is the interaction between lamotrigine and oestrogen containing contraceptives?

A

Oestrogen containing contraceptives may reduce the plasma concentration of lamotrigine, which may result in a loss of seizure control

92
Q

Can levetiracetam be given in pregnancy and breastfeeding?

A

Pregnancy - yes

Breastfeeding - no

93
Q

What is the brand name of levetiracetam?

A

Keppra

94
Q

Does levetiracetam interact with hepatic enzymes?

A

Not as much as other AEDs - it is not extensively metabolised by the liver

95
Q

Should carbamazepine be titrated quickly?

A

No

96
Q

How long does it take for carbamazepine to reach a steady state?

A

About 2 weeks

97
Q

What types of seizures can carbamazepine worsen?

A

Myoclonic
Absence
Tonic
Atonic

98
Q

Does carbamazepine cause hypernatraemia of hyponatraemia?

A

Hyponatraemia

99
Q

What are the optimal plasma concentrations of carbamazepine?

A

4-12 mg/litre

20-50 micromol/litre

100
Q

What is the brand name of carbamazepine?

A

Tegretol

101
Q

Is phenytoin base and phenytoin salt bioequivalent?

A

No

Phenytoin salt 100mg = phenytoin base 92mg

102
Q

Why is phenytoin not commonly used?

A

Poor side effect profile
Narrow therapeutic window (requires lots of monitoring)
Lots of drug interactions (hepatic enzyme inducer)
Unpredictable kinetics

103
Q

How is phenytoin given in patients who have enteral feeding?

A

Interrupt enteral feeding 2hours before and after the phenytoin dose

104
Q

Can phenytoin be given IM?

A

No - absorption is slow and erratic

105
Q

What type of seizures can phenytoin exacerbate?

A

Absence

Myoclonic

106
Q

What are some symptoms of phenytoin toxicity?

A 
Confusion 
Slurred speech 
Hyperglycaemia 
Ataxia 
Loss of balance 
Muscle weakness
107
Q

What is the optimal phenytoin concentration in:

a) adults
b) children <3 years
c) children 3-18 years

A

a) adults 10-20mg/litre (40-80 micromol/litre)
b) 6-15mg/litre (25-60micromol/litre)
c) 10-29mg/litre (40-80 micromol/litre)

108
Q

When might you want to measure free plasma phenytoin concentration?

A

When there is reduced protein binding e.g. in pregnancy and neonates

109
Q

What increase the risk of respiratory depression in patients taking gabapentin?

A

Elderly
Renal impairment
Compromised respiratory function

110
Q

What was gabapentin and pregabalin reclassified from and to in 2019

A

POM to schedule 3 CD

111
Q

Why were gabapentin and pregabalin reclassified?

A

Risk of abuse - can be mixed with other drugs e.g. methadone

112
Q

Is gabapentin renally or hepatically excreted?

A

100% renal excretion

113
Q

At what CrCl does the dose of gabapentin need to be reduced?

A

<79ml/min

114
Q

What Pre-treatment screening may be required for some patients due to the risk of Stevens-Johnson syndrome?

A

Test for the allele HLA-B*1502 in Han Chinese and Thai patients

These patients are at an increased risk of Stevens-Johnson syndrome

115
Q

Which AEDs are associated with a risk of Stevens-Johnson syndrome?

A

Carbamazepine
Lamotrigine
Phenytoin
Phenobarbital

116
Q

Which AEDs are associated with a risk of blood disorders?

A 
Carbamazepine 
Lamotrigine 
Phenytoin 
Phenobarbital 
Sodium valproate 
Ethosuximide
117
Q

Which AEDs are associated with a risk of hepatic disorders?

A

Sodium valproate

Carbamazepine

118
Q

What are the symptoms of heparins disorders?

A 
Jaundice
Dark urine
Abdominal pain
Vomiting 
Anorexia
119
Q

Why is folate supplementation used in pregnancy?

A

To prevent neural tube defects

Pharmacy Pre-Reg 2020/2021 (18 decks)

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