CNS epilepsy

Question 1

when prescribing anti-epileptics, what is the dosage frequency determined by

Answer 1

plasma-drug half-life,
should be kept as low as possible for adherence

Question 2

most antiepileptics when used in normal dosage can be given BD.
which 4 antiepileptics have long t1/2 and can be given OD at bedtime

Answer 2

Lamotrigine
perampanel
phenobarbital
phenytoin

Question 3

2 types of seizures

Answer 3

focal
generalised

Question 4

what are focal seizures

Answer 4

pt doesn’t lose consciousness
but symptoms of genaralised seizures still occur

Question 5

first and second line tx for FOCAL seizures

Answer 5

first: Lamotragine or Levetiracetam
(take 2 Ls to get focused)

second: carbamazepine, oxcarbazepine, or zonisamide (COZ)

Question 6

types of GENERALISED SEIZURES? TAM

Answer 6

TONIC-CLONIC/ATONIC/TONIC

ABSENCE

MYOCLONIC

Question 7

GENERALISED SEIZURES- 1st LINE & 2ND LINE
for TONIC-CLONIC/ATONIC/TONIC?

Answer 7

1) Sodium Valproate 2) Lamotrigine /
leve (unlicensed)

Question 8

GENERALISED SEIZURES- 1st LINE & 2ND LINE
for ABSENCE?

Answer 8

1) Ethousixime or sodium valproate (valp if high risk of generalised tonic-clonic)
2) Lamotrigine

Question 9

GENERALISED SEIZURES- 1st LINE & 2ND LINE
for MYOCLONIC (myoclonic jerks) ?

Answer 9

1) Sodium Valproate
2) Levetiracetam

Question 10

what is status epilepticus?

Answer 10

seizure lasting longer than 5 minutes

Question 11

how is status epilepticus treated?

Answer 11

IV lorazepam (if rescus facilities available)

buccal midazolam/ rectal diazepam (community)

give 2nd dose if seizure doesnt stop after 5-10mins of first dose

Question 12

status epilepticus what to do if seizure fails to respond after 2 benzo doses?
PLS

Answer 12

levetiracetam [unlicensed use], phenytoin, or sodium valproate as second line

Question 13

what to do if status epilepticus fails to respons after 2nd line?

Answer 13

phenobarbital/ general anaesthesia

Question 14

category 1 anti-epileptics are MOST severe and must ensure pt maintained on specific brands!
give 4 examples of these drugs (CP3)

Answer 14

Carbamazepine
Phenobarbital
Phenytoin
Primidone

Question 15

category 2 anti-epileptics - specific brands maintained based on clinical judgement

give examples (CL-VOP)

Answer 15

Clobazam
Clonazepam
Lamotrigine
Oxcarbazepine
Perampanel
Rufinamide
Topiramate
Valproate
Zonisamide

Question 16

category 3 anti-epileptics - unnecessary to maintain specific brands

give examples (BEG-LePre)

Answer 16

Brivaracetam
Ethosuximide
Gabapentin
Lacosamide
Levetiracetam
Pregabalin
Tiagabine
Vigabatrin

Question 17

ANTI-EPILEPTIC INTERACTIONS

CARBAMAZEPINE/PHENYTOIN/SODIUM VALPROATE? HIGH-RISK DRUGS, MUST KNOW IT ALL

Answer 17

Hepatoxicity: amiodarone, itraconazole, macrolides, alcohol

CYP inducer (CPPheno) inhibitor (Sodium Valproate)

Drugs that lower seizure threshold: Q-TTie! Quinolones (cipro, levo), Tramadol, Theophylline

Question 18

valproate must NOT be prescribed in pt < 55 (male/ female) unless what

Answer 18

2 independant specialists ocnsider + document there is no other effective/ tolerated tx
and
PPP conditions are fulfilled

Question 19

what to do if pregnancy suspected with pt on valproate?

Answer 19

DO NOT STOP. make urgent GP appt asap

Question 20

ANTI-EPILEPTIC INTERACTIONS

CARBAMAZEPINE only?

Answer 20

Hyponatraemic drug (SSRI, diuretics)

Question 21

ANTI-EPILEPTIC INTERACTIONS

PHENYTOIN only?

Answer 21

Anti-folates (Methotrexate, Trimethoprim)

phenytoin has anti folate effects thus can cause blood dyscrasias

Question 22

ANTI-EPILEPTIC SIDE-EFFECTS

CARBAMAZEPINE/PHENYTOIN/SODIUM VALPROATE? DH^2BV

Answer 22

Depression+Suicide
Hepatotoxicity
Hypersensitivity
Blood Dyscrasia
Vitamin D Deficiency (bone pain)

(drugs that work on cyp almost always cause hepatotox)

trigger words in exam: bone pain –> vit D, joint pain.. rickets !

Question 23

ANTI-EPILEPTIC SIDE-EFFECTS
CARBAMAZEPINE ONLY?

Answer 23

Hyponatraemia+Oedema

Question 24

ANTI-EPILEPTIC SIDE-EFFECTS
PHENYTOIN ONLY?

Answer 24

Coarsening Appearance + Facial Hair

Question 25

ANTI-EPILEPTIC SIDE-EFFECTS SODIUM VALPROATE ONLY?

Answer 25

Pancreatitis Teratogenic - must be on PPP

Question 26

hypersensitivity eg skin rash, allergic rhinitis, asthma is a rare but potentially fatal SE of which anti-epileptics? CP3L

Answer 26

Carbamazepine Phenytoin Phenobarbital Primidone Lamotrigine SKIN RASH? Lamotrigine->Steven-Johnson syndrome

Question 27

blood dyscrasia SE of which anti-epileptics C.VET.PLZ

Answer 27

Carbamazepine Valproate Ethosuximide Topiramate Phenytoin Lamotrigine Zonisamide

Question 28

eye disorders can be a SE of which anti epileptics? and what disorder specifically VT

Answer 28

Vigabatrin (reduced visual field) Topiramate (secondary glaucoma)

Question 29

which anti epileptic may cause encephalopathy

Answer 29

Vigabatrin

Question 30

which 2 anti epileptics (GP) may cause resp depression

Answer 30

Gabapentin Pregabalin bc given for pain. think similar to opioids - also can cause resp depression

Question 31

carbamazepine and phenytoin: high risk drugs !! whats the therap range of carbamazepine

Answer 31

4-12mg/L (Carb, 4 letters, full 12 kind of)

Question 32

signs of carbamaz toxicity HANDBAG

Answer 32

Hyponatraemia Ataxia Nystagmus Drowsiness Blurred Vision Arrhythmias GI Disturbances

Question 33

PHENYTOIN THERAPEUTIC RANGE?

Answer 33

10-20mg/L (same as theophylline)

Question 34

PHENYTOIN SIGNS OF TOXICITY? SsNA()tCH(e)D-V snachd

Answer 34

Slurred Speech Nystagmus Ataxia Confusion Hyperglycaemia Double Vision

Question 35

EPILEPSY- DRIVING. safe to drive? need to inform dvla?

Answer 35

stop driving asap and inform dvla

Question 36

if had first unprovoked (unknown cause)/ single isolated seizure, stop driving for X

Answer 36

6 months if dont have another can start driving again

Question 37

Established epilepsy: Y seizure-free, no impact on consciousness (+no history of unprovoked) can drive

Answer 37

1 year

Question 38

if have Medication change/withdrawal: Should not drive for Z after last dose

Answer 38

6 months Seizure occurs: License revoked for 1 year, but early relicense if treatment has been reinstated for 6 month+seizure-free

Question 39

epilepsy in preg. continue therapy? yes no why

Answer 39

risk of harm to mother and fetus > risk of continued therapy yes

Question 40

what drug given to reduce risk of neural tube defects in first trimester for mother on anti epileptics

Answer 40

folci acid (5mg OD)

Question 41

what injection admin at birth reduces risk of neonatal haemorrhage

Answer 41

vit K

Question 42

which is the riskiest anti epilep drug in preg

Answer 42

Sodium Valproate (PPP)

Question 43

which anti epileptic -> cleft palate

Answer 43

Topiramate

Question 44

EPILEPSY- BREASTFEEDING, BABIES MONOTHERAPY vs COMBINED?

Answer 44

Monotherapy- breast-feeding encouraged Combined therapy/Risk factors- specialist advice

Question 45

which anti epileptics ahve high presence in milk PELZ

Answer 45

Primidone Ethosuximide Lamotrigine Zonisamide

Question 46

which antiepileptics associated with RISK OF DROWSINESS? BP2

Answer 46

Benzodiazepine Phenobarbital Primidone

Question 47

which anti epileptics associated with WITHDRAWAL EFFECTS? BP2L (if mother suddenly stops breastfeeding)

Answer 47

Benzodiazepine Phenobarbital Primidone Lamotrigine *BONUS: Monitor infants for: sedation, feeding difficulties, weight gain and developmental milestones