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Central Nervous System > epilepsy > Flashcards

epilepsy Flashcards

1
Q

what is the aim of epilepsy control

A

prevent the occurrence of seizures by maintaining an effective dose of one or more antiepileptic drugs

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2
Q

what should you consider when choosing an antiepileptic drug

A
  • first the presenting epilepsy syndrome
  • If the syndrome is not clear, the seizure type should determine the choice of treatment
  • note you should also take into account patients other medication, co-morbidity, age, and sex*
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3
Q

what determines the dosage frequency of antiepileptic drugs

A

The plasma half life.

- frequency of doses should be kept as low as possible to encourage adherence to meds

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4
Q

which antiepileptics can be given once daily due to their long half life

(acronym: LPPP)

A
  • Lamotrigine
  • perampanel
  • phenobarbital
  • phenytoin
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5
Q

how do you switch a patient from one antiepileptic to another

A
  • if first line monotherapy has failed, check the diagnosis again and then consider starting a second drug (monotherapy)
  • slowly withdraw the first drug only when the new regimen with the second drug has been established
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6
Q

what are the disadvantages of combination therapy with antiepileptics

A

increased risk of:

  • adverse reactions
  • drug interactions

note monotherapy with antiepileptics should be prescribed whenever possible

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7
Q

why should patients/carers be advised to report any mood changes, distressing thoughts/feelings when taking antiepileptics

A

because all antiepileptics are associated with an increased risk of suicidal thoughts and behaviours

note this can be seen as early as 1 week into treatment

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8
Q

Should a patient taking antiepileptics stop treatment if they are experiencing suicidal thoughts/behaviours

A

No, do not stop or switch antiepileptic treatment. Seek advice from a healthcare professional if concerned

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9
Q

why are antiepileptic drugs categorised into 3 risk-based categories

A

to help healthcare professionals decide whether it is necessary to supply a specific manufacturers version of antiepileptic drug

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10
Q

what are the 3 risk-based categories of antiepileptics

name examples of antiepileptic drugs in each category

A
  • CATEGORY 1: ensure patient is maintained on a specific manufacturer’s product.
    e. g Carbamazepine, phenobarbital, phenytoin, primidone
  • CATEGORY 2: need to supply a specific manufacturers product based on clinical judgement + consultation with the patient and/or carer taking into account factors such as seizure frequency, treatment history, and potential implications to the patient of having a breakthrough seizure.

E.g clobazam, clonazepam, eslicarbazepine acetate, lamotrigine, oxcarbazepine, perampanel, rufinamide, topiramate, valproate, zonisamide

  • CATEGORY 3: it is usually unnecessary to ensure that patients are maintained on a specific manufacturer’s product as therapeutic equivalence can be assumed.
    e. g Brivaracetam, ethosuximide, gabapentin, lacosamide, levetiracetam, pregabalin, tiagabine, vigabatrin
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11
Q

name the antiepileptic drugs (category 1) that you need to make sure a patient stays on a specific manufacturer’s brand

A
  • Carbamazepine
  • phenobarbital
  • phenytoin
  • primidone
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12
Q

what are the symptoms of Antiepileptic hypersensitivity syndrome

name some antiepileptics are associated with this

A

fever, rash, and lymphadenopathy (enlarged lymph node) are most commonly seen. other signs could be liver dysfunction, renal/pulmonary abnormalities, multi-organ failure.

antiepileptics associated with this: carbamazepine, lamotrigine, oxcarbazepine, phenobarbital, phenytoin, primidone, and zonisamide

note symptoms can start between 1-8 weeks of starting treatment

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13
Q

what should happen if a patient shows symptoms of antiepileptic hypersensitivity syndrome

A

the drug should be withdrawn immediately, the patient must not be re-exposed, and expert advice should be sought

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14
Q

what normally causes interactions between antiepileptic drugs

A

hepatic enzyme induction or inhibition

note interactions between antiepileptics are varibale + unpredictable

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15
Q

how do you withdraw a patient taking an antiepileptic

A
  • should be withdrawn under specialist supervision
  • Avoid abrupt withdrawal (particularly of barbiturates and benzodiazepines)
  • In patients receiving several antiepileptic drugs, only one drug should be withdrawn at a time
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16
Q

why must you avoid abrupt withdrawal especially when a patient is taking barbiturates (e.g phenobarbital) and benzodiazepines (e.g clonazepam, clobazam)

A

because abrupt withdrawal in these can cause severe rebound seizures

note withdrawal of barbiturates can take months

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17
Q

what are the rules around epilepsy + Driver and Vehicle Licensing Agency (DVLA).

A
  • If a driver has a seizure (of any type) they must stop driving immediately and inform DVLA
  • DVLA recommends not to drive during medication changes or withdrawal. if a seizure occurs during this, driving license revoked for 1 year
  • after first unprovoked epileptic seizure or a single isolated seizure do not drive for 6 months. Then assessed by specialist as fit to drive
  • those with established epilepsy can drive as long as not danger to public + compliant with treatment. Must be seizure-free for at least one year or have no history of unprovoked seizures
  • if a seizure occurs whilst asleep, stop driving for 1 year from last seizure date. unless pattern established that seizures only occur during sleep over 1 year
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18
Q

what is the risk of taking antiepileptic drugs whilst pregnant

when is this risk the highest

A

increased of teratogenicity

highest risk:

  • during first trimester
  • if patient is taking 2 or more antiepileptic drugs
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19
Q

when is the only time sodium valporate can be used in women of childbearing age

A
  • conditions of the Pregnancy Prevention Programme are met

- alternative treatments are ineffective or not tolerated

20
Q

name the 2 safest antiepileptic drugs to take during pregnancy

A

lamotrigine and levetiracetam

21
Q

what advice would you give to epileptic women planning a pregnancy

A
  • not to stop their antiepileptic treatment without discussing this with their doctor (treatment based on clinical condition + circumstance)
  • urgently referred to a specialist for advice and offered folic acid
22
Q

which contraception is part of the pregnancy prevention programme

A

The long-acting reversible contraceptives (LARC):

  • copper intrauterine device (Cu-IUD),
  • levonorgestrel intrauterine system (LNG-IUS)
  • progestogen-only implant (IMP)

note some antiepileptic drugs can reduce the efficacy of hormonal contraceptives, and the efficacy of some antiepileptics may be affected by hormonal contraceptives

23
Q

what is given during the first trimester to reduce neural tube defects from antiepileptics

A

folate supplementation (folic acid) is advised throughout the first trimester

24
Q

how do you minimise the risk of neonatal haemorrhage associated with antiepileptics

A

Routine injection of vitamin K at birth

25
Q

which antiepileptics can cause withdrawal effects in newborns

A

some antiepileptic drugs, in particular benzodiazepines (e.g clonazepam, clobazam) and phenobarbital.

26
Q

TRUE OR FALSE

women taking antiepileptics should not breastfeed

A

False.

Women taking antiepileptic monotherapy should generally be encouraged to breastfeed. if on combination therapy- seek specialist advice

note withdrawal effects can occur if a mother suddenly stops breastfeeding

27
Q

what should all breastfed infants from women taking antiepileptics be monitored for

A
  • monitored for: sedation, feeding difficulties, adequate weight gain, and developmental milestones
  • if breast-fed infants are suspected of having adverse drug effects, monitor serum-drug concentration
28
Q

what is the treatment options for Focal seizures with or without secondary generalisation

mnemonic: foCAL

A
  • Carbamazepine and lamotrigine are first-line options. (oxcarbazepine, sodium valproate and levetiracetam can be used if first-line intolerated)

extra info:
- if monotherapy unsuccessful with first line options, consider adjunctive therapy with clobazam, gabapentin, lamotrigine, levetiracetam, oxcarbazepine, sodium valproate, or topiramate

  • if adjunctive therapy isn’t successful a tertiary epilepsy specialist should be consulted
29
Q

what are the treatment options for generalised tonic-clonic seizures

A
  • sodium valproate

- lamotrigine is the alternative if sodium valproate unsuitable (e.g women of childbearing age)

30
Q

what are the treatment options for absence seizures and syndromes

mnemonic: SEAL

A
  • first line: Ethosuximide, or sodium valproate
    lamotrigine is the alternative is both unsuitable
  • A combination of any two of these drugs may be used if monotherapy is ineffective
31
Q

what are the treatment options for Myoclonic seizures (myoclonic jerks)

mnemonic: SALT

A

first line: sodium valproate

  • topiramate (has less favourable side effects) and levetiracetam are alternative options
  • A combination of two of these drugs may be used if monotherapy is ineffective or not tolerated
32
Q

which type of seizures are usually seen in childhood or associated with cerebral damage or mental retardation

what is the treatment for them
mnemonic: SLART

A

Atonic and tonic seizures

Treatment:

  • first line: sodium valproate
  • lamotrigine can be added as adjunctive treatment
33
Q

what are epilepsy syndromes

name the 2 type of epilepsy syndromes

A

specific types of epilepsy that are characterised based on the number of features including seizure type, age of onset, and EEG characteristics

  • Dravet syndrome
  • Lennox-Gastaut syndrome
34
Q

Name the 6 types of seizures/syndromes where sodium valproate is the first-line treatment

A
  • generalised tonic-clonic seizures
  • absence seizures and syndromes
  • Myoclonic seizures
  • Atonic and tonic seizures
  • Dravet syndrome
  • Lennox-Gastaut syndrome
35
Q

what are Gabapentin and Pregabalin used to treat

A
  • focal seizures with or without secondary generalisation

- neuropathic pain

36
Q

which antiepileptics should NOT be used in tonic, atonic, myoclonic and absence seizures

A
  • Carbamazepine
  • Oxcarbazepine
  • Gabapentin
  • Pregabalin

this is because these drugs exacerbate these types of seizures

37
Q

which antiepileptic causes a cleft palate in newborns if taken during pregnancy

A

topiramate

38
Q

which antiepileptic increases the plasma concentration of lamotrigine

A

sodium valproate

39
Q

which antiepileptic is converted to phenobarbital in the body

A

Primidone. It is largely converted to phenobarbital which causes it’s antiepileptic effect

40
Q

Phenytoin has a narrow therapeutic index and the relationship between dose and plasma-drug concentration is non-linear. How does this affect dosage

A
  • small dosage increases in some patients may produce large increases in plasma concentration with acute toxic side-effects
  • Similarly, a few missed doses or a small change in drug absorption may result in a marked change in plasma-drug concentration
  • note non-linear dose and plasma-drug concentration means that the plasma concentration does not correlate with the dose*
41
Q

which antiepileptic is used to treat Lennox-Gastaut syndrome (an epilepsy syndrome)

A

Rufinamide

  • topiramate can also be used in adjunctive treatment
42
Q

what needs to be monitored in patients taking sodium valproate

A
  • liver function tests and full blood count

this is because it has widespread metabolic effects

43
Q

what is Convulsive status epilepticus

A
  • when a seizure lasts for 5+ minutes

OR

  • One tonic-clonic seizure follows another without the person regaining consciousness in between
44
Q

what are the immediate measures to manage Convulsive status epilepticus

A
  • positioning the patient to avoid injury
  • supporting respiration including the provision of oxygen
  • maintaining blood pressure
  • correction of any hypoglycaemia
45
Q

how do you treat seizures lasting more than 5 minutes during Convulsive status epilepticus

A
  • intravenous lorazepam (a benzodiazepine) .repeated once after 10 minutes if seizures recur or fail to respond.
  • monitor patients for respiratory depression and hypotension

note Intravenous diazepam is effective but it carries a high risk of thrombophlebitis (blood clot formation).

46
Q

how do you treat seizures lasting more than 5 minutes during Convulsive status epilepticus if there are no facilities for resuscitation

A
  • diazepam can be administered as a rectal solution or

- midazolam oromucosal solution can be given into the buccal cavity

47
Q

what can be used to treat Convulsive status epilepticus if benzodiazepines have failed to treat it after 25 minutes

A

phenytoin sodium, fosphenytoin sodium, or phenobarbital sodium should be used; contact intensive care unit if seizures continue

Central Nervous System (12 decks)

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