Epilepsy Flashcards
What further information may be required for epilepsy case?
History of presenting complaint
Past medical
Family history
What investigations may be carried out for epilepsy?
Electroencephalograph (EEG)
Electrocardiogram (ECG)
Imaging (MRI)
Blood tests (FBC, U&Es, Blood glucose)
What is considered for treatment of epilepsy?
Type of epilepsy
Age (pregnancy)
Side effects
Co-morbidities
Education about epilepsy
Information about epilepsy Lifestyle factors impacted by seizures Driving regulations Home safety adaptations Sports and physical activity
Initiating anti-epileptic drug
Monotherapy Preferred
Star low dose
1-2 daily for adherence
Wean if changing
Why is combination of anti-epileptics avoided?
Increased risk of adverse effects and interactions
Generalised tonic-clonic seizures first line drugs
Carbamazepine
Lamotrigine
Oxcarbazepine
Sodium valproate
Tonic or atonic seizures first line drugs
Sodium valproate
Absence seizures first line drugs
Ethosuximide
Lamotrigine
Sodium valproate
Myoclonic seizures first line drugs
Levetiracetam
Sodium valproate
Topiramate
Generalised tonic-clonic seizures adjunctive drugs
Clobazam Lamotrigine Levetiracetam Sodium valproate Topiramate
Tonic or atonic seizures adjunctive drugs
Lamotrigine
Absence seizures adjunctive drugs
Ethosuximide
Lamotrigine
Sodium valproate
Myoclonic seizures adjunctive drugs
Levetiracetam
Sodium valproate
Topiramate
Why is Sodium valproate commonly prescribed?
It has a broad spectrum and able to have action on arrange of different seizures.
Side effects of sodium valproate
•Aggression, anaemia, drowsiness/ confusion, tremor, nausea & diarrhoea
- Weight gain: progressive and significant
- Increase in seizures
- Menstrual disturbances
- Transient hair loss
- Rarely: hepatotoxicity, thrombocytopenia, pancreatitis
Monitoring with sodium valproate
LFTs, FBC and BMI
Interaction with sodium valproate
- Broad enzyme inhibitor - CYPs, UGTs, epoxide hydrolase
- Inc plasma level of interacting drugs
- Inc risk of toxicity
- Other AEDs especially Lamotrigine, Phenytoin (highly protein bound)
- Other drugs: TCA’s, olanzapine
- Effect on valproate levels: COCs, carbapenems
How does oral contraceptives affect sodium valproate?
Reduce the sodium valproate due to CYP450 so dose will need to be increased.
What is sodium valproate contra-indicated in?
Childbearing potential, pregnancy and children (females). Appropriate contraception and counselling required.
Lamotrigine side effects
- Generally well tolerated
- Blurred vision, agitation, arthralgia, ataxia, back pain, diarrhoea, drowsiness, dry mouth, headache, insomnia, nausea & vomiting, tremor
Lamotrigine skin reactions
Severe reactions can occur usually within first 8 weeks.
Greater risk in children, patients with previous allergies, patients on combination treatment and with high starting dose / rapid titration
Carbamazepine use
Effective for focal seizures; primary clonic and secondarily generalised tonic clonic seizures
What can Carbamazepine worsen
Absence and myoclonic seizures
Carbamazepine side effects
Lots
CNS active so CNS side effects.
Carbamazepine monitoring
FBC, U&Es prior to initiation and periodically
What enzyme does carbamazepine induce?
Potent CYP3A4 inducer (auto inducer), So interactions associated with other CYP3A4 inducers and inhibitors.
What is Oxcarbazepine
Structural derivative of carbamazepine to avoid metabolites causing side effects and interactions
What does Oxcarbazepine do with hormonal contraceptives?
Loss of effectiveness of hormonal contraceptive
Levtiracetam (Kepra) use
Monotherapy OR adjunctive therapy for focal seizures with or without secondary generalisation
Levtiracetam (Kepra) side effects
Well tolerated: drowsiness, headache, Gi effects, mood alterations including anxiety
Risk of suicidal thoughts and behaviour and AEDs
All AEDs associated with a small increased risk of suicidal thoughts and behaviour. Seek adive.
Supply of AEDs Category 1
– Maintain on a specific manufacturer’s product.
– E.g. - Phenytoin, Carbamazepine, Phenobarbital, Primidone
Supply of AEDs Category 2
– Use of same brand based on clinical judgement and consultation with patient
– E,g, - Valproate, Lamotrigine, Oxcarbazepine, Eslicarbazepine, Zonisamide, Topiramate
Supply of AEDs Category 3
– Usually unnecessary to keep specific brand
– E.g. - Levetiracetam, Tiagabine, Gabapentin, Pregabalin
Lifestyle advice
Maintain a balanced diet
Exercise regularly
Good sleep hygiene
Driving advice
Lifestyle advice: Maintain a balanced diet
– Some people may have food “triggers”
– Avoid excessive alcohol intake
– Avoid dehydration
Lifestyle advice: Exercise regularly
– People with epilepsy tend to exercise less than others
– Exercise has been shown to reduce seizures
– Associated with protective effects against common co-morbidities