Epilepsy Flashcards by Salimah Ali

What further information may be required for epilepsy case?

History of presenting complaint
Past medical
Family history

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What investigations may be carried out for epilepsy?

Electroencephalograph (EEG)
Electrocardiogram (ECG)
Imaging (MRI)
Blood tests (FBC, U&Es, Blood glucose)

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What is considered for treatment of epilepsy?

Type of epilepsy
Age (pregnancy)
Side effects
Co-morbidities

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Education about epilepsy

Information about epilepsy
 Lifestyle factors impacted by seizures
 Driving regulations
 Home safety adaptations
 Sports and physical activity

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Initiating anti-epileptic drug

Monotherapy Preferred
Star low dose
1-2 daily for adherence
Wean if changing

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Why is combination of anti-epileptics avoided?

Increased risk of adverse effects and interactions

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Generalised tonic-clonic seizures first line drugs

Carbamazepine
Lamotrigine
Oxcarbazepine
Sodium valproate

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Tonic or atonic seizures first line drugs

Sodium valproate

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Absence seizures first line drugs

Ethosuximide
Lamotrigine
Sodium valproate

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Myoclonic seizures first line drugs

Levetiracetam
Sodium valproate
Topiramate

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Generalised tonic-clonic seizures adjunctive drugs

Clobazam
 Lamotrigine
 Levetiracetam
 Sodium valproate
 Topiramate

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Tonic or atonic seizures adjunctive drugs

Lamotrigine

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Absence seizures adjunctive drugs

Ethosuximide
Lamotrigine
Sodium valproate

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Myoclonic seizures adjunctive drugs

Levetiracetam
Sodium valproate
Topiramate

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Why is Sodium valproate commonly prescribed?

It has a broad spectrum and able to have action on arrange of different seizures.

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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