Epilepsy Flashcards
What are the 2 types of seizures?
Generalised and Focal
What is the definition of a seizure
Abnormality in the flow of electrical activity in the brain
What are the different types of generalised seizures
MATA
Myoclonic
Atonic/tonic
Tonic-clonic
Absence
What are the different types of Focal seizures
simple and complex
What are the drug treatments of choice for Atonic/Tonic seizures
SLaRCT (a= alternatively)
(1st line) S: sodium valporate (Males, Girls under 10 years old or unable to have children)
(2nd line) L: Lamotrigine
alternatively (used as add on therapy)
R= Rufinamide
C= clobazam (new to guidance)
T= Topiramate
What are the drug treatments of choice for Tonic- Clonic seizures
SaLL
1) Sodium valporate
alternatively
2) Lamotrigine or Levetiracetam (lev= unlicensed)
potential add ons: Clobazam, perampanel, Topiramate
What are the drug treatments of choice for Absence seizures
ESaLL
1) Ethosuximide
2) Sodium valporate
alternatively
3) Lamotrigine or Levetiracetam (lev= unlicensed)
What are the drug treatments of choice for Myoclonic seizures
SaLE
1) sodium valporate (Males, Girls under 10 years old or unable to have children)
2) Levetiracetam
Add ons:
brivaracetam, clobazam, clonazepam, phenobarbital, piracetam,topiramate,zonisamide.
Which antiepileptic can exacerbate Myoclonic seizures?
Lamotrigine
What are Category 1 antiepileptics? What are their additional requirements?
CPr3
Carbamazepine
Phenytoin
Phenobarbital
Primidone
Brand continuity
Category 2 antiepileptics
Clonazepam, Clobazam, valproate, Topiramate, Lamotrigine
Category 3 antiepileptics
Levetiracetam, gabapentin, Pregabalin, Vigabatrin, Ethosuximide, Tigabine, Brivaracetam
What Generalised seizure can carbamazepine and vigabatrin be used in?
Tonic clonic (exacerbates all other types of generalised seizures)
What are the drug treatments of choice for Focal seizures seizures
1) Lamotrigine or levetiracetam
alternatively
2) Zonisamide
oxcarbazepine
carbamazepine
3) Lacosamide
What antiepileptics have a long half life (can have OD dosing)
LP3
Lamotrigine
perampanel
phenobarbital
phenytoin
What antiepileptics have an increased risk of causing hypersensitivity syndrome?
CPr3 (Carbamazepine, Phenytoin,Phenobarbital, Primidone) Lamotrigine, lacosamide and Rufinamide
what are the symptoms of hypersensitivity syndrome?
Fever, rash, liver dysfunction (abdo pain, jaundice, dark urine), pulmonary abnormalities (SOB), multi-organ failure.
STOP drug and refer
What are the MHRA warnings associated with antiepileptics?
Sodium Valproate- teratogenicity (PPP)
ALL antiepileptics= Risk of suicidal thoughts, brand switching and use in pregnancy
Topiramate= Increased risk of neurodevelopmental disabilities in children and prenatal exposure. (also can cause Cleft lip if used in pregnancy)
Benzos (clonazepam/Clobazam) + Gabapentinoids: risk of respiratory depression
What is the % risk of teratogenicity associated with sodium valproate
30-40%
How long should patients not drive for if they have a first unprovoked seizure/single isolated seizure?
6 months
How long does a patient have to be seizure free for before they continue driving?
1 year
How long should patients stop driving if they have had a dose change or are withdrawing a medication?
6 months
If a seizure occurs during dose change or withdrawal how long will their license be revoked for?
1 year
SODIUM VALPROATE- PPP
What are the contraceptive requirements?
at least ONE highly effective contraception method
or at least TWO complementary forms plus the barrier method
SODIUM VALPROATE- PPP
What are the highly effective contraceptions?
IUD (CU, Levonogestrel only), or progesterone implant
SODIUM VALPROATE- PPP
What are the complementary/user dependent forms of contraception that should be used?
Condom, cap, diaphragm, COC, fertility awareness methods
What can be given in pregnancy to prevent neuronal tube defects, and what is the dose?
folic acid 5mg
What are the antiepileptics of choice during pregnancy?
lamotrigine and levetiracetam
What can be given for the management of status epilepticus?
Iv lorazepam (where there are resuscitation facilities. e.g., hospital)
No resus facilities=
buccal midazolam (oral solution into buccal cavity- 1st line in community) OR
Rectal diazepam
How would you manage status epilepticus?
- protect head
- maintain BP, correct hypoglycemia (could be the cause), support respiration (give ox)
- parenteral thiamine if alcohol related
- Give pyridoxine (B6) if cause
Drug management of status epilepticus
1st dose of benzo- if no response call 999
2) no response= refer to emergency management plan OR give second dose of benzo after 5-10 minutes
3) No response after 2 benzo doses= second line treatment (levetiracetam, phenytoin or sodium valproate)
4) no response= 3rd line option (general anesthesia or phenobarbital (thiopental- 75–125 mg for 1 dose)
Carbamazepine indications (epileptic and non epileptic)
Focal seizures, tonic clonic seizures, Prophylaxis of bipolar (unresponsive to lithium), trigeminal neuralgia (licensed)
acute alcohol withdrawal + diabetic neuropathy (unlicensed)
Carbamazepine
Patient and carer advice
can cause Blood, hepatic and skin disorders.
medical attention if fever, rash, sore throat, mouth ulcers, bleeding or bruising.
Carbamazepine
What is the therapeutic range?
4-12mg/L (20-50mcmol/L)
measured 1-2 weeks after dosing
Carbamazepine
Side effects?
HANDBAG
HYPONATRAEMIA
Ataxia
Nystagmus (involuntary movement of the eyes)
Drowsiness/Dizziness
Blurred vision
Arrhythmias
Gastro (N&V)
common at the start of treatment and can be reduced by giving MR preps
Carbamazepine
Cautions
Cardiac disease; history of haematological reactions to other drugs; presence of HLA-B1502 or HLA-A3101 allele (chinese or Han Thai origin) ; seizures (Dravet syndrome, Lennox-Gastaut syndrome. also may be exacerbated- generalised except tonic clonic); skin reactions- SJS ; susceptibility to angle-closure glaucoma
Carbamazepine
Treatment cessation (withdrawing for bipolar)
withdraw gradually over a period of 4 weeks
Carbamazepine
Interactions
- DOAC- Apixaban (reduces efficacy of apix by 50%)
- CYP enz inducers and inhibitors (macrolides, some antifungals, omep, metronidazole)
- Clozapine
- contraceptives/progestogens - decrease efficacy of COC/deso/norethist/ ulipristal (avoid for 4 weeks after stopping)
- Isoniazid
- Lithium (inc neurotox)
- Ticagrelor (decrease exposure of Tic)
- Tramadol (decrease conc)
- rate limiting CCB- inc conc of carbamazepine and decreases exposure to CCB
- atorv/amlod decrease exposure
How long should you avoid Ulipristal after stopping carbamazepine
4 weeks
MHRA warnings for sodium valproate?
ALL antiepileptics= risk of suicidal thoughts
Sod Val= teratogenic
Sodium valporate indications
epilepsy, mania and migraine prophylaxis
Sodium valporate
Side effects
V
Appetite increase
Liver failure
Pancreatitis
Reversible hair loss (alopecia)
Oedema
Ataxia
Teratogenicity and tremor
Encephalopathy
+ Hyponatraemia
When should Sodium valproate be withdrawn?
Liver dysfunction (particularly children <3) - persistent vomiting, abdo pain, anorexia, jaundice, oedema, malaise, drowsiness, or loss of seizure control
pancreatitis- pain in abdomen, N&V, fever, chills, tachycardia, SOB
Serious Sodium Valproate interactions
Lamotrigine- Increases exposure= increase risk of SJS
Olanzapine
Phenytoin- monitor conc
Topiramate- increased risk of toxicity
Pivmecillinam- avoid
Carbapenems- imipenem, etrapenem and meropenem (AVOID)
Phenytoin
indications
Tonic clonic seizures, focal seizures, status epilepticus
Phenytoin
What route should be avoided?
IM- slow and erratic absorption
Phenytoin
Target range
10-20mg/L (40-80micromol/L)
PhenyTEN= pneumonic
Phenytoin
Toxicity symptoms
Nystagmus
slurred speech
ataxia
confusion
hyperglycaemia
Blood and skin disorders- Med attention
Rash= discontinue
Phenytoin
serious interactions
Amiodarone
DOACs (all)
Bupropion and buspirone
carbamazepine
ciclosporin
Oral contraceptives- COC, desogestrel, ulipristal,levonogestrel
miconazole
valproate
Folic acid
(phenytoin= enzyme inducer)
Phenytoin
Side effects
P-450 INDUCER
Hair changes- hirsutism (thick and dark body hair)
Enlarged gums (gingival hyperplasia)
NYstagmus and ataxia
Teratogenicity
Osteopenia (loss in bone density)
Insomnia, Immune system- agranulocytosis, thrombocytopenia.
Neuropathy
What antiepileptic needs to be endorsed with SLS?
Clobazam
What is the most common side effect of vigabatrin
Visual disturbances (VIgabatrin- VIsual) - REPORT
test 6 months before treatment and at 6 monthly intervals
