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Pre-reg > Epilepsy > Flashcards

Epilepsy Flashcards

1
Q

What are the 2 types of seizures?

A

Generalised and Focal

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2
Q

What is the definition of a seizure

A

Abnormality in the flow of electrical activity in the brain

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3
Q

What are the different types of generalised seizures

A

MATA
Myoclonic
Atonic/tonic
Tonic-clonic
Absence

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4
Q

What are the different types of Focal seizures

A

simple and complex

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5
Q

What are the drug treatments of choice for Atonic/Tonic seizures

A

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

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6
Q

What are the drug treatments of choice for Tonic- Clonic seizures

A

SaLL
1) Sodium valporate
alternatively
2) Lamotrigine or Levetiracetam (lev= unlicensed)

potential add ons: Clobazam, perampanel, Topiramate

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7
Q

What are the drug treatments of choice for Absence seizures

A

ESaLL
1) Ethosuximide
2) Sodium valporate
alternatively
3) Lamotrigine or Levetiracetam (lev= unlicensed)

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8
Q

What are the drug treatments of choice for Myoclonic seizures

A

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.

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9
Q

Which antiepileptic can exacerbate Myoclonic seizures?

A

Lamotrigine

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10
Q

What are Category 1 antiepileptics? What are their additional requirements?

A

CPr3
Carbamazepine
Phenytoin
Phenobarbital
Primidone

Brand continuity

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11
Q

Category 2 antiepileptics

A

Clonazepam, Clobazam, valproate, Topiramate, Lamotrigine

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12
Q

Category 3 antiepileptics

A

Levetiracetam, gabapentin, Pregabalin, Vigabatrin, Ethosuximide, Tigabine, Brivaracetam

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13
Q

What Generalised seizure can carbamazepine and vigabatrin be used in?

A

Tonic clonic (exacerbates all other types of generalised seizures)

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14
Q

What are the drug treatments of choice for Focal seizures seizures

A

1) Lamotrigine or levetiracetam
alternatively
2) Zonisamide
oxcarbazepine
carbamazepine

3) Lacosamide

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15
Q

What antiepileptics have a long half life (can have OD dosing)

A

LP3
Lamotrigine
perampanel
phenobarbital
phenytoin

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16
Q

What antiepileptics have an increased risk of causing hypersensitivity syndrome?

A

CPr3 (Carbamazepine, Phenytoin,Phenobarbital, Primidone) Lamotrigine, lacosamide and Rufinamide

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17
Q

what are the symptoms of hypersensitivity syndrome?

A

Fever, rash, liver dysfunction (abdo pain, jaundice, dark urine), pulmonary abnormalities (SOB), multi-organ failure.
STOP drug and refer

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18
Q

What are the MHRA warnings associated with antiepileptics?

A

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

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19
Q

What is the % risk of teratogenicity associated with sodium valproate

A

30-40%

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20
Q

How long should patients not drive for if they have a first unprovoked seizure/single isolated seizure?

A

6 months

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21
Q

How long does a patient have to be seizure free for before they continue driving?

A

1 year

22
Q

How long should patients stop driving if they have had a dose change or are withdrawing a medication?

A

6 months

23
Q

If a seizure occurs during dose change or withdrawal how long will their license be revoked for?

A

1 year

24
Q

SODIUM VALPROATE- PPP
What are the contraceptive requirements?

A

at least ONE highly effective contraception method

or at least TWO complementary forms plus the barrier method

25
Q

SODIUM VALPROATE- PPP
What are the highly effective contraceptions?

A

IUD (CU, Levonogestrel only), or progesterone implant

26
Q

SODIUM VALPROATE- PPP
What are the complementary/user dependent forms of contraception that should be used?

A

Condom, cap, diaphragm, COC, fertility awareness methods

27
Q

What can be given in pregnancy to prevent neuronal tube defects, and what is the dose?

A

folic acid 5mg

28
Q

What are the antiepileptics of choice during pregnancy?

A

lamotrigine and levetiracetam

29
Q

What can be given for the management of status epilepticus?

A

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

30
Q

How would you manage status epilepticus?

A
  • protect head
  • maintain BP, correct hypoglycemia (could be the cause), support respiration (give ox)
  • parenteral thiamine if alcohol related
  • Give pyridoxine (B6) if cause
31
Q

Drug management of status epilepticus

A

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)

32
Q

Carbamazepine indications (epileptic and non epileptic)

A

Focal seizures, tonic clonic seizures, Prophylaxis of bipolar (unresponsive to lithium), trigeminal neuralgia (licensed)
acute alcohol withdrawal + diabetic neuropathy (unlicensed)

33
Q

Carbamazepine
Patient and carer advice

A

can cause Blood, hepatic and skin disorders.
medical attention if fever, rash, sore throat, mouth ulcers, bleeding or bruising.

34
Q

Carbamazepine
What is the therapeutic range?

A

4-12mg/L (20-50mcmol/L)
measured 1-2 weeks after dosing

35
Q

Carbamazepine
Side effects?

A

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

36
Q

Carbamazepine
Cautions

A

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

37
Q

Carbamazepine
Treatment cessation (withdrawing for bipolar)

A

withdraw gradually over a period of 4 weeks

38
Q

Carbamazepine
Interactions

A
  • 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
39
Q

How long should you avoid Ulipristal after stopping carbamazepine

A

4 weeks

40
Q

MHRA warnings for sodium valproate?

A

ALL antiepileptics= risk of suicidal thoughts

Sod Val= teratogenic

41
Q

Sodium valporate indications

A

epilepsy, mania and migraine prophylaxis

42
Q

Sodium valporate
Side effects

A

V
Appetite increase
Liver failure
Pancreatitis
Reversible hair loss (alopecia)
Oedema
Ataxia
Teratogenicity and tremor
Encephalopathy
+ Hyponatraemia

43
Q

When should Sodium valproate be withdrawn?

A

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

44
Q

Serious Sodium Valproate interactions

A

Lamotrigine- Increases exposure= increase risk of SJS
Olanzapine
Phenytoin- monitor conc
Topiramate- increased risk of toxicity
Pivmecillinam- avoid
Carbapenems- imipenem, etrapenem and meropenem (AVOID)

45
Q

Phenytoin
indications

A

Tonic clonic seizures, focal seizures, status epilepticus

46
Q

Phenytoin
What route should be avoided?

A

IM- slow and erratic absorption

47
Q

Phenytoin
Target range

A

10-20mg/L (40-80micromol/L)
PhenyTEN= pneumonic

48
Q

Phenytoin
Toxicity symptoms

A

Nystagmus
slurred speech
ataxia
confusion
hyperglycaemia
Blood and skin disorders- Med attention
Rash= discontinue

49
Q

Phenytoin
serious interactions

A

Amiodarone
DOACs (all)
Bupropion and buspirone
carbamazepine
ciclosporin
Oral contraceptives- COC, desogestrel, ulipristal,levonogestrel
miconazole
valproate
Folic acid
(phenytoin= enzyme inducer)

50
Q

Phenytoin
Side effects

A

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

51
Q

What antiepileptic needs to be endorsed with SLS?

A

Clobazam

52
Q

What is the most common side effect of vigabatrin

A

Visual disturbances (VIgabatrin- VIsual) - REPORT
test 6 months before treatment and at 6 monthly intervals

Pre-reg (13 decks)

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