Epilepsy

Question 1

What is the first line treatment for focal seizure

Answer 1

Lamotrigine or levetiracetam

Question 2

What is the second line treatment for focal seizures

Answer 2

Carbamazepine, oxcarbazepine, zonisamide

Question 3

What is the first line for tonic- clonic, myoclonic, atonic, tonic and absence with another type of seizure

Answer 3

Sodium valproate

Question 4

What is the first line for abscence seizure on its own

Answer 4

Ethosuximide

Question 5

What is the second line treatment for tonic clonic seizure

Answer 5

Lamotrigine/ levetiracetam

Question 6

What is the second line for absence seizure alone

Answer 6

Sodium valproate

Question 7

What is the second line treatment of absence seizure with another type of seizure

Answer 7

Lamotrigine and levetiracetam

Question 8

What is the second line treatment for myoclonic seizures

Answer 8

Levietiracetam

Question 9

What is the second line treatment for myoclonic seizures

Answer 9

Levietiracetam

Question 10

What is the second line treatment for myoclonic seizures

Answer 10

Levietiracetam

Question 11

What is the second line treatment for atonic seizures

Answer 11

Lamotrigine

Question 12

What is the second line treatment for tonic seizures

Answer 12

Lamotrigine

Question 13

What medicine is avoided in women who have child bearing potential

Answer 13

Sodium valproate

Question 14

What is meant by status epilepticus

Answer 14

Seizures lasting longer than 5 minutes
Provide resuscitation and immediate emergency treatment
1- patients has an individualised emergency management plan that is immediately available

2- patients doesn’t have an individualised emergency management plan immediately available

Question 15

What is the treatment plan for status epilepticus

Answer 15

Seizures lasting more than 5 minutes:
1- IV Lorazepam ( if resuscitation facilities are available)
2- buccaneers midazolam or rectal diazepam (if in community

Give a second dose if seizure doesn’t stop within 5-10 minutes of first dose

If seizure fails to respond after 2 benzodiazepams doses:
Levetiracetam, phenytoin, sodium valproate

If seizure fails to respond, try another second line. If still fails to respond then:
Phenobarbital or general anaesthesia

Question 16

What are the 3 categories of anti-epileptic drugs

Answer 16

Category 1: ensure that the patient is maintained on the same brand
Carbamazepine, phenobarbital, phenytoin, primidone

Category 2: maintaining on specific brand should be based on clinical judgment with patients factor considered
Clobazam, clonazepam, Lamotrigine, oxcarbazepine, perampanel, rufinamide, topiramate, valproate, zonisamide

Category 3: unnecessary to ensure patients are maintained on specific brands
Brivaracetam, ethosuximide, gabapentin, lacosamide, levetiracetam, pregabalin, tiagabine, vigabatrin

Question 17

What are the interactions of carbamazepine, phenytoin and sodium valproate

Answer 17

Hepatotoxicity: Amiodarone, itraconazole, macrolides, alcohol

CYP enzyme:
INDUCERS (phenytoin, phenobarbital and carbamazepine)
INHIBITORS: (sodium valproate)

Drugs that lowers the seizure threshold: Tramadol, theophylline, quinolones

Carbamazepine: Hyponatraemic drug (SSRIs, Diuretics)
Phenytoin: anti-folates (methotrexate and trimethoprim )

Question 18

What are the side effects of carbamazepine, phenytoin and sodium valproate

Answer 18

FOR ALL:
Depression and suicide
Hepatotoxicity
Hypersensitivity
Blood dyscrasia
Vitamin D deficiency (look for trigger words; bone pain)

Carbamazepine SE: hyponatraemia and Odema
Phenytoin SE: coarsening appearance and facial hair
Sodium valproate SE: pancreatitis and teratogenic (should be on pregnancy prevention programme)

Question 19

What are the other side effects for the other anti-epileptic drugs?

Answer 19

Hypersensitivity: carbamazepine, phenobarbital, phenytoin and primidone, Lamotrigine

Skin rash: Lamotrigine- Steven Johnson syndrome

Blood dyscrasia: carbamazepine, valproate, ethosuximide, topiramate, phenytoin, Lamotrigine, zonisamide

Eye disorders: vigabatrin (reduced visual field) topiramate (secondary glaucoma)

Encephalopathy: Vigabatrin

Respiratory depression: gabapentin and pregabalin

Question 20

What is the therapeutic range or carbamazepine and what are the toxic side effects

Answer 20

Therapeutic range : 4-12mg/l

Aligns of toxicity:
Hyponatraemia
Ataxia
Nystagmus
Drowsiness
Blurred vision
Arrhythmias
GI disturbances

Question 21

What is the therapeutic range of phenytoin and what are the toxic side effects

Answer 21

Therapeutic range: 10-20mg/l

Toxic side effects:
Slurred speech
Nystagmus
Ataxia
Confusion
Hyperglycaemia
Double vision

Question 22

What are the conditions of driving in epilepsy

Answer 22

If you have an epileptic fit you need to stop driving immediately and inform the DVLA

First unprovoked/single isolated- stop for 6 months

Established epilepsy: 1 year (or a pattern of seizures established for 1 year with no impact of consciousness

Medication change or withdrawal
shouldn’t drive for 6 months after last dose
Seizures occurs: licence revoked for 1 year, reinstated for after 6 months if treatment resumed and no further seizures occurred

Question 23

What are the risk of epilepsy in pregnancy

Answer 23

Risk of harm to the mother and foetus from convulsive seizure outweighs the risk of continued therapy

Folic acid is given to reduce the risk of neural tube defects in first trimester

Vitamin k injection administered at birth to minimise risk of neonatal haemorrhage

Most risk: sodium valproate
Topiramate: cleft palate

Question 24

What are the guidelines on Epilepsy and breast feeding

Answer 24

Encouraged to breast feed (combination therapy/risk factors (premature birth) give specialist advice

High prescience in milk : primidone, ethosuximide, Lamotrigine and zonisamide

Risk of drowsiness: primidone, phenobarbital and benzodiazepine

Withdrawals effects (mother stops breast feeding): phenobarbital, primidone, benzodiazepines and Lamotrigine