EPILEPSY Flashcards
What is epilepsy?
Common condition that affects the brain and causes frequent seizures
What are the types of seizures?
- Focal
- Generalised
- Status epilepticus
What is a FOCAL seizure?
- Affects one hemisphere
- Can become generalised
- Patient aware they are having a seizure
What is a GENERALISED seizure?
- Can affect both hemispheres
- Typically associated with impaired awareness (unconscious, pt may not know they’ve had a seizure)
o Tonic clonic
o Absence
o Atonic
What is the FIRST line treatment for FOCAL seizures?
Lamotrigine
Levetiracetam
What is the SECOND line treatment for FOCAL seizures?
Carbamazepine
Oxcarbazepine
Zonisamide
What is the treatment for TONIC CLONIC seizures?
- SV
- L/L
What is the treatment for ABSENCE seizures?
- E
- SV
What is the treatment for ABSENCE + OTHER seizures?
- SV
- L/L
What is the treatment for MYOCLONIC seizures?
- SV
- Levetiracetam
What is the treatment for ATONIC/TONIC seizures?
- SV
- Lamotrigine
Should women take first or second line?
- Women to take second-line option if at child bearing potential age – currently or in the future.
- Except for in absence
What is SUDEP?
Sudden Unexpected Death in Epilepsy (SUDEP)
* Rare
* Person dies during or following seizure
What are the risk factors for SUDEP?
- Uncontrolled/poorly controlled seizures
- Frequent seizures
- Nocturnal seizures
What is the non-pharmacological treatment for management of seizures?
- Write seizure in a seizure diary: date, time, brought on by any certain activity, day time, night time
- Protect from injury
- Do not restrain them or put anything in their mouth
- Check airways and place in recovery position
- Observe until recovered
- Examine for injuries
What is status epilepticus?
Seizure last more than 5 mins/ recurrent seizure with no recovery
FIRST line treatment of SE in community
Buccal midazolam or
PR diazepam
FIRST line treatment of SE in hospital
IV lorazepam
What do we give if there is no response within 5-10 mins of first line treatment for SE?
NO RESPONSE within 5-10mins of 1st dose = 2nd DOSE
SECOND line treatment of SE
LEVETIRACETAM, PHENYTOIN, SV
- If no response, try a different 2nd line
- If still no response = phenobarbital or
general anaesthesia
When would you call an ambulance for SE?
- Call ambulance for urgent hospital admission if seizures DO NOT respond promptly to treatment
- Call an ambulance for urgent hospital admission if seizures DO respond to treatment but:
a. Seizures were prolonged or recurrent before treatment
b. High risk of recurrence
c. Difficulties monitoring persons conditions
d. First seizure
Category 1 AEDs
- Carbamazepine
- Phenobarbital
- Phenytoin
- Primidone
Category 2 AEDs
- Clobazam
- Clonazepam
- Lamotrigine
- Oxcarbazepine
- Perampanel
- Rufinamide
- Topiramate
- Valproate
- Zonisamide
Category 3 AEDs
- Brivaracetam
- Leveiracetam
- Ethosuximide
- Gabapentin
- Lacosamide
- Pregabalin
- Tiagabine
- Vigabatrin
Which drugs interact with AEDs to cause hepatotoxicity?
- amiodarone
- itraconazole
- macrolides (mycins)
- alcohol
Which AEDs are CYP enzymes INDUCERS?
- carbamazepine
- phenytoin
- phenobarbital
Phenytoin as an enzyme inducer
Reduces conc of
- hormonal concentreptive/ HRT
- warfarin
- levothyroxine
Causes increased antifolaxe effect with methotrexate and trimethoprim
Which drugs interact with AEDs to lower seizure threshold?
o Tramadol
o Theophylline
o Quinolones
What are the SFx of Carbamazepine?
- Oedema
- Hyponatraemia
What drugs should you avoid with carbamazepine?
Hyponatraemic drugs
- SSRIS
- Diuretics
What are the SFx of Phenytoin?
- Antifolate reaction
- Coarsening appearance e.g. gingivitis + facial hair
What drugs should you avoid with Phenytoin?
Anti-folates
- methotrexate
- trimethoprim
can lead to blood dyscrasias
What is blood dyscrasia
An imbalance of the four bodily fluids - blood, bile, lymph, phlegm
AEDs SFx general
- Depression + suicide
- Hepatotoxicity
- Hypersensitivity: CPPPLamo
- Blood dyscrasia: C,V,E,T,Phen,Lamo,Z (C VET PLZ)
- Vit d def
- Skin rash e.g. stevens-johnsons syndrome: lamotrigine
- Eye disorder
o Vigabatrin (reduces visual field)
o Topiramate (secondary glaucoma) - Encephalopathy: Vigabatrin
- Respiratory depression: Gabapentin, pregabalin
What is the therapeutic range for carbamazepine?
4-12mg/L
What is the therapeutic range for Phenytoin?
10-20mg/L
What are the signs of toxicity of carbamazepine?
Hyponatraemia
Ataxia
Nystagmus
Drowsiness
Blurred vision
Arrythmias
Gastrointestinal disturbances
What are the signs of toxicity of Phenytoin?
Slurred speech
Nystagmus
Ataxia
Confusion
Hyperglycaemia
Double vision
What AEDs cause blood dyscrasia?
Carbamazepine
Valproate
Ethosuxidimide
Topiramate
Phenytoin
Lamotrigine
Zonisamide
C VET PLZ
Which AED reduces visual field?
Vigabatrin
Which AED causes encephalopathy?
Vigabatrin
Which AED can cause secondary glaucoma
topiramate
Which AEDS can cause respiratory depression
Gabapentin
Pregabalin
When would you consider Vit D supplementation in epileptic patients
- In those who are immobilised for long period of time
- Inadequate sun exposure or dietary intake of Ca
Monitoring for AEDs
- Test for HLA-B* 1502 allele in individuals of Han Chinese or Thai origin - Risk of SIS
- Plasma conc
- Renal
- Hepatic
What is the dose equivalence between phenytoin sodium and the phenytoin base
100mg of phenytoin sodium is approx equivalent in therapeutic effect to 92mg phenytoin base
Driving with epilepsy: 1st unprovoked/ single isolated
- Driver must stop immediately and inform the DVLA
- must not drive for 6 months
Driving with epilepsy: established epilepsy
o 1 year (or pattern of seizures established for 1 year with no impact on consciousness)
Driving with epilepsy: seizure while asleep
o Not permitted to drive for 1 yr
Driving with epilepsy: med change withdrawal
o Should not drive for 6 months after last dose
o Seizure occurs: license revoke for 1 year, reinstated after 6 months if treatment resumed and no further seizures occurred
Teratogenicity and sodium valproate
- Increased risk of teratogenicity associated with the use of AEDs
o Valproate highly teratogenic
o Congenital malformations and neurodevelopmental disorders
What are safer alternative to sodium valproate
lamotrigine
levetiracetam
What is the risk to babies of topiramate
cleft palate
Folic acid in pregnancy
reduces the risk of neural tube defects in 1st trimester
Vitamin K injection in pregnancy
administered at birth to minimises risk of neonatal haemorrhage
o Phytomenadione
What should infants be monitored for
o Sedation
o feeding difficulties
o adequate weight gain
o developmental milestones
BREASTFEEDING: high presence in breast milk
Primidone, Etho, Lamo, Z (PELZ)
BREASTFEEDING: Risk of drowsiness
Primidone, Phenobarbital, Benzodiazepines
BREASTFEEDING: Withdrawal effects
Phenobarbital, Primidone, Benzodiazepines, Lamotrigine
AEDS and suicidal thoughts and behaviour
- Symptoms may occur as early as 1 week after starting treatment.
- Patients advised to seek medical advice of any mood changes, distressing thoughts, or feelings about suicide or self-harming develop
Antiepileptic hypersensitivity syndrome
Rare
* Potentially fatal syndrome associated with:
o carbamazepine lacosamide, lamotrigine, oxcarbazepine, phenobarbital, phenytoin, primidone, and rufinamide
When do symptoms of Antiepileptic hypersensitivity syndrome begin to present?
Symptoms start between 1 and 8 weeks of exposure
What are the symptoms of Antiepileptic hypersensitivity syndrome
fever, rash, and lymphadenopathy
* If signs hypersensitivity syndrome occur, the drug should be withdrawn.
