Epilepsy Flashcards by Erica Lugada

What is epilepsy?

Neurological disorder where sudden recurrent episodes of sensory disturbance, behavioural change and/or convulsions occur

How well did you know this?

Not at all

Perfectly

What occurs when a seizure happens?

Abnormally high excitability of neurons in one or more parts of the brain

How well did you know this?

Not at all

Perfectly

What is a focal seizure and examples?

Simple

Complex - loss of consciousness

A seizure where the excitation occurs in one section of the brain

How well did you know this?

Not at all

Perfectly

What is a generalised seizure?

Excitation starts from a focal point and spreads to majority of the brain

How well did you know this?

Not at all

Perfectly

What are examples of a generalised seizure?

Motor:

Myoclonic - clonic to atonic

Tonic-clonic - tonic to clonic

Non-motor:
absence seizure

How well did you know this?

Not at all

Perfectly

How does a generalised tonic-clonic seizure present?

Begins with a tonic phase with muscle stiffness that causes falls

Clonic phase with rhythmic jerking and convulsions

How well did you know this?

Not at all

Perfectly

How does an absence seizure look?

Patient stares with a blank expression for a few seconds

How well did you know this?

Not at all

Perfectly

What are the features of a myoclonic seizure?

Less dangerous with rapid, jerking of limbs

How well did you know this?

Not at all

Perfectly

What are the features of atonic seizures and safety measures?

Loss of muscle tone and strength suddenly causing falls

Protective head gear worn by patients

How well did you know this?

Not at all

Perfectly

What are seizures called if they begin as focal and become generalised?

Focal to generalised secondary seizure

Starts with focal symptoms

How well did you know this?

Not at all

Perfectly

What are the signs and symptoms of focal seizures?

Motor - lip smacking, jerking, hand rubbing, repetitive chewing/swallowing

ANS (peripheral) - Sweating, gastointestinal changes, flushing and tachycardia

Sensory - Smelling/tasting things, hearing things, seeing things, feeling pins and needles

Cognitive - Intense feeling of fear, fiddling with objects, intense joy, behavioural changes like aggression

How well did you know this?

Not at all

Perfectly

What is temporal lobe epilepsy (TLE)?

Most common type of focal seizure

Clouds consciousness and alters perception, which gets confused with mental health

How well did you know this?

Not at all

Perfectly

What are the common epilepsy syndromes?

Occur during childhood

West syndrome

Lennox-Gastaut Syndrome (LGS)

Dravet Syndrome

Juvenile Myoclonic Epilepsy

How well did you know this?

Not at all

Perfectly

What are the causes of epilepsy classified as?

Idiopathic - genetic component

Symptomatic - underlying cause such as an abnormality

Cryptogenic - unknown cause on investigation

How well did you know this?

Not at all

Perfectly

What is reflex epilepsy?

Patients have a predisposition for seizures that are triggered by photic, auditory or environmental changes

Example:
Heat/cold

Loud sounds

Thinking/reading

Eating/chewing

How well did you know this?

Not at all

Perfectly

How is epilepsy diagnosed?

Detailed history and account of events from a witness

EEG for diagnosis and to classify the type of epilepsy

Difficult to diagnose as it could be confused with other conditions that cause loss of consciousness

How well did you know this?

Not at all

Perfectly

What is a confirmed diagnosis of epilepsy?

2 or more unprovoked or reflex seizures, more than 24 hours apart

1 unprovoked of reflex seizure with a probability of 60% of recurrence over the next 10 years

Diagnosis of an epilepsy syndrome

How well did you know this?

Not at all

Perfectly

What is seizure freedom?

Go 12 months without having a seizure

How well did you know this?

Not at all

Perfectly

What is a therapeutic effect?

3 x the longest previous interval between seizures on the drug

How well did you know this?

Not at all

Perfectly

What are the therapeutic objectives for epilepsy?

Reduce the length of time of seizures

Reduce or control frequency of seizures

Improve impact to quality of life

Minimise risk of ADRs with anti-epileptic drugs

How well did you know this?

Not at all

Perfectly

What is the likelihood of success with AED?

50% of patients are seizure free within 12 months of starting monotherapy

10-20% success of seizure freedom with 2nd AED after failure with 1st drug

How well did you know this?

Not at all

Perfectly

What considerations are there for carbamazepine?

Plasma levels can take up to 2 weeks to reach a steady state

Start low, go slow

Drug toxicity side effects can be reduced by using modified release

Bioequivalence varies with formulation

How well did you know this?

Not at all

Perfectly

What are the monitoring requirements for carbmazepine?

Urea and electrolytes - hyponatraemia

Liver function

FBC

How well did you know this?

Not at all

Perfectly

What considerations are there for sodium valproate?

Does not need therapeutic drug monitoring, has no defined therapeutic range

Can increase levels of other antiepileptic drugs - inhibits hepatic enzymes

Can cause hepatotoxicity or worsen it

What is the monitoring for sodium valproate?

Liver function - hepatotoxic FBC - low WBC and platelets

What are the risks of valproate in pregnancy?

Can cause congenital malformations (spina bifida, cleft palate) risk of neurodevelopment disorders in childhood

What is included in the PPP?

Risk form signed annually by patient Patient put on a LARC <1% failure rate and pregnancy excluded Treatment reviewed by specialist once a year

What are the considerations for phenytoin?

Narrow therapeutic index, likely to cause toxicity Start low, go slow Poor side effect profile Many drug interactions Bioequivalence varies with formulation Third line for focal and used in status epilepticus

What is the monitoring for phenytoin?

Liver function FBC ECG and BP (IV) - cardiovascular issues (brady and hypo)

What are the considerations for lamotrigine?

Rash can occur so titrate dose slowly Synergistic effect with valproate for reducing seizures Less side effects and interactions

What are the considerations for levetiracetam?

No monitoring required Few ADRs and well tolerated Can mask cognitive and behavioural issues related to brain injury

What are considerations for gabapentinoids (pregabalin and gabapentin)?

Mainly used for neuropathic pain No monitoring involved, few ADRs Renally excreted so dose adjustments for impairment is key

What are the considerations for benzodiazapines?

Pam and lam drugs Used to terminate seizure activity or status epilepticus Leads to dependency and tolerance Can be used when switching from one AED to another (short-term) Sedation effect - diazepam has a long half-life Clabazam - least sedating

What is the treatment for status epilepticus in community and hospital?

Buccal midazolam or rectal diazepam IV lorazepam

What are the next steps if the patient does not respond to status epilepticus treatment?

Call 999 Give a second dose of benzos if the seizure does not stop within 5 to 10 minutes of first dose If second dose does not work give: IV levetiracetam (least side effects) IV phenytoin or IV sodium valproate

What are the non-pharmacological treatment options?

Drug-resistant epilepsy on max. doses of AED: Resective epilepsy surgery or vagus nerve stimulation with antiepileptic drugs

What is the treatment for generalised tonic-clonic seizure?

First-line: sodium valproate Boys/men, girls under 10 unlikely to need treatment when older Alternative: Lamotrigine or levetiracetam Girls and women of child-bearing age Second-line add-on: Any of the above or clobazam

What is the treatment for focal seizures?

First -line: Lamotrigine or levetiracetam Second-line: carbamazepine or oxcarbazepine Third line: Lacosamide

What is the treatment for absence seizures?

First-line: Ethosuxamide Second-line: sodium valproate Third: Lamotrigine or levetiracetam

What is the treatment for myoclonic seizures?

First-line: sodium valproate Second-line: Levetiracetam Third-line: Add-on with lamotrigine

Which AEDs reduce the effectiveness of hormonal contraceptives?

Carbamazepine Phenytoin COC with 50micrograms or more is recommended Avoid progesterone-only

Which drugs for women reduce the effect of lamotrigine?

Oestrogen-containing contraceptives HRT

Which supplement reduces the chance of neural tube defects with AEDs?

Folate supplements

What should be done for patients if monotherapy or combination fails?

Allow the patient to choose the regimen that was most comfortable for them In terms of seizure control vs ADRs

What is refractory epilepsy?

Drug-resistant or intractable Failure to respond to two attempts with AED to achieve sustained seizure freedom High seizure burden

Which drugs are therapeutic drug monitoring useful for?

Carbamazepine and phenytoin Plasma levels correlate to efficacy

When is therapeutic drug monitoring conducted?

Starting treatment- to get a baseline Monitor adherence Toxicity Manage PK interactions Pregnancy, organ failure and status

What is status epilepticus?

When a seizure lasts for 5 minutes or longer Repeated convulsions without recovery of consciousness

What are the complications of status epilepticus?

Brain death or injury Catecholamine surge: arrhythmias, tachycardia, high BP Hypoglycaemia Lactic acidosis

What must you do if someone is having refractory status epilepticus?

Admit them into the ICU Induce a coma

Which AEDs have to be given for a specific brand?

Carbamazepine, phenytoin and phenobarbital Primidone

How should treatment be switched for intolerance or ADRs?

Gradually reduce and stop 1st AED then start 2nd AED with a gradual increase

How should treatment be switched for poor seizure control with no interaction?

Start 2nd AED and gradually increase, then gradually reduce and stop 1st AED

How should treatment be switched for poor seizure control with possible interaction?

Start 2nd AED and gradually increase and at the same time gradually reduce and stop the 1st

How long should it take for AEDs to be stopped?

2-3 months Longer for phenobarbital and benzos

What drug interactions are important for AEDs?

Older AEDs are inducers of CYP450 enzymes Lower the plasma concentration of many drugs

Which drugs lower seizure threshold?

Tricyclic antidepressants - amitriptyline (SSRI) Tramadol - SNRI Ciprofloxacin

What are the signs of anti-epileptic hypersensitivity?

Occur within 2-8 weeks of exposure Rash, fever, swollen lymph nodes and organ failure Stop drug immediately