Epilepsy Flashcards
Types of Partial Seizures
simple partial and complex partial
simple partial seizures
motor symptoms: jerking, lip smacking, chewing motions.
autonomic sx: sweating, pupil dilation, consciousness is not impaired
complex partial seizures
consciousness impaired
-seizure begins locally, simple. with or without automatism.
1st line treatment for simple partial seizures
- lamotrigine
- carbamazepine
- levetiracetam
first line drugs for complex partial seizures
- CBMZ
- phenytoin
- lamotrigine
- levetiracetam
automatism
involuntary, repetitive movements/behaviors (lip-smacking, pouting, picking at clothes/objects, fidgeting, rubbing hands), typically in focal seizures, pt has no memory of them after
-duration: seconds to minutes
absence seizures (petit mal)
non-motor symptoms
10-30 seconds alteration of consciousness.
occasional blinking
1st line treatment for absence seizures
ethosuximide
myoclonic seizures
involuntary jerking of facial, limb, trunkl MUSCLES/all of the body (MYO = MUSCLE)
tonic-clonic seizures (grand mal)
common in children
MUSCLE STIFFENING
clonic = muscle contraction -> relaxation
-sudden loss of consciousness, rigid, falls to ground, lasts ~ 1 min
first line treatment for myoclonic seizures
- valproic acid
- divalproex sodium
- levetiracetam
first line treatment for grand mal seizure
- LMTG
- VPA/Divalproex
- levetiracetam
What are generalized seizures?
involve both hemispheres of the brain, leads to loss of consciousness
-absence, myoclonic, tonic-clonic
what drugs to avoid in generalized seizures?
absence- phenytoin, cbmz, gabapentin, vigabatrin
myoclonic- cbmz, phenytoin, gabapentin, vigabatrin
status epilepticus
single PROLONGED seizure, lasts > 5 minutes. sometimes no regain of consciousness between attacks
1st line tx for status epilepticus
IV diazepam
2nd line tx for status epilepticus
Propofol 1-2 mg/kg
when is combination tx used in epilepsy?
after monotherapy with 2-3 different drugs has failed
what kind of diet can be used in patients with refractory seizures?
ketogenic diet- low carbs, normal proteins, high fat
Avoid ____ in women of child-bearing age not using contraception
valproic acid
which drug can increase the risk of congenital malformation?
topiramate
which anti-seizure drugs are safe in pregnancy with a low rate of teratogenicity?
lamotrigine
levetiracetam
oxcarbazepine
Patient Y was taking leviteracetam at a maintenance dose for epilepsy. She recently became pregnant. What should be done with levi?
monitor the dose as it may decrease in pregnancy, needs monitoring
why is lamotrigine preferred in pregnancy?
lower risk of congenital malformations (cleft palate)
why might you need to increase the dose of lamotrigine in pregnancy?
lamotrigine metabolism is increased in 2nd and 3rd trimester (due to increased hepatic glucuronidation and renal clearance) = lower serum levels = may need to increase by 100% or more to maintain therapeutic levels, then reduce dose after delivery to prevent toxicity
if patient is on anti-seizure drug while pregnant, what supplement should be taken?
folic acid 5 mg/day to reduce risk of neural tube defects
vitamin K in the last 4 weeks (10 mg/day) to prevent hemorrhagic disease in newborn
A patient taking antiepileptic drugs phenytoin, CBZ, and lamotrigine should take what supplement?
folic acid 1 to 5 mg / day
what vitamin is given to all new-born babies at delivery to prevent hemorrhagic disease?
vitamin K
what is the treatment for juvenile epilepsy?
valproic acid (lifelong)
Which anti-seizure med can impair cognition?
topiramate
which anti-seizure drug can cause dose-dependent skin rash?
lamotrigine (if titrating up too fast)
which anti-seizure drug has the highest risk of hepatotoxicity?
valproic acid
General side effects of anti-seizure drugs
CNS effects (drowsy/dizzy), hepatotoxicity, skin rash leading to SJS
Symptoms of steven johnson syndrome
starts with fever and flu-like symptoms, leading to painful/purple-red rash, blisters spreading on mucous membranes
which drugs require renal dose adjustment?
topiramate
oxcarbazepine
levetiracetam
pregabalin
What is a chronic long-term side effect associated with PHENYTOIN?
gingival hyperplasia (overgrowth of gum tissue = dental issues)
other chronic AEs of phenytoin
hirsutism (excess hair growth/coarse facial hair),
osteopenia/osteoporosis, peripheral neuropathy, cognitive impairment, skin/tissue changes, folate and vit K deficiency, vision loss
what kind of anemia is caused by folic acid deficiency?
megaloblastic anemia
which anti-seizure drugs have no liver enzyme activity?
gabapentin
levetiracetam
brevetiracetam
lamotrigine
valproic acid
patient X is taking phenytoin and wants to start contraceptives. Which forms of contraceptives are appropriate and wont be affected by anti-seizure meds?
Barrier methods (condom)
Depo-Provera injection
IUDs
Which anti-seizure medications interact with oral contraceptives?
carbamazepine
oxcarbazpine
phenytoin
(increased risk of contraceptive failure in women taking enzyme-inducing AEDs)
Drug interaction between lamotrigine and oral contraceptive pills?
lamotrigine effectiveness is decreased by 50% by OCP. therefore, need to increase lamotrigine dose by 50%.
Which AEDs are cyp2c9 and 3a4 inducers?
phenytoin
carbamazepine
oxcarbazepine (3a4 and 5)
which AEDs are cyp2c9 inhibitors?
VOT
Valproic acid
Oxcarbazepine
Topiramate
which AEDs have no involvement with liver enzymes?
lamotrigine
gabapentin
ethosuccimide
levetiracetam
Which AED requires a thyroid test?
valproic acid
which AED has a warning for suicidal ideation?
valproic acid
What are the early onset of AEs of AEDs?
-somnolence (oxcarbazepine)
-dizziness (oxc, phenytoin, topiramate)
-GI toxicity (oxc, phenytoin)
-SJS/TEN
-Rash (cbz, LMTG)
-seizure aggravation (VGB)
which AED has the highest risk of LEUKOPENIA (late onset)?
carbamazepine
which AED has the highest risk of THROMBOCYTOPENIA (late onset)?
valproic acid
which AED has the highest risk of ENCEPHALOPATHY (late onset)?
vigabatrin
which AED has the highest risk of behavioral problems (late onset)?
vigabatrin, topiramate
which AED has the highest risk of PSYCHOTIC EPISODES (late onset)?
vigabatrin
which AED has the highest risk of LIVER FAILURE (late onset)?
valproic acid
which AED has the highest risk of renal failure (late onset)?
valproic acid
which AED has the highest risk of teratogenicity?
valproic acid
what are the idiosyncratic drug reactions of valproic acid and divalproex?
thrombocytopenia
acute hepatic failure
acute pancreatitis
alopecia
low incidence of rash/SJS
what should be monitored for patients on valproic acid or divalproex na?
LFT and CBC
If liver failure, stop drug.
which drug can cause coarse facial features with long-term use?
phenytoin
treatment for gingival hyperplasia
0,15% chlorhexidine mouth rinse
Carbamazepine dosing
100 mg BID, increase by 200 mg/day Q3-4 days.
Maintenance dose: 400-1200 mg/day in 2-4 divided doses with meals when possible.
what happens when lamotrigine is combined with valproic acid
lamotrigine levels increased by 200%, increases the risk of rash.
need to lower dose of LMTG by 50%
maintenance dose of lamotrigine
200-400 mg/day in 2 divided doses
how should LMTG be titrated up?
within 8 weeks to avoid dose-related rash. start at 25 mg q 2 days to 50 mg/day. in 2 weeks, increase to 50 mg BID, then increase by 100 mg/day at 1-2 weeks
true or false - topiramate is 1st line therapy
false. it is 2nd line.
maintenance dose of topiramate
200-400 mg BID
Drug/Food interactions with GABA Derivatives i.e., gabapentin, pregabalin or vigabatrin?
Administration with Al/Mg/Ca containing antacids can reduce bioavailability of drug, no COC interactions
Which drugs do not interact with COCs?
gabapentin
valproic acid
ethosuximide
What side effects of carbamazepine are dose dependent, except rash 5-10% ?
dizziness, drowsiness, nausea, lethargy, diplopia (double vision)
what side effects require immediate discontinuation of a drug?
rash with fever
