epilepsy Flashcards
treatment for focal seizures - with or w/o secondary generalisation
1st line treatment:
- levetiracetam
- lamotrigine
2nd line treatment:
- carbamazepine
- oxcarbazepine
- zonisamide
treatment for generalised seizures
tonic clonic - 1st sodium valprate 2nd lamotrigine/levetiracetam
absence 1st ethosuximide 2nd sodium valproate
absence with other seizure types 1st sodium valproate 2nd lamotrigine/levetiracetam
myoclonic 1st sodium val 2nd levetiracetam
atonic 1st sodium val 2nd lamotrigine
tonic 1st sodium val 2nd lamotrigine
women to take 2nd line option if at childbearing age or future
what is status epilepticus and how to treat it?
status epilepticus - seizure lasting longer than 5 mins OR recurrent seizures without recovery in b/w
provide resuscitation and immediate emergency treatment
follow individualised emergency management plan if immediately available
treatment:
- IV lorazepam (if resus facilities available)
- buccal midazolam or rectal diazepam (if in community)
give 2nd dose if seizure doesn’t stop within 5/10mins of 1st dose
if seizure fails to respond after 2 benzo doses:
- levetiracetam, phenytoin, sodium val
if seizure not responding - try another 2nd line if still not responding
- phenobarbital or general anaesthesia
what are the 3 categories of anti-epileptics
category 1 - ensure patients are maintained on a specific brand
- carbamazepine, phenobarbital, phenytoin, primidone
category 2 - maintaining specific brand based on clinical judgement
- clobazam, clonazepam, lamotrigine, valproate, topiramate
category 3 - unnecessary to maintain on specific brand
- ethosuximide, levetiracetam, pregabalin, gabapentin
anti-epileptic interactions
carbamazepine, phenytoin, sodium valproate:
hepatotoxicity - amiodarone, macrolides, alcohol
cyp inducers - phenytoin, phenobarbital, carbamazepine
inhibitors - sodium valproate
drugs that lower seizure thresholds - tramadol, quinolones, theophylline
carbamazepine - hyponatremic (ssri, diuretics)
phenytoin - anti folate (methotrexate, trimethoprim)
anti-epileptic drug side effects
carbamazepine, phenytoin, sodium valproate:
depression + suicide
hepatotoxicity
hypersensitivity
blood dyscrasia
vit D deficiency
carbamazepine - hyponaetremia + oedema
phenytoin - coarsening appearance + facial hair
sodium valproate - pancreatitis + teratogenic
carbamazepine therapeutic range and toxicity
range 4-12 mg/L
signs of toxicity:
H - hyponaetremia
A - ataxia
N - nystagmus
D - drowsiness
B - blurred vision
A - arrhythmia
G - GI disturbances
phenytoin therapeutic range and toxicity
range 10-20 mg/L
signs of toxicity:
S - slurred speech
N - nystagmus
A - ataxia
C - confusion
H - hyperglycaemia
D - double vision
Driving in epilepsy
if driver has seizure of any time - must stop driving immediately and report to DVLA
pts who have first unprovoked/single isolated - wait 6 months - then can resume driving provided they are fit to drive by a specialist
pts who have established epilepsy - must be seizure free for a year to be able to drive or pattern of seizures established for 1 year where no influence on consciousness
medication change/withdrawal:
- should not drive for 6 months after last dose
- if seizure occurs due to change or withdrawal - license will be revoked for 1 year
- relicensing will be considered earlier if medication has been reinstated for 6 months and pt is seizure free
pregnancy in epilepsy
risk of harm to mother and foetus from seizure outweighs risk of continued therapy
folic acid given to reduce risk of neural tube defects
vitamin K - injection administered at birth to prevent neonatal haemorrhage
sodium val - most risk
topiramate - cleft palate
breastfeeding in epilepsy
encouraged to breastfeed
high presence in milk - primidone, ethosuximide, lamotrigine, zonisamide
risk of drowsiness - phenobarbital, primidone, benzodiazepines
withdrawal effects - if mother suddenly stops breastfeeding - phenobarbital, primidone, benzodiazepines, lamotrigine
