Epilepsy Flashcards
Risk of suicidal thoughts/behaviours - MHRA
- All anti epileptics
- Symptoms may occur 1 week in
- Seek medical advice if mood changes/ distressing thoughts
category 1 AED - Brand specific
Carbamazepine
Phenobarbital
Phenytoin
Primidone
CP3
Category 2 AED - Clinical judgement should be used; consistency is preferred
Clobazam
Clonazepam
Eslicarbazepine
Lamotrigine
Oxcarbazepine
Perampanel
Rufinamide
Topirimate
Valproate
Category 3 - Safe to switch
Brivaracetam
Ethosuximide
Gabapentin
Lacosamide
Levetiracetam
Pregabalin
Tiagabine
Vigabatrin
AED WITHDRAWAL criteria
1) If seizure free for 2+ years
2) Withdraw one AED at a time
3) Avoid abrupt withdrawal (especially barbiturates and bdz- rebound seizures)
4) Reduce over 3+ months (longer in barbiturates and BDZ)
5) If seizure recur during/after= last dose reduction should be reversed
Q: How long must a patient stop driving after a first unprovoked or single isolated seizure?
A: 6 months, provided a specialist assesses them as fit and there’s no high risk of further seizures.
Q: What if a patient has a history of unprovoked seizures and epilepsy?
A: They must be seizure-free for 1 year before driving again.
Q: What is the rule for patients who have had a seizure during sleep?
A: They cannot drive for 1 year from the last seizure unless:
There’s a 1-year history of only sleep seizures, or
There’s a 3-year pattern of purely sleep seizures if there were previous awake seizures.
Q: What does the DVLA recommend during medication changes or AED withdrawal?
A: Do not drive during the change or for 6 months after the last AED dose.
Q: What happens if a seizure occurs due to AED change or withdrawal?
A: The licence will be revoked for 1 year; relicensing may be considered after 6 months seizure-free post-treatment reinstatement.
Focal seizures with/without secondary generalisation
1st- Lamotrigine/Levetiracetam monotherapy (switch if one not effective)
2nd- Carbamazepine, oxcarbazepine, zonisamide mono therapy
3rd - Lacosamide mono therapy. If monotherapy unsuccessful consider adjunct
Tonic- clonic treatment
1st - SV (male + females unable to have children). Female - lamotrigine/Levetiracetam monotherapy (switch if one is ineffective)
2nd- lamotrigine/Levetiracetam monotherapy (switch if one is ineffective)
3rd- Monotherapy unsuccessful: consider
adjunctive treatment. 1st line: clobazam,
lamotrigine, levetiracetam, perampanel,
sodium valproate (in
males, and females unable to have
children), or topiramate.
2nd line: brivaracetam*
, lacosamide,
phenobarbital, primidone, or zonisamide
Absence seizures treatment
1st- Ethosuximide
2nd- sodium valproate
(monotherapy or
adjunctive treatment
for males, and females
unable
to have children)
3rd- (if sodium valproate
unsuitable/unsuccessful): lamotrigine or
levetiracetam* as monotherapy or
adjunctive treatment. If monotherapy with
one of these is unsuccessful, try the other.
Myoclonic seizures treatment
1st - sodium valproate in males, and
females unable to have children.
1st line in females who are able
to have children: levetiracetam*
monotherapy.
2nd - Levetiracetam
as monotherapy or
adjunctive treatment.
3rd - 2nd line in females who are able to have
children
monotherapy or adjunctive treatment
with brivaracetam* clobazam, clonazepam,
lamotrigine, phenobarbital, piracetam,
topiramate*
, or zonisamide*
.
Atonic or tonic seizures treatment
1st- sodium
valproate in males, and females
unable to have children
in females who are able to have
children: lamotrigine as
monotherapy.
2nd- lamotrigine as
monotherapy or
adjunctive treatment
3rd - And 2nd line in females who are able to
have children: monotherapy or adjunctive
treatment (for all patients) with clobazam,
rufinamide*
, or topiramate*
.
consider felbamate* as adjunctive
treatment
Antiepiletic hypersensitivity syndrome
CP3 and rufinamide, lamotrigine, lacosamide
Symptoms: Fever, rash, liver dysfunction, renal+ pulmonary abnormalities and multi organ failure
Stop immediately
What birth defect can occur with topiramate use
Cleft palate
why is vitamin K injection given at birth with mothers on AED
Minimises the risk of neonatal haemorrhages
How to reduce the risk of neural defects in pregnancy while on AED
Folic acid for first trimester. Should also be used if planning pregnancy
Breastfeeding while on AED
Generally encourage
Monitor baby for signs of sedation, feeding difficulties, adequate weight gain, developmental milestones and adverse events. If these occur use formula feeds
What is a repeated or cluster seizure
Typically 3+ self terminating seizures in 24 hrs
Q: What defines a prolonged convulsive seizure?
A: A seizure that continues for more than 2 minutes longer than the patient’s usual seizure duration
Q: What is convulsive status epilepticus?
A: A seizure lasting 5 minutes or longer, or recurrent seizures without recovery in between.
Q: How should repeated, cluster, or prolonged seizures be treated if there is no emergency plan?
A: Urgently consider treatment with a benzodiazepine such as clobazam or midazolam.
Q: What should you follow for seizures lasting ≥5 minutes or without recovery between seizures?
1) Position patient to avoid injury, support respiration, maintain BP, correct any hyperglycaemia
2) if alcohol abuse suspected-> parenteral thiamine
3) If pyridoxine deficiency -> pyridoxine HCL
4) Follow patient emergency medical management plan
5) If plan unavailable treat with buccal midazolam or rectal diazepam in community/ IV lorazepam in hospital
6) Call emergency services if no response to 1st dose -> give 2nd dose of biz if seizure does not stop within 10mins of first dose
What to give if BDZ fail in convulsive status epilepticus
Leviracetam, phenytoin or SV as second line treatment. If there is still no response then try another agent under specialist advice. 3rd line is phenobarbital.
Febrile convulsion
seizure triggered by a fever in young children, usually between the ages of 6 months and 5 years.
Give paracetamol unless 5+ minutes or recurrent without recovery then treat as for convulsive status epilepticus
