epilepsy Flashcards
1
Q
This type of seizure starts in one part of the brain and the patient may or may not lose consciousness
A
partial
2
Q
What is the similarities & differences between a simple partial seizure & a complex partial seizure?
A
In both, the seizure originates in 1 part of the brain, but
Simple partial seizures- pt is still conscious
Complex partial seizure- pt is unconscious
3
Q
This type of seizure begins in both hemispheres of the brain and consciousness is impaired.
A
generalized
4
Q
What is the difference between a secondary and primary generalized seizure?
A
Secondary generalized seizure is actually a partial seizure (1 part of the brain) that spreads to the other side of the brain.
5
Q
status epilepticus is defined as
A
5 minutes or 2 or more seizures upon which the pt does not regain consciousness
6
Q
what antiepileptic drug caries the highest risk of fetal harm
A
valproate
7
Q
which seizure drugs cause weight loss
A
topiramate, keppra, zonisamide
8
Q
what antiepileptic drugs are strong inducers
A
carbamazepine, oxcarbazepine, phenobarbital, phenytoin, fosphenytoin, primidone, topiramate
9
Q
MEDGUIDE must be dispensed with antiepileptic drugs due to warnings of
A
suicidal thoughts
10
Q
what BZD is used in seizures (NOT STATUS EPILEPTICUS)
A
clonazepam
11
Q
klonopin
A
clonazepam
12
Q
clonazepam is a C__
A
4
13
Q
clonazepam side effects
A
dizziness, drownsiness, ataxia, cognitive impairment
14
Q
clonazepam is a ___ substrate
A
3A4
15
Q
What is the generic for Tegretol & Tegretol XR
A
Tegretol: carbamazepine suspension, chewable & tablet Tegretol XR: carbamazepine ER tablets
16
Q
What is the generic for Carbatrol & Equetro
A
carbamazepine ER capsules
17
Q
What is the generic for Epitol
A
carbamazepine
18
Q
equetro is indicated for only what?
A
carbamazepine for bipolar illness only
19
Q
carbamazepine dosage forms
A
tab, cap, suspension, chewable tablet
20
Q
carbamazepine therapeutic range
A
4 - 12 mcg/ml
21
Q
what antiepileptic drug is an autoinducer and will decrease its own levels
A
carbamazepine after ~ 21 days of use
22
Q
carbamazepine black box warning
A
Serious skin rxtn: SJS & TENS (usually w/in 2-8wks)
Aplastic anemia: WBC <1,000-1,500
Liver disease
23
Q
carbamazepine pharmacogenomic testing must be done in everyone of what decent
A
asian
24
Q
when doing pharmacogenomic testing for carbamazepine what are you testing for
A
HLA-B*1502 (if positive pt is at high risk for hypersensitivity reactions)
25
carbamazepine contraindications
MAOIs within 2 weeks
bone marrow suppression
Hypersensitivity to TCAs
Concurrent use with nefazodone (antidep) or NNRTIs
26
How is osteomalacia managed?
1. if alk. phos is elevated = give Vitamin D
| 2. if alk phos is low = give 25-hydroxychloecalciferol (D3)
27
carbamazepine side effects
Short term use: neutropenia, rash
Chronic use: SIADH/hyponatremia, Osteomalacia, hepatotoxicity, lowered folate
Toxic: blurred vison & diplopia
28
carbamazepine is a ___ substrate
3A4
29
Zarontin is the brand name for what?
ethosuximide
30
What is the drug of choice for absence seizures
ethosuximide
31
When is valproate category X
Valproate is pregnancy X ONLY if used for migraine prophylaxis
32
Luminal is the brand name for?
phenobarbital
33
barbital
phenobarbital
34
phenobarbital/ primidone are a C__
4
35
What is the mechanism of action for Carbamazepine/ Tegretol?
Tegretol is a fast Na channel blocker structurally similar to TCAs & causes the release of ADh = water reabsorption
36
Mysoline is the brand name for?
primidone
37
therapeutic range for primidone/phenobarbital in adults
20 - 40 mcg/ml
38
therapeutic range for primidone/phenobarbital in kids
15 - 30 mcg/ml
39
phenobarbital/primidone side effects
SEDATION
ataxia
skin reactions (sjs/ten RARE)
40
Dilantin is the brand name for
phenytoin suspension, chewable tablet, Prompt-release capsule, ER capsule & injection
41
phenytek is the brand name for
phenytoin ER capsule
42
max infusion rate of phenytoin
50 mg/min
43
what agents undergo saturable kinetics
phenytoin
theophylline
voriconazole
44
when do you have to use the phenytoin correction equation
albumin < 3.5
45
Why is it important to correct phenytoin levels when albumin level is <3.5?
albumin levels of <3.5 give you a falsely low phenytoin level, so pt can actually become toxic & labs do not show it
46
what is the equation for phenytoin correction
PHT = Phenytoin / [(albumin * 0.2) + 0.1]
47
therapeutic range of total phenytoin & fosphenytoin
Phenytoin: 10 - 20 mcg/ml
Fospheytoin: 1-2.5mcg/ml
48
what dosage forms does phenytoin come in
IV
suspension
tab
caps
49
Enteral feedings can decrease the absorption of phenytoin. How is this managed?
when giving phenytoin suspension via enteral feeding you must hold tube feedings 2 hours before and 2 hours after dosing
50
phenytoin IV:PO ration
1:1
51
phenytoin toxicity symptoms
```
ataxia
slurred speech
nystagmus
blurred/double vision
drowsiness
headache
```
52
what are the serious adverse effects of phenytoin
```
serious skin reactions (sjs/ten)
P - purple glove/potent inducer
H-hirsutism, hepatotoxic
E-enlarged gums/SLE
N-nystagmus
Y-yukky dyscrasias/extravasates
T-tertogenic
O-osteomalacia/osteoporosis (low Vit. D & Ca)
I-intereferes with folate absorption
N-neuropathy
```
53
If a pt is on phenytoin at home comes in for status epileptics and the Dr would like to use fosphenytoin instead. What is the conversion
1mg Phenytoin = 1mg of Phenytoin equivalence
54
IV phenytoin can only be mixed with
NS
55
IV fosphenytoin can be mixed with
NS & D5W
56
what dosage forms does fosphenytoin come in
IV & IM
57
how long is phenytoin IV stable for
4 hours
58
how is IV phenytoin stored
room temp
59
if IV phenytoin is infused too fast what may occur
severe bradycardia
hypotension
arrhythmias
60
What is the brand name for the extended release formulation of divalproex
Depakote ER
61
Depakene is brand name for
valproate caps, solution & syrup
62
Stavzor is brand name for
valproate delayed release caps
63
Depacon is brand name for
valproate IV
64
valproate dosage forms
IV caps solution
65
Depakote is the delayed release formulation for
divalproex
66
depakote sprinkle can be opened and sprinkled on food
read
67
valproate/divalproex therapeutic levels
50 - 100 mcg/ml
68
what antiepileptic drugs are highly protein bound
phenytoin valproate/divalproex
69
albumin levels of __ give you a falsely low valproate/divalproex level
< 3.5
70
what equation do you use to calculate true valproate/divalproex levels when albumin is < 3.5
phenytoin correction equation
71
valproate/divalproex black box
teratogenic= sina bifida, lower IQ
liver damage- during 1st 6 months
pancreatitis- fatal
72
valproate/divalproex side effects
```
N/V, abdominal pain
tremors, alopecia
weight gain, Vit D & Ca deficiency
PCOS
thrombocytopenia- toxicity
```
73
what can be given to treat alopecia
Use a multivitamin with selenium + zinc
74
if a patient is experiencing a lot of nausea on valproate what can be done
switch to delayed release divalproex (depakote)
75
valproate inhibits what enzyme
2C9
76
What must be done if a patient is being switched between Depakote & Depakote ER
if going from Depakote (DR) to Depakote ER- Must increase the Depakote ER dose by 8-20%
77
what agents will decrease valproate levels
carbapenem
78
valproate will increase levels of
lamotrigine 2 fold
warfarin
phenytoin
carbamazepine
79
why could phenytoin toxicity occur if valproate is given with phenytoin
valproate will displace phenytoin from albumin (it also inhibits its metabolism via 2C9)
80
What agents should be used with caution due to their ability to displace valproate from protein binding sites
salicylates
81
Lamictal is the brand name for
lamotrigine
82
lamotrigine dosage forms
tabs
ODT
chewable
83
lamotrigine is titrated slowly via weekly intervals due to risk of
serious skin reactions (sjs ten)
84
lamotrigine side effects
nausea, ataxia, insomnia, rash
| rhinitis, dry mouth
85
lamotrigine black box warning
serious skin reactions (sjs ten)
86
keppra
levetiracetam
87
levetiracetam dosage forms
tablet
injection
solution
88
levetiracetam side effects
somnolence
dizziness
mood change- aggression, irritability
89
What is the MOA of lamotragine
inhibits glutamate & aspartate as well as being a fast Na & T-type Ca channel blocker
90
trileptal
oxcarbazepine
91
oxcarbazepine is a ___ inhibitor/inducer
2C19 weak inhinitor
| 3A4 inducer
92
phenytoin/fosphenytoin is a ___ inhibitor/inducer
3A4 inducer
93
oxcarbazepine side effects
Somnolence, dizziness, n/v, double vision, ataxia, tremor, skin reactions (sjs tens), hyponatremia- more than carbamazepine
94
if a patient had a rash with carbamazepine what agent are they automatically contraindicated for
oxcarbazepine
95
what agents are preg cat D
```
phenytoin (and its prodrug)
carbamazepine
phenobarbital (and its prodrug)
valproate
clonazepam
topiramate
```
96
lyrica
pregabalin
97
neurontin
gabapentin
98
pregabalin & gabapentin common side effects
peripheral edema, weight gain, somnolence, ataxia, blurred vision, dry mouth
99
How are Lyrica & gabapentin dosed in a pt with CrCl<30ml/min
Must decrease the dose and extend the dose intervals
100
pregabalin is C_ due to slight euphoria
5
101
topamax brand for
topiramate
102
topiramate side effects
```
FOGS UP YOUR BRAIN (difficulty with memory/thinking/concentration)
weight loss
decreased bicarb, nephrolethiasis
taste perversion
lowers Vit D & Ca
```
103
what agents cause oligohydrosis (reduced perspiration) which can lead to hyperthermia, nephrolithiasis & metabolic acidosis
topiramate
| zonisamide
104
what agents cause oral clefts in the newborn if used during pregnancy
topiramate
| BZD
105
zonegran
zonisamide
106
zonisamide contraindication
Sulfonamide allergy
| CrCl<50
107
when you see felbamate think
LIVER FAILURE AND APLASTIC ANEMIA
108
how do you treat status epilepticus
administer a bzd (lorazepam) then long acting agent (phenytoin or fosphenytoin)
109
what is the order of onset of the BZD used in status epilepticus
diazepam > midazolam > lorazepam
110
what is the order for duration of action with lorazepam diazepam midazolam
lorazepam > midazolam > diazepam
111
diastat
diazepam rectal
112
what agents are teratogenic
```
valproate- spina bifida & decreased IQ
clonazepam
carbamazepine
phenobarbital
phenytoin
topiramate- cleft palate or lip
```
113
what agents are hepatotoxic
```
Carbamazepine
valproate
felbamate
Phenobar/Primidone
Phenytoin
```
114
what agents should be used with caution in patients with renal failure
gabapentin/ pregabalin- increase dose & lower dose interval
115
what agents decrease the effects of oral contraceptives
```
topiramate
carbamazepine
oxcarbazepine
phenytoin
phenobarbital
```
116
what agents cause fatal pancreatitis
valproate
117
what agents cause aplastic anemia
felbamate
| carbamazepine
118
what agents that cause oligohydrosis
zonisamide
| topiramate
119
what agents cause weight gain
valproate
| pregabalin
120
what agents cause weight loss
topiramate (Topamax)
zonisamide (Zonegran)
ethosuxamide (Zarontin)
Levitriacetam (Keppra)
121
what natural product decreases the seizure threshold
evening primrose, dendrobium, ginkgo, melatonin
122
what drugs lower the seizure threshold
```
bupropion
pcn, cepalosporins, carbapenems(in poor renal function)
fluroquinolones
tramadol
Metoclopramide
meperidine( in poor renal function)
lithium & theophylline( when toxic)
Antipsychotics
Antivirals( amantadine, rimantadine, foscarnet, ganciclovir, acyclovir IV)
```
123
patients taking phenytoin must be supplemented with
folic acid
calcium
vit d
124
you may experience abnormal sensitivity to light while on this agent
lamotrigine
125
blistering of your mucous membranes around your eyes nose and or mouth may occur while on this agent
lamotrigine
126
how should valproate be taken
with full glass of water and food to decrease nausea
127
Potiga is brand name for
ezogabine
128
Vimpat is brand name for
lacosamide
129
gabitril
tigabine
130
what agents cause vit D and calcium deficiency
valproate
phenytoin
phenobarbital
carbamazepine
131
what antiepileptic med comes in sprinkle caps
divalproex
132
what are the acute drug toxicities that can be seen with most antiepileptic drugs
ataxia
double/blurred vision
confusion
dizziness
133
phenytoin causes what type of anemia and why
macrocytic due to folate deficiency
134
Anticonvulsants commonly cause these CNS side effects:
somnolence (sleepiness), dizziness, ataxia, diplopia, confusion and fatigue
135
carbamazapine dosage forms
tabs
caps
suspension
136
if a patient has only had one seizure they must be seizure free for ____ in order for you to D/C the meds
6 - 12 months
137
What is to be done as soon as possible in a pt in status epilepticus
Asses heart, open airways
Start infusion NS
Check chemistry
Give 25g or glucose & 100mg of thiamine IV
138
what antiepileptic agent increases your risk of glaucoma
topiramate
139
lamotrigine starting dose
50 mg qd (for first 2 weeks)
140
with antiepileptics nausea, drowsiness and dizziness are more likely initially as the patient is getting used to the drug
read
141
Cerebyx is the brand name for
fosphenytoin
142
does fosphenytoin control seizures faster than phenytoin
no
143
The theoretical advantage to the use of fosphenytoin is that seizures can be controlled faster, or at least it can be pushed faster since it causes less hypotension. However, the conversion of fosphenytoin to phenytoin takes time (15-30 minutes) and the seizures are not controlled faster. An advantage to fosphenytoin is that it can be given IM, and it can be mixed with either NS or D5W.
read
144
phenobarbital and topiramate can cause a lot of memory impairment difficulty concentrating etc
read
145
phenobarbital is activating in some kids even though for the most part it is known to be sedating
read
146
what agents can cause kidney stones
zonisamide
| topiramate
147
What is the first line agent for a pt in status epilepticus
Lorazepam (Ativan) IV preferred
| Diazepam IV or rectal in children
148
antidote for TCA intoxication
sodium bicarb
149
lorazepam is preferred over other BZD in controlling status epileptics
because it works longer due to its reduced lipophilic properties
150
what seizure meds are used in neuropathic pain
pregabalin
151
What is the dose of Ativan used in status epilepticus
4mg slow IV in adults max 2mg/min may repeat in 5-10 min if no response
152
What is the max daily dose of Tegretol usually
1,600mg/day ( some pt may need higher)
153
Tegretol causes a decrease in the levels of
Levothyroxine
warfarin
hormone contraceptives (need non-hormonal opt)
other seizure meds
154
What is the therapeutic range and max daily dose of Zarontin/ethosuxamide?
Therapeutic range: 40-100mg/L
| Max daily dose: 1,500mg/d
155
What is the MOA of ethosuxamide(Zarontin)
T-type calcium channel blocker = increased seizure threshold & suppresses paroxysmal spike-and-wave in absences
156
What are the contraindications to the use of Valproate/Devalproex?
Significant liver disease
Prophylactic use in migraines
mitochondrial disorders b/c of POLG mutation
children <2 with POLG mutation
157
What is the dose of Diazepam used in status epilepticus
5-20mg slow IV, repeats q5-10min max total dose of 30mg
| 5-20mg rectally (per age & weight) repeats only once
158
What medications are given if the pt is still seizing after Lorazepam or diazepam?
Phenytoin LD 15-20mg/kg/ fosphenytoin- 1st
| Then loading dose phenobrab or start infusion of midazolam
159
What is the max infusion rate for phenobarb
Adults- 60mg/min
| Children- 30mg/min
