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Semester 4 - Clinical Pharmacology And Therapeutics > Epilepsy > Flashcards

Epilepsy Flashcards

1
Q

What is a seizure?

A

A sudden, irregular discharge of electrical activity in the brain causing a physical manifestation such as sensory disturbance, unconsciousness or convulsions

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2
Q

What are convulsions?

A

Uncontrolled shaking movements of the body due to rapid and repeated contraction and relaxation of muscles

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3
Q

What is an aura?

A

A perceptual disturbance experienced by some prior to a seizure. e.g. strange light, unpleasant smell, confusing thoughts

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4
Q

What is epilepsy?

A

Neurological disorder marked by sudden recurrent episodes of sensory disturbance, LOC or convulsions, associated with abnormal electrical activity in the brain.

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5
Q

What is status epilepticus?

A

Epileptic seizures occurring continuously without recovery of consciousness in between

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6
Q

What are the classifications of seizures?

A

Partial - simple or complex

Generalised - absence, myoclonic, tonic-clonic, tonic, atonic

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7
Q

What is the difference between a simple or a complex seizure?

A

Simple - same consciousness

Complex - Consciousness is impaired

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8
Q

What different types of epilepsy can cause partial seizures?

A

Temporal lobe epilepsy - 1st/2nd decade in most people, following seizures with fever oran early injury to the brain.
Aura’s - e.g. auditory hallucinations, rush of memories

Frontal lobe epilepsy - next most common

Abnormal movements when motor areas affected (contralateral side)

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9
Q

What are the different types of generalised seizures?

A

Tonic-clonic: tonic = muscles tense, clonic - convulsions

Absence: ‘daydreaming’

Status epilepticus: medical emergency

Myoclonic: brief shock-like muscle jerks

Atonic: ‘without tone’ - drop attack

Tonic: increased tone

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10
Q

What investigations do you do for seizures?

A

Clinical history
EEG
MRI
ECG, bloods

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11
Q

What things do you ask about in a clinical history?

A

Before - PMH, FH, triggers, aura, first sign / symptoms

During - description of seizures, duration, abrupt/gradual end

After - post-ictal state, tongue biting, incontinence, neurological deficit.

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12
Q

What is the difference between primary and secondary epilepsy?

A

Primary (idiopathic)- no apparent cause, may be inherited

Secondary (symptomatic)- known cause

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13
Q

What are some possible causes of epilepsy?

A 
Vascular: Stroke, TIA
Infection: Abscess, Meningits
Trauma: Intracerebral haemorrhage 
Autoimmune: SLE
Metabolic: hypoxia, electrolyte imbalance, hypoglycaemia, thyroid dysfunction
Iatrogenic: drugs, alcohol, withdrawal
Neoplastic: Intracerebral mass
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14
Q

Why is EEG used?

A

EEG supports diagnosis - not diagnostic

In first unprovoked seizure - assess risk of seizure recurrence (unequivocal epileptiform activity on EEG

Standard EEG assessment involves photic stimulation and hyperventilation - patient warned that it may induce a seizure

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15
Q

When do you not use EEGs?

A

Probable sincope (risk of false positive)
Clinical presentation supports diagnosis of non-epileptic event
In isolation to make a diagnosis of epilepsy

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16
Q

What do you go if EEG is unclear?

A

Repeat standard EEGs
Sleep EEGs (sleep deprivation or melatonin in children / young people)
Long term video or ambulatory EEG

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17
Q

What anti-epileptic drugs are there?

A

Na channel blockers
GABA potentiators
Ca channel blockers

Other drugs affecting GABA:
Levetiracetam

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18
Q

What do Na channel blockers do?

A

Cause Na channels to remain in an inactive state

They prevent axons from firing repetitively.

19
Q

Give examples of Na channel blockers?

A 
Carbamazepine
Phenytoin
Lamotrtrigene 
Sodium valproate
Topiramate
20
Q

What are Ca channel blockers and when are they used?

A

Prevent activity of Ca channels
Prevent depolarisation causing “spike and wave” discharge.
Used in absence seizures

21
Q

Give examples of Ca channel blockers

A

Ethosuximide

Sodium valproate

22
Q

What are GABA potentiators? (give examples)

A

They enhance the effect of GABA at the synaptic junction
For example:
Barbituates (phenobarbartal)
Benzodiazepines (Midazolam)

23
Q

What are GABA-transaminase inhibitors? (Give examples)

A

Prevent the breakdown of GABA

e.g. Vigabatrin

24
Q

Why increase GABA production?

A

To improve the utilisation of glutamate.

For example: Gabapentin

25
Q

What is levetiracetam?

A

Trade name: Keppra

Binds to synaptic vesicles to inhibit pre-synaptic calcium channel activity.

Therefore, inhibiting neurotransmitter release from the pre-synaptic neurone

26
Q

When do you initiate anti-epileptics?

A

When an epilepsy specialist / neurologist confirms diagnosis (usually after more than one seizure)

Consider if first unprovoked seizure and…
Neurological deficit
EEG shows unequivocal epileptic activity
Risk of a further seizure is unacceptable
Imaging reveals a structural abnormality

27
Q

What do you start with when starting anti epileptics?

A

Start with monotherapy and if ineffective change to mono therapy with different AED

First line for generalised or tonic-clonic seizures - sodium valproate (or Iamotrigine)
-If ineffective, other adjuncts considered

Titrate up to achieve a balance of therapeutic effect vs adverse side effects

28
Q

What interactions do you have to be aware of?

A

Liver enzyme inducers: Carbamazine, phenytoin

Liver enzyme inhibitors: Sodium valproate

29
Q

What are the adverse effects of anti-epileptics?

A

All: Dizziness, Fatigue, Ataxia, Diplopia

Irritability, behaviour changes
Weight loss / anorexia
Weight gain
Tics  and insomnia
Metabolic acidosis
Language dysfunction
30
Q

How do you change anti-epileptics?

A

Start at initial dose and slowly increase to middle of recommended therapeutic range.
Then, slowly withdraw old drug over about 6 weeks.

Change if unacceptable side effects, failure of treatment or on inappropriate drug.

31
Q

What patients have an increased risk of seizure if treatment is withdrawn?

A 
Epilepsy since childhood
Patients on more than one drug
Myoclonic or tonic-clonic seizures
Abnormal EEG in last year
Known underlying brain damage
32
Q

How do you stop anti epileptics?

A

Gradually taper off

Aim is to avoid withdrawal features such as recurrent seizuresand anxiety and restlessness.

Reduce rates of ethosuximide, barbiturates and benzodiazepines more slowly.

33
Q

What anti-epileptic drug is safe in pregnancy?

A

Carbamazepine

34
Q

What anti-epileptic drugs is bad in pregnancy? Why?

A

Sodium Valproate

Thought to cause decreased serum folate - neural tube defects.

Cranio-facial and skeletal abnormalities.

Developmental disorders after brith.

If have to describe, use lowest effective dose

Start folate before pregnancy.

Have specialist prenatal monitoring

35
Q

What are the side effects of phenytoin?

A

Common congenital malformations - cleft lip and congenital heart defects (septal defects).

Anticonvulsant (epilepsy)

Cardiac depressant (arrhythmias)

36
Q

What does phenytoin require therapeutic monitoring?

A

Because it has a narrow therapeutic window and non-linear pharmacokinetics.

Toxicity = nausea, CNS dysfunction, decreased consciousness, coma.

Monitoring to:

  • Establish individual therapeutic concentration
  • Aid diagnosis of clinical toxicity
  • Assess compliance
  • Guide dose adjustments in patients with greater pharmacokinetic variability
37
Q

What is the pneumonic to remember the treatment of partial seizures?

A

LAMB TOP GAVE FUNNY CARBS

lamb - lamotrigine

top - topiramate can’t be explained off the Top a Ma Head. Also used in migraines

gave - gabapentin: wishes it worked like GABA but has pent up frustration

funny - phenytoin: can’t be funny for too long, so use in Status Epilepticus

Carbs - carbamazepine: keeps Na channels inactive like phenytoin.

38
Q

What is the pneumonic to remember the treatment of general seizures?

A

BARBARA VALIANTLY SUX GOOD-PAM

Barbra: pheNOcarbitol: NO barb mena dont use unless desperate

Valiantly: Sodium Valproate: valiantly tries to do many things (inc attacking liver enzymes)

Sux: Ethosuximide: sucks to learn it; but make sure it doesn’t go absent from revision

Good-Pam: ends in pam, so its a benzo. Act’s quickly so its good 1st line for status epilepticus

39
Q

How do you initially manage seizures?

A

ABCDE

Lorazepam or Midazolam

Pre-hospital: PR or buccal
Hospital: IV

40
Q

What is status epilepticus?

A

Epileptic seizures occurring continuously without recovery

Neither funny nor good

So used benzodiazepines
or phenytoin.

41
Q

What is the first fit clinic?

A

Following first seizure, patient deemed safe for discharge.

Referral to first fit clinic follows.

Advise patient of lifestyle changes in the meantime.

If treatment initiated:
aim to control seizures with the lowest dose and least side effects.

42
Q

What daily living considerations are there, within epilepsy?

A

Driving: licence is taken away until seizure free for a while

Do not operate dangerous machinery

Avoid potentially dangerous work or activities, e.g. swimming, climbing ladders

Bathe with supervision or leave bathroom door unlocked

Do not bathe babies alone

Do not cycle on busy roads

Avoid consuming alcohol

43
Q

What long term considerations are there with epilepsy?

A

Annual review: check compliance, seizure control, advise on contraception, pregnancy, employment issues, benefits.

SUDEP (sudden, unexpected detain epilepsy): Increased risk of uncontrolled seizures (to 1 in 150)

Increased his of mental health illness: abnormal activity of neurotransmitters, structural abnormalities, functions abnormalities.

Semester 4 - Clinical Pharmacology And Therapeutics (26 decks)

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