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Pharm Y3S2 > Epilepsy > Flashcards

Epilepsy Flashcards

1
Q

What percentage of patients with epilepsy will become seizure free with treatment?

A

70%

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2
Q

What is SUDEP?

A

Sudden unexpected death in epilepsy

During seizure, where no other causes are found

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3
Q

Define seizure.

A

Episode of neurological dysfunction of abnormal firing of neurones, manifesting as changes in motor control, autonomic function, senses or behaviour

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4
Q

Define epilepsy.

A

Recurrent, spontaneous seizures arising from abnormal electrical activity in the brain

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5
Q

What may cause an acute symptomatic seizure?

A 
Head injury
Infection
Electrolyte imbalance
Migraine
Encephalitis
Syncope
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6
Q

What information is needed to diagnose epilepsy?

A 
Description of attack
Family history
Blood tests (Na)
ECG
Medication history
MRI
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7
Q

Why should an EEG never be used in isolation to diagnose epilepsy?

A

10% of epileptic patients show no changes
Some healthy patients show abnormalities
Main role is classification

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8
Q

What is a partial seizure?

A

Occurs in one part of the brain

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9
Q

What is a simple partial seizure?

A

Maintain consciousness

May present with aggression prior

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10
Q

What is a complex partial seizure?

A

Lose consciousness
May get an aura
Autonomic movements such as playing with clothes, lip smacking

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11
Q

What is a secondary generalisation?

A

Partial seizure that spreads to another part of the brain

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12
Q

What is a tonic-clonic seizure?

A

Tonic phase- muscles tense and patient may let out a cry (diaphragm)
Clonic phase- limb shaking, usually self-terminate within 1-2 minutes
Post distal phase- exhaustion, confusion

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13
Q

What is an absence seizure?

A

May only last seconds

Person looking into distance

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14
Q

What is a myoclonic seizure?

A

Limbs jerk

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15
Q

What is an atonic seizure?

A

Drop attack

Patient loses all tone and falls

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16
Q

Give examples of potential seizure triggers?

A 
Fatigue
Stress
Alcohol
Flashing lights
Excitement
Menstruation
Missing meals
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17
Q

What is first line treatment in epilepsy?

A

Sodium valproate

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18
Q

What is the normal starting dose of sodium valproate?

A

600mg daily in 1-2 divided doses

Increase gradually every 3 days

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19
Q

Compare the oral and IV doses of sodium valproate?

A

The doses are equivalent

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20
Q

What monitoring is required with sodium valproate?

A

Transient liver changes

Blood and pancreatic disorders

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21
Q

What is the main contraindication of sodium valproate?

A

Avoid in pregnancy and women of childbearing potential

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22
Q

Give side effects of sodium valproate.

A

Nausea
GI irritation
Weight gain
Hair loss

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23
Q

When is carbamazepine first line treatment?

A

Focal seizures

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24
Q

What is the normal starting dose of carbamazepine?

A

100-200mg 1-2 times daily

Increased every 2 weeks

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25
Q

What monitoring is required with carbamazepine?

A

Blood, liver and skin disorders

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26
Q

Compare the oral and suppository doses of carbamazepine.

A

125mg suppository is equivalent to 100mg oral dose

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27
Q

Give side effects of carbamazepine.

A 
Headache
N+V
Drowsiness
Rash
Ataxia
Hyponatraemia
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28
Q

When is lamotrigine indicated?

A

In focal and generalised seizures

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29
Q

What is the normal starting dose of lamotrigine?

A

25mg daily

Titrated every 2 weeks

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30
Q

What is the most important side effect of lamotrigine?

A

Serious skin reactions

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31
Q

Which AED is generally considered the safest in pregnancy?

A

Lamotrigine

32
Q

What formulations of lamotrigine are available?

A

Oral tablet

Dispersible tablet

33
Q

Give side effects of lamotrigine.

A

N+V
Diarrhoea
Dry mouth
Skin reactions

34
Q

How is carbamazepine metabolised?

A

Via CYP3A4

35
Q

What is important to consider with co-administration of sodium valproate and lamotrigine?

A

Valproate blocks the metabolism of lamotrigine

36
Q

When is levetiracetam indicated?

A

In partial seizures

Adjunctive therapy in myoclonic and tonic-clonic

37
Q

What is the normal starting dose of levetiracetam?

A

250mg daily
Increased every 1-2 weeks
Up to 1.5g BD

38
Q

Compare the oral and IV doses of levetiracetam?

A

They are equivalent

39
Q

Give side effects of levetiracetam.

A 
Nasopharyngitis
Somnolence
Fatigue
Dizziness
Headache
Mood changes
40
Q

When is phenytoin indicated?

A

Role in refractory seizures and status epilepticus

41
Q

What is the normal starting dose of phenytoin?

A

3-4mg/kg.day

Normally 200-500mg/day

42
Q

Describe the PK of phenytoin.

A

Narrow therapeutic index
Half life of 4-72 hours
Steady state reached after 7-10 days
Highly albumin bound

43
Q

Describe the effects of phenytoin on the liver.

A

High hepatic metabolism

Strong inducer of CYP450

44
Q

Compare the base and sodium forms of phenytoin.

A

Base in liquid or chewable tablets
Sodium in IV or capsules
100mg phenytoin sodium is equal to 92mg phenytoin base

45
Q

Give side effects of phenytoin.

A 
N+V
Constipation
Drowsiness
Parasthesia
Gingival hyperplasia
Acne
Hirsutism
Coarsening of facial features
46
Q

Give signs of phenytoin overdose.

A 
Nystagmus
Ataxia
Diplopia
Slurred speech
Confusion
Hyperglycaemia
47
Q

Which AEDs fall into category 1 for brand name prescribing?

A

Phenytoin
Carbamazepine
Phenobarbital

48
Q

Which AEDs fall into category 2 for brand name prescribing?

A

Sodium valproate
Lamotrigine
Oxcarbazepine

49
Q

Which drug class in particular can reduce effectiveness of lamotrigine?

A

Oral contraceptives

50
Q

What is status epilepticus?

A

Medical emergency

Tonic clonic seizure lasting longer than 30 minutes or repeated within 30 minutes

51
Q

Describe the stages of treatment of status epilepticus.

A

Rectal diazepam may be given en route to hospital
IV lorazepam 0.1mg/kg (usually 4mg), repeated once after 10-20 minutes if seizure continues
Give usual AEDs if already on treatment
IV diazepam or buccal midazolam may be alternative to lorazepam but risk of thrombophlebitis
Phenytoin IV 20mg/kg over 20 minutes (phenobarbital if already on phenytoin)
General anaesthesia if above does not work

52
Q

Describe the requirements for AED withdrawal.

A

Must be seizure free for 2 years
Must occur slowly over months
One drug at a time if on combination therapy

53
Q

What are the 3 main social considerations in epilepsy?

A

Cannot be refused employment under 2010 Equality Act but H+S must be considered
Driving licensed must be revoked, 1 year seizure free for renewal
Alcohol can trigger seizures and interact with AEDs

54
Q

Give three potential types of non-epileptic seizures.

A

Febrile seizure- due to increased temperature
Trauma
Metabolic- hyponatraemia, hypoglycaemia

55
Q

Describe a paroxysm.

A

‘Breath holding attack’
Anoxic tonic-clonic seizure
Over-exaggerated temper trantrum

56
Q

What is a reflex anoxic seizure?

A

Response to something they are introduced to i.e. cold food, trauma, fright

57
Q

Describe a febrile seizure.

A

Generalised tonic-clonic seizure
Last between 3 and 5 minutes
Short lived and self resolving
Associated with rapid rising body temperature

58
Q

What steps can be taken when a child is experiencing a febrile seizure?

A

Reassur parents
Cool child down
Try not to pick them up
Often due to child getting ill

59
Q

What is Dravets syndrome?

A

Genetic mutation of SCN1A in most sufferers
Intractable seizures
Developmental delay
Failure to thrive
Dysregulated autonomic nervous system (lower body temperature)

60
Q

What is the treatment for Dravets Syndrome?

A

Sodium valproate
AND clobazam
ADD stiripentol if first two don’t work

61
Q

What must be done to doses of VPA and CLB if stiripentol is added?

A

Reduced

Stiripentol is strong inhibitor of CYP450, 2C19, 2D6 and 3A4

62
Q

From what age is stiripentol licensed?

A

Over 3 years

63
Q

What is the normal dose for stiripentol?

A

10mg/kg BD for 1 week
15mg/kg BD for 1 week
Then alter for age
Younger patients can have dose increased over a shorter period

64
Q

Describe the gastric pH of children under 2? What AED in particular is affected by this?

A

Gastric pH higher

Oral bioavailability of phenytoin <75%

65
Q

Describe the gastric motility of children ? What AEDs in particular are affected by this?

A

Reduced peak levels of phenobarbital

Slower time to reach peak levels of carbamazepine

66
Q

What impact do milk based diets have on phenytoin?

A

Absorption reduced by 35% if administered with enteral feed

67
Q

How does metabolism of AEDs vary in children?

A

Increased hepatic extraction
Liver is larger by SA
Higher mg/kg doses needed for carbamazepine and VPA
CYp enzyme expression >50% higher in children under 12 years

68
Q

What are the characteristics of Lennox-Gastaut Syndrome?

A 
Drop attacks
Generalised absence seizures
Atypical focal absence seizures
Tonic seizures
Can have developmental delay and learning difficulties
69
Q

Describe the treatment for Lennox-Gastaut Syndrome.

A

First line- VPA
Second line- LMT, TPA, CLB, PHY
Corticosteroids can reduce inflammation and neuronal damage
Surgery to remove affected area

70
Q

Describe the PK of sodium valproate.

A

Half life 4-8 hours in children, 8-20 hours in adults
90% protein bound
Renally cleared

71
Q

Describe the PK of carbamazepine.

A 
Half life of 30 hours after single dose
15 hours after repeated dose
0.5-12 hours when given with phenytoin
65% protein bound
Hepatically metabolised
72
Q

What are the four main categories of anti-convulsant?

A

Sodium channel inhibitors
Calcium channel inhibitors
GABA-mediated inhibition enhancers
Glutamate receptor inhibitors

73
Q

How do sodium channel inhibitors work?

A

No firing of action potential

Dampen down excitation

74
Q

How do calcium channel inhibitors work?

A

Without calcium entry into the cell, there is no transmitter release
Reduce excessive glutamate release

75
Q

Describe the production and action of GABA?

A

Synthesis of GABA mediated by glutamic acid decarboxylase
Release in response to action potential and presynaptic calcium elevation
Reuptake via receptors into neurons and glia cells
Four GABA transporters identified (GATs)
Breakdown occurs within cells by mitochondrial enzyme GABA-transaminase

76
Q

Describe the action of glutamate receptors?

A

AMPA and kainate (ionotropic) sites open a channel through receptor allowing sodium and small amounts of calcium to enter
NMDA (ionotropic) sites open a channel allowing large amounts of calcium and sodium, channel is blocked by magnesium in the resting state, only activated by higher voltages

Pharm Y3S2 (29 decks)

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