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Pharmacy Year 3 > Epilepsy > Flashcards

Epilepsy Flashcards

1
Q

Why do epilepsy patients have a higher mortality rate?

A

Accidents
Falling from heights
Head injuries etc

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2
Q

What is Sudden Unexpected Death in Epilepsy?

A

Thought to be due to impaired cardiac or respiratory function
More common in generalised tonic-clonic seizures or poor seizure control (high freq.)

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3
Q

What is the pharmacist role in Sudden Unexpected Death in Epilepsy?

A

Increases adherence and manage side effects to try and control seizures

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4
Q

Define a seizure

A

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

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5
Q

What affects the symptoms exhibited in a seizure?

A

The location of the neurones

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6
Q

When can seizures be classed as epilepsy?

A

Two or more seizures separated in time

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7
Q

What could be potential causes of epilepsy?

A

Idiopathic - Genetic
Symptomatic - Head injury etc
Provoked - Drug abuse etc

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8
Q

What tests should be done in the diagnosis of epilepsy and why?

A

Bloods - Infection markers, electrolyte imbalances
ECG - Arrhythmias
MRI - Structural abnormalities
EEGs - May show epileptic activity to confirm diagnosis

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9
Q

Which medications can lower the seizure threshold?

A 
SSRIs
Tricyclics
Quinolones
Tramadol
Overdoses of medications
Illicit drugs
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10
Q

What other tools can be used in diagnosis of epilepsy?

A

Family history

Description of attack - witnesses?

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11
Q

What could mimic a seizure?

A

Non-Epileptic Attack Disorder

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12
Q

Why is it important to properly classify seizures?

A

For appropriate treatment and management

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13
Q

What are partial seizures?

A

Abnormal firing in one area of brain, location is manifestation

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14
Q

What is secondary generalisation?

A

Starts as partial seizure, then moves into other regions of the brain

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15
Q

Describe a simple partial seizure

A

Maintains consciousness
Limb twitching
Sensory changes
Aggression

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16
Q

Describe a complex partial seizure

A

Lose consciousness
May experience aura (ensure safety)
Automatisms (rhythmic, purposeless movements)
Can be dangerous if unaware of surroundings

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17
Q

Describe a generalised tonic/clonic seizure

A 
Tonic - Muscles tense
Clonic - Limb shaking, self terminates in 1-2 mins
Bite tongue
Lose continence
Fatigue and confusion after
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18
Q

Describe a generalised absence seizure

A

Lasts for seconds

Like zoning out

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19
Q

Describe a generalised myoclonic seizure

A

Limb jerking
Usually during working hours
Awake and aware
Interferes with day-to-day life

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20
Q

Describe a generalised atonic seizure

A

Patient loses all tone

Collapses

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21
Q

What are potential triggers of seizures?

A 
Fatigues, lack of sleep
Stress
Excess alcohol
Flashing lights (~5%)
Menstruation (catamenial epilepsy)
Excitement
Medicines
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22
Q

When would combination therapy be used for epilepsy?

A

After 2-3 drugs have been tried as mono therapy without seizure control

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23
Q

How is treatment for epilepsy initiated?

A

Start at lowest dose, titrate up until seizures controlled or side effects are limiting

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24
Q

When would treatment be started after first case seizure?

A

If EEG shows clear epileptic activity or a structural abnormality

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25
What is the treatment aim of epilepsy drugs?
Seizure control at lowest dose with minimum side effects
26
What factors should be considered when choosing an anti epileptic drug?
``` Syndrome and seizure type Comorbidities Lifestyle Gender Age Preference Drug factors - Formulation, dose, interactions, side effects etc. ```
27
Which drugs are first line for generalised tonic/clonic seizures?
Carbamazepine Lamotrigine Sodium Valproate Oxcarbazepine
28
Which drugs are adjuncts in generalised tonic/clonic seizures?
``` Clobazam Lamotrigine Levetiracetam Sodium Valproate Topiramate ```
29
Which drugs may worsen generalised tonic/clonic seizures?
``` Carbamazepine Gabapentin Oxcarbazepine Phenytoin Pregabalin ```
30
Which drug is first line for tonic or atonic seizures?
Sodium Valproate
31
Which drug is adjunct for tonic or atonic seizures?
Lamotrigine
32
Which drugs may worsen tonic or atonic seizures?
Carbamazepine Gabapentin Oxcarbazepine Pregabalin
33
Which drugs are first line and adjunct in absence seizures?
Ethosuximide Lamotrigine Sodium Valproate
34
Which drugs may worsen absence seizures?
``` Carbamazepine Gabapentin Oxcarbazepine Phenytoin Pregabalin ```
35
Which drugs are first line and adjunct for myoclonic seizures?
Levetiracetam Sodium Valproate Topiramate
36
Which drugs may worsen myoclonic seizures?
``` Carbamazepine Gabapentin Oxcarbazepine Phenytoin Pregabalin ```
37
Which drugs are first line for partial seizures?
``` Carbamazepine Lamotrigine Levetiracetam Oxcarbazepine Sodium Valproate ```
38
Which drugs are adjunct for partial seizures?
``` Carbamazepine Lamotrigine Levetiracetam Oxcarbazepine Sodium Valproate Clobazam Gabapentin ```
39
What is the initial dosing routine for sodium valproate? | What dosage forms are available?
Initially 600mg a day in 1-2 divided doses Gradually increase every 3 days until seizures controlled Dosage forms: EC, MR tabs, liquids, granules, IV
40
What are the monitoring requirements for sodium valproate?
Signs of liver, blood and pancreatic disorders | Platelet monitoring for clotting disorders and thrombocytopenia
41
When is sodium valproate contraindicated?
Women of childbearing potential (unless completely necessary) due to teratogenic effects
42
What are the side effects of sodium valproate?
``` Nausea Gastric irritation Diarrhoea Weight gain Hair loss ```
43
What is the initial dosing routine for carbamazepine? | What are the dosage forms?
Initially 100-200mg 1-2 times a day Increase every 2 weeks Dosage Forms: Oral or suppositories
44
What is the conversion between carbamazepine dosage forms?
125mg suppository = 100mg oral formulation
45
What are the monitoring requirements for carbamazepine?
``` Signs of blood, skin and liver disorders Leukopenia LFT changes/liver failure Rash Steven-Johnson Syndrome ```
46
What interactions may occur with carbamazepine and why?
``` CYP3A4 substrates (e.g. reduces efficacy of the pill) Potent enzyme inducer ```
47
What are the side effects of carbamazepine?
``` Headaches Nausea and vomiting Drowsiness Dizziness Rash Ataxia (Discoordinated movements) Hyponatraemia ```
48
What is the initial dosing routine for lamotrigine? | What are the available dosage forms?
Initially 25mg daily Increase every 2 weeks to avoid rash Dosage Forms: Oral formulations (normal, dispersible)
49
What is the dosing regime for lamotrigine as an adjunct?
25mg every other day if taken with valproate
50
When is lamotrigine an alternative to sodium valproate?
In young women as it is safer in pregnancy
51
What are the side effects of lamotrigine?
Nausea and vomiting Dry mouth Skin reactions
52
When should a patient consult their doctor if on lamotrigine?
If they get a rash within the first 8 weeks, treatment may be withdrawn
53
What is the initial dosing routine for levetiracetam? | What are the dosage forms available?
250mg daily Increase every 1-2 weeks Max. 1.5g twice a day Oral, IV
54
What are the side effects of levetiracetam?
``` Nasopharyngitis Somnolence Fatigue Dizziness Headache ```
55
When may levetiracetam be discontinued and when is it contraindicated?
If experiencing symptoms of depression or low mood | Avoid in patients with a history of severe depression
56
When is phenytoin used?
If everything else has been tried and hasn't worked Refractory seizures and status epilepticus Seizures caused by brain tumours and head injuries
57
What is the dosing regimen for phenytoin? | What are the available dosage forms?
3-4mg/kg/day loading dose - adjust according to levels Then 200-500mg daily Capsules and IV phenytoin base, liquid and chewable tabs phenytoin base
58
How long does it take to reach steady state concentrations with phenytoin? What is the steady state concentration?
7-10 days | 10-20mg/L
59
What does phenytoin interact with?
CYP450 inhibitors and inducers | Enteral feeding
60
When may patients need a lower dose of phenytoin?
Low albumin patients - highly protein bound usually
61
What is the conversion between phenytoin sodium and phenytoin base?
100mg phenytoin sodium = 92mg phenytoin base
62
What are the side effects of phenytoin?
``` Nausea and vomiting Constipation Drowsiness Parasthesia Gum hypertrophy Acne Excessive hair growth Coarsening of facial features ```
63
What are the symptoms of an overdose of phenytoin?
``` Eye flickering Ataxia Double vision Blurred vision Confusion Hyperglycaemia ```
64
What are the categories of antiepileptics and what do they mean?
Categorised on bioavailability Category 1 - Use specific brands to prevent loss of seizure control Category 2 - Supply based on advice of a specialist, if brand switched and seizures uncontrolled specialist may prescribe specific brand Category 3 - No specific measures
65
Which drugs are category 1?
Phenytoin Carbamazepine Phenobarbital
66
Which drugs are category 2?
Sodium Valproate Oxcarbazepine Lamotrigine
67
Which drugs are category 3?
Levetiracetam Lacosamide Gabapentin
68
Which drug may require an increase in dose if on EHC?
Lamotrigine
69
What should be given to women on antiepileptics before pregnancy?
5mg folic acid once a day
70
Why may treatment with antiepileptics be changed in the elderly and how?
``` May have a smaller volume of distribution Impaired metabolism Number of medications Comorbidities May require lower dose ```
71
How would carbamazepine be altered when given to the elderly?
Give MR release formulation
72
What is status epilepticus?
Prolonged seizures lasting more than 30 minutes (or multiple within 30 minutes) Convulsive seizures Breathing may be impaired
73
What is the treatment for status epilepticus?
IV lorazepam 0.1mg/kg Repeat once after 10-20mins if seizure continues If unavailable, IV diazepam or buccal midazolam Give normal antiepileptics if possible If lorazepam hasn't worked give IV phenytoin 20mg/kg over 20 minutes If already on phenytoin, give phenobarbital, sodium valproate, lacosamide or levetiracetam If still not working call anaesthetist for GA
74
What are the possible reasons for treatment failure?
``` Check compliance Brand/formulation changes Wrong seizure type diagnosis Brain tumours Alcohol/drug misuse ```
75
How should drugs be switched in epilepsy treatment?
Start second line, titrate to therapeutic dose and wean off first drug
76
What could be the result of abrupt withdrawal of antiepileptics?
Rebound seizures
77
What should be done if combination therapy doesn't work?
Revert to regimen that gave best balance of efficacy and tolerability (may be combination or monotherapy)
78
What are the issues surrounding combination therapy of antiepileptics?
Drug interactions DDIs between antiepileptics Similar ADRs make cause difficult to determine Compliance issues with complex drug regimes
79
How is treatment withdrawn and when?
Slowly withdrawn over months Withdraw one drug at a time if combination therapy If seizures recur reverse last dose reduction Can only withdraw once seizure free for 2 years
80
What counselling points should be given to patients on antiepileptics?
``` Importance of compliance Advise against swimming/bathing - SUDEP Dosing schedule and titrations Signs and symptoms of ADRs - Bruising, bleeding, liver dysfunction, rashes OTC and other medications ```
81
What are the social aspects to be aware of?
Health and safety risk for employers Have to inform DVLA, cannot drive until one year seizure free Avoid binge drinking
82
What are some causes of seizures in children?
``` Cardiac defects Low blood flow to brain Structural defects in brain Congenital problems in brain Metabolic reasons (build up of noxious chemicals in blood) ```
83
Describe febrile seizures
Temperature rises rapidly causing child to fit Usually family history High incidence Generalised tonic/clonic seizure
84
How are febrile seizures managed?
Environmental interventions - Turn heating down, open windows Hold child with head down to allow blood to reach brain while sleeping
85
Describe trauma seizures
Usually after hitting head/accidents | Tonic/clonic or clonic seizures
86
What are paroxysms?
Anoxic tonic/clonic seizures resulting from child holding their breath
87
What are reflex anoxic seizures?
From cold food, head trauma, fright
88
What can cause metabolic seizures?
Hypoglycaemia | Hyponatraemia
89
What are the causes of epileptic seizures in children?
Depolarisation on EEG Genetics Seconday causes - Tumour, neural damage Neurodegenerative disorders
90
What is Dravet's Syndrome?
SCN1A mutations Intractable seizures in first year of life Doesn't respond to conventional antiepileptics Developmental delays - walking, talking learning Child doesn't grow properly Lower normal body temperature
91
What are the treatment options for Dravet's Syndrome?
1st Line - Sodium Valproate (high dose) 2nd Line - Clobazam (orally) 3rd Line - Stiripentol (reduce doses of first 2) - if child > 3years
92
How does Stiripentol work?
Increases GABA to down regulate transmission in brain and inhibits metabolism of other antiepileptics
93
What are the dosage forms for Stiripentol?
Capsule | Sachet for oral suspension
94
What are the doses for Stiripentol?
10mg/kg BD for 1 week, then 15mg/kg BD for 1 week Then: <6years - Increase to 25mg/kg BD over 3 weeks 6-12years - Increase to 25mg/kg BD over 4 weeks >12 years - Increase slowly to maximum tolerated dose
95
What is the goal of treatment in Dravet's Syndrome?
Reduce frequency and severity of seizures
96
What is Lennox-Gastaut Syndrome?
Most common form of intractable epilepsy "Drop attacks" - Generalised absence seizures Focal tonic seizures Developmental delay and learning difficulties May progress to generalised tonic seizures
97
What are the treatment options for Lennox-Gastaut Syndrome?
1st Line - Sodium Valproate | 2nd Line - Lamotrigine, Topiramate, Clobazam, Phenytoin (depends on age and tolerance)
98
What is the purpose of corticosteroid use in Lennox-Gastaut Syndrome?
May reduce inflammation and neuronal damage Reduce longevity and spreading of seizures Prolong functional life
99
What is a non-pharmacological treatment option for Lennox-Gastaut Syndrome?
Surgery for focal seizures - identify causal structure and remove
100
What are the pharmacokinetics of Sodium Valproate?
Half life: 4-8hrs (child), 8-20hrs (adult) 90% protein bound Renally cleared "Therapeutic Concentration" 40-100mg/L (more about toxicity)
101
What are the possible teratogenic effects of Sodium Valproate?
``` Neural tube defects - Cleft lip, spina bifida Congenital Heart Disease Hole in Heart Renal Defects Developmental delay ```
102
What should be done if a patient on Sodium Valproate falls pregnant?
Give smallest dose more frequently or prolonged release formulation 5mg Folic acid
103
How does Sodium Valproate work?
Inhibits GABA reuptake in CNS
104
How does Carbamazepine work?
Voltage gated sodium channel antagonist - prevents repetitive action potentials GABA agonist
105
When is Carbamazepine contraindicated?
Dravet's Syndrome | Myoclonic Seizure Disorders
106
What are the pharmacokinetics of Carbamazepine?
``` 30hr half life after single dose, 15hr after repeated dosing 12hr half life if given with phenytoin 65% protein bound Extensive hepatic metabolism Therapeutic level 4-12mg/L ```
107
How does Lamotrigine interact with other antiepileptics?
Can result in increased Sodium Valproate or decreased Carbamazepine
108
When is Lamotrigine used 1st line?
Focal seizures Generalised tonic/clonic seizures Girls and women of childbearing age
109
How does gastric pH vary in children?
Increased if <2years (prevents denaturing of proteins in milk)
110
What effect does childhood gastric pH have on Phenytoin?
Lower oral bioavailability Phenytoin is a prodrug - no activation Give higher doses
111
How does gastric motility vary in children?
Slower than in adults
112
What effect does childhood gastric motility have on Phenobarbital and Carbamazepine?
Reduced peak levels of Phenobarbital - Rapid absorption through GIT Slower time to reach peak levels of Carbamazepine - Absorbed in GIT
113
How does a milk-based diet affect Phenytoin dosing?
Raise dose by 50% | If enteral feeding, Phenytoin absorption reduced by 35%
114
How does metabolism vary in children?
Increased hepatic extraction (large SA ratio) Increased first pass Higher CYP1A2, 2C9 and 3A4 expression
115
How should antiepileptics be started in children?
Slow increase of dose to prevent reaching toxic levels

Pharmacy Year 3 (15 decks)

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