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7118 - Clinical Therapeutics for Core Conditions > Epilepsy > Flashcards

Epilepsy Flashcards

1
Q

What two types of seizures can we get?

A

generalised - both hemispheres

focal - starts in on hemisphere but can move into the other

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2
Q

Provoked seizures in patients who do not have epilepsy may be caused by

A

alcohol or drug withdrawal
fever
hypoxia
hypoglycaemia

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3
Q

Different ways in which drugs can cause seizures

A
  • lowering the seizure threshold e.g. cipro, tramadol
  • drug interaction reducing anti-epileptic drug levels (e.g. hepatic microsomal enzyme induction with rifampicin)
  • effects secondary to other medical causes (e.g drug induced hyponatraemia)
  • individual anti-epileptic drugs which may themselves cause worsening of some seizure types.
  • drug withdrawal (e.g. illicit, alcohol, benzodiazepine, baclofen)
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4
Q

Diagnosis of epilepsy

A
  • two unprovoked seizures more than 24 hours apart
  • one unprovoked seizure with a high risk of another
  • diagnosis of epilepsy syndrome
  • ECG, EEG, neuroimagine

differential diagnosis - non-epileptic attack disorders (pseudo seizures) Characterised by a change in behaviour or movement but unlike epilepsy are not caused by primary change in electrical activity of the brain. More prevent in females and early onset in adolescence.

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5
Q

When is it appropriate to take phenytoin levels?

A
  • Adjusting phenytoin doses
  • Assessing adherence to therapy
  • Identifying potential treatment toxicity
  • Assessing potential changes to drug metabolism e.g. pregnancy, drug-drug interactions
  • unexplained loss of seizure control
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6
Q

What bloods should be monitored when using sodium valproate?

A

LFT’s. Can cause hepatic dysfunction.

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7
Q

How do we load phenytoin naive patients?

A

20mg/kg IV

capped at 2gram

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8
Q

What is the phenytoin salt factor (for caps and injection)

A

0.92

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9
Q

What is the phenytoin volume of distribution?

A

0.65L/kg

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10
Q

What is usually the initial maintenance dose for phenytoin?

A

3-4mg/kg/day

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11
Q

What is a clinically effective serum phenytoin concentration?

A

10-20

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12
Q

Phenytoin levels

A

Total serum phenytoin levels reflect both free and unbound drug. Only the free fraction of phenytoin is active and in healthy adults around 90% of phenytoin is bound therefore levels have to be adjusted in patients with low albumin.

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13
Q

What is the corrected phenytoin level equation for patients with low albumin but normal renal function

A

observed phen level/(0.9x(albumin g/dL/44)) + 0.1

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14
Q

What is the usual dose increments we see with phenytoin?

A

25-50mg max

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15
Q

what do women of child baring age have to sign up to if they’re on sod val

A

PPP

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16
Q

what sort of contraception do we recommend in epileptic patients who are taking enzyme inducing anti epileptics?

A

COC with at least 50microgram os oestrogen

POC and rings/implants/patch are not recommended

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17
Q

What are enzyme inducing anti-epileptics?

A 
Esilcarbamazepine
carbamazepine
oxcarbamazepine
perampanel (12mg/day)
phenobarbital
phenytoin
primidone
rufinamaide
topiramate (>200mg/day)
18
Q

What contraception can women take who are taking non-enzyme inducing anti epileptics?

A

They can take anything.

Lamotrigine is a none enzyme inducing drug however it does interact with some contraceptions.

Lamotrigine clearance is doubles by ethinyloestrodiol/levonorgestrel 30mcg/150mcg, threatening seizure control, lamotrigine dose may need to be increased.

Desogestrel may increase lamotrigine concentrations.

19
Q

Advice for emergency contraception?

A
  • single dose of levonorgestrel 3mg as soon as possible within 72 hours of unprotected intercourse.
  • ulipristal acetate is not recommended due to reduced efficacy
  • insertion of non-hormonal intra-uterine device within 5 days of intercourse is effective
20
Q

What emergency hormonal contraception is not recommended?

A

ulipristal acetate due to reduced efficacy

21
Q

When could patients think about surgery?

A

Patients who have focal seizures who are on two medicines at adequate doses for two years without a substantial response.

22
Q

VNS and DBS

A

vagus nerve stimulator
deep brain stimulator

Supply mild electrical impulses. If the patient feels an aura then they can press a button which send impulse to the right place.

23
Q

What is status epileptics defines as?

A

seizure > 30 minutes whether it is a prolonged seizure or repeated seizures with no recovery in-between.

24
Q

duration of tonic-clonic seizure which should then be treated as a medical emergency

A

5 minutes

25
Q

what can long term status epileptics cause?

A
  • respiratory compromise
  • cardiorespiratory arrest
  • if left untreated - permanent cerebral damage
26
Q

timings of seizures

A

5 mins is the earliest point at which we ca treat

30 mins indicates a risk at which long term damage can occur

27
Q

What is first line treatment for status epilepticus

A

Benzodiazepines:
community - buccal midazolam or rectal diazepam
hosp - IV lorazepam favoured.

An anti epileptic should be started irrespective of whether a patient is convulsing or not as when the benzo wears off we don’t want rebound seizures.

  • Phenytoin is first line
  • Fosphenytoin may be given if poor IV access. It is a prodrug of phenytoin and can be given IM.
  • Historically if this persists then phenobarbital can be given but is rarely used as it can cause respiratory and CNS depression
28
Q

Does carbamazepine induce its own metabolism?

A

Yes therefore it should be gradually increased every two weeks.

29
Q

Points taken from the SANAD trial

READ!!!

A
  • gabapentin was found to be more likely than other convulsants to be associated with treatment failure in the management of focal epilepsy
  • lamotrigine is the drug of choice in focal epilepsy
  • valproate is the drug of choice in generalised and unclassified epilepsy
  • rash was more commonly reported for patients on carbamazepine than lamotragine
30
Q

Shall we take sodium valproate levels to ensure it is therapeutic?

A

NO!!

31
Q

Give examples when it is appropriate to do TDM

A
  • assess the adherence of sodium valproate therapy
  • unexplained status epileptics in a patient taking lamotragine
  • To ensure phenytoin levels are therapeutic
  • suspected carbamazepine toxicity
32
Q

Are women at higher risk of seizing when they are pregnant?

A

No they are generally unlikely to have a seizure in pregnancy and a few months after birth

33
Q

Are lamotrigine levels increased or decreased by oestrogen containing contraceptives?

A

They are DECREASED. As clearance of the drug doubles so we may have to increase the dose.

34
Q

Facts about contraception

A
  • The progesterone only pill is not recommended as a reliable contraception in women taken enzyme inducing anti epileptics
  • The dose of levonorgestrel required for emergency contraception in women taking enzyme inducing drugs is 3mg.
  • Desogestrel may increase lamotrigine concentration
  • insertion of non-hormonalinteruterine device within 5 days of intercourse is an effective method of emergency contraception regardless of AED therapy.
35
Q

SUDEP

A

there is an apparently increase in SUDEP in people with frequent daytime seizures.

36
Q

a medicine which can reduce the seizure threshold is

A

baclofen

37
Q

Is carbamazepine excreted by the kidney and should it be avoided in renal impairment?

A

No

38
Q

What epileptic drug cause PR interval prolongation?

A

Lacosamide

39
Q

Which antiepileptic can cause progressive visual loss

A

Vigabatran

40
Q

Which antiepileptic causes urilothiasis

A

Topiramate

41
Q

Which antiepileptic causes SJS

A

Lamotrigine and carbamazepine

42
Q

Best antidepressant in epilepsy

A

They can all lower the seizures threshold

Best is SSRI
sertraline

CI in patient s with poorly controlled epilepsy

7118 - Clinical Therapeutics for Core Conditions (31 decks)

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