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Y3 Patient Sem 2 > Epilepsy > Flashcards

Epilepsy Flashcards

1
Q

what is the prognosis of epilepsy?

A

— Up to 70% can become seizure free.
— 50% can withdraw medication
— 20-30% will continue to have seizures despite treatment

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2
Q

what is the mortality of epilepsy?

A

— Rate 2-3 times higher than general population
— Accidents due to the seizure
— Can be due to accidents as well as disease itself
— SUDDEN UNEXPECTED DEATH IN EPILEPSY (SUDEP)
— Dies due to a seizure and when there is NO other cause found to cause the death, due to convulsion cardiac or respiratory restriction

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3
Q

what is a seizure?

A

— A SEIZURE is an episode of neurological dysfunction of abnormal firing of neurones manifesting as changes in motor control/sensory perception/behaviour/autonomic function

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4
Q

what is epilepsy?

A

— EPILEPSY is the condition of recurrent, spontaneous seizures arising from abnormal, synchronous and sustained electrical activity in the brain.

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5
Q

what is the aetiology of epilepsy?

A

— Idiopathic epilepsy – genetic cause around 40%
— Symptomatic epilepsy (e.g. Head injury/stroke)
— Up to 50% have no apparent cause
— Up to 40% may have a genetic component

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6
Q

what is the diagnosis of epilepsy?

A

faints, fits and funny turns

  • First step of diagnosis is to establish if paroxysmal event was actually a seizure or something else.
    — -Lack of sodium
    — -Acute symptomatic seizure
  • Caused by direct ‘insult’
    — E.g. Head injury, infection, biochemical imbalance
  • Non-Epileptic attack disorder? Migraines? Encephalitis? Syncope?
  • Faint and limb twitching
  • Good history taking and witnesses are useful
  • Epilepsy is spontaneous and recurrent.
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7
Q

what is best at imaging for a seizure?

A

MRI as it can show structural abnormalities (bleed)

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8
Q

what are the two main types of seizures?

A
  • focal

- generalised

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9
Q

what are the different types of focal seizures?

A
  • Simple focal seizures – may become aggressive
  • Focal seizures with impaired awareness - may get a warning before and then zone out and then rhythmic movements. Can spread to the whole brain
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10
Q

what are the different types of generalised seizures?

A
  • Tonic/Clonic = tonic phase is where all the muscles tense up, the diaphragm tenses so patient may let out a cry. The clonic phase is when you have chronic shaking of limbs, usually on the floor. Usually self terminate within 2-3 minutes. Then they will have a post phase – extremely exhausted and sleep for a long period of time
  • Absence – can be very short (seconds)
  • Myoclonic – limb jerking. Occurs during waking hours and interferes with day to day life
  • Atonic – drop attacks, looses all control and falls to the ground
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11
Q

what are common triggers?

A 
—	Fatigue
—	Lack of sleep
—	Stress
—	Alcohol in excess
—	Flashing lights (photosensitive epilepsy) - 5%
—	Excitement 
—	Menstruation – catamenial epilepsy
—	Missing meals
—	Some medications
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12
Q

what are the NICE guidelines ?

A

— Always initiated by a specialist, after a diagnosis
— Monotherapy should be used where possible
— Start low, go slow titration until we have control or maximum side effects
— Adjunctive (add on) treatment should only be considered when monotherapy has failed
— Two or three drugs before you would try add on therapy
— AEDs are not usually started after a first seizure
— Quite a lot of people have 1 seizure, we would then refer them to get the bigger picture
— EEG confirms epileptic seizure you may start one straight away

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13
Q

what is the aim of treatment?

A
  • single agent
  • at the lowest dose
  • with the minimum side effects
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14
Q

what patient factors do you need when deciding therapy?

A
  • Epilepsy syndrome
  • Seizure type
  • Co-morbidity
  • Lifestyle
  • Gender
  • Age
  • Preferences of individual/family/carers
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15
Q

what drug factors do you need to take into account when chosing therapy?

A
  • Side effect profile
  • Dose
  • Treatment schedule
  • Formulation
  • Interactions
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16
Q

what is sodium valporate?

A

first line in many seizure types

600mg 1-2 times a day and increase gradually over time

17
Q

when should sodium valporate be avoided?

A

Should be avoided in pregnant women and women of childbearing potential due to risk of neurodevelopmental defects.
— Higher risk of child having neurodevelopmental defects
— Only reason we would use this in a young lady is if we have tried everything else, but they need to know all the risks of being on this

18
Q

what do you need to monitor in sodium valporate admin?

A

— Monitor for signs of liver, blood, pancreatic disorders
— You may get initial spike in LFTs when starting this
— Clotting disorders so need to keep an eye on platelet
— Severe abdo pain and nausea and vomiting need to be reviewed

19
Q

what are the side effects of sodium valporate?

A

nausea, gastric irritation, diarrhoea, weight gain, hair loss (grows back curly)

20
Q

what is carbamazepine?

A

1st line treatment for focal seizures

Initially 100-200mg 1-2times daily increased slowly every 2 weeks.

21
Q

what do you need to monitor in carbamezapine?

A

monitor for blood, liver and skin disorders

22
Q

what are the side effects?

A

— Side effects – Headache, N+V, drowsiness, dizziness, rash, ataxia (staggering, appear drunk), hyponatraemia (low sodium)
— Dose related, can be dose limiting
— Can be reduced by using MR tabs

23
Q

what is lamotrigine?

A

used for focal and generalised seziures

initially 25mg/day and slowly titrated every 2 weeks

24
Q

what are side effects?

A

serious skin disorders
nausea, vomiting, diarrhoea, dry mouth, skin reactions. Steven Johnson syndrome (blister on mucus membranes – life threatening)

25
what is levetiracetam?
— Used for partial seizures and adjunctive therapy for myoclonic seizures and tonic-clonic seizures — 250mg/day, increased every 1-2 weeks to max 1.5g BD
26
what is the side effects of levetiracetam?
Nasopharyngitis, somnolence, fatigue, dizziness, headache
27
what is phenytoin?
not recommended by NICE role in refractory seizures narrow therapeutic window
28
why is phenytoin rarely used?
— Extensive hepatic metabolism - — Strong inducer of CYP450 – interactions reduces effect of oral contraceptive pill — Highly protein bound – albumin. Unbound fraction that crosses blood brain barrier and has the effect. Low albumin will have toxicity at normal levels, so you might need to just take the unbound level
29
what are the 3 categories of antiepileptics?
• Category 1: Includes phenytoin, carbamazepine, phenobarbital, Specific measures are necessary to ensure consistent supply of a particular product • Category 2: Includes sodium valproate, lamotrigine, oxcarbazepine The need for continued supply based on clinical judgement • Category 3: Includes levetiracetam, lacosamide, gabapentin No specific measures required
30
what is status epilepticus?
* Medical emergency associated with significant morbidity and mortality * Efficient and effective treatment is key * Aim of treatment is seizure termination * Generalised Convulsive Status Epilepticus is defined as a tonic clonic seizure which lasts longer than 30 minutes or repeated tonic clonic seizures within 30 minutes
31
what is the treatment of status epilepticus?
• IV Lorazepam 0.1mg/kg (usually 4mg), repeated once after 10-20 minutes if seizure continues o Give usual AEDs if already on treatment o Alternatives to lorazepam are IV diazepam or buccal midazolam o Phenytoin IV 20mg/kg over 20 minutes (or phenobarbital if already on phenytoin) • General anaesthesia if above does not work
32
what are the problems with combination therapy?
``` • Drug interactions o Potent inducers/inhibitors of hepatic enzymes o Drug-Drug interactions between AEDs • Increased toxicity o Interactions can increase plasma concentration o Additive side effects • Identifying ADRs o Can be difficult to differentiate • Non—compliance o Increased pill burden o Unpleasant side effects ```
33
what happens during treatment withdrawal?
• Joint decision taken by patient and family/carers • Under the guidance of a specialist • Must be seizure free for 2 years before considering withdrawal o Withdrawal must be carried out slowly over months o One drug at a time if on combination therapy o A failsafe plan must be in place in case seizures recur.  Last dose reduction is reversed and medical advice sought

Y3 Patient Sem 2 (26 decks)

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