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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
Q

what is levetiracetam?

A

— 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
Q

what is the side effects of levetiracetam?

A

Nasopharyngitis, somnolence, fatigue, dizziness, headache

27
Q

what is phenytoin?

A

not recommended by NICE
role in refractory seizures

narrow therapeutic window

28
Q

why is phenytoin rarely used?

A

— 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
Q

what are the 3 categories of antiepileptics?

A

• 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
Q

what is status epilepticus?

A
  • 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
Q

what is the treatment of status epilepticus?

A

• 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
Q

what are the problems with combination therapy?

A 
•	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
Q

what happens during treatment withdrawal?

A

• 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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