EPILEPSY

Question 1

Which epileptics can be given once daily at bedtime ?

Answer 1

Lamotrigine, perampanel, phenobarbital, and phenytoin, which have long half-lives, can be given once daily at bedtime

Question 2

Category 1 epileptic drugs that must be maintained on the same brand when dispensing ?

Answer 2

Carbamazepine, phenobarbital, phenytoin, primidone.

Question 3

Category 2 epileptic drugs?

Answer 3

Clobazam, clonazepam, eslicarbazepine acetate, lamotrigine, oxcarbazepine, perampanel, rufinamide, topiramate, valproate, zonisamide. For these drugs, the need for continued supply of a particular manufacturer’s product should be based on clinical judgement and consultation with the patient

Question 4

Category 3 epileptic drugs ?

Answer 4

Brivaracetam, ethosuximide, gabapentin, lacosamide, levetiracetam, pregabalin, tiagabine, vigabatrin. For these drugs, it is usually unnecessary to ensure that patients are maintained on a specific manufacturer’s product

Question 5

Which drugs have a risk of anti epileptic hypersensitivity syndrome ?

Answer 5

carbamazepine, lacosamide, lamotrigine, oxcarbazepine, phenobarbital, phenytoin, primidone, and rufinamide); rarely cross-sensitivity occurs between some of these antiepileptic drugs

Question 6

what are the symptoms of Antiepileptic hypersensitivity syndrome ?

Answer 6

The symptoms usually start between 1 and 8 weeks of exposure; fever, rash, and lymphadenopathy are most commonly seen.
Other systemic signs include liver dysfunction, haematological, renal, and pulmonary abnormalities, vasculitis, and multi-organ failure.

Question 7

The MHRA has advised (August 2008) that all antiepileptic drugs are associated with a small increased risk of …… ?

Answer 7

suicidal thoughts and behaviour. Symptoms may occur as early as one week after starting treatment.

Question 8

why should abrupt withdrawal of benzodiazepines and barbiturates should be avoided ?

Answer 8

can precipitate severe rebound seizures.

In patients receiving several antiepileptic drugs, only one drug should be withdrawn at a time.

Question 9

Patients who have had a first unprovoked epileptic seizure or a single isolated seizure must not drive for how long ?

Answer 9

6 months

Question 10

Patients with established epilepsy may drive a motor vehicle provided they are not a danger to the public and are compliant with treatment and follow up. To continue driving, these patients must be seizure-free for how long ?

Answer 10

at least one year (or have a pattern of seizures established for one year where there is no influence on their level of consciousness or the ability to act); also, they must not have a history of unprovoked seizures.

Question 11

Patients who have had a seizure while asleep are not permitted to drive for how long ?

Answer 11

for one year from the date of each seizure, unless:
a history or pattern of sleep seizures occurring only ever while asleep has been established over the course of at least one year from the date of the first sleep seizure; or
an established pattern of purely asleep seizures can be demonstrated over the course of three years if the patient has previously had seizures whilst awake (or awake and asleep).

Question 12

What is DVLA recommendation when about medication changes and withdrawal?

Answer 12

The DVLA recommends that patients should not drive during medication changes or withdrawal of antiepileptic drugs, and for 6 months after their last dose.

Question 13

What is a first line and second line treatment for focal (partial ) seizures with or without secondary generalisation ?

Answer 13

first line lamotrigine or carbamazepine

Alternative=levitaracetam, valrpoate, oxcarbazepine

Question 14

First line treatment for tonic clonic seizures ?

Answer 14

first line: valproate or carbamazepine.

Alternative is lamotrigine

Question 15

First line treatment for absence seizures ?

Answer 15

Ethosuximide is first line. However, valproate if high risk of generalised tonic clonic seizure. Alternative is lamotrigine

Question 16

First line for myoclonic seizures ?

Answer 16

Valproate is first line, however alternatives are topiramate, levetiracetam

Question 17

First line for atonic/tonic seizures?

Answer 17

valproate

Question 18

Which anti epileptic has the highest risk of teratogenicity ?

Answer 18

valproate/ valproic acid

Question 19

Which anti epileptic may cause cleft palate when use in first trimester of pregnancy ?

Answer 19

topiramate

Question 20

Carbamazepine + contraception =?

Answer 20

reduced efficacy of contraceptives

Question 21

Feotal growth should be monitored when patient is taking which anti epileptic drugs ?

Answer 21

topiramate/levetiracetam

Question 22

In women taking anti epileptic drugs what dose of folic acid they should take and how ?

Answer 22

5 mg taken before conception and until week 12 of pregnancy

Question 23

Women who are breastfeeding and taking anti epileptics, what are the monitoring requirements for their baby ?

Answer 23

monitor drowsiness, weight gain, feeding difficulty, adverse effect, developmental milestone

Question 24

Which anti epileptics are present in milk in high amounts ?

Answer 24

zosinamide, ethosuximide, lamotrigine and primidone

Question 25

Which anti epileptics accumulate in infant due to slower metabolism ?

Answer 25

phenobarbital, lamotrigine

Question 26

Which anti epileptics inhibit sucking reflex ?

Answer 26

phenobarbital and primidone

Question 27

With which anti epileptic drugs abrupt withdrawal of breast-feeding especially should be avoided ?

Answer 27

phenobarbital/primidone

Question 28

What factors would predispose to higher risk of developing skin rashes while on lamotrigine ?

Answer 28

High initial dose, rapid dose increase, if lamotrigine is given with valproate ( valproate is enzyme inhibitor )

Question 29

Which anti epileptic drugs may cause blood dyscrasias?

Answer 29

ethosuximide, valrpoate, carbamazepine, phenytoin, lamotrigine, topiramate, zonisamide. Patients should report signs of infection, bruising or bleeding

Question 30

Which anti epileptic may cause visual field defects ?

Answer 30

vigabatrin. patients should report new visual symptoms

Question 31

Which anti epileptic may cause acute myopia with secondary angle-closure glaucoma and therefore patients should be advised to report sings of raised intra-ocular pressure ?

Answer 31

Topiramate

Question 32

With which anti epileptic encephalopathic symptoms may occur and what action should be taken ?

Answer 32

vigabatrin , withdraw or reduce dose. Encephalopathic symptoms: marked sedation, stupor and confusion with non-specific slow wave EEG.

Question 33

MOA of phenytoin ?

Answer 33

binds to neuronal sodium channels in their inactive state: prolongs inactivity

Question 34

Phenytoin indications ?

Answer 34

focal seizures and generalised tonic clonic seizures

Question 35

Which seizures does phenytoin exacerbates and thus should be avoided ?

Answer 35

absence and myoclonic seizures

Question 36

What is phenytoin therapeutic range ?

Answer 36

10-20mg/l

Question 37

In which patient groups protein binding would be reduced, thus potentially increasing phenytoin toxicity ?

Answer 37

pregnancy, children, elderly and liver failure

Question 38

what are the signs and symptoms phenytoin toxicity ?

Answer 38

- slurred speech - nystagmus - ataxia - confusion - hyperglycaemia - diplopia/blurred vision

Question 39

Phenytoin (antifolate ) side effects ?

Answer 39

- Change in appearance= coarsening of facia features, acne, hirsutism, gingival hyperthropy. - Blood dyscrasias= leucopenia that is severe requires withdrawal. - Antiepileptic hypersensitivity syndrome - Rashes , rarely SJS

Question 40

Which patient groups have increased risk of SJS and require screening before treatment ?

Answer 40

Han Chinese and Thai patients with HLA-B*1502 allele

Question 41

Phenytoin patients counselling ?

Answer 41

Report signs of infections=fever, sore throat, mouth ulcers, or unexplained bruising or bleeding ( blood dyscrasias ) Report fever, rash, swollen lymph nodes ( anti epileptic hypersensitivity syndrome ) Report signs of liver toxicity: dark urine, nausea and vomiting, abdominal pain, itching, jaundice

Question 42

How does phenytoin affects vitamin D levels ?

Answer 42

phenytoin induces vitamin D metabolism

Question 43

Monitoring requirements for phenytoin ?

Answer 43

serum vitamin D, liver function

Question 44

Side effects of IV phenytoin ?

Answer 44

BRADYCARDIA, HYPOTENSION | Arrythmias, cardiovascular collapse, reparatory arrest

Question 45

What could happen if phenytoin IV administered too rapid ?

Answer 45

CVS/CNS depression

Question 46

If during IV phenytoin administration bradycardia or hypotension occurs, what should be done ?

Answer 46

reduce administration rate

Question 47

What monitoring should be in place for IV phenytoin ?

Answer 47

ECG/BP

Question 48

Side effects of fosphenytoin IV ?

Answer 48

``` Accosciated with severe cardiovascular reactions; Asystole ventricular fibrilation cardiac arrest heart block hypotension bradycardia ```

Question 49

Why could potentially fosphenytoin IV be preferred over phenytoin IV ?

Answer 49

fosphenytoin has less infection site reactions and can be given more rapidly with IV

Question 50

IV fosphenytoin monitoring ?

Answer 50

heart rate, BP, respiratory function during infusion and observe patient for at least 30 minutes after

Question 51

Which drugs given with phenytoin can potentially lead to phenytoin toxicity ?

Answer 51

amiodarone, cimetidine, miconazole, fluconazole, chloramphenicol, metronidazole, clarithromycin, fluoxetine, sertraline, diltiazem, valproate, trimethoprim

Question 52

Trimethroprim + phenytoin = interaction?

Answer 52

Increased anti folate effects that may lead to blood dyscrasias + increased phenytoin interactions

Question 53

Which drugs would reduce phenytoin concentrations and result in therapeutic failure ?

Answer 53

St Johns wort, rifampicin

Question 54

Which drugs would antagonise anticonvulsant effects of phenytoin?

Answer 54

quinolones, tramadol, mefloquine, SSRIs, antipsychotics, TCA all lower seizure threshold

Question 55

Which drugs given with phenytoin would lead to increased risk of blood dyscrasias?

Answer 55

methotrexate, trimethoprim

Question 56

Phenytoin is enzyme inducer, therefore which drugs concentration would phenytoin reduce?

Answer 56

Hormoanl contraceptives/HRT reduced efficacy Warfarin ( reduces anticoagulant effect ) Cotricosteroids Levothryoxine ( increased risk of hypothyroidism ) Liothyronine

Question 57

MOA of carbamazepine ?

Answer 57

inhibits neuronal sodium channels, stabilises membrane potential and reduces neuronal excitability

Question 58

In which types of seizures carbamazepine is a first line treatment ?

Answer 58

Focal seizures and generalised tonic clonic seizures

Question 59

Which seizures carbamazepine may exacerbate and thus should be avoided ?

Answer 59

atonic, clonic and myoclonic seizures

Question 60

Carbamazepine therapeutic range ?

Answer 60

4-12 mg/L

Question 61

When should carbamazepine plasma concentrations should measured ?

Answer 61

after one to two weeks

Question 62

What are the signs and symptoms of carbamazepine toxicity ?

Answer 62

``` Incordination Hyponatraemia Ataxia Nystagmus Drowsiness Blurred vision and diplopia Arrythmias Nausea, vomiting, diarrhoea ```

Question 63

Carbamazepine side effects ?

Answer 63

``` Hyponatraemia Leucopenia, thrombocytopenia Hepatoxicity Antiepileptic hypersensitivity syndrome SJS ( increased risk if given with phenytoin ) ```

Question 64

What side effects of carbamazepine are common in the beginning of the treatment and. in the elderly ? How can these side effects be minimised ?

Answer 64

Headache, ataxia, drowsiness, nausea, vomiting, blurred vision, unsteadiness, allergic skin reactions MR preparations may help to reduce the risk of side effects

Question 65

Which drugs can lead to increased concentrations of carbamazepine ?

Answer 65

cimetidine, macrolides, fluoxetine, miconazole

Question 66

Which drugs can decrease carbamazepine concentrations ?

Answer 66

St Johns wort, phenytoin

Question 67

Which drugs given with carbamazepine may lead to increased risk of hyponatraemia ?

Answer 67

aldosterone antagonists, SSRIs, TCA's, diuretics, NSAIDs,

Question 68

Which drugs given with carbamazepine may lead to increased risk of hepatoxicity ?

Answer 68

tetracyclines, sulfasalazine, sodium valproate, methotrexate, isoniazid, statins, fluconazole, alcohol

Question 69

Sodium valproate mechanism of action ?

Answer 69

Weak inhibitor of neuronal sodium channels, stabilises, resting membrane potential and reduces neuronal excitability.

Question 70

Sodium valproate is first line treatment in what type of seizures ?

Answer 70

First line treatment in all types of generalised seizures

Question 71

What are the side effects of sodium valproate ?

Answer 71

hepatoxicity, blood dyscrasias, pancreatitis

Question 72

Patient is on sodium valproate and they have abnormally prolonged prothrombin time, what action should be taken ?

Answer 72

discontinue

Question 73

How patient should be counselled if they are taking sodium valproate ?

Answer 73

Must report signs of liver toxicity: persistent vomiting, abdominal pain, jaundice, malaise, drowsiness Must report signs of infection: fever, sore throat, mouth ulcers, bruising or bleeding Must report signs of pancreatitis: abdominal pain, nausea or vomiting

Question 74

Sodium valproate monitoring requirements ?

Answer 74

Monitor liver function before therapy and during first 6 months especially in patients most at risk. Measure full blood count and ensure no undue potential for bleeding before starting and before surgery.

Question 75

STATUS EPILEPTICUS : Seizures lasting longer than 5 minutes should be treated urgently with ??

Answer 75

IV lorazepam (repeated once after 10 minutes if seizures recur or fail to respond).

Question 76

Intravenous diazepam is effective FOR STATUS EPILEPTICUS but it carries a high risk OF WHAT ?

Answer 76

thrombophlebitis (reduced by using an emulsion formulation)

Question 77

How should non-convulsive status epilepticus should be treated ?

Answer 77

If there is incomplete loss of awareness, usual oral antiepileptic therapy should be continued or restarted.

Question 78

How should febrile convulsions should be treated ?

Answer 78

Brief febrile convulsions need no specific treatment; antipyretic medication (e.g. paracetamol), is commonly used to reduce fever and prevent further convulsions