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Nervous system 1 > EPILEPSY > Flashcards

EPILEPSY Flashcards

1
Q

Which epileptics can be given once daily at bedtime ?

A

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

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2
Q

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

A

Carbamazepine, phenobarbital, phenytoin, primidone.

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3
Q

Category 2 epileptic drugs?

A

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

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4
Q

Category 3 epileptic drugs ?

A

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

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5
Q

Which drugs have a risk of anti epileptic hypersensitivity syndrome ?

A

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

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6
Q

what are the symptoms of Antiepileptic hypersensitivity syndrome ?

A

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.

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7
Q

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

A

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

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8
Q

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

A

can precipitate severe rebound seizures.

In patients receiving several antiepileptic drugs, only one drug should be withdrawn at a time.

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9
Q

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

A

6 months

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10
Q

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 ?

A

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.

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11
Q

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

A

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).

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12
Q

What is DVLA recommendation when about medication changes and withdrawal?

A

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

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13
Q

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

A

first line lamotrigine or carbamazepine

Alternative=levitaracetam, valrpoate, oxcarbazepine

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14
Q

First line treatment for tonic clonic seizures ?

A

first line: valproate or carbamazepine.

Alternative is lamotrigine

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15
Q

First line treatment for absence seizures ?

A

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

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16
Q

First line for myoclonic seizures ?

A

Valproate is first line, however alternatives are topiramate, levetiracetam

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17
Q

First line for atonic/tonic seizures?

A

valproate

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18
Q

Which anti epileptic has the highest risk of teratogenicity ?

A

valproate/ valproic acid

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19
Q

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

A

topiramate

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20
Q

Carbamazepine + contraception =?

A

reduced efficacy of contraceptives

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21
Q

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

A

topiramate/levetiracetam

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22
Q

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

A

5 mg taken before conception and until week 12 of pregnancy

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23
Q

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

A

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

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24
Q

Which anti epileptics are present in milk in high amounts ?

A

zosinamide, ethosuximide, lamotrigine and primidone

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25
Q

Which anti epileptics accumulate in infant due to slower metabolism ?

A

phenobarbital, lamotrigine

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26
Q

Which anti epileptics inhibit sucking reflex ?

A

phenobarbital and primidone

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27
Q

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

A

phenobarbital/primidone

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28
Q

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

A

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

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29
Q

Which anti epileptic drugs may cause blood dyscrasias?

A

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

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30
Q

Which anti epileptic may cause visual field defects ?

A

vigabatrin. patients should report new visual symptoms

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31
Q

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 ?

A

Topiramate

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32
Q

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

A

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

33
Q

MOA of phenytoin ?

A

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

34
Q

Phenytoin indications ?

A

focal seizures and generalised tonic clonic seizures

35
Q

Which seizures does phenytoin exacerbates and thus should be avoided ?

A

absence and myoclonic seizures

36
Q

What is phenytoin therapeutic range ?

A

10-20mg/l

37
Q

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

A

pregnancy, children, elderly and liver failure

38
Q

what are the signs and symptoms phenytoin toxicity ?

A
  • slurred speech
  • nystagmus
  • ataxia
  • confusion
  • hyperglycaemia
  • diplopia/blurred vision
39
Q

Phenytoin (antifolate ) side effects ?

A
  • 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
40
Q

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

A

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

41
Q

Phenytoin patients counselling ?

A

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

42
Q

How does phenytoin affects vitamin D levels ?

A

phenytoin induces vitamin D metabolism

43
Q

Monitoring requirements for phenytoin ?

A

serum vitamin D, liver function

44
Q

Side effects of IV phenytoin ?

A

BRADYCARDIA, HYPOTENSION

Arrythmias, cardiovascular collapse, reparatory arrest

45
Q

What could happen if phenytoin IV administered too rapid ?

A

CVS/CNS depression

46
Q

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

A

reduce administration rate

47
Q

What monitoring should be in place for IV phenytoin ?

A

ECG/BP

48
Q

Side effects of fosphenytoin IV ?

A 
Accosciated with severe cardiovascular reactions; Asystole
ventricular fibrilation
cardiac arrest
heart block 
hypotension
bradycardia
49
Q

Why could potentially fosphenytoin IV be preferred over phenytoin IV ?

A

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

50
Q

IV fosphenytoin monitoring ?

A

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

51
Q

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

A

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

52
Q

Trimethroprim + phenytoin = interaction?

A

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

53
Q

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

A

St Johns wort, rifampicin

54
Q

Which drugs would antagonise anticonvulsant effects of phenytoin?

A

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

55
Q

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

A

methotrexate, trimethoprim

56
Q

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

A

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

57
Q

MOA of carbamazepine ?

A

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

58
Q

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

A

Focal seizures and generalised tonic clonic seizures

59
Q

Which seizures carbamazepine may exacerbate and thus should be avoided ?

A

atonic, clonic and myoclonic seizures

60
Q

Carbamazepine therapeutic range ?

A

4-12 mg/L

61
Q

When should carbamazepine plasma concentrations should measured ?

A

after one to two weeks

62
Q

What are the signs and symptoms of carbamazepine toxicity ?

A 
Incordination
Hyponatraemia
Ataxia
Nystagmus
Drowsiness
Blurred vision and diplopia 
Arrythmias
Nausea, vomiting, diarrhoea
63
Q

Carbamazepine side effects ?

A 
Hyponatraemia 
Leucopenia, thrombocytopenia
Hepatoxicity
Antiepileptic hypersensitivity syndrome 
SJS ( increased risk if given with phenytoin )
64
Q

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

A

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

65
Q

Which drugs can lead to increased concentrations of carbamazepine ?

A

cimetidine, macrolides, fluoxetine, miconazole

66
Q

Which drugs can decrease carbamazepine concentrations ?

A

St Johns wort, phenytoin

67
Q

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

A

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

68
Q

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

A

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

69
Q

Sodium valproate mechanism of action ?

A

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

70
Q

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

A

First line treatment in all types of generalised seizures

71
Q

What are the side effects of sodium valproate ?

A

hepatoxicity, blood dyscrasias, pancreatitis

72
Q

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

A

discontinue

73
Q

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

A

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

74
Q

Sodium valproate monitoring requirements ?

A

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.

75
Q

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

A

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

76
Q

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

A

thrombophlebitis (reduced by using an emulsion formulation)

77
Q

How should non-convulsive status epilepticus should be treated ?

A

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

78
Q

How should febrile convulsions should be treated ?

A

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

Nervous system 1 (13 decks)

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