Epilepsy

Question 1

What is the MHRA advice surrounding switching between different manufacturers’ products in epilepsy?

Answer 1

Antiepileptic drugs have been divided into three risk-based categories to help healthcare professionals decide whether it is necessary to maintain continuity of supply of a specific manufacturer’s product.

Category 1:
Carbamazepine, phenobarbital, phenytoin, primidone. For these drugs, doctors are advised to ensure that their patient is maintained on a specific manufacturer’s product.

Category 2
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 and/or carer taking into account factors such as seizure control

Category 3
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 as therapeutic equivalence can be assumed

Question 2

What is antiepileptic hypersensitivity syndrome?

Answer 2

Rare but potentially fatal syndrome associated with some antiepileptic drugs

The symptoms usually start between 1 and 8 weeks of exposure; fever, rash, and lymphadenopathy are most commonly seen.

Question 3

What is the MHRA advice regarding antiepileptic drugs and psychological side effects?

Answer 3

Associated with a small increased risk of suicidal thoughts and behaviour (can occur as early as one week after starting treatment)

Seek medical advice if they develop mood changes

Question 4

What is 1st line for newly diagnosed focal seizures?

Answer 4

Carbamazepine or Lamotrigine

Question 5

What is 1st line for tonic-clonic seizures?

What would be an alternative if this is unsuitable? What is the problem with this?

Answer 5

Sodium valproate

Lamotrigine, carbamazepine is an alternative however may exacerbate myoclonic seizures

Question 6

What is 1st line for absence seizures?

What would be an alternative?

Answer 6

Ethosuximide or sodium valproate

Lamtorogine is an alternative

Question 7

What is 1st line for myoclonic seizures?

What would be alternative options?

Answer 7

Sodium valproate

Topiramate or levetiracetam

Question 8

Atonic and clonic seizures are usually seen in which patient group?

What is the drug of choice for this?

Answer 8

Childhood or associated with cerebral damage or mental retardation

Sodium valproate
Lamotrigine can be added

Question 9

Which benzodiazepines can be used in epilepsy management (not status epilepticus)?

Answer 9

Clobazam

Clonazepam

Question 10

Seizures lasting longer than 5 minutes should be treated with what benzodiazepine?

What should you monitor?

Answer 10

IV lorazepam - can repeat once after 10 minutes if response fails

Monitor for hypotension and respiratory depression

Question 11

IV diazepam is effective in seizures but carries a high risk of what?

Answer 11

Thrombophlebitis

Question 12

True or false:

Diazepam IM or suppositories should be used for status epilepticus

Answer 12

False- absorption is too slow

Question 13

If after initial treatment of IV lorazepam and there is no response after 25 mins, what should be used?

Answer 13

Phenytoin/phenobarbital/fosphenytoin

If this does not work- anaesthesia

Question 14

Do brief febrile convulsions need any treatment?

Answer 14

No, may give paracetamol to reduce fever

However, if prolonged (>5 mins) or recurrent, treat as epileptic seizure.

Question 15

Is long term anticonvulsant prophylaxis recommended?

Answer 15

Rarely indicated

Question 16

If an epileptic patient becomes pregnant, what supplement is recommended alongside their pregnancy, especially in the first trimester?

Answer 16

Folate supplementation to prevent neural tube defects (folic acid)

High dose 5mg OD

Question 17

Pregnant patients who are taking what antiepileptics should have fetal growth monitoring?

Answer 17

Topiramate or levetiracetam

Question 18

What conditions can lamotrigine exacerbate?

Answer 18

Parkinson’s Disease

Myoclonic seizures

Question 19

What is a main side effect of lamotrigine?

What are the risk factors of this?

Answer 19

Hypersensitivity syndrome. Serious skin reactions including Stevens-Johnson syndrome and toxic epidermal necrolysis have developed (especially in children); most rashes occur in the first 8 weeks.

Risk factors include concomitant use of valproate, too high dose or too rapid dose increase

Question 20

What is the patient advice surrounding lamotrigine?

Answer 20

• Don’t suddenly stop treatment as needs to be tapered off gradually
• Contact doctor immediately if any rash or signs of hypersensitivity
• Rare - be alert for symptoms and signs suggestive of bone-marrow failure, such as anaemia, bruising, or infection.

Question 21

What vitamin supplementation should you consider if a patient is on carbamazepine?

Answer 21

Vitamin D

Especially if immobilised for long periods, or who have inadequate sun exposure/dietary intake of calcium

Question 22

What are the main side effects to look out for if a patient is on carbamazepine?

Answer 22

Blood or skin disorders
Antiepileptic hypersensitivity syndrome

Seek medical help if fever, rash, mouth ulcers etc occur

ALSO can cause hepatotoxicity so report signs of dark urine, nausea, vomiting

Question 23

What is the MHRA advice regarding gabapentin?

Answer 23

Risk of severe respiratory depression

Question 24

What are the serious side effects of lamotrigine?

Answer 24

Skin reactions: these develop within 1-8 weeks. They include serious skin reactions i.e. Steven-
Johnson syndrome and toxic epidermal necrolysis

Blood disorders - Patients and their carers should be alert for symptoms and signs suggestive of bone-marrow failure, such as anaemia, bruising, or infection

Question 25

What antiepileptic is licensed for migraine prophylaxis?

Answer 25

Topiramate

Question 26

What vitamin supplementation should you consider if a patient is on sodium valproate?

Answer 26

Consider vitamin D supplementation in patients that are immobilised for long periods or who have inadequate sun exposure or dietary intake of calcium.

Question 27

What types of toxicity is associated with sodium valproate?

Answer 27

Blood disorders
Hepatic failure
Pancreatitis

Question 28

What is the safety alert associated with injectable phenytoin?

Answer 28

Risk of death and severe harm from error with the prescribing/preparation/administration

Question 29

What vitamin supplementation should you consider if a patient is on phenytoin?

Answer 29

Consider vitamin D supplementation in patients that are immobilised for long periods or who have inadequate sun exposure or dietary intake of calcium.

Question 30

What are the symptoms of phenytoin toxicity?

Answer 30

Nystagmus (involuntary eye movement), diplopia (double vision), slurred speech, ataxia, confusion, and hyperglycaemia

Question 31

What is nystagmus?

Answer 31

Involuntary eye movement

Question 32

What is the patient advice surrounding phenytoin?

Answer 32

Can cause agranulocytosis- Recognise signs of blood or skin disorders- report if mouth ulcer, bruising, bleeding develops
Antiepileptic sensitivity syndrome

Question 33

What are specific side effects with topiramate?

Answer 33

Acute myopia (near sightedness) with secondary angle-closure glaucoma
Encephalopathic symptoms - sedation, confusion

Patients should report signs of raised intra-ocular pressure

Question 34

What is primidone used for?

Answer 34

Essential tremor

Epilepsy

Question 35

What are specific side effects of IV phenytoin?

Answer 35

Bradycardia

Hypotension

Question 36

What investigations are carried out during epilepsy diagnosis?

Answer 36

• Electroencephalogram (EEG)
• Neuroimaging (MRI)
• Blood tests (plasma electrolytes, glucose, calcium)
• 12-lead ECG in adults

Question 37

What can be offered in focal seizures if first line carbamazepine or lamotrigine are unsuitable or not tolerated?

Answer 37

• levetiracetam oxcarbazepine or sodium valproate to boys, men and women who
  are not of childbearing potential

*Levetiracetam is not cost effective at June 2011 unit cost