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Pre-reg Exam 2021 > Epilepsy And Seizure Disorders > Flashcards

Epilepsy And Seizure Disorders Flashcards

1
Q

What is epilepsy?

A

A sudden surge of electrical activity of neurones in the brain

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2
Q

What are non-epileptic seizures?

A

Unrelated to abnormal electrical activity in the brain

Organic
Psychogenic

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3
Q

What are the drugs used to treat seizures?

A 
Barbiturates - phenobarbital (ON), primidone, thiopental
Benzodiazepines 
Carbamazepine
Ethosuximide
Gabapentin, pregabalin 
Lacosamide
Lamotrigine (ON)
Levetiracetam 
Phenytoin (ON)
Sodium valproate
Topiramate
Zonisamide
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4
Q

What is the first line treatment for focal seizures with/without secondary generalisation?

A

Lamotrigine or carbamazepine

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5
Q

What is the second line treatment for focal seizures with/without secondary generalisation?

A

Levetiracetam
Valproate
Oxcarbazepine

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6
Q

What is the first line treatment for tonic clonic seizures?

A

Valproate

Carbamazepine

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7
Q

What is the second line treatment for tonic clonic seizures?

A

Lamotrigine

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8
Q

What is the first line treatment for absence seizures?

A

Ethosuximide or valproate

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9
Q

What is the second line treatment for absence seizures?

A

Lamotrigine

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10
Q

What is the first line treatment for myoclonic seizures?

A

Valproate

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11
Q

What is the second line treatment for myoclonic seizures?

A

Topiramate

Levetiracetam

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12
Q

What is the first line treatment for atonic/tonic seizures?

A

Valproate

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13
Q

What seizures use lamotrigine as first line?

A

Focal seizures

Tonic clonic

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14
Q

What seizures use carbamazepine as first line?

A

Focal

Tonic clonic

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15
Q

What seizures use levetiracetam as second line?

A

Focal

Myoclonic

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16
Q

What seizures use valproate as second line?

A

Focal

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17
Q

What seizures use valproate as first line?

A

Tonic clonic
Absence
Myoclonic
Atonic/tonic

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18
Q

What seizures use oxcarbazepine as second line?

A

Focal

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19
Q

What seizures use ethosuximide as first line?

A

Absence

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20
Q

What seizures use topiramate as second line?

A

Topiramate

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21
Q

What is the MHRA warning for epilepsy?

A

Antiepileptic drugs - new advice on potential harm when switching between different manufacturer products for a particular drug in the treatment of epilepsy

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22
Q

What are the category one antiepileptics?

A

Carbamazepine
Phenytoin
Phenobarbital
Primidone

Maintain on same product

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23
Q

What are the category two antiepileptics?

A

Valproate
Lamotrigine
Clonazepam
Topiramate

Clinical judgement and patient consultation

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24
Q

What are category three antiepileptics?

A

Levetiracetam
Gabapentin
Pregabalin
Ethosuximide

Do not need to maintain on same product

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25
Q

How do you withdraw epilepsy treatment?

A

Gradually reduce dose under specialist supervision

Avoid abrupt withdrawal - can precipitate severe rebound seizures

Withdraw one epileptic drug at a time

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26
Q

Do you need to inform DVLA of epilepsy?

A

Yes, can drive car but not passenger carrying vehicle

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27
Q

How long do you need to be seizure free for in order to be able to drive?

A

1 year

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28
Q

When is there a driving ban in people with epilepsy?

A

During medication changes or withdrawal
6 months after last dose
6 months for first unprovoked epileptic seizure

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29
Q

Which antiepileptics have an increased risk of teratogenicity?

A

Valproate/valproate acid - highest risk

Carbamazepine, phenytoin, phenobarbital, primidone, lamotrigine - increased risk

Topiramate in first trimester - cleft palate

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30
Q

What do you have to be cautious with contraception and antiepileptics?

A

Enzyme inducing e.g. carbamazepine reduce efficacy of hormonal contraception

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31
Q

Which antiepileptics need dose adjustments in pregnancy?

A

Phenytoin
Carbamazepine
Lamotrigine

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32
Q

Which antiepileptics need foetal growth monitoring?

A

Topiramate

Levetiracetam

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33
Q

What needs to be taken before conception and until week 12 of pregnancy if taking antiepileptics?

A

5mg folic acid daily to reduce risk of neural tube defects

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34
Q

Which antiepileptics cause withdrawal effects in newborns?

A

Benzodiazepines and phenobarbital

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35
Q

What do you need to monitor if taking antiepileptics me breastfeeding?

A

Drowsiness
Weight gain
Feeding difficulty
Developmental milestones

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36
Q

Which antiepileptics are present in high amounts in milk?

A

Zonisamide
Ethosuximide
Lamotrigine
Primidone

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37
Q

Which antiepileptics accumulate due to a slower metabolism in infant?

A

Phenobarbital

Lamotrigine

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38
Q

Which antiepileptics inhibit the sucking reflex?

A

Phenobarbital

Primidone

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39
Q

Which antiepileptics have an established risk of drowsiness in babies?

A

Benzodiazepines
Phenobarbital
Primidone

40
Q

Which antiepileptics have a higher risk of withdrawal when breastfeeding?

A

Phenobarbital

Primidone

41
Q

What are the side effects of antiepileptics?

A 
Antiepileptic hypersensitivity syndrome 
Risk of suicidal behaviour and thoughts
Skin rashes
Blood dyscrasias 
Eye problems
Encephalopathic symptoms
42
Q

What are the symptoms associated with anti epileptic hypersensitivity syndrome?

A

Rash
Fever
Lymphadenopathy
Systemic involvement

Discontinue immediately

43
Q

What antiepileptics are associated with hypersensitivity syndrome?

A 
Carbamazepine 
Phenytoin
Phenobarbital
Primidone
Lamotrigine
44
Q

What are the MHRA warnings for antiepileptics?

A

Small increased risk of suicidal behaviour and thoughts

Gabapentin risk of severe respiratory depression

45
Q

What are the counselling points for antiepileptics?

A

Report any mood changes, distressing thoughts or feelings about suicide or self harm

Report signs of infection, bruising or bleeding

Report new visual symptoms

Report signs of raised intraocular pressure

46
Q

What antiepileptics have a high risk of skin rashes?

A

Lamotrigine

Valproate

47
Q

What antiepileptics have a risk of blood dyscrasias?

A 
Ethosuximide
Valproate
Carbamazepine 
Phenytoin
Lamotrigine
Topiramate
Zonisamide
48
Q

Which antiepileptic causes visual field defects?

A

Vigabatrin

Topiramate

49
Q

Which antiepileptics cause encephalopathic symptoms?

A

Vigabatrin

50
Q

What antiepileptics are enzyme inhibitors and cause an increased plasma concentration?

A

Sodium valproate

51
Q

What antiepileptics are enzyme inducers and cause a decreased plasma concentration?

A

Carbamazepine
Phenytoin
Phenobarbital

Interact with oral contraceptives and warfarin

52
Q

What is the mechanism of action of phenytoin?

A

Binds to neuronal sodium channels in their inactive state, prolongs inactivity

53
Q

What is phenytoin used for?

A

Focal seizures and generalised tonic clonic seizures

Exacerbates absence and myoclonic seizures

54
Q

That is the therapeutic range of phenytoin?

A

10-20mg/L

40-80 micromol/L

55
Q

What are the monitoring requirements for phenytoin?

A

Small changes in dose = large changes in plasma concentration

When protein binding is reduced, monitor the plasma free drug concentration

56
Q

Why are the signs and symptoms of toxicity of phenytoin?

A

Snatched

Slurred speech
Nystagmus
Ataxia
Confusion
Hyperglycaemia 
Diplopia, blurred vision
57
Q

What is the equivalent dose conversions of phenytoin sodium to phenytoin base?

A

100mg phenytoin sodium = 92 mg phenytoin base

58
Q

What are the side effects of phenytoin?

A 
Change in appearance
Blood dyscrasias
Hypersensitivity
Rashes
Low vitamin D = osteomalacia and rickets
Hepatotoxicity 
Suicidal ideation
Bradycardia 
Hypotension
CV reactions
59
Q

What are the counselling points for phenytoin side effects?

A

Report signs of infection

Report fever, rash, swollen, lymph nodes

Report signs of liver toxicity

60
Q

What are the NHS improvement patient safety alerts for phenytoin?

A

Risk of death and severe harm from error with injectable phenytoin

61
Q

What is the equivalent dose of fosphenytoin to phenytoin sodium?

A

Fosphenytoin 1.5mg = phenytoin sodium 1mg

62
Q

What are the interactions that increase phenytoin concentration and therefore toxicity?

A 
Amiodarone
Cimetidine
Miconazole
Fluconazole
Chloramphenicol
Metronidazole
Clarithromycin 
Fluoxetine
Sertraline
Diltiazem
Valproate
Trimethoprim
63
Q

What are the interactions that decrease phenytoin concentration?

A

St. John’s wort

Rifampicin

64
Q

What interactions antagonise the anticonvulsant effect of phenytoin?

A 
Quinolones
Tramadol
Mefloquine
SSRIs
Antipsychotics 
TCA
65
Q

What interactions increase the antifolate effect of phenytoin and therefore increase the risk of blood dyscrasias?

A

Methotrexate

Trimethoprim

66
Q

Phenytoin is an enzyme inducer and reduces the concentration of which drugs?

A 
Hormonal contraceptives 
Warfarin
Corticosteroids
Levothyroxine 
Liothyronine
67
Q

What is the mechanism of action of carbamazepine?

A

Inhibits neuronal sodium channels

Stabilises membrane potential and reduces neuronal excitability

68
Q

When is carbamazepine used?

A

First line in focal seizures, generalised tonic clonic seizure

Exacerbates atonic, clonic and myoclonic seizure

69
Q

What is the therapeutic range of carbamazepine?

A

4-12mg/L or 20-50 micromol/L

Measures after 1-2 weeks

70
Q

What are the signs and symptoms of carbamazepine toxicity?

A

I handbag

In coordination 
Hyponatraemia
Ataxia
Nystagmus 
Drowsiness
Blurred vision and diplopia
Arrhythmias
GI disturbance
71
Q

What are the side effects of carbamazepine?

A 
Blood dyscrasias
Hepatotoxicity
Hypersensitivity reactions
Rashes
Hyponatraemia
72
Q

What are the counselling points of carbamazepine side effects?

A

Signs of infection
Signs of liver toxicity
Fever, rash, lymphadenopathy

73
Q

Who are at risk of SJS with carbamazepine use?

A

Han Chinese and Thai patients with allele

74
Q

What are the monitoring requirements for carbamazepine?

A

Plasma concentration
FBC
LFT

75
Q

Which side effects of carbamazepine are dose related and dose limiting?

A 
Headache
Ataxia
Drowsiness
Nausea
Vomiting
Blurred vision
Unsteadiness
Allergic skin reactions

MR reduce risk of side effects

76
Q

What are the interactions that increase carbamazepine toxicity?

A

Cimetidine
Macrolides
Fluoxetine
Miconazole

77
Q

What interactions with carbamazepine decrease the concentration?

A

St Johns Wort

Phenytoin

78
Q

What interactions with carbamazepine antagonise the anticonvulsant effects?

A 
Quinolones
Mefloquine
SSRI
Antipsychotics 
TCA
79
Q

What interactions with carbamazepine increase the risk of hyponatraemia?

A 
Aldosterone antagonists 
SSRIs
TCAs
Diuretics
NSAIDs
80
Q

What carbamazepine interactions increase the risk of hepatotoxicity?

A 
Tetracyclines 
Sulfasalazine 
Sodium valproate
Methotrexate 
Isoniazid
Statins
Fluconazole 
Alcohol
81
Q

Carbamazepine is an enzyme inducer, which drugs does it reduce the concentration of?

A

Warfarin

Hormonal contraceptives

82
Q

What is the mechanism of action of sodium valproate?

A

Weak inhibitor or neuronal sodium channels

Stabilises resting membrane potential and reduces neuronal excitability

83
Q

When is sodium valproate used?

A

First line in all types of generalised seizures

84
Q

What is the MHRA warnings for sodium valproate?

A

Valproate medicines are contraindicated in women and girls of childbearing potential unless in PPP and only if no other alternatives

Contraindicated in pregnant women for bipolar disorder and only considered in epilepsy if no other alternative

Consult GP immediately if pregnant/planning pregnancy

85
Q

Who is the PPP for?

A

For all women of child bearing potential under specialist supervision

86
Q

What contraceptives do the PPP need to use!

A

User independent methods

User dependent methods - 2+ e.g. COC + barrier method + pregnancy test

87
Q

What are the side effects of sodium valproate?

A

Hepatotoxicity
Blood dyscrasias
Pancreatitis

88
Q

What are the side effect counselling points for valproate?

A

Report signs of liver toxicity
Report signs of infections
Report signs of pancreatitis

89
Q

What interactions with sodium valproate antagonise the anticonvulsant effects?

A 
Quinolones
Mefloquine
SSRIs
Antipsychotics 
TCA
90
Q

What interactions with sodium valproate increase the risk of hepatotoxicity?

A 
Statins
Carbamazepine 
Tetracyclines 
Fluconazole
Isoniazid
Itraconazole 
Methotrexate 
Sulfasalazine
91
Q

As valproate is an enzyme inhibitor, it increases the drug concentration of what drugs?

A

Other anti epileptics

92
Q

What is status epilepticus?

A

Epileptic fits follow one after the other without regaining consciousness

93
Q

What do you give for convulsive status epilepticus?

A

IV lorazepam

Avoid diazepam as it causes thrombophlebitis

94
Q

What do you give for incomplete loss of awareness for non-convulsive status epilepticus?

A

Continue or restart usual oral antiepileptic drug

95
Q

What do you give for complete loss of awareness for non-convulsive status epilepticus?

A

IV Lorazepam

96
Q

What do you give for febrile convulsions?

A

Paracetamol

If > 5 mins then IV lorazepam

97
Q

What do you give for convulsive seizures or febrile seizures > 5 mins in the community?

A

Diazepam rectal solution

Midazolam oromucosal solution

Repeat once after 10-15 mins if necessary

Pre-reg Exam 2021 (79 decks)

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