Epilepsy - Block 1 Flashcards

1
Q

What is a seizure?

A

a transient alteration of behavior due to the disordered, synchronous, and rhythmic firing of populations of brain neurons

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2
Q

What is epilepsy?

A

a chronic brain disorder characterized by recurrent (≥ 2) seizures that are unprovoked

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3
Q

What can cause acute symptomatic sz?

A
  1. Neurologic insult
  2. Metabolic disorder
    * Electrolyte imbalances: Hyponatremia (<115 mmol/L); Hypocalcemia (<5 mmol/L); Hypomagnesemia (<0.8 mg/dL)
    * Hypo- or hyper-glycemia
  3. Medication
  4. Alcohol and toxics
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4
Q

What are the medications that cause seizures?

A
  1. Beta lactams
  2. Fluroroquinolones
  3. Theophylline
  4. Bupropion
  5. Second gen clozapine
  6. Lithium
  7. Meperidine, morphine, propoxyphene
  8. Tramadol
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5
Q

What are the causes of epilepsy?

A
  1. Genetic
  2. Structural
  3. Infection
  4. Metabolic
  5. Immune
  6. Idiopathic
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6
Q

Descibe the age onset of epilepsy?

A

Before age 2: Fever, hereditary or congenital neurologic disorders, birth injuries, and inherited or acquired metabolic disorders
Ages 2 to 14: Idiopathic seizure disorders
Adults: Cerebral trauma, alcohol withdrawal, tumors, strokes, and an unknown cause (in 50%)
Older people: Tumors and strokes

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7
Q

What are the 2 facotrs that contribute to the development of epilepsy?

A
  1. Hyperexcitability
  2. Hypersynchronization
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8
Q

What are the phases of a seizure?

A
  1. Prodromal: hours/days before seizure
  2. Aural: deja vu, jamais vu, odd smells, tastes, dz
  3. Ictal: first sx to end of seizure
  4. Recovery: confusion, lack of consciousness
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9
Q

What are the 2 classes of seizure types?

A
  1. Focal: One side
  2. Generalized: Both sides
  3. Unclassified
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10
Q

How are seizures classified?

A
  1. Onset
  2. If focal, must identify aware or impaired if known (if unknown omit). Don’t have to identify this for generalized since impaired awareness is implied
  3. First sign or symptom
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11
Q

What is the difference between focal aware and focal impaired awareness sz?

A

FA: simple partial sz
FIA: complex partial sz

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12
Q

Another name for focal to bilateral tonic clonic?

A

partial onset with secondary generalization or secondarily generalized tonic–clonic (GTC) seizure

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13
Q

What is most commonly seen in focal aware sz?

A

Aura

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14
Q

What is the most common form of generalized motor sz?

A

Tonic clonic (grand mal)

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15
Q

What are the oresentations of generalized nonmotor sz?

A

Absense: Abrupt onset and offset of impaired consciousness
* Duration is about 2 to 30 seconds
* No postictal confusion or lethargy

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16
Q

What is the tx goal for sz?

A

No seizures, no ADRs

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17
Q

How should we treat sz?

A
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18
Q

What are the tx for sz?

A

Non pharm: Diet, vagus nerve stim, surgery, support groups
Pharm: ASD (1st, 2nd, 3rd)

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19
Q

What type of diet is used for epilepsy?

A

Ketogenic: high in fats and low carbs and proteins -> acidosis and ketosis

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20
Q

What are the forms of ketogenic diets?

A
  1. Classic (4:1 (90% fat and 10% protein and carbohydrate) with restricted calories and fluids
  2. Modified Atkins (1:1 (65% fat, 25% protein, and 10% carbohydrate)
  3. Low glycemic index (least ADRs)
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21
Q

What is vagal nerve stimi?

A

Implantable and non-implantable options for refractory and generalized sz
ADR: hoarseness, voice alteration, increased cough, pharyngitis, dyspnea, dyspepsia, and nausea

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22
Q

Why do seizures occur?

A
  1. Def of inhibitory GABA
  2. Excess of excitatory NT glutamate
23
Q

What are the MOA of AED meds?

A

reduce abnormal electrical activity by:
1. Increasing GABA
1. Decreasing glutamate
1. Blocking/altering calcium channels – reduces transmission of electrical signal
1. Blocking sodium channels – reduces neuronal firing rate

24
Q

What are the factors to consider for tx?

A
  1. The most tolerable adverse effect profile, considering patient-specific factors including age and gender
  2. ASD can also treat patient’s comorbid conditions (topiramate: neuropathy, Pregabalin, carbamazepine: bipolar disorder)
  3. DDI
25
What are the considerations for women taking AED?
1. menstrual cycle influences on seizure activity 2. drug interactions betweeN contraceptives and antiepileptic drugs 3. teratogenicity of antiepileptic drugs
26
Med for generalized onset tonic clonic?
1. Lamotrigiene 2. Valproic
27
Med for focal sz?
1. Lamotrigine 2. Carbamazepine 3. Phenytoin 4. Levetiracetam 5. Oxcarbazepine
28
Med of typical absence?
1. Valprioc 2. Ethosuximide
29
Med for atypical absence, myoclonic, atonic?
1. Valproic 2. Lamotrigine 3. Topiramate
30
ASD ADRs?
All AEDs increase risk of CNS depression **Idiocratic:** drug rashes (carbamazepine, phenytoin, phenobarbital, lamotrigine) **Long term:** Osteomalacia and porosis (carbamazepine, phenytoin, phenobarbital, oxcarbazepine, felbamate, valproate)
31
What are the 1st gen ASD?
Carbamazepine, clonazepam, ethosuximide, phenobarbital, phenytoin, primidone, valproate
32
ADR of first gen?
**Carbamazepine** – BOXED WARNINGS OF BLOOD DYSCRASIAS AND FATAL DERM RXNS; hyponatremia **Phenobarbital** - Hyperactivity in children **Phenytoin (chronic)** - Gingival hyperplasia and osteoporosis **Valproate** - many AEs including thrombocytopenia and well-known teratogenicity
33
What are the 2nd gen?
Felbamate, gabapentin, lamotrigine, levetiracetam, oxcarbazepine, tiagabine, topiramate, zonisamide
34
What can prevent OC from working?
Oxcarbazepine and topiramate
35
What drug is effected by OC?
Lamotrigine
36
What should be avoided in patients with sulfa allergy?
Zonisamide
37
ADR of 2nd gen?
Lower incidence of CNS ADRs; considered better tolerated with the exception of topiramate and zonisamide **Felbamate** – could cause acute liver failure, aplastic anemia **Tiagabine** – has been associated with new onset seizures and SE **Lamotrigine** – can cause rash but can progress to SJS
38
What are the 3rd gen ASD?
Brivaracetam, cannabadiol, cenobamate, clobazam, eslicarbazepine, fenfluramine, lacosamide, perampanel, pregabalin, rufinamide, stiripentol, and vigabatrin
39
What medications are approved for specific epilepsy syndromes?
Cannabadiol, clobazam, fenfluramine, rufinamide, stiripentol, and vigabatrin
40
WHat are the ADR of 3rd gen?
**Perampanel** – BOXED WARNING: monitor for life-threatening psych/behavioral changes including aggression, hostility, irritability, anger, and homicidal ideation and threats (can occur with and without prior psych history or prior aggressive behavior) **Cenobamate** – DRESS with fast titration; QT interval shortening, appendicitis **Fenfluramine** – BOXED WARNING: risk of valvular heart disease and PAH **Vigabatrin** - Most serious in this gen effects on vision, aggravate seizures, pts with history of psych conditions may develop psychiatric effects
41
Medication for elderly?
Due to age, more likely to be on multiple medications (polypharmacy), have hypoalbuminemia and decreased renal/hepatic function, and change in body mass **Lamotrigine**
42
Medication for youth?
TDM
43
Medication for women?
Consider potential for an unplanned as well as planned pregnancy and teratogenicity of ASDs Epileptic women taking ASDs and OCs are recommended to use other forms of birth control
44
Medications to avoid in pregnancy?
Valproate and topiramate
45
Pregnancy and lactation increases clearance of what drugs?
lamotrigine, carbamazepine, phenytoin, oxcarbazepine, and levetiracetam
46
What are the teratogenic profiles of ASD?
47
How much folic acid is given to pregnant patients?
1-4 mg QD
48
What is the most common reason for tx failure?
Med adherence
49
What ADRs should we assess?
**Idiosyncratic** - serious rash (ie, SJS, TEN), hematologic dyscrasias, electrolyte abnormalities **Laboratory assessment** (complete blood cell (CBC) counts, chemistries, and liver function tests)  baseline and after initiation of ASDs **Long-term effects:** Screen for osteoporosis, neuropathy, and gingival hyperplasia (phenytoin)
50
What do we do during a seizure?
51
How do we improve QoL?
1. Limit driving 2. Economic security 3. Sz diary 4. Safety 5. Social isolation 6. Stigma
52
What are common sz triggers?
1. Sleep deprivation 2. Flashing lights 3. Alcohol 4. Stress 5. Menstration 6. Meds 7. Missed med
53
What are the approaches to tx at follow up?
Monotherapy is preffered * If not seizure free, switch to second ASD as monotherapy * If not seizure free, dual ASD therapy may be necessary: Adjunctive ASD should be gradually added:
54
When do we dc ASD?
Seizures free for many years (2-5yr) + low risk of recurrence = ASD withdrawal may be considered