epilepsy clinical Flashcards
what is epilepsy
a neurological condition - defined by
- At least 2 unprovoked or reflex seizures occurring more than 24 hours apart
- One unprovoked or reflex seizure and probability of further seizures similar to the general recurrence risk after 2 unprovoked seizures over the next 10 years (at least 60%)
- Diagnosis of epilepsy syndrome
what is a seizure
transient occurrence of signs or symptoms due to abnormal, excessive or synchronous neuronal activity in the brain
epilepsy incidence
70 mill worldwide
5-10 per 1000 in UK
what is the mortality risk with epilepsy
increased risk - tonic clonic, night time seizures, no treatment
aetiology of epilepsy
structural abnormalities
genetic mutations
infections
metabolic disorder
immune disorder
what are the risk factors for epilepsy
premature birth
complicated febrile seizures
brain development malformation
family history
head trauma
infections
tumours
cerebrovascular disease
dementia
drug/alcohol withdrawal
what are focal seizures
increased neuronal activity originating from and staying on one hemisphere of the brain
- simple - no loss of consciousness
- complex - impaired awareness
what are the signs and symptoms of focal seizures
depends on the area of the brain affected
- motor symptoms or non-motor symptoms
what are the motor symptoms of focal seizures
clonic, atonic, automatisms, epileptic spasms, irregular big movements
what are the non-motor symptoms of focal seizures
changes in HR, behaviour arrest, cognitive symptoms, emotional symptoms, confusion
what are generalised seizures
increased neuronal activity that is widespread across both hemispheres of the brain
- can have motor or non-motor symptoms
what is status epilepticus
prolonged seizure lasting for 5 minutes or more OR recurrent seizures one after another without recovery in between
what can trigger status epilepticus
head injury
metabolic disturbances - hypo
cerebrovascular events
alcohol withdrawal
how is status epilepticus treated in community
- note time
- first aid to protect from injury (if/when stops - recovery position)
- if >5 mins - buccal midazolam or rectal diazepam
- if >5 mins since meds, history of status epilepticus or 1st emergency treatment call 999
how is status epilepticus treated in hospital
high potency thiamine/glucose if withdrawal/hypo
- IV loraz/diaz or buccal midaz (max 2 doses)
- if still happening after 40 mins - IV AEDs
- at 60mins - ICU for propofol, midazolam and thiopental sodium
- EEG monitoring
what are the general management strategies for treating epilepsy
individualised treatment
monotherapy is the aim
sodium valproate indications
in males and women not of childbearing age
- tonic clonic
- myoclonic
- tonic
- atonic
- absence - others c/i
sodium valproate side effects
nausea
weight gain
PCOS
transient LFT elevation
blood dyscrasias
alopecia
liver toxicity
pancreatitis
sodium valproate pharmacokinetics
CYP inhibitor
present in placenta
monitoring requirements for sodium valproate
LFTs 6m
blood dyscrasias
liver disorders
pancreatitis
carbamazepine indications
focal seizures
carbamazepine s/e
dry mouth
drowsiness
nausea
vision disorders
blood disorders
hyponatraemia
skin disorders
carbamazepine pharmacokinetics
CYP inducer
carbamazepine monitoring
pre-treatment screening in patients of Thai or Chinese origin for HLAB 1520 - stevens Johnson’s
indications for ethosuximide
absence seizures or myoclonic-atonic seizures
ethosuximide side effects
- GI discomfort
- Anxiety
- Sleep disturbances
- Ataxia
- Drowsiness
- Blood disorders
- Rash
- Stevens Johnson’s syndrome
monitoring with ethosuximide
blood dyscrasias
suicidal behaviours
indications for lamotrigine
monotherapy in
- focal
- generalised tonic clonic
- absence
- tonic
- atonic
- idiopathic
lamotrigine side effects
- Dizziness
- Drowsiness
- Headache
- Dry mouth
- Diplopia
- Rash - when given with other AEDs
- Hypersensitivity syndrome
- Suicidal ideation
- Blood disorders
lamotrigine pharmacokinetics
induces its own metabolism
when given with other hepatic enzyme inducers or inhibitors, half life is altered
lamotrigine monitoring
skin reactions
bone marrow failure
levetiracetam indications
all seizure types - excluding absent
phenobarbital indications
generalised tonic clonic
focal
myoclonic
phenobarbital side effects
- Stevens-Johnson’s
- Bone fracture disorders
- Blood disorders
- Folate deficiency
- Drowsiness
- Suicidal behaviours
- Hepatic disorders
phenobarbital pharmacokinetics
cyp inducer
phenobarbital monitoring
increased hypersensitivity risk
blood dyscrasias
if IV - ECG and BP
clobazam indications
no monotherapy
- myoclonic
- atonic
- tonic
- generalised tonic clonic
clobazam side effects
- Similar to other benzodiazepines
- Suicidal behaviours
- Muscle weakness
Skin reactions
lacosamide indications
generalised tonic clonic
focal
lacosamide side effects
- dizziness
- suicidal ideation
- PR interval prolongation
- Hypersensitivity syndrome
gabapentin indications
potential add on for all seizure types
gabapentin side effects
- Respiratory depression - MHRA warning
- Suicidal ideation
- Increased seizures
- Drowsiness
- Dizziness
pregabalin indications
add on in focal seizures
pregabalin side effects
- Hypersensitivity reactions - angioedema
- Dizziness
- Drowsiness
- Weight gain
- Blurred vision
rufinamide indications
add on or third line for atonic or atonic
rufinamide side effects
hypersensitivity syndrome
- TERATOGENIC
Vigabatrine indications
focal seizures
vigabatrine side effects
- visual field defects - 6m testing
- encephalopathic symptoms
- suicidal ideation
- head ache
- GI disturbances
- joint pain
tiagabine indications
focal seizures
tiagabine side effects
- Suicidal behaviours
- Visual field disorders
- Depression
- Drowsiness
- Tremor
- Increased seizures
topiramate indications
add on
- focal
- tonic
- atonic
- tonic clonic
- myoclonic
topiramate s/e
- Drowsiness
- Dizziness
- Confusion
- Decreased sweating
- Hyperthermia
- Suicidal behaviours
- Mood disturbances
- Vision disorders
- Weight changes
zonisamide indications
add on
- tonic clonic
- focal
- myoclonic
zonisamide s/e
- decreased sweating
- kidney stones
- suicidal ideation
- metabolic acidosis
- weight loss
- blood disorders
Perampanel indications
add on for tonic clonic, focal seizures
perampanel s/e
- suicidal behaviours
- Severe cutaneous skin reactions
- dizziness
- drowsiness
- aggression
- weight gain
brivaracetam indications
add on for focal and myoclonic seizures
brivaracetam s/e
- suicidal ideation
- decreased appetite
- drowsiness
- dizziness
- fatigue
what is a category one AED and what are the examples
patient MUST be kept on one brand only
- carbamazepine
- phenobarbital
- phenytoin
what is a category two AED and what are the examples
need to supply of singular brand should be based on clinical judgement and consultation
- perampanel
- zonisamide
- topiramate
- rufinamide
- clobazam
- lamotrigine
- levetiracetam
- oxcarbamazepine
- esilcarbazepine
what is a category three AED and what are the examples
usually unnecessary to be on one brand - therapeutic equivalence is assumed
- brivaracetam
- tiagabine
- vigabatrine
- pregabalin
- gabapentin
- lacosamide
- levetiracetam
- ethosuximide
what is the ketogenic diet
high fat, low protein, low carb diet- mimics starvation in the brain forcing the body to break down fat to produce ketones (anti-convulsive)
how are AEDs withdrawn
if patients have been seizure free for 2 years
- slowly over 3m minimum
- one at a time
what are the risks associated with stopping AEDs
seizure recurrence
SUDEP
how do AEDs impact bone health
long term AED use can increase the likelihood of bone loss- supplementation required for those at risk
which contraception is recommended for women taking enzyme inducing AEDs
PO depot
IUD - hormonal or non
- COC if absolutely no other alternatives unlicensed tricycling
what emergency contraception can be offered to patients on enzyme inducing AEDs
- Copper IUD
2. Levonorgestrel 1.5mg double dose - effectiveness unknown
Ulipristal acetate - not really appropriate
what contraceptive methods can people taking non-inducing AEDs
- Can use normal contraceptive methods
EXCEPT LAMOTRIGINE - COC reduces lamotrigine effectiveness (non oral preferred)
which medications are recommended for monitoring at preconception
□ Phenobarbital, phenytoin, carbamazepine, lamotrigine, levetiracetam, Oxcarbamazepine
what supplement must be given in 1st trimester in pregnant epileptic patients
folic acid 5mg OD - reduces neural tube defect
what must pregnant epileptic mothers do
notify uk epilepsy and pregnancy register
what type of pregnant epileptic patients require more frequent monitoring
- Bilateral tonic clonic
- Learning difficulties
- Under 18s
- Seizure within last year
- Modifiable factors for SUDEP
which AEDs are the safest in pregnancy
lamotrigine and levetiracetam
what happens after an epileptic patient has given birth
baby given 1mg vit k
breastfeeding advised
