epilepsy clinical Flashcards

1
Q

what is epilepsy

A

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

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2
Q

what is a seizure

A

transient occurrence of signs or symptoms due to abnormal, excessive or synchronous neuronal activity in the brain

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3
Q

epilepsy incidence

A

70 mill worldwide
5-10 per 1000 in UK

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4
Q

what is the mortality risk with epilepsy

A

increased risk - tonic clonic, night time seizures, no treatment

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5
Q

aetiology of epilepsy

A

structural abnormalities
genetic mutations
infections
metabolic disorder
immune disorder

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6
Q

what are the risk factors for epilepsy

A

premature birth
complicated febrile seizures
brain development malformation
family history
head trauma
infections
tumours
cerebrovascular disease
dementia
drug/alcohol withdrawal

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7
Q

what are focal seizures

A

increased neuronal activity originating from and staying on one hemisphere of the brain
- simple - no loss of consciousness
- complex - impaired awareness

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8
Q

what are the signs and symptoms of focal seizures

A

depends on the area of the brain affected
- motor symptoms or non-motor symptoms

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9
Q

what are the motor symptoms of focal seizures

A

clonic, atonic, automatisms, epileptic spasms, irregular big movements

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10
Q

what are the non-motor symptoms of focal seizures

A

changes in HR, behaviour arrest, cognitive symptoms, emotional symptoms, confusion

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11
Q

what are generalised seizures

A

increased neuronal activity that is widespread across both hemispheres of the brain
- can have motor or non-motor symptoms

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12
Q

what is status epilepticus

A

prolonged seizure lasting for 5 minutes or more OR recurrent seizures one after another without recovery in between

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13
Q

what can trigger status epilepticus

A

head injury
metabolic disturbances - hypo
cerebrovascular events
alcohol withdrawal

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14
Q

how is status epilepticus treated in community

A
  • 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
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15
Q

how is status epilepticus treated in hospital

A

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

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16
Q

what are the general management strategies for treating epilepsy

A

individualised treatment
monotherapy is the aim

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17
Q

sodium valproate indications

A

in males and women not of childbearing age
- tonic clonic
- myoclonic
- tonic
- atonic
- absence - others c/i

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18
Q

sodium valproate side effects

A

nausea
weight gain
PCOS
transient LFT elevation
blood dyscrasias
alopecia
liver toxicity
pancreatitis

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19
Q

sodium valproate pharmacokinetics

A

CYP inhibitor
present in placenta

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20
Q

monitoring requirements for sodium valproate

A

LFTs 6m
blood dyscrasias
liver disorders
pancreatitis

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21
Q

carbamazepine indications

A

focal seizures

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22
Q

carbamazepine s/e

A

dry mouth
drowsiness
nausea
vision disorders
blood disorders
hyponatraemia
skin disorders

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23
Q

carbamazepine pharmacokinetics

A

CYP inducer

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24
Q

carbamazepine monitoring

A

pre-treatment screening in patients of Thai or Chinese origin for HLAB 1520 - stevens Johnson’s

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25
Q

indications for ethosuximide

A

absence seizures or myoclonic-atonic seizures

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26
Q

ethosuximide side effects

A
  • GI discomfort
  • Anxiety
  • Sleep disturbances
  • Ataxia
  • Drowsiness
  • Blood disorders
  • Rash
  • Stevens Johnson’s syndrome
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27
Q

monitoring with ethosuximide

A

blood dyscrasias
suicidal behaviours

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28
Q

indications for lamotrigine

A

monotherapy in
- focal
- generalised tonic clonic
- absence
- tonic
- atonic
- idiopathic

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29
Q

lamotrigine side effects

A
  • Dizziness
  • Drowsiness
  • Headache
  • Dry mouth
  • Diplopia
  • Rash - when given with other AEDs
  • Hypersensitivity syndrome
  • Suicidal ideation
  • Blood disorders
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30
Q

lamotrigine pharmacokinetics

A

induces its own metabolism
when given with other hepatic enzyme inducers or inhibitors, half life is altered

31
Q

lamotrigine monitoring

A

skin reactions
bone marrow failure

32
Q

levetiracetam indications

A

all seizure types - excluding absent

33
Q

phenobarbital indications

A

generalised tonic clonic
focal
myoclonic

34
Q

phenobarbital side effects

A
  • Stevens-Johnson’s
  • Bone fracture disorders
  • Blood disorders
  • Folate deficiency
  • Drowsiness
  • Suicidal behaviours
  • Hepatic disorders
35
Q

phenobarbital pharmacokinetics

A

cyp inducer

36
Q

phenobarbital monitoring

A

increased hypersensitivity risk
blood dyscrasias
if IV - ECG and BP

37
Q

clobazam indications

A

no monotherapy
- myoclonic
- atonic
- tonic
- generalised tonic clonic

38
Q

clobazam side effects

A
  • Similar to other benzodiazepines
  • Suicidal behaviours
  • Muscle weakness
    Skin reactions
39
Q

lacosamide indications

A

generalised tonic clonic
focal

40
Q

lacosamide side effects

A
  • dizziness
  • suicidal ideation
  • PR interval prolongation
  • Hypersensitivity syndrome
41
Q

gabapentin indications

A

potential add on for all seizure types

42
Q

gabapentin side effects

A
  • Respiratory depression - MHRA warning
  • Suicidal ideation
  • Increased seizures
  • Drowsiness
  • Dizziness
43
Q

pregabalin indications

A

add on in focal seizures

44
Q

pregabalin side effects

A
  • Hypersensitivity reactions - angioedema
  • Dizziness
  • Drowsiness
  • Weight gain
  • Blurred vision
45
Q

rufinamide indications

A

add on or third line for atonic or atonic

46
Q

rufinamide side effects

A

hypersensitivity syndrome
- TERATOGENIC

47
Q

Vigabatrine indications

A

focal seizures

48
Q

vigabatrine side effects

A
  • visual field defects - 6m testing
  • encephalopathic symptoms
  • suicidal ideation
  • head ache
  • GI disturbances
  • joint pain
49
Q

tiagabine indications

A

focal seizures

50
Q

tiagabine side effects

A
  • Suicidal behaviours
  • Visual field disorders
  • Depression
  • Drowsiness
  • Tremor
  • Increased seizures
51
Q

topiramate indications

A

add on
- focal
- tonic
- atonic
- tonic clonic
- myoclonic

52
Q

topiramate s/e

A
  • Drowsiness
  • Dizziness
  • Confusion
  • Decreased sweating
  • Hyperthermia
  • Suicidal behaviours
  • Mood disturbances
  • Vision disorders
  • Weight changes
53
Q

zonisamide indications

A

add on
- tonic clonic
- focal
- myoclonic

54
Q

zonisamide s/e

A
  • decreased sweating
  • kidney stones
  • suicidal ideation
  • metabolic acidosis
  • weight loss
  • blood disorders
55
Q

Perampanel indications

A

add on for tonic clonic, focal seizures

56
Q

perampanel s/e

A
  • suicidal behaviours
  • Severe cutaneous skin reactions
  • dizziness
  • drowsiness
  • aggression
  • weight gain
57
Q

brivaracetam indications

A

add on for focal and myoclonic seizures

58
Q

brivaracetam s/e

A
  • suicidal ideation
  • decreased appetite
  • drowsiness
  • dizziness
  • fatigue
59
Q

what is a category one AED and what are the examples

A

patient MUST be kept on one brand only
- carbamazepine
- phenobarbital
- phenytoin

60
Q

what is a category two AED and what are the examples

A

need to supply of singular brand should be based on clinical judgement and consultation
- perampanel
- zonisamide
- topiramate
- rufinamide
- clobazam
- lamotrigine
- levetiracetam
- oxcarbamazepine
- esilcarbazepine

61
Q

what is a category three AED and what are the examples

A

usually unnecessary to be on one brand - therapeutic equivalence is assumed
- brivaracetam
- tiagabine
- vigabatrine
- pregabalin
- gabapentin
- lacosamide
- levetiracetam
- ethosuximide

62
Q

what is the ketogenic diet

A

high fat, low protein, low carb diet- mimics starvation in the brain forcing the body to break down fat to produce ketones (anti-convulsive)

63
Q

how are AEDs withdrawn

A

if patients have been seizure free for 2 years
- slowly over 3m minimum
- one at a time

64
Q

what are the risks associated with stopping AEDs

A

seizure recurrence
SUDEP

65
Q

how do AEDs impact bone health

A

long term AED use can increase the likelihood of bone loss- supplementation required for those at risk

66
Q

which contraception is recommended for women taking enzyme inducing AEDs

A

PO depot
IUD - hormonal or non
- COC if absolutely no other alternatives unlicensed tricycling

67
Q

what emergency contraception can be offered to patients on enzyme inducing AEDs

A
  1. Copper IUD
    2. Levonorgestrel 1.5mg double dose - effectiveness unknown
    Ulipristal acetate - not really appropriate
68
Q

what contraceptive methods can people taking non-inducing AEDs

A
  • Can use normal contraceptive methods
    EXCEPT LAMOTRIGINE - COC reduces lamotrigine effectiveness (non oral preferred)
69
Q

which medications are recommended for monitoring at preconception

A

□ Phenobarbital, phenytoin, carbamazepine, lamotrigine, levetiracetam, Oxcarbamazepine

70
Q

what supplement must be given in 1st trimester in pregnant epileptic patients

A

folic acid 5mg OD - reduces neural tube defect

71
Q

what must pregnant epileptic mothers do

A

notify uk epilepsy and pregnancy register

72
Q

what type of pregnant epileptic patients require more frequent monitoring

A
  • Bilateral tonic clonic
    • Learning difficulties
    • Under 18s
    • Seizure within last year
    • Modifiable factors for SUDEP
73
Q

which AEDs are the safest in pregnancy

A

lamotrigine and levetiracetam

74
Q

what happens after an epileptic patient has given birth

A

baby given 1mg vit k
breastfeeding advised