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Neurologic & Psych > Epilepsy Dr. Thomason Pt. 2 > Flashcards

Epilepsy Dr. Thomason Pt. 2 Flashcards

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1
Q

Which agent would be appropriate in a patient with a seizure disorder and additional has migraine or
a bipolar disorder?

A

-Valproic acid, divalproex (Depakote)
-> NOT for young women in childbearing age
-> most teratogenic antiseizure drug
(can also be used for absent seizures)

also:
-Carbamazepine (FDA approved)
-Lamotrigine

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2
Q

Appropriate drug for absence seizures

A

Ethosuximate

Valproic acid

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3
Q

What is the BBW for Valproic acid, Depakote?

A

-Hepatoxcicty in patients under the age of 2

ADE: GI, nausea, drowsiness
-> that’s why they made Depakote (delayed release)

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4
Q

Antiseizure drugs associated with hepatotoxicity

A

Valproic acid
Ethosuximide
Felbamate

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5
Q

Antiseizure drugs metabolized hepatically

A

Carbamazepine
Oxcarbazepine
Phenobarbital
Phenytoin
Primidone
Clonazepam
Ethosuxumide
Felbamate
Valproic acid
Zonisamide
Lamotrigine
Levetiracetam (to 30%)
…

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6
Q

Idiosyncratic side effects of Valproic acid?

A

-Thrombocytopenia -> check RBC
-Osteoporisis
-weight gain (common)
-polycystic ovarian syndrome (abdominal fat distribution, irregular menstrual cycle, hair growth on the face, fertility decreases)

-hyperammonemia -> encephalopathy (looks like dementia)
-pancreatis
-tremor
-alopecia

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7
Q

Which parameters should be checked with the use of Carbamazepine and Valproic acid?

A

Carbamazepine: WBC

Valproic acid: RBC

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8
Q

What are the consequences of an elevated serum concentration of valporic acid?

A

tremor, usually in the hands

-normal serum concentration (therapeutic range): 50 - 100 mg/L

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9
Q

How should Carbamazapeine be titrated?

A

Titrated up slowly over 3-4 weeks (4-12 weeks)

-usually start with 100-200 mg BID -> go up every week

-due to autoinduction (it is also a CYP inducer to other drugs)

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10
Q

Idiosyncratic side effects of Carbamazepine

A

-aplastic anemia
-leucopenia (lack of leukocytes WBC)
-hyponatremia (Oxcarbazepine higher risk)
-heart block

-RASH -> can go to SJS
-> Asians should be tested for the HLA-B 1502 allele!!!

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11
Q

Indication/Contrainidcation Carbamezpine

A

-good for partial and secondarily generalized tonic-clonic seizure; also for bipolar disorder

-may make absence or myoclonic seizure worse
-dont keep in a humid place (makes it concert, or hard)

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12
Q

Indication for pregabalin and gabapentin

A

-not actually for seizures

-more often used for neuropathy and other pain syndromes
-adjunct for partial seizures
-generalized anxiety

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13
Q

Most common side effects of Pregabalin and Gabapentin

A

-Lower peripheral edema
-weight gain
-myoclonus (tighten muscle, rare)

-dose-related ADE (does too high): ataxia (look drunk), somnolence, blurred vision, dizziness

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14
Q

Which drugs should be tapered off?

A

Pregabalin - over 1 week or even more
Gabapentin -> addictive, especially hard to taper off for patients with substance use disorder
for Gabapentin: caution with concurrent use of opioids -> may cause .. depression

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15
Q

How do Cimetidine (H2 blocker) and Erythromycin affect the metabolism (CYP) of antiseizure drugs?

A

they are potent CYP inhibitors
-> increases serum concntration of antiseizure drugs

-> REMINDER: Valproic acid is CYP inhibitor

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16
Q

What alteration has to be done if a woman gets pregnant while on antiseizure drugs?

A

the metabolism increases significantly during the third trimester

-> may increase the dose

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17
Q

Which antiseizure should NOT be used while breastfeeding?

A

-Phenobarbital

-will be absorbed by the baby in high concentration -> sedation

18
Q

Recommended antiseizure drug for pregnant women?

A

-Lamotrigine, but recently tetratogenicity seen

-might use Keppra

19
Q

Guidelines for women with seizure disorder who would liek to become pregnant

A

-seizure fee for 2-5 years
-only 1 seizure type
-normal neurologic exam
-normal IQ
-normal EEG

-> taper them off and see if they have seizure for 6 months

20
Q

Considerations for antiseizure therapy during pregnancy

A

-measure levels each trisemester to see if they are therapeutic (metabolism of pregnant women goes up)

-if they are on 2 meds, try to get them on 1 before pregnancy -> should not change antiseizure meds during pregnancy if they are controlled

21
Q

What should be the dose for folic acid for women who want to become pregnant?

A

4 mg -> if teratogenic drugs

1 mg -> with newer and less teratogenic antisezure drugs

22
Q

What should be considered if a patient decides to continue using an estrogen contraceptive despite the DDI?

A

the OC should have at least 50 mg of estrogen to be effective

-> consider using an IUD

23
Q

Does seizure disorder affect fertility?

A

Yes, it causes less progesterone secretion -> may not ovulate

-> patients may be treated with progesterone

24
Q

Which Vitamin is recommended in patients with a seizure disorder?

A

Vitamin K

Carbamazepine, Phenytoin increase the metabolism of Vitamin K

25
Q

What is the therapeutic range of Phenytoin?

A

10-20 mg/L

free concentration: 1-2 mg/L

for Carbamaezpein: 4-12 mg/L

26
Q

Idiosyncratic side effects of Phenytoin

A

-gingival hyperplasia (can be irreversible)
-hirsutism
-anemia, lymphadenopathy
-hepatitis
-osteoporosis
-rash

27
Q

How should Phenytoin be tapered when considering D/C?

A

Yes, slowly at least 6 months

criterias that have to be met:
-no seizures for 2-5 years
-normal neuro exam
-normal IQ
-normal EEG during treatment
-a single type of partial or generilzed seizure

28
Q

Why must seizures in children be controlled ASAP?

A

because development changes occur rapidly in children
-choose drugs that are less likely to interfere with cognitive function and development

29
Q

Patient population who are at risk for Status epilepticus

A

-under the age of 2 yo and older than 60 yo

-considered status epillepticus when they have a seizure for more than 5 minutes -> call 911

-recurrent (they do not regain consciousness in between) or continuous seizure

30
Q

Treatment options for Status epilepticus

A

-intranasal or IM midazolam
-intransal diazepam

31
Q

Why is thiamine administered in adults with status epilepticus in the ER?

A

alcohol cause thiamin (vitamin B1) deficiency

-thiamine is a cofactor of dextrose metabolism
-if its inot replaced before given dextrose it can cause Wernicke encepohlopathy (can be irreversible)

32
Q

What might be given to patients in the ER when they are having status epilepticus

A

-thiamin (vitamin B1) - adults
-Glucose - adults, infants
-Pyridoxine (in case they have a pyridoxine dependent epilepsy - infants

-Naloxone if narcotic overdose suspected
-Antibiotics if infection is suspected

33
Q

Which labs to check in the ER (status epilepticus)

A

-CBC: infection
-serum chemisty: electrolytes, glucose, renal/hepatic function, calcium, magnesium
-arterial blood gas: they may have been without O2 during epilepsy; also to see if they have alkalosis or acidosis
-serum anticonvulsant (to see if they are on meds)
-alcohol screen

34
Q

Which drug is preferred in the first 30 minutes?

A

Benzodiazepines, bc they work quickly

-IV lorazepam OR midazolam

35
Q

Why is diazepam not the drug of choice to stop seizures?

A

-it goes to the brain quickly (highly lipophilic), but also redistributes out of the brain quickly -> risk of seizing again

-the half-life? is less than 1 hour -> its effect may last for 30 min

-another long-acting antiseizure drug has to be used: Phenotoyin, Fosphenytoin or Keppra
-> Diazepam is not used anymore unless there is no other benzodiazpane available

-> Lorazepam is #1 because it is not as lipophilic, so it doesn’t redistribute out of the brain as quickly -> effective for up to 24 hr

36
Q

How would Midazolam (Versed) be used for rapid seizure treatment?

A

it has a short half-life, it has to be administered through continuous infusion

37
Q

How to treat status epileptic at 30-60 minutes

A

drug of choicce: Fosphenytoin, Phenytoin
IV Valproic acid
Keppra

38
Q

What is Phenytoin formulation mixed with?

A

-can only be mixed with normal saline
-40% propylen glycol

-if infused too fast it can cause purple glove syndrome
-> Fosphenytoin is more water-soluble -> and it will be converted to Phenytoin as soon it hits the tissue (can be administered faster)

39
Q

Generalized convulsive status epilepticus (GCSE) for over 120 minutes

A

-continous EEG monitoring, check blood volume, end brain perfusion

often seen Propofol used
OR midazolam, Pentobarbital

40
Q

Super Refractory GCSE over 24 hours

A

Ketamine
Hypothermia (lower body temperature)
Lidocaine
Topiramate

Neurologic & Psych (37 decks)

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