Epilepsy - Management Flashcards
The sudden development of very frequent attacks of seizures in a patient with previously well controlled epilepsy is unusual. What are some causes for this?
Pregnancy, stopping and swapping medications, new CNS pathology, psychogenic non-epileptic attacks
Which type of epilepsy is most likely to have a genetic predisposition?
Generalised
What will generalised epilepsy show on an EEG?
Generalised spike-wave abnormalities
When does juvenile myoclonic epilepsy typically present?
In the teens
What are some features of juvenile myoclonic epilepsy?
Early morning jerks, daytime generalised seizures (tonic clonic and absence)
What are some factors which can trigger seizures in juvenile myoclonic epilepsy?
Flashing lights (photosensitivity) and sleep deprivation
What are the outcomes of juvenile myoclonic epilepsy?
Remission is rare, and without medication the risk of recurrence is high
What is the first line treatment of choice for the vast majority of cases of generalised epilepsy?
Sodium valproate
What is the most important thing to be aware of about sodium valproate? What should be done about this?
This is teratogenic, any females taking this medication should be counselled about this and given appropriate contraception
Who should sodium valproate always be avoided in unless absolutely necessary?
Young females of reproductive age
Apart from the teratogenicity, what are some other side effects of sodium valproate?
Weight gain, hair loss and fatigue
What is the most common 2nd 1st line drug for generalised epilepsy?
Lamotrigine
What are the downsides to using lamotrigine?
Can sometimes make clonus worse and can precipitate Stevens-Johnsons Syndrome if given quickly at a high dose
How must lamotrigine be started?
Titrated up slowly
Which anti-epileptic medication is well-tolerated in both generalised and focal epilepsies?
Lamotrigine
When is levetiracetam used?
2nd line treatment for generalised epilepsy
Levetiracetam is a popular drug why?
It has few interactions with other medications and is usually well tolerated
At high doses, levetiracetam can cause what?
Moodswings
What are some side effects of topiramate, another 2nd line drug for generalised epilepsy?
Sedation, dysphagia and weight loss
Which anti-epileptic drugs is used for acute management only and requires a rapid loading dose?
Phenytoin
After sodium valproate, the next drug in line for generalised epilepsy is lamotrigine. The exception to this is absence seizures when the next drug in line would be what?
Ethosuximide
How do most anti-epileptic drugs work?
Block voltage gated Na+ channels which decrease pre-synaptic excitability and the ability of action potentials to spread
How does sodium valproate work?
Enhances the action of GABA (an inhibitory neurotransmitter)
What medication should never be given in generalised epilepsy and why?
Carbamazepine - can precipitate status
The treatment plan for focal epilepsy also includes secondary generalised epilepsy - true/false?
True!!
Name a specific example of a type of focal epilepsy?
Complex partial seizures with hippocampal sclerosis
Complex partial seizures with hippocampal sclerosis can be caused by what?
Febrile seizures in the past
What are the two treatment options for focal seizures?
Carbamazepine and lamotrigine
Carbamazepine is only used to treat which type of epilepsy?
Focal
Lamotrigine should not be used in combination with what other drug? Why?
Sodium valproate - increases risk of SJS
Using carbamazepine can make what less effective?
Chemotherapy
Can valproate be used as a treatment for focal epilepsy?
Yes, but is it not used first line because of side effects when other options work as well
Why is topiramate not used first line in focal epilepsy?
Can cause psychosis and massive weight loss
What are the outcomes of treating epilepsy with anti-epileptics?
55% of patients will be seizure free on monotherapy, another 10% on polytherapy and another 35% will be drug resistant
How should anti-epileptic drugs be stopped and why?
Titrate down slowly, never stop suddenly to avoid rebound seizures
When should anti-epileptic drugs be given?
When a person is diagnosed with epilepsy OR when there has been a single seizure but there is high risk of recurrence (e.g. brain tumour, head injury, genetic predisposition)
Are anti-epileptics usually given after a first seizure?
No
What is the role of anti-epileptic drugs?
Make the patient less likely to have more seizures in the future
Name some anti-epileptic drugs which are hepatic enzyme inducers (i.e. increase speed of metabolism)?
Carbamazepine, phenobarbitol, phenytoin, topiramate
Enzyme inducing anti-epileptic drugs alter the efficacy of what medication?
Combined oral contraceptive pill
Can patients with epilepsy, taking enzyme inducing AEDs be prescribed the combined oral contraceptive pill?
Yes, but it should be given at a higher dose than normal
What methods of contraception should someone on an enzyme inducing anti-epileptic drug not use?
Progesterone only pill, progesterone implants
Can patients using enzyme inducing AEDs use the depot provera injections for contraception?
Yes, but it will need more frequent dosing
What are the rules regarding the morning after pill and enzyme inducing anti-epileptic drugs?
The standard dose of the morning after pill will not be adequate and so the dose will need to be increased. This means these patients won’t be able to go to the pharmacy to get it, they will need to go to their GP or a sexual health clinic
Before getting pregnant, females with epilepsy should get what?
Pre-pregnancy counselling to balance the risks of uncontrolled seizures against the teratogenicity of their medications
If a woman has a lot of fits while pregnant this can be dangerous and cause what?
Miscarriage, early birth and pre-eclampsia
When a woman with epilepsy is pregnant, what supplements should they take?
5mg folic acid and also vitamin K
What are some lifestyle changes that can be used in the treatment of epilepsy?
Abstain from/decrease smoking and alcohol consumption and also sleep deprivation should be avoided
