Epilepsy - Treatment

Question 1

What is the first and second line treatment for generalised tonic-clonic seizures?

Answer 1

first line - sodium valproate
second line - lamotrigine OR carbamazepine, oxcarbazepine

Question 2

What is the first and second line treatment for generalised absence seizures?

What should be avoided?

Answer 2

first line - sodium valproate or ethosuximide
second line - lamotrigine

avoid
- carbamazepine, oxcarbazepine
- gabapentin, pregabalin, tiagabine or vigabatrin
- phenytoin

Question 3

What is the first and second line treatment for myoclonic seizures?

What should be avoided?

Answer 3

first line - sodium valproate
second line - levetiracetam or topiramate

avoid
- carbamazepine, oxcarbazepine
- gabapentin, pregabalin, tiagabine or vigabatrin
- phenytoin

Question 4

What is the first and second line treatment for tonic and atonic seizures?

Answer 4

first line - sodium valproate
second line - lamotrigine

Question 5

What is the first and second line treatment for focal seizures?

Answer 5

first line - carbamazepine or lamotrigine
second line - levetiracetam, oxacarbazepine or sodium valproate

Question 6

What are side effects of vigabatrin?

Answer 6

irreversible effect on visual field

depression
psychosis

Question 7

What types of medicinal cannabis are there? Which is used for epilepsy?

Answer 7

chemicals cannabidiol (CBD) and tetrahydrocannabinol (THC)

Epidyolex can be used for epilepsy
- contains pure CBD

Question 8

What are common side effects of phenytoin?

Answer 8

Acute
- ataxia (lack of voluntary movement), nystagmus (involuntary eye movement), slurred speech (dose related), dizziness, diplopia (double vision)

Chronic
- Gingival hyperplasia, hirsutism (excessive growth of coarse dark hair), aggravation of acne
- megaloblastic anaemia (large RBCs)
- peripheral neuropathy
- enhanced vitamin D metabolism
= increased risk of fracture

blood or skin disorders
- fever, sore throat, rash, mouth ulcers, bruising, or bleeding

leucopenia would require withdrawal

Question 9

What are common side effects of sodium valproate?

Answer 9

tremor, appetite stimulation, weight gain, thinning and loss of hair (dose related)

hepatotoxicity
blood disorders
pancreatitis

Question 10

What are common side effects of carbamazepine?

Answer 10

drowsiness, hyponatraemia, neutropenia (dose related)

bone marrow depression
toxic hepatitis
Stevens-Johnson syndrome

Question 11

What are common side effects of lamotrigine?

Answer 11

skin reactions - rashes occur in 5-10% of patients, typically within first 8 weeks of treatment

blood disorders

Question 12

What are common side effects of topiramate?

Answer 12

increased risk of renal stone formation
decreases appetite
excreted unchanged by the kidneys

has been associated with acute myopia (short sightedness) with secondary angle-closure glaucoma
- typically occurring within 1 month of starting treatment

Question 13

Which anti-epileptics are enzyme inducers?

Answer 13

phenytoin
phenobarbital
primidone
carbamazepine
topiramate
rufinamide

Question 14

Which anti-epileptics are enzyme inhibitors?

Answer 14

sodium valproate

Question 15

How does lamotrigine interact with oral contraceptives?

Answer 15

oral contraceptives reduce lamotrigine efficacy

Question 16

What is status epilepticus? What are factors that can trigger its occurrence?

Answer 16

a medical emergency which exists when 2 or more seizures follow each other without recovery of consciousness
- there is a risk of death from cardiorespiratory failure

precipitating factors in epileptics include
- abruptly stopping anti-epileptic drugs
- intercurrent illness
- alcohol abuse
- poor compliance with therapy

Question 17

How should status epilepticus be treated?

Answer 17

initial treatment is i.v lorazepam or i.v clonazepam or diazepam as an alternative
- repeated once after 10 minutes if seizure recurs

if lorazepam fails to control seizures
- an infusion of phenytoin or phosphenytoin (second line) or phenobarbital (third line) should be started

rectal diazepam solution or oromucosal midazolam solution into buccal cavity can be given if iv access difficult

Question 18

What immediate measure should be taken when treating status epilepticus?

Answer 18

Avoid injury
Support respiration
Maintain BP
Correct hypoglycaemia if present
Parenteral thiamine if alcohol abuse is suspected
Pyridoxine if status is caused by its deficiency

Question 19

When should therapeutic drug monitoring be initiated for anti-epileptics?

Answer 19

When therapy is initiated

During intravenous therapy in status epilepticus

When toxicity is suspected

Adjustment of phenytoin dose

When there is a loss of seizure control (including a compliance check)

To monitor the effects of drug interactions

Question 20

What drugs should be avoided in
absence seizures
myoclonic seizures
juvenile myoclonic epilepsy (JME)

Answer 20

risk of respiratory depression

carbamAZEpine
oxacarbAZEpine

GABapentin
preGABaline
viGABatrin
tiaGABine

phenytoin