Epilepsy - Treatment Flashcards
What is the first and second line treatment for generalised tonic-clonic seizures?
first line - sodium valproate
second line - lamotrigine OR carbamazepine, oxcarbazepine
What is the first and second line treatment for generalised absence seizures?
What should be avoided?
first line - sodium valproate or ethosuximide
second line - lamotrigine
avoid
- carbamazepine, oxcarbazepine
- gabapentin, pregabalin, tiagabine or vigabatrin
- phenytoin
What is the first and second line treatment for myoclonic seizures?
What should be avoided?
first line - sodium valproate
second line - levetiracetam or topiramate
avoid
- carbamazepine, oxcarbazepine
- gabapentin, pregabalin, tiagabine or vigabatrin
- phenytoin
What is the first and second line treatment for tonic and atonic seizures?
first line - sodium valproate
second line - lamotrigine
What is the first and second line treatment for focal seizures?
first line - carbamazepine or lamotrigine
second line - levetiracetam, oxacarbazepine or sodium valproate
What are side effects of vigabatrin?
irreversible effect on visual field
depression
psychosis
What types of medicinal cannabis are there? Which is used for epilepsy?
chemicals cannabidiol (CBD) and tetrahydrocannabinol (THC)
Epidyolex can be used for epilepsy
- contains pure CBD
What are common side effects of phenytoin?
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
What are common side effects of sodium valproate?
tremor, appetite stimulation, weight gain, thinning and loss of hair (dose related)
hepatotoxicity
blood disorders
pancreatitis
What are common side effects of carbamazepine?
drowsiness, hyponatraemia, neutropenia (dose related)
bone marrow depression
toxic hepatitis
Stevens-Johnson syndrome
What are common side effects of lamotrigine?
skin reactions - rashes occur in 5-10% of patients, typically within first 8 weeks of treatment
blood disorders
What are common side effects of topiramate?
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
Which anti-epileptics are enzyme inducers?
phenytoin
phenobarbital
primidone
carbamazepine
topiramate
rufinamide
Which anti-epileptics are enzyme inhibitors?
sodium valproate
How does lamotrigine interact with oral contraceptives?
oral contraceptives reduce lamotrigine efficacy
What is status epilepticus? What are factors that can trigger its occurrence?
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
How should status epilepticus be treated?
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
What immediate measure should be taken when treating status epilepticus?
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
When should therapeutic drug monitoring be initiated for anti-epileptics?
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
What drugs should be avoided in
absence seizures
myoclonic seizures
juvenile myoclonic epilepsy (JME)
risk of respiratory depression
carbamAZEpine
oxacarbAZEpine
GABapentin
preGABaline
viGABatrin
tiaGABine
phenytoin
