Epileptic management

Question 1

How do you manage focal seizures?

Answer 1

1st line: lamotrigine or carbamazepine

2nd line: sodium valproate or levetiracetam

Question 2

How do you manage generalised seizures?

Answer 2

1st line = sodium valproate

2nd line = lamotrigine or carbamazepine

Question 3

When do you give treatment for seizures?

Answer 3

Normally after second sezure

• Patients having their 1st seizure are usually not given antiepileptic medication unless there is evidence of a condition that makes seizure recurrence likely (tumour)
• Referral to seizure clinic

Question 4

What is the mechanism of action of sodium valproate?

Answer 4

Increases GABA activity

Question 5

What are the adverse affects of sodium valproate?

Answer 5

• Increased appetite and weight gain
• Alopecia
• P450 enzyme inhibitor
• Ataxia
• Tremor
• Hepatitis
• Pancreatitis
• Thrombocytopenia
• Teratogenic

Question 6

What is the advice regarding sodium valproate and young women?

Answer 6

o Need advice on contraception
o Must be avoided in young women and girls unless they are unsuitable to alternatives and strict criteria is met to ensure they do not become pregnant

Question 7

What is the mechanism of action of carbamazepine?

Answer 7

Binds to Na+ channels increasing their refractory period

Question 8

What are the adverse affects of carbamazepine?

Answer 8

• P450 enzyme inducer
• Dizziness and ataxia
• Drowsiness
• Leukopenia and agranulocytosis
• SIADH
• Diplopia

Question 9

What is the mechanism of action of lamotrigine?

Answer 9

Na+ channel blocker

Question 10

What are the adverse affects of lamotrigine?

Answer 10

• Steven-Johnson syndrome

Question 11

What is the mechanism of action of phenytoin?

Answer 11

Binds to Na+ channels increasing their refractory period

Question 12

What are the adverse affects of phenytoin?

Answer 12

• P450 enzyme inducer
• Dizziness and ataxia
• Drowsiness
• Gingival hyperplasia, hirsutism, coarsening of facial features
• Megaloblastic anaemia (folate deficiency)
• Peripheral neuropathy
• Osteomalacia (vitamin D deficiency)
• Lymphadenopathy

Question 13

What drugs reduce the effectiveness of oral contraceptives, transdermal patches and vaginal ring, progestogen-only implants?

Answer 13

• Carbamazepine
• Phenytoin
• Topiramate (≥200mg)

Question 14

What must be reviewed every year in patients with seizures?

Answer 14

• Seizure control
• Impact on QoL
• DVLA
• Carers’ skills in managing seizures
• Contraception needs and planning pregnancy information

Question 15

What are the DVLA guidelines for seizures?

Answer 15

o Must inform DVLA
o 1st seizure = 6 months off driving
o Can only drive if 1 year free of seizures

Question 16

When can you consider tapering or stopping epileptic drug treatment?

Answer 16

Seizure-free for 2 years

Question 17

How do you manage status epilepticus in the community?

Answer 17

1. Buccal midazolam

2. Rectal diazepam

Question 18

How do you manage status epilepticus in the hospital?

Answer 18

• ABCDE
• Secure airway
• Give high-concentration oxygen
• Assess cardiac and respiratory function
• Check blood glucose levels
• IV lorazepam 4mg (Repeat after 5 minutes if seizure continues)
• If seizures persist: IV phenobarbital or phenytoin

Question 19

When do you call an ambulance for status epilepticus?

Answer 19

Call ambulance if seizures do not respond to treatment

Call ambulance if seizure DO respond to treatment but:
• Seizures were prolonged or recurrent before treatment was given
• High risk of recurrence
• Difficulties in monitoring patient’s condition
• 1st seizure