Exam 3 lecture 8 Flashcards
What is antiseizure drug withdrawal syndrome
Associated with abrupt discontinuation of antiseizure medication therapy.
may cause a recurrence of seizures, doses should always be tapered for discontinuation.
Antiseizure drugs that are controlled substances may have physiological and psychological dependence associated with them.
abrupt discontinuation can cause additional symptoms such as anxiety, agitation, physical complaints
What happens to Vd in pregnancy?
Which drugs should not be used in pregnancy?
Supplements?
What should infants receive?
Vd changes in pregnancy
Many antiseizure drugs are known teratogens. Carbamezapine, clonazepam, fosphenytoin, phenobarbital, phenytoin, primidone, topiramate. Counsel for people of child bearing age to use contraceptives.
Valproate is also not recommended as it has neural tube effects associated with it. Also a decrease in IQ of child associated with it.
Supplemental folic acid should be consodered in pregnancy.
Infant child should receive 1 mg IM vit K to reduce risk of hemorrhagic disease
What are contraceptive drug interactions mediated by?
How to manage these drug interactions?
How does estrogen affect lamotrigine and vice versa?
Mediated by CYP 3A4 induction. Estrogen cpds are mahor 3A4 substrates.
These interactions can be managed by using a higher dose of estrogen contraceptives.. Warning for increased thromboembolism. Can use progestin (depot or IUD)
estrogen can reduce lamotrigine serum concentration and lamotrigine can reduce estrogen concentration.
Cardiovascular adverse effects associated with each anticonvulsant drug
Arrhythmia- lamotrigine, phenytoin, phosphenytoin
PR interval changes- Lacosamide, pregabalin
Heart block- lacosamide
Vascular heart disease- fenfluramine
Which anticonvulsant drugs are associated with syndrome of inappropriate antidiuretic hormone (SIADH)
Carbamezapine, eslicarbazapine, oxcarbamezapine,
Which anticonvulsant drugs alter vit D metabolism? What does this cause?
Phenytoin. Causes reduced calcium concentration, leading to OP with long term use.
Which anticonvulsant drug leads to metabolic acidosis? What to monitor? What does this cause
Topiramate
monitor serum bicarbonate (is also a CAI)
associated with reduced sweating, heat tolerance and oligohydrosis
psychiatric side effects of levetiracetam
Psychosis, suicidal thoughts/behaviors, unusual mood changes, worsening of depression
Perampanel boxed warning
Dose related serious and/or life threatening neuropsychiatric events (use with caution in pre existing psychosis)
psychiatric side effects of valproate
acute mental status changes related to hyper ammonemia
psychiatric side effects of topiramate
Associated with cognitive dysfunction if dose is increased too rapidly. Use slow dose titration
Which antuconvulsant drugs cause visual abnormalities
Topiramate
vigabatrin
What are risk factors to look out for when considering gabapentin or pregabalin for treatment
Risk for respiratory depression in pt who is taking other CNS depressants, has pulmonary disease or is elderly
Which anticonvulsant drugs cause hyponatremia
Carbamezapine, oxcarbamezapine, esilcarbamezapine
Which anticonvulsant drug causes thrombocytopenia? What to minitor? What can it cause in pt who are taking this drug
Valproate
Monitor CBC/platelets
can cause PCOS, weight gain, sedation
What does carbamezapine induce? Oxcarbamezapine?
Carbamezapine- strong 1A2, 2C9, 2C19, 3A4 and p-glycoprotein inducer
oxcarbamezapine- 3A4
Topiramate and zonisamide what do they cause?
Weight loss, oligohydrosis, nephrolithiasis
What can phenytoin cause?
Gingival hyperplasia and hirsutism
What decreases phenytoin absorption in body
Food. take 1-2 hours before and after feeding
when is zonisamide contraindicated
sulfa allergies
How are gabapentin and pregabalin eliminated
Renally. Decrease dose with renal impauirement
Lamotrigine is associated with what adverse effect
Arrhythmia
What is epidolex (oral canabioid solution) indicated for?
Lennox gastaut syndrome- multiple seizure types that develop in childhood, usually accompanied by intellectual disability
Dravet syndrome- Rare genetic epileptic encephalopathy with normal childhood development until seizure begin in 1st year of life
What is ketogenic diet? how to do it? effects of epilepsy in adults and children? side effects?
used in pediatric seizure disorders. 3:1 or 4:1 fats:carbs/protein
side effects- adults seem to respond only when on diet, effects in children may continue after diet is dx
sideeffects- hyperlipidemia, weightloss, constipation, kidney stones, reduced bone mass
depression in epilepsy. WHich patients to be areful in? what drug to avoid?
All antiseizure drugs carry a warning for increased suicidal thinking and behaviors during tx in pts below 24
Use of bupropion is avoided as it can increase risk of seizures and seizure therapy
Define and describe characteristics of different types of migraines
Migraine without aura (common)
- atleast 5 attacks
- headaches lasting 4-72 hours
-unilateral location, pulsating quality, moderate/severe pain
-N/V, photophobia, phonophobia
Migraine with aura (classic)
-atleast 2 attacks
-atleast one fully reversibe aura
-no aura lasting more than 60 min
-headache follows aura within 60 min
aura symptoms
visual, sensory, speech, language, motor, brainstem, retinal
Migraine headache phases
1) prodrome- hours/days before onset of headache.
May experience euphoria, depression, irritability,
food cravings, constipation, neck stiffness
2) aura- 15-30% of pts
commonly visual, may be sensory, verbal, motor
before or during migraine. Lasts less than 60mins
Photopsia (glash of light, floater in eye)
3) migraine headache- Dull aches that intensify
Unilateral and throbbing
Phonophobia and photophobia
4) postdromal- tiredness, h/a, GI distress, mood changes, weakness, cognitive difficulties
what to limit analgesic treatment to for migraines?
max 2-3 days per week
compare abortive vs preventive tx for migraines
Abortive- education to avoid medication overuse. Mild to moderate NSAIDs, Acetaminophen.
Moderate-severe- ergots, triptans
preventive- 4 or more attacks/ month with disability atklest 3 days/month
abortive migraine tx 1st and 2nd line
1st line- triptans, NSAIDs
2nd line- NSAIDs
Preventive tx guidelines for migraines
1st line- valproate, topiramate, metoprolol, propranolol, timolol,
frovatriptan,
2nd line- aminitriptyline
Non pcol therapy fro migraines
Biofeedback and relaxation therapy
Cognitive behavioral therapy
TENS (transcuaneal nerve stimulation)
exercise
sleep
diet
contraindication of triptans
Recent use (within 24 hrs) of ergots or other triptans.
MAO-A inhibitor use in last 2 weeks (frovatriptan, rizatriptan)
ischemic heart disease
angina
hx of stroke
HTN
aarythmia
severe hepatic impairement
bowel disease
triptan warning/precautions
MI
pain
pressure tightness in chest/neck/throat/jaw
CVA
HTN
GI ischemia
serotonin syndrome
seizures
triptan side effects and drug interactions
Oral side effects- tingling, dizziness, drowsiness, fatigue, chest tightness, pressure, flushing
drug i/a- SSRI/SNRI (increased risk of serotonin syndrome)
avoid strong 3A4 inhibitors with eletriptan
ergot alkaloid drug interactions
3A4 inhibitors- ergot toxicity can result
Ergot side effects
retroperitoneal, pleuropulmonary and vascular fibrosis,
ergotism
gangrene
numbness
weakness
N/V
boxed warning of ergots
serious life threatening peripheral ischemia, warnings for cardiovalvular fibrosis, vasospasms or vasoconstrictive, CVE, ergotism
What is CGRP and what is it used for? contraindicated? drug i/a?
calcitonin gene related peptide- abortive treatment
contraindicatd in 3A4 inhibitors
drug i/a- moderate/string- 3A4 inducers and inhibitors, p glycoprotein inhibitors
What is lasmiditan used for? warnings/precaution? side effects?
Abortive therapy for migraines
warnings/precautions- medication overuse headaches
sedation
dizziness
serotonin syndrome
driving impairement (avoid atleast 8hrs after dose)
side effects- dizziness, fatugue, sedation
Monitor- LFTs, blood pressure, HR
Other abortive therapies for migraines
Butorphenol nasal spray
Other preventive drug therapies for migrainesq
Beta blockers (FDA approved)- contraindicated in raynauds syndrome
Tricyclic antidepressants- not FDA approved
Valproate
topiramate
BB drugs and doses for migraines.
Tricyclic drugs and doses for migraines
BB-
propanolol- 80-240 mg/dose
metoprolol- 100-200 mg/day
Tricyclic antidepressants
Amitriptyline- 25-150 mg/day
CGRP antagonist drug and side effects
atogepant- nausea, constipation, fatigue
Rimegepant- N/V/dyspnea
Valproate and topiramate use? dose? not recommended in?
Valproate- 500-1500 mg/day
topiramate 50-100 mg/day
not recommended in people of child bearing age unless using contraception
preventive natural therapy for migraines
Butter bur/petasites 150 mg/day
Migraine therapy in pregnant women? (triptans, valproate, topiramate, dihydroergotamine/ergotamine)
Triptans- Only if benefit outweighs risk to fetus
dihydroergotamines/ergotamines- contraindicated. use OC
valproate- contraindicated, use contraceptions
topiramate- may cause fetal harm during pregnancy. Monitor for symotoms of metabolic acidosis during and after pregnency
Migraine therapy in children. What are the drugs approved for 12 year olds? Only drug approved for 6 year olds? What is not FDA approved for children
Almotriptan, zulmatriptan, sumatriptan, topiramate
rizatriptan only one approved for 6 year olds
