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PHRM 845 > Exam 3: Seizure > Flashcards

Exam 3: Seizure Flashcards

1
Q

Seizure

A

paroxysmal disorder of the CNS characterized by abnormal cerebral neuronal discharges with or without loss of consciousness

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2
Q

Epilepsy

A

repeated seizures due to damage, irritation, and/or chemical imbalance in the brain which leads to a sudden, excessive, synchronous electrical discharge

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3
Q

Seizures are a result of what?

A

disordered, synchronous, and rhythmic firing of a population of brain neurons (synchronized hyperexcitiability)

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4
Q

Focal Onset

A

classified to either aware or impaired awareness

motor or non-motor onset

and may progress to focal to bilateral tonic-clonic (generalized seizure) (with aura)

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5
Q

Generalized Onset

A

Classified to either motor (tonic clonic or other motor) or non-motor (absence seizure)

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6
Q

Unknown Onset

A

Classified to either motor (tonic clonic or other motor) or non-motor

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7
Q

Where do focal seizures begin

A

temporal lobe

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8
Q

What are generalized seizures presumed to be

A

genetic

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9
Q

Partial Seizure Spread

A

seizure activity spreads from a focus in one part of the brain (focal seizure)

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10
Q

Partial Seizure Secondary Generalized

A

focal seizures frquently progress to secondary generalized seizures via projections to the thalamus (focal to bilateral)

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11
Q

primary generalized seizure

A

propagate via diffuse interconections between the thalamus and cortex (no discrete focus)

earliest clinical signs show involvement of both brain hemispheres

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12
Q

AWARE type of seizure

A

simple partial

no loss of consciousness

subjective experiences (auras) also occur (sense of fear, unpleasant smell, abdominal discomfort)

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13
Q

Impaired Awareness seizure

A

complex partial

most common among focal seizures

clouding of consciousness

staring

repetitive motor behaviors (swallowing, chewing, lip smacking)

disturbances of visceral, emotional, and autonomic systems

seizure followed by confusion, fatigue, and throbbing headache

aura is common

postictal state due to impaired awareness

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14
Q

postictal state

A

after a seizure, a pt will not recover a normal level of consciousness immediatlely

may last seconds to hours

confusion, disorientation, anterograde amnesia

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15
Q

absence seizure

A

typical: petit mal
- brief loss of consciousness (10-45 seconds)
- staring or eye flickering
- begin abruptly
- often repetitive
- may not realize it after the seizures
- no convulsions, aura, or postictal period

Atypical
- slower onset than typical
more difficult to control

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16
Q

First phase generalized seizure

A

tonic phase

begins abruptly, often with diaphragm contraction (no aura)

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17
Q

Second phase generalized seizure

A

clonic phase

begins as relaxation periods become more prolonged

involves violent jerking of the body that lasts 1-2 minutes

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18
Q

Therapeutic Goal

A

bring seizures under control within 60 minutes

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19
Q

does one seizure define epilepsy?

A

no

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20
Q

Drug therapy withdrawal

A

gradually withdrawn in patients who have been clinically free of seizures for 2-5 years

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21
Q

depolarization

A

involves the activation of AMPA and NMDA channels by the excitatory neurotransmitter glutamate and voltage gated calcium channels

influx of cation Ca2+

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22
Q

Hyperpolarization

A

activation of GABA receptors

influx of chloride ions

efflux of potassium

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23
Q

homeostasis

A

neuronal signaling (depolarization) is normally dampened by feed-forward and feedback inhibition involving GABAergic neurons

disrupted E/I balance

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24
Q

Tonic Phase Mechanism

A

GABA mediated inhibition disappears

Glutamate-mediated AMPA and NMDA receptor activity increases

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25
Q

Clonic Phase Mechanism

A

GABA mediated inhibition gradually returns, leading to a period of oscillations

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26
Q

drugs that aggravate or increase risk of seizure

A

alcohol
theophylline
bupropion
oral contraceptives
withdrawal from depressants
CNS stimulants
Clozapine (1A2)

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27
Q

Drugs that decrease sodium influx, prolong the inactivation of Na channels

A

carbamexepine
oxcarbazepine
phenytoin
lacosamide
lamotrigine
valproate

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28
Q

drugs that reduce calcium influx (absence)

A

ethosuximide
lamotrigine
valproate

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29
Q

drugs that enhance GABA mediated neuronal inhibition

A

Barbiturates (activate GABA receptor)
Benzos (activate GABA receptor)
valproate (increases GABA levels)
gabapentin (increases GABA release)
vigabatrin (inhibits GABA transaminase)
tiagabine (inhibits GAT-1)

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30
Q

antagonism of excitatory transmitters (glutamate)

A

felbamate (antagonist of NMDA)
topiramate (antagonist of kainate/AMPA receptors)

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31
Q

Presynaptic targets of drugs at the excitatory synapse

A

sodium (phenytoin, carbamazepine, lacosamide)
calcium (ethosuximide)

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32
Q

postsynaptic targets of drugs at the excitatory synapse

A

NMDA (felbamate)
AMPA (topiramate)

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33
Q

presynaptic targets of drugs at the inhibitory synapse

A

GABA transporter (GAT-1) (tiagabine)
GABA transaminase (GABA-T) (vigabatrin)

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34
Q

postsynaptic targets of drugs at the inhibitory synapse

A

GABA a and b (phenobarbital, benzos)

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35
Q

phenytoin MOA

A

binds and stabilizes the inactivated state of sodium channels (not isoform selective thus can target sodium channels in the brain as well as other parts of the body)

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36
Q

fosphenytoin

A

injectable phosphate prodrug

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37
Q

phenytoin elimination kinetics

A

dose dependent

non linear pharmacokinetics

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38
Q

drug interactions: phenytoin

A

displaced from plasma proteins by other drugs (valproate) leading to an increase in its plasma concentrations

phenytoin induces liver cytochrome P450 enzymes

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39
Q

Side effects: phenytoin

A

arrhythmia
visual
ataxia
gi symptoms
gingival hyperplasia, hirsutism
hypersensitivity reactions

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40
Q

Carbamazepine MOA

A

binds and stabilizes the inactivated state of Na channels

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41
Q

carbamezepien drug interactions

A

induces liver cyp P450 increasing the metabolism of itself and other drugs

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42
Q

carbamezepine toxicity

A

blurred vision, ataxia, gi disturbances, sedation at high doses, serious skin rash, DRESS

oxcarbazepine reduced toxicity

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43
Q

lacosamide moa

A

enhances inactivation of voltage gated sodium channels

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44
Q

lacosamide toxicitiy

A

dermatologic rxn
cardiac risks
visual disturbances

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45
Q

Barbiturates moa

A

binds to allosteric regulatory site on the GABA receptor, increases duration of the chloride channel opening events (enhances GABA inhibitory signaling)

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46
Q

barbiturates drug interactiosn

A

liver cyp P450 enzymesb

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47
Q

barbituates toxicity

A

sedation, physical dependence

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48
Q

drug of choice in inhants up to 2 months old

A

phenobarbital

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49
Q

primidone moa

A

may be more similar to that of phenytoin than phenobarbital

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50
Q

Diazepam use

A

especially useful for tonic-clonic status epilepticus

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51
Q

diazepam moa

A

binds to an allosteric regulatory site on the GABA receptor

increases the frequency of CL channel opening events (enhances GABA inhibitory signaling)

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52
Q

diazepam toxicity

A

sedation
physical dependence
not useful for chronic treatments

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53
Q

clonazepam use

A

useful for acute treatment and absence seizures

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54
Q

Gabapentin MOA

A

increases GABA release

decreases presynaptic calciuim influx, thereby reducing glutamate release

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55
Q

gabapentin toxicity

A

sedation, ataxia

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56
Q

vigabatrin and tiagabine use

A

adjunct therapy for refractory patient

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57
Q

vigabatrin MOA

A

irreversible inhibitor of GABA-T (enzyme that degrades GABA)

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58
Q

vigabatrin toxicity

A

sedation, depression, visual field disturbancest

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59
Q

tiagabine MOA

A

inhibits gaba transporter (GAT-1)

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60
Q

Tiagabine toxicity

A

sedation, ataxia

61
Q

NMDA receptor

A

glutamate binding triggers an influx of Na and Ca and an efflux of K

62
Q

AMPA receptor

A

glutamate binding triggers an influx of sodium and an efflux of potassium. this is also true of a 3rd type of ionotropic glutamate receptor, the kainate receptor

63
Q

Felbamate MOA

A

NMDA recepotr antagonist

64
Q

Felbamate toxicity

A

severe hepatitis (which is why its a 3rd line drug)

65
Q

Topiramate MOA

A

AMPA and kainate receptor antagonist

66
Q

Topiramate Toxicity

A

nervousness, confusion, cognitive dysfunction, sedation, vision loss

67
Q

ethosuximide MOA

A

blocks T-type Ca2+ channels (low-threshold current) in thalamic neurons

T-type calcium channels are thought to be involved in generating the rhythmic discharge of an absence attack

68
Q

ethosuximide toxicity

A

GI distress, sedation

69
Q

Lamotrigine use

A

for focal and primary generalized seizures, include absence; also used for bipolar disorder

70
Q

Lamotrigine MOA

A

inhibits sodium and voltage-gated Ca channels

71
Q

Lamotrigine toxicity

A

sedation, ataxia, serious skin rash (stevens johnson syndrome/toxic epidermal necrolysis)

72
Q

Valproate MOA

A

inhibits sodium and calcium channels

73
Q

valproate drug interactions

A

displaces phenytoin from plasma proteins

inhibits the metabolism of phenytoin, carbamazepine, phenobarbital, lamotrigine

74
Q

valproate toxicity

A

GI distress, hyperammmonemia, hepatotoxicity (can be fatal, careful monitoring)

75
Q

levetiracetam MOA

A

binds to the synaptic vesicular protein SV2A, and thus interferes with synaptic vesicle release and neurotransmission

also appears to interfere with calcium entry through calcium channels and with intraneuronal calcium signaling

candidate for treatment of status epilepticus cases that are refractory to other therapies

76
Q

levetiracetam use

A

focal and generalized seizures, myoclonic seizures, status epilepticus

77
Q

Drugs used for any seizure

A

lamotrigine
levetiracetam
valproate
zonisamide

78
Q

Drugs that Lower the Seizure Threshold at Usual Doses

A

Bupropion
Clozapine
Theophylline
Varenicline
Phenothiazine Antipsychs
CNS Stimulants (amphetamines)

79
Q

Drugs that Lower the Seizure Threshold at High Doses or Impaired Renal Functions

A

carbapenems (imipenem)
lithium
meperidine
penicillin
quinolones
tramadol

80
Q

Quality of LIfe Monitoring

A

Seizure Frequency

Functional Status

Social Functioning (drivers license)

Mental Health Status (depression)

Cognition

Number of doses of drug per day

cost of drug therapy

81
Q

Risk Factors for Seizure Recurrence

A

<2 years seizure free

onset of seizure after age 12

history of atypical febrile seizures

2-6 years before good seizure control in treatment

signficant number of seizures (>30) before control acheived

partial seizures (most common type)

abnormal EEG throughout treatment

organic neurological disorder (TBI, dementia)

Withdrawal of phenytoin or valproate

82
Q

Possible reason for treatment failure

A

failure to reach the CNS target

alteration of drug targets in the CNS

drugs missing the real target

83
Q

Management of treatment failure

A

rule out pseudo-resistance (wrong drug or diagnosis)

combination therapy

electrical/surgical intervention

84
Q

Status epilepticus

A

defined as continuous seizure activity lasting 5 minutes or more, or two or more discrete seizure with incomplete recovery between seizures

85
Q

Possible Drug Therapy for Status epilepticus

A

benzos, most commonly lorazepam or midazolam

86
Q

Status Epilepticus Treatment (5-20 minutes)

A

if seizure continues, give IV lorazepam or IV midazolam

87
Q

Phenytoin loading dose adverse effect

A

hypotension (propylene glycol, limits infusion rate)

88
Q

Fosphenytoin vs Phenytoin loading dose

A

prodrgu of phenytoin

better IV tolerance of dosing

89
Q

Fosphenytoin Loading Dose

A

20 mg PE/kg IV, may give additional dose 10 minutes after load

90
Q

What is required when giving phenytoin/fosphenytoin loading dose

A

cardiac monitoring

purple glove syndrome

91
Q

Oral phenytoin dosing considerations

A

must obtain both phenytoin serum concentration and serum albumin in the same blood draw

therapeutic serum concentration range: 10-20 mcg/mL

92
Q

Valproate IV to PO conversion

A

1:1 mg/mg

93
Q

Valproate desired serum concentration

A

80 mcg/mL

range (50-125 mcg)

94
Q

1A2 inducers

A

carbamezepine
phenobarbital
phenytoin

95
Q

2C9 inducers

A

Carbamezepine
phenobarbital
phenytoin

96
Q

3A4 inducers

A

carbamezepine
lamotrigine
oxcarbazepine
phenobarbital
phenytoin
topiramate

97
Q

UGT inhibitor

A

valproate

98
Q

Lamotrigine dosing with UGT inhibitor (valproate)

A

25 mg every other day x 14 days

25 mg once daily x 14 days

50 mg once daily x 7 days

100 mg once daily

99
Q

lamotrigine dosing without UGT drug interactions

A

25 mg once daily x 14 days

50 mg once daily x 14 days

100 mg once daily x 7 days

200 mg once daily

100
Q

lamotrigine dosing with UGT inducers (carbamezepine, phenytoin)

A

50 mg once daily x 14 days

100 mg once daily x 14 days

200 mg once daily x 7 days

400 mg once daily

101
Q

lamotrigine boxed warning

A

Stevens-Johnson/Toxic Epidermal Necrolysis

102
Q

Anticonvulsant Hypersensitivity Syndrome Black box warning

A

genetic screen for HLA-B*1502 allele prior to initiation carbamazepine or like derivatives (oxcarbazepine, eliscarbazepine)

103
Q

patients with positive HLA-B*1502 allele should/should not be treated with carbamazepine or like derivatives unless benefit clearly outweighs risk

A

should not

104
Q

Strong correlation for positive HLA-B*1502 in what populations

A

patients of asian descent

105
Q

HLA-A*3101

A

norhtern europeans

may confer similar risk of anticonvulsant hypersensitivity syndrome

106
Q

DRESS Syndrome

A

potentially life threatening 10%

generally occurs 2-6 weeks after initiation of drug therapy

increased risk in patients who are psoitive for HLA-A*3101 allele

107
Q

drugs associated with DRESS

A

carbamazepine
cenobamate
lamotrigine
phenobarbital
phenytoin
valproate
zonisamide

108
Q

anti-seizure drug withdrawal syndrome

A

associated with abrupt discontinuation of antiseizure medication therapy

may cause recurrence of seizures, doses of antiseizure medication should always be tapered for discontinuation

109
Q

drug serum concentrations in pregnancy

A

may be altered in pregnancy due to changes in volume of distribution

110
Q

drugs with teratogenic risk

A

carbamazepine
clonazepam
fosphenytoin
phenobarbital
phenytoin
primidone
topiramate

111
Q

Valproate and pregnancy

A

not recommended

neural tube defects and decreased IQ in offspring

112
Q

What should be considered in pregnancy

A

supplemental folic acid (5 mg)

infant should receive vitamin K 1 mg IM at birth to decrease risk of hemorrhagic disease

113
Q

Estrogen compounds drug interactions

A

3A4 substrates

use higher dose estrogen contraceptives (warning for increased thromboembolism)

IUD or progestin only contraceptives recommended

114
Q

estrogen and lamotrigine

A

can significantly serum concentration by 50%

115
Q

what drug causes arrhythmia

A

lamotrigine
phenytoin/fosphenytoin (contraindicated in heart block)

116
Q

what drug causes PR interval changes

A

lacosemide, pregabalin

117
Q

what drug causes heart block

A

lacosemide

118
Q

what drug causes valvular heart disease

A

fenfluamine

119
Q

electrolyte abnormalities: carbamazepine/eslicarbazepine/oxcarbazepine

A

hyponatremia
SIADH

120
Q

zonisamide adverse effect

A

metabolic acidosis
renal calculi

121
Q

phenytoin metabolic adverse effect

A

vitamin d metabolism altered

decreased calcium concentrations leading to osteoporosis with long term use

122
Q

metabolic effect: topiramate

A

decreased serum bicarbonate leadingi to metabolic acidiosis

nephrolithiasis

decreased sweating, heat intolerance, oligohydrosis

123
Q

Psych AEs: levetiracetam

A

psychosis

suicidal thoughts/behaviors

unusual mood

worsening depression

most often seen in children/adolescents

124
Q

Psych AEs: perampanel

A

boxed warning: dose-related serious and /or lifethreatening neuropsychiatric events

125
Q

Psych AEs: valproate

A

acute mental status changes

hyperammonemia

differentiate from sedation side effect

126
Q

Psych AEs: topiramate

A

associated with cogntive dysfunction if the dose is increased too rapidly, use a slow dose titration

127
Q

Visual abnormalities: topiramate

A

vision loss
myopia
retinal detachment

128
Q

visual abnormalities: vigabatrin

A

contrainidcated in patients who have other risk factors for irreversible vision loss

129
Q

Gabapentin and Pregabalin FDA warning

A

evaluate the appropriateness of gabapentin or pregabalin use and risk for respiratory depression in a patient who is takign other CNS depressants, has pulmonary disease, or is elderly

130
Q

Clinical Pearls: Carbamazepine

A

strong P450(1A2, 2C9, 2C19, 3A4) and pgp inducer (induces own metabolism)

131
Q

Clinical Pearls: oxcarbazepine

A

induces 3A4

132
Q

Clinical Pearls: hyponatremia

A

carbamazepine
oxcarbazepine
eslicarbazepine

133
Q

Clinical Pearls: carbamazepine serum concentration

A

4-12 mcg/mL

134
Q

Clinical Pearls: valproate

A

can cause thrombocytopenia, monitor CBX/platelets

can cause PCOS, weight gain, sedation

135
Q

Clinical Pearls: topiramate and zonisamide

A

weight loss
oligohydrosis
nephrolithiasis

136
Q

Clinical Pearls: phenytoin absorpiton

A

decreased when given with enteral feeds

hold feedings 1-2 hours before and after administration

137
Q

Clinical Pearls: pheytoin adverse effects

A

gingival hyperplasia
hirsutism

138
Q

Clinical Pearls: zonisamide contraindication

A

sulfa allergy

139
Q

Clinical Pearls: gabapentin and pregabalin elimination

A

renally

decrease dose in renal impairment

140
Q

Clinical Pearls: lamotrigine

A

associated with arrhythmia with people with underlying cardiac conditions

141
Q

Lennox Gastaut Syndrome

A

multiple seizure types that develop in childhood, usually accompanied by intellectual disability, sometimes responsive to combination of some AEDs

142
Q

Dravet Syndrome

A

rare genetic epileptic encephalopathy with normal childhood development until seiuzres begin in 1st year of life leading ot multiple sizure types and developmental disability

143
Q

Epidiolex (cannabidiol)

A

indicated for dravet and lennox gastaut syndrome

144
Q

Ketogenic diet

A

3:1 or 4:1 fats:carbs/protein

adults seem to respond only while on the diet, effects in children may continue after diet is discontinued

145
Q

ketogenic diet side effects

A

hyperlipidemia
weight loss
kidney stones
constipation
decreased bone mass/growth

146
Q

depression in epilepsy

A

all antiseizure drugs carrry a warning for increased risk of suicidal thinking and/pr behaviors during treatment

antidepressents also carry warning in pts < 24 years of age

147
Q

which drug should be avoided in pts with uncontrolled seizure disorders

A

bupropion

increases risk for seizure and seizure frequencyc

148
Q

co-morbid conditions

A

depression

149
Q
A

PHRM 845 (14 decks)

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