Guidelines Flashcards
What does choice of anti-epileptic depend upon?
Medication is categorised and chosen by syndrome and seizure type
However other considerations include:
Age (some meds are unlicensed)
Gender
Child bearing potential
Co-morbidities and other medications
Experience with AEDs
Pregnancy and breastfeeding
Who initiates AEDs medications?
Medications are initiated by a specialist under an Epilepsy care plan.
This involves an agreement between the patient/family/carers and primary and secondary care teams.
The patient will be
What is the Epilepsy care plan?
It is an individualised care plan detailing diagnosis, treatment, care and support. It is discussed and agreed with the person and, if appropriate, their family or carers. The plan allows people to make informed choices about their epilepsy and helps to coordinate care between healthcare and other professionals in different settings (primary and secondary care teams).
This involves both the consultant and epilepsy specialist nurses.
What is the main aim of AEDs?
Ideally want the patient to be seizure free on monotherapy, with limited interactions and side effects
How should doses of AEDs be managed?
Initiate the patient on a low dose and gradually titrate upwards to monitor for response but also toxicity.
What should you do if the first AED fails and the second AED fails?
If the first AED is insufficient/lack of response/toxicity - I think you introduce a second AED uptitrate that medication before tapering the dose of the first AED to ensure some epileptic control. However I think this may depend upon the circumstances in which the first AED has been stopped.
If the second AED fails, you then tend to use combination therapy of multiple AEDs.
What is the purpose of regular therapeutic drug monitoring of AEDs?
Depending on the type of AED, specialist may request regular blood tests.
These are used to:
Explore toxicity
Identify non-adherence
Adjustment of Phenytoin
Managing interactions with other drugs
For specific clinical conditions
What is the first line treatment for generalised tonic-clonic seizures?
First line monotherapy of sodium valproate in:
Boys and men
Girls aged under 10 years and who are unlikely to need treatment when they are old enough to have children
Women who are unable to have children
Offer Lamotrigine or Levetiracetam as first line monotherapy in:
Women and girls of a child bearing age including girls who are likely to need treatment when they are old enough to have children.
What is the second line monotherapy for generalised tonic-clonic seizures?
If sodium valproate was unsuccessful as first line monotherapy offer Lamotrigine or Levetiracetam as second line monotherapy.
If Levetiracetam or Lamotrigine was unsuccessful as first line monotherapy, try the other.
What are the first-line add on treatments for generalised tonic-clonic seizures?
If monotherapy is unsuccessful in people with generalised tonic-clonic seizures, consider 1 of the following first-line add-on treatment options:
-Clobazam
-Lamotrigine
-Levetiracetam
-Perampanel
-Sodium valproate, except in women and girls able to have children
-Topiramate.
If the first choice is unsuccessful, consider the other first-line add-on options.
If the first line add on are unsuccessful in generalised tonic-clonic seizures what are the second line add on?
Consider one of the following second line treatment add on:
-Brivaracetam
-Lacosamide
-Phenobarbital
-Primidone
-Zonisamide
If the first choice is unsuccessful, consider the other second-line add-on options
What is the first line choice for patients with focal seizures?
First-line monotherapy for focal seizures should be Levetiracetam or Lamotrigine. If one of these are unsuccessful the other should be considered.
What are the second line monotherapy for focal seizures?
If the first line monotherapy for focal seizures are unsuccessful, consider 1 of the following second-line monotherapy options:
-Carbamazepine
-Oxcarbazepine
-Zonisamide.
If the first choice is unsuccessful, consider the other second-line monotherapy options.
What is the third line monotherapy for focal seizures?
If second-line monotherapies tried are unsuccessful in people with focal seizures, consider lacosamide as third-line monotherapy.
What are the first line add on for focal seizures?
If monotherapy is unsuccessful in people with focal seizures, consider one of the following first-line add on:
-Carbamazepine
-Lacosamide
-Lamotrigine
-Levetiracetam
-Oxcarbazepine
-Topiramate
-Zonisamide.
If the first choice is unsuccessful, consider the other first-line add-on options.
What are the second line add on for focal seizures?
If first-line add-on treatments tried are unsuccessful in people with focal seizures, consider 1 of the following second-line add-on treatment options:
-Brivaracetam
-Cenobamate
-Eslicarbazepine acetate
-Perampanel
-Pregabalin
-Sodium valproate, except in women and girls able to have children.
If the first choice is unsuccessful, consider the other second-line add-on options
What are the third line add on for focal seizures?
If second-line add on are insufficient, consider one of the third line add on therapies:
Phenobarbital
Phenytoin
Tiagabine
Vigabatrin.
If the first choice is unsuccessful, consider the other third-line add-on options
What is the first line monotherapy for absence seizures (inc childhood absence seizures)?
Ethosuximide
What is the second and third line monotherapy for absence seizures?
Sodium valproate can be offered as second line / add on therapy in:
Boys and men
Girls under 10 unlikely to need treatment when they are old enough to have children
Women who can’t have children
If second-line treatment is unsuccessful for absence seizures, consider lamotrigine or levetiracetam as a third-line monotherapy or add-on treatment options.
(This would be considered second line for women and girls of child bearing potential, or girls under 10 likely to need treatment when they are old enough to have children).
If the first choice is unsuccessful, consider the other of these options
Which anti-seizure medication can exacerbate absence and myoclonic seizures and therefore should be avoided in patients with this type?
Carbamazepine
Gabapentin
Oxcarbazepine
Phenobarbital
Phenytoin
Pregabalin
Tiagabine
Vigabatrin
Lamotrigine may also exacerbate myoclonic seizures
What is the first line monotherapy for absence seizure with other seizure types?
Sodium valproate should be consider first-line monotherapy for absence seizures with other types (or those at risk) in:
Boys and men
Girls aged under 10 years and who are unlikely to need treatment when they are old enough to have children
Women who are unable to have children
Lamotrigine or Levetiracetam should be considered first-line monotherapy in women and children of childbearing potential and girls under 10 likely to need treatment when they are old enough to have children.
If the first choice is unsuccessful, consider the other of these options.
What is the second line treatment for absence seizure with other seizure types?
If first-line treatments tried are unsuccessful for absence seizures and other seizure types (or at risk of these), consider:
-Lamotrigine or levetiracetam as a second-line monotherapy or add-on treatment options or
-Ethosuximide as a second-line add-on treatment.
If the first choice is unsuccessful, consider the other second-line options.
What is the first line treatment for myoclonic seizures?
Sodium valproate should be offered as first line treatment for myoclonic seizures in:
Boys and men
Girls aged under 10 years and who are unlikely to need treatment when they are old enough to have children
Women who are unable to have children
Levetiracetam should be offered as first line treatment for myoclonic seizures:
Women and girls and girls under 10 who will need treatment when they are old enough to have children
What is the second line treatment for myoclonic seizures?
If sodium valproate is unsuccessful as first line treatment, offer Levetiracetam as second line monotherapy or as add on
