Lecture 2 - Seizures 1 Flashcards by Patryk Lasiuk

Non-pharm seizure treatments

Surgery =
Ketogenic Diet
Vagus Nerve stim
Seizure dogs

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When is neurosurgery indicated

Failed 2-3 trials of meds
Has high efficacy with complex partial seizures of temporal lobe

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Ketogenic Diet for seizures

High fat: Low protein + carb diet (4 to 1 calories)
no sugar

indicated for primarily young children with drug refactor seizures (Lennox-Gastaut
Potential for growth retardation n long term hyperlipidemia effects

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Vagus Nerve Stimulation

implanted generator, intermittently stimulates left vagus nerve

about 1/2 pts see 50% reduction in seizures

infection risk at site, but fairly low

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Vagus Nerve stimulation adverse effects

hoarseness
cough
throat pain
tingling at electrode site

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Seizure dogs

dogs can predict seizure 15-45min before seizure

trained to alert seizure before happening, help prevent harm during seizure

usually in those that have >1 per month

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Ideal AED properties

effective
QD or BID dosing
Low cost
Minimal side effects or major organ toxicity
Few or no DIs
Linear PK
Little or no allergic or idiosyncratic reactions
IV form

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AED safety alert

inc risk of suicidal behavior

All pts currently taking or starting on any AED should be closely monitored for changes in behavior that could indicate emergence or worsening of suicidal thought or behavior or depression

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General AED monitoring

QOL, Seizure freq, serum drug conc

toxic: specific drug Sessions, suicidal ideation/depression

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General AED counseling

explain use of drug n regimen
stress adherence
minimize alc and stress
never abruptly stop, inc status epilepticus risk
monitoring periodic blood lvls

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Carbamazepine (Tegretol, carbatrol) MOA

Blocks Na+ and L-type Ca channels
blocks firing of AP, dec release of excitatory NMT

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Carbamazepine (Tegretol, carbatrol) Side Effects

Agranulocytosis**
Aplastic Anemia**
SJS**

N/V
Dizziness
Headache
Nystagmus
Hyponatremia*
Osteoporosis*

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Carbamazepine (Tegretol, carbatrol) Kinetics

Good absorption, food doesnt alter

Autoinduction, low lvls may not be non-adherence, ~4wks then take lvls

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Carbamazepine (Tegretol, carbatrol) DDI

AEDs, oral contraceptives, warfarin. = dec lvls

Caffeine, Phenytoin = dec CBZ lvls

Clarithromycin, Diltiazem, Valproate, Verapamil = inc CBZ lvls

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Carbamazepine (Tegretol, carbatrol) Monitoring

Therapeutic lvls = 4-12mg/dl
CBC (Na+)
Rash, SJS
BMD/fractures if on it for years

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Carbamazepine (Tegretol, carbatrol) Common dose

600mg PO BID, adjusted based on drug lvls

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Phenytoin (Dilantin) Side effects

Gingival hyperplasia
Behavior changes
Folate deficiency
Agranulocytosis*
SJS*
Lupus*

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Phenytoin (Dilantin) Kinetics

Non-linear, zero order at therapeutic lvls
90% bound, 10% free and therapeutic effect
CYP450 inducer

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Phenytoin (Dilantin) lvl if Hypoalbuminemia (< 4)

PHT(observed) / (0.2 X alb) + 0.1

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Phenytoin (Dilantin) lvl if Hypoalbuminemia (<4) + Click < 20 or ESRD

PHT (observed) / (0.1 X alb) + 0.1

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Phenytoin (Dilantin) toxicity

watch for inc N/V, Nystagmus, CNS depression

can occur at therapeutic lvls

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Drugs that Phenytoin (Dilantin) will dec

Other AEDs
Warfarin
Digoxin
Oral contraceptives

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Drugs that will inc Phenytoin (Dilantin) lvls

amiodarone
Fluc

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Drugs that will dec Phenytoin (Dilantin) lvls

Antacids

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Phenytoin (Dilantin) lvls

10-20 = therapeutic SE > 15mg/L Loading dose = 15-18mg/kg, dose on weight usually 300mg per day good starting place

Fosphenytoin (Cerebyx) info

less toxic than IV phenytoin Dose 300-400mg PE equiv per day Max infusion rate - 150mg/min

Valproate (Depakote, Depakene) SE

a lot of weight gain sedation Folate deficiency Hepatic failure* Pancreatitis* Teratogenic* Rash/SJS*

Valproate (Depakote, Depakene) is both...

Anti seizure and Anti-epileptogenic

Does Valproate inc oral contraceptives?

nah

Drugs that decrease Valproate lvls

Carbamazepine Phenobarbital Phenytoin

Valproate (Depakote, Depakene) dosing

~ 500mg BID, done based on lvls

Ethosuximide is only effective in what kind of seizures?

absence seizures most common in kids

Ethosuximide Side effects

Blood dyscrasia* Liver failure* Lupus* Hiccups

Ethosuximide dosing

250mg QD Peds 3-6yrs old, inc q 4-7 days 500mg QD >6yrs old, inc q4-7 days

Primidone (Mysoline) info

pro drug converted into phenobarbital

Phenobarbital info

take at HS due to sedation not really used, last line

Felbamate (Felbatol) rare used due to...

side effects Aplastic anemia and hepatic failure**

Gabapentin (Neurontin) dosing

400-600 TID can titrate quickly, Clcr < 60 = adjust not many drug interactions dont really monitor lvls

Gabapentin side effects

wt gain dizziness somnolence

Lamotrigine (Lamictal) side effects

SJS* Weight gain

Lamotrigine dosing

dont monitor lvls ~ 150mg PO BID inc bi-monthly by 50mg/day until seizures controlled

Leviteracetam (Keppra) SE

fairly good HA, somnolence, asthenia, behavior change common

Leviteracetam (Keppra) dosing

no serum monitoring Common dose 500-750mg BID, 500mg start, inc by 1000mg/day at wkly interval MDD = 3000mg/day

Leviteracetam (Keppra) Renal Dosing

CrCl < 80, have to start renal dosing

Oxcarbazepine (Trileptal) SE

SJS*

Oxcarbazepine Dosing

600mg BID Click < 30ml/min, give 300mg/day start then titrate up

Oxcarbazepine effect on oral contraceptives

will dec lvls, weak inducer

Tiagabine (Gabitril) dosing

8-16mg BID-QID not used often, $$ and hard to dose QID

Topiramate (Topamax) SE

Nephrolithiasis = kidney stone = drink enough water Weight loss + common ones

Topiramate (Topamax) Dosing

100-200mg BID ClCr < 70 = dose adjust

Topiramate (Topamax) effect on oral contraceptives

dec lvls

Zonisamide (Zonegran) SE

SJS* + common ones

Zonisamide (Zonegran) dosing

100-200mg BID not really commonly used

Brivaracetam (Briviact) info

similar to keppra, maybe better tolerated for SE IV form available

Cannabidiol (Epidiolex) used for

Lennox-Gastaut or Dravet Syndrome which is usually in kids

Clobazam (Onfi) used for....

Lennox-Gastaut syndrome C4 start 5mg BID, inc to ~20-40mg QD

Eslicarbazepine (Aptiom) info

prodrug oxcarbazepine MDD 1200mg Click < 50 adjustment, 600mg MDD

Everolimus (Afinitor Disperse) indicated for...

Tuberous sclerosis complex associated focal seizures in pts 2yrs or older $$$$

Everolimus (Afinitor Disperse) SE

> 10% mouth ulceration Stomatitis fever

Lacosamide (Vimpat) dosing

50mg BID, target 200-400mg/day Take w/ or w/o food 100% Po Bioavail Crcl < 30ml/min = adjust

Perampanel (Fycompa) info

1st drug for glutamate receptors C3, 2mg QD, 12mg MDD

Pregabalin (Lyrica) dosing

Crcl < 60 adjust initial dose = 150mg QD MDD = 600mg BID/TID

Pregabalin (Lyrica) SE

weight gain

Rufinamide (Banzel) primarily used in...

Lennox-Gastaut

Rufinamide (Banzel) SE

May shorten QTc Leukopenia *can Dec Oral contraceptives*

Rufinamide (Banzel) dosing

200-400mg BID to start, 3200mg MDD Give with food