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integrated studies in mental health > Management of epilepsy > Flashcards

Management of epilepsy Flashcards

1
Q

define epilepsy

A

Neurological condition which affects the brain

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2
Q

Repeated seizures in epilepsy may cause tragic consequences. TRUE OR FALSE

A

TRUE

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3
Q

repeated seizure in epilepsy can be categorised as various sub types. what are the two subtypes

A

tonic clonic seizures
absence seizures
and myoclonic seizures
focal
generalised tonic clonic

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4
Q

Seizure activity may cause

A

-Progressive intellectual disability
-Sudden unexplained death in epilepsy (SUDEP)
-Status epilepticus ( a clinical activity in which seizure continues for long or multiple seizure occurs but no chance of recovery or conscious in between)
-Quality of life (complicated seizures)

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5
Q

Who can clinical diagnose and investigate epilepsy

A

Specialist medical practitioner with training and expertise in epilepsy

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6
Q

what investigations are required to confirm the diagnosis of epilepsy

A

-Clinical History
the detailed description of the event, an eyewitness to the attack (where possible)

-Electroencephalogram (EEG)/Video telemetry ( this should be performed only when clinical history suggests that that seizure is likely to be epileptic in origin)

-Neuroimaging - Magnetic Resonance Imaging (MRI)

-Biochemistry tests – e.g. serum electrolytes, glucose, calcium

-12-lead Electrocardiogram(ECG)

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7
Q

Aim of anti epileptic treatment is to keep the patients seizure free with fewest drugs. TRUE OR FALSE

A

TRUE

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8
Q

Prior/during the initiation of drug treatment, what must be checked?

A

Confirmed diagnosis
Types of epilepsy
Monotherapy
Slow titration/withdrawal
Monitor therapeutic levels
Be careful with changing drug regimens

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9
Q

Anti epilepsy drug should be prescribed based on seizure types. TRUE OR FALSE

A

TRUE

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10
Q

what are the Absence seizure AED for first line treatment?

A

ethosuximide, sodium valproate*

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11
Q

what are the Absence seizure AED for second line treatment?

A

lamotrigine

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12
Q

what are the Absence seizure AED for adjuvant treatment

A

ethosuximide , sodium valproate, lamotrigine

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13
Q

what are the Absence seizure AED for additional consideration on referral to sec/tert hospitals

A

clobazam, clonazepam, levetiracetam, topiramate, zonisamide

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14
Q

What are the absence seizure AED to avoid as ineffective or deteriorate

A

carbamazepine, gabapentin, oxcarbazepine, phenytoin, pregabalin, tiagabine, vigabatrin

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15
Q

what are the focal seizure AED for first line treatment?

A

carbamazepine
lamotrigine

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16
Q

what are the focal seizure AED for second line treatment?

A

levetiracetam
oxcarbazepine
sodium valproate

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17
Q

what are the focal seizure AED for adjuvant treatment

A

carbamazepine, clobazam, gabapentin, lamotrigine, levetiracetam, oxcarbazepine, topiramate

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18
Q

what are the focal seizure AED for additional consideration on referral to sec/tert hospitals

A

eslicarbazepine acetate, lacosamide, phenobarbital, phenytoin, pregabalin, tiagabine, vigabatrin and zonisamide

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19
Q

what are the generalised tonic clonic seizure AED for first line treatment?

A

Sodium valproate

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20
Q

what are the generalised tonic clonic seizure AED for second line treatment?

A

Lamotrigine
Carbamazepine (3rd)
Oxcarbazepine (3rd)

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21
Q

what are the generalised tonic clonic seizure AED for adjuvant treatment

A

clobazam, lamotrigine, levetiracetam, sodium valproate, topiramate

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22
Q

What are the generalised tonic clonic seizure AED to avoid as ineffective or deteriorate

A

If absence or myoclonic seizures, juvenile, myoclonic epilepsy is suspected,
carbamazepine, gabapentin, oxcarbazepine, phenytoin, pregabalin, tiagabine, vigabatrin.

23
Q

what are the myoclonic seizure AED for first line treatment?

A

Sodium valproate

24
Q

what are the myoclonic seizure AED for second line treatment?

A

Levetiracetam, topiramate

25
Q

what are the myoclonic seizure AED for adjuvant treatment

A

Levetiracetam, topiramate, sodium valproate

26
Q

what are the myoclonic seizure AED for additional consideration on referral to sec/tert hospitals

A

Clobazam, clonazepam, piracetam, zonisamide

27
Q

What are the myoclonic seizure AED to avoid as ineffective or deteriorate

A

Carbamazepine, gabapentin, oxcarbazepine, phenytoin, pregabalin, tiagabine, vigabatrin

28
Q

what are the tonic or atonic seizure AED for first line treatment?

A

Sodium valproate

29
Q

what are the tonic or atonic seizure AED for adjuvant treatment

A

Lamotrigine

30
Q

what are the tonic or atonic seizure AED for additional consideration on referral to sec/tert hospitals

A

rufinamide, topiramate

31
Q

What are the tonic or atonic seizure AED to avoid as ineffective or deteriorate

A

carbamazepine, gabapentin, oxcarbazepine, pregabalin, tiagabine, vigabatrin.

32
Q

Carbamazepine

A

Hyponatremia via induction of SIADH
Starting at a low dose with slow titration

Formulation
Tablet
Modified-release tablet
Oral suspension/solution
Suppository - maximum 250mg QDS which is equivalent to 800mg daily orally, up to 7 days

Dose equivalence and conversion
100mg tablet = 125mg suppository

note sodium level should be measured before starting therapy, 2 weeks after initiation and every month for 2 months

33
Q

Phenytoin

A

Dose equivalence and conversion
100mg capsule/IV = 92mg oral solution (Phenytoin sodim vs phenytoin base)

How to give phenytoin via Intravenous administration?
Dilute in 50-100ml Sodium Chloride 0.9%
Give into a large vein through an in-line filter (0.22-0.5micron) – why?
Maximum rate of 50mg/minute (lower to 25mg/minute if elderly or patients with heart disease)

34
Q

Lamotrigine

A

Tolerability – reasonably well

Adverse drug events
Rash (in the first 8 weeks, if given too quickly) - this can be life threatening
Blood disorders

Drug-drug interactions
With valproate: increased plasma concertation
Enzyme inducing AEDs: decrease plasma concentration

35
Q

Levetiracetam

A

Extremely well tolerated

Effective in most types of epilepsy

Usually recommended as 2nd line or adjuvant therapy
Red-flag symptoms

Skin rash (SJS), allergic reactions

Caution/avoid in patient with;
Renal impairment
Depression, thoughts of harming/killing
Pregnancy

Formulation
Tablets, liquid, granules, solution for infusion

36
Q

Sodium valproate

A

Metabolic effects
Monitor LFTs and FBC

Teratogenicity
Must NOT be used in females of childbearing potential unless Pregnancy Prevention Programme is in place, and only if used as a last option

Dose equivalence and conversion
PO = IV (doses are equivalent between formulations)

Formulation
Tablets – crushable, enteric-coated, modified-release
Liquid
Solution for IV injection

37
Q

Sodium valproate

A

Metabolic effects
Monitor LFTs and FBC

Teratogenicity
Must NOT be used in females of childbearing potential unless Pregnancy Prevention Programme is in place, and only if used as a last option

Dose equivalence and conversion
PO = IV (doses are equivalent between formulations)

Formulation
Tablets – crushable, enteric-coated, modified-release
Liquid
Solution for IV injection

38
Q

what happens during the initiation of AED therapy

A

patients invited for consultation to discuss options

4 weeks of treatment in hospital followed by continuation in primary care

39
Q

Why are patient referred back to the hospital during therapy in community care

A

Abnormal blood results
uncontrolled seizures in community

40
Q

Treatment regimens are decided in the epilepsy clinic
TRUE OR FALSE

A

TRUE

41
Q

What is done during Treatment regimens

A

Personalised care plan
current seizure frequency
Indication for new drug regime
titration schedule
potential side effects
need for specific monitoring

Changes in treatment to be communicated with GP

42
Q

refer back to slide 14 and 15

A
43
Q

what is status epilepticus

A

Prolonged seizure activity either
For more than 30 minutes
or

A series of seizures without recovery in between
Medical Emergency if
Occurs during convulsive (tonic-clonic) seizure

Urgent treatment is required
at approximately 5 minutes after seizure started
Or

Repeated convulsive seizures (3 or more episodes) in community
Non-convulsive status epilepticus

44
Q

What class of drugs is the first line treatment for hospital convulsive status epilepticus

A

Benzodiazepine

45
Q

List the drugs used in hospital for convulsive status epilepticus

A

IV lorazepam (1st)
- 0.1mg/kg, repeat after 10 mins)

IV diazepam

Buccal midazolam (if IV access is not available)

IV phenobarbital/phenytoin (2nd)
- ?IV valproate/ levetiracetam

46
Q

List the drugs used in hospital for refractory convulsive status epilepticus

A

IV midazolam,
Propofol,
Thiopental sodium
With General anaesthesia

47
Q

List the drugs used in community for status epilepticus

A

Buccal midazolam (1st)

Rectal diazepam

IV lorazepam (only if IV access/resus facilities are available)

then Call an ambulance
After another 5 mins of emergency drug intervention
Unable to open airway/breathing

48
Q

what are the Non-pharmacological interventions

A

Brain surgery
-Resective surgery
-Focal resection (e.g. temporal, extratemporal resection)
-Lesionectomy
- Functional procedures
Vagal nerve stimulation (VNS)

Dietary therapies
- Ketogenic Diet

49
Q

what does MHRA says on the use of AED in pregnancy

A

Lamotrigine (Lamictal) and levetiracetam (Keppra) are safer than other AEDs

Carbamazepine, phenobarbital, phenytoin, topiramate increases the risk of physical birth abnormalities

Phenobarbital or phenytoin increases the risk the child may have difficulties with learning and thinking ability, but NOT as high as for valproate

Phenobarbital, topiramate, or zonisamide increases the risk of the baby being born smaller than expected

Offer folic acid 5mg OD before possible pregnancy

When use AED
Offer monotherapy
Start with the lowest effective dose
Report any adverse drug effects via Yellow Card Scheme

Drug level monitoring is required for
Lamotrigine, Levetiracetam, Oxcarbazepine, phenytoin

50
Q

Applying for drivers license is acceptable as long as the patient is how many months free from seizure

A

12 months

51
Q

What are the conditions for applying for drivers license

A

12 months seizure free

if you have had an awake seizure in the past, and in last 3 years you had only sleep seizures

if you have never had an awake seizure and had only sleep seizure in the last 12 months

52
Q

You must report to DVLA if you have a seizure, TRUE OR FALSE

A

TRUE

53
Q

You must stop driving for 6 months if what?

A

changed treatment dose
withdrawn from AEDs
had a single episode of seizure

54
Q

What do you avoid when you have epilepsy

A

Swimming alone
bathing a baby on your own

integrated studies in mental health (20 decks)

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