Management of epilepsy Flashcards
define epilepsy
Neurological condition which affects the brain
Repeated seizures in epilepsy may cause tragic consequences. TRUE OR FALSE
TRUE
repeated seizure in epilepsy can be categorised as various sub types. what are the two subtypes
tonic clonic seizures
absence seizures
and myoclonic seizures
focal
generalised tonic clonic
Seizure activity may cause
-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)
Who can clinical diagnose and investigate epilepsy
Specialist medical practitioner with training and expertise in epilepsy
what investigations are required to confirm the diagnosis of epilepsy
-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)
Aim of anti epileptic treatment is to keep the patients seizure free with fewest drugs. TRUE OR FALSE
TRUE
Prior/during the initiation of drug treatment, what must be checked?
Confirmed diagnosis
Types of epilepsy
Monotherapy
Slow titration/withdrawal
Monitor therapeutic levels
Be careful with changing drug regimens
Anti epilepsy drug should be prescribed based on seizure types. TRUE OR FALSE
TRUE
what are the Absence seizure AED for first line treatment?
ethosuximide, sodium valproate*
what are the Absence seizure AED for second line treatment?
lamotrigine
what are the Absence seizure AED for adjuvant treatment
ethosuximide , sodium valproate, lamotrigine
what are the Absence seizure AED for additional consideration on referral to sec/tert hospitals
clobazam, clonazepam, levetiracetam, topiramate, zonisamide
What are the absence seizure AED to avoid as ineffective or deteriorate
carbamazepine, gabapentin, oxcarbazepine, phenytoin, pregabalin, tiagabine, vigabatrin
what are the focal seizure AED for first line treatment?
carbamazepine
lamotrigine
what are the focal seizure AED for second line treatment?
levetiracetam
oxcarbazepine
sodium valproate
what are the focal seizure AED for adjuvant treatment
carbamazepine, clobazam, gabapentin, lamotrigine, levetiracetam, oxcarbazepine, topiramate
what are the focal seizure AED for additional consideration on referral to sec/tert hospitals
eslicarbazepine acetate, lacosamide, phenobarbital, phenytoin, pregabalin, tiagabine, vigabatrin and zonisamide
what are the generalised tonic clonic seizure AED for first line treatment?
Sodium valproate
what are the generalised tonic clonic seizure AED for second line treatment?
Lamotrigine
Carbamazepine (3rd)
Oxcarbazepine (3rd)
what are the generalised tonic clonic seizure AED for adjuvant treatment
clobazam, lamotrigine, levetiracetam, sodium valproate, topiramate
What are the generalised tonic clonic seizure AED to avoid as ineffective or deteriorate
If absence or myoclonic seizures, juvenile, myoclonic epilepsy is suspected,
carbamazepine, gabapentin, oxcarbazepine, phenytoin, pregabalin, tiagabine, vigabatrin.
what are the myoclonic seizure AED for first line treatment?
Sodium valproate
what are the myoclonic seizure AED for second line treatment?
Levetiracetam, topiramate
what are the myoclonic seizure AED for adjuvant treatment
Levetiracetam, topiramate, sodium valproate
what are the myoclonic seizure AED for additional consideration on referral to sec/tert hospitals
Clobazam, clonazepam, piracetam, zonisamide
What are the myoclonic seizure AED to avoid as ineffective or deteriorate
Carbamazepine, gabapentin, oxcarbazepine, phenytoin, pregabalin, tiagabine, vigabatrin
what are the tonic or atonic seizure AED for first line treatment?
Sodium valproate
what are the tonic or atonic seizure AED for adjuvant treatment
Lamotrigine
what are the tonic or atonic seizure AED for additional consideration on referral to sec/tert hospitals
rufinamide, topiramate
What are the tonic or atonic seizure AED to avoid as ineffective or deteriorate
carbamazepine, gabapentin, oxcarbazepine, pregabalin, tiagabine, vigabatrin.
Carbamazepine
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
Phenytoin
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)
Lamotrigine
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
Levetiracetam
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
Sodium valproate
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
Sodium valproate
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
what happens during the initiation of AED therapy
patients invited for consultation to discuss options
4 weeks of treatment in hospital followed by continuation in primary care
Why are patient referred back to the hospital during therapy in community care
Abnormal blood results
uncontrolled seizures in community
Treatment regimens are decided in the epilepsy clinic
TRUE OR FALSE
TRUE
What is done during Treatment regimens
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
refer back to slide 14 and 15
what is status epilepticus
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
What class of drugs is the first line treatment for hospital convulsive status epilepticus
Benzodiazepine
List the drugs used in hospital for convulsive status epilepticus
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
List the drugs used in hospital for refractory convulsive status epilepticus
IV midazolam,
Propofol,
Thiopental sodium
With General anaesthesia
List the drugs used in community for status epilepticus
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
what are the Non-pharmacological interventions
Brain surgery
-Resective surgery
-Focal resection (e.g. temporal, extratemporal resection)
-Lesionectomy
- Functional procedures
Vagal nerve stimulation (VNS)
Dietary therapies
- Ketogenic Diet
what does MHRA says on the use of AED in pregnancy
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
Applying for drivers license is acceptable as long as the patient is how many months free from seizure
12 months
What are the conditions for applying for drivers license
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
You must report to DVLA if you have a seizure, TRUE OR FALSE
TRUE
You must stop driving for 6 months if what?
changed treatment dose
withdrawn from AEDs
had a single episode of seizure
What do you avoid when you have epilepsy
Swimming alone
bathing a baby on your own
