Neuro: Epilepsy Flashcards
what is a seizure?
transient series of uncontrolled electrical dischargees which often start in the brain and the person may or may not experience what is going on around them
what are the 4 classes of seizures?
- focal aware = full consiousness, may be motor or sensory depending on location of foci (unilateral)
- focal unaware (tonic/atonic) = consciousness is disturbed or completley lost, pt less aware of their symptoms. Associated with automatisisms (licking lips, turning head) - usually damage in temporal cortex (unilateral)
- generalised absence seizures = bilateral activity, generally not noticed by the patient. Clinically characterised by sudden interuptions of ongoing activities, sometimes automatisms
- Generalsied motor (tonic-clonic) = bilateral activity, sudden loss of consiousness and pt falls to floor, followed by tonic phase where muscles become stiff, then immediate clonic movements (shaking)
what factors should you consider when choosing an antiepileptic drug?
- type of seizure
- epilepsy syndrome
- need for treatment
- risks vs benefits inc risk of epilesy-related death
- age
- sex
- other medicines/conditions
- education, employment, pregnancy
name 4 AEDs which are OD dosing. Why can they be given OD?
lamotrigine
perampanel
phenobarbital
phenytoin
they have long half lives
what are the 1st line and adjunct AED for generalised tonic-clonic seizures? What AEDs are ineffective/cause worsening?
1st line:
Sodium valproate
Lamotrigine
Carbamazepine
Oxacarbazepine
Adjuctive:
Clobazam
Lamotrigine
Levetiracetam
Sodium Valproate
Topiramate
(if there are absence/myoclonic seizures) Ineffective:
Carbamazepine
Gabapentin
Oxacarbazepine
Phenytoin
Pregabalin
Tigabine
Vigabatrin
what are the 1st line and adjunct and other AEDs that can be used in seocndary care for tonic/atonic seizures? What AEDs are ineffective?
1st line:
Sodium valproate
Adjunct:
Lamotrigine
Other:
Rufinamide
Topiramate
Ineffective:
Carbamazepine
Gabapentin
Oxacarbazepine
Pregabalin
Tigabine
Vigabatrin
What are the 1st line, adjunct, seconary care and ineffective AEDs for absence siezures?
1st line:
(1st)sodium valproate (if not F) or ethosuximide
(2nd) lamotrigine
Adjunct:
Ethosuximide
Lamotrigine
Sodium Valproate
Secondary Care:
Clobazam
Clonazepam
Levetiracetam
Topiramate
Zonisamide
Avoid:
Carbabmazepine
Gabapentin
Oxacarbazepine
Phenytoin
Pregabalin
Tigabine
Vigabatrin
What are the 1st line, adjunctive, secondary care AEDs and what should you avoid in myoclonic seizures?
1st:
Sodium valproate
Levetiracetam or topiramate
Adjunct:
Leviteracetam
Sodium valproate
Topiramate
Secondary care:
clobazam
clonazepam
piracetam
zonisamide
Avoid:
carbamazepine
gabapentin
oxacarbazepine
phenytoin
pregabalin
tigabine
vigabatrin
what are the 1st line, adjunct, secondary care AEDs for focal seizures and what ones should you avoid?
1st line:
(1s) carbamazepine or lamotrigine
(2nd) levetiracetam or sodium valproate or oxacarbazine
Adjunct:
carbamazepine
clobazam
gabapentin
lamotrigine
levetiracetam
oxacarbazepine
sodium valproate
topiramate
Secondary Care:
Eslicarbazepine
lacosamide
phenobarbital
phenytoin
pregabalin
tigabine
vigabatrin
Avoid:
none
How would you manage prolonged seizures and status epilepticus in the community? are there adjunctive therapies?
buccal midazolam (1st) - give 2nd dose in 5 - 10 mins if no response
rectal diazepam
IV lorazepam if IV access
2nd line after no response to 2 doses of benzo = levetriacetam, phenytoin or valproate
what is first line treatment for status epilepticus in secondary care? Are there adjunctive therapies?
IV lorazepam (1st)
IV diazepam
buccal midazolam
Adjunctive therapies:
IV phenobarb/phenytoin
Can you offer sodium valproate to females of childbearing age?
no - only if other therapies are ineffective or not tolerated and pregnancy prevention programme is in place
What other patient group qualify for the pregnancy prevention programme since summer 2023?
in men less than 55 years of age and men above 55 years of age who have chance of convieing a child (fertile spouse)
name 2 AEDs that can impair the effectiveness of oral contraceptives.
oxacarbazepine
topiramate
should you aim to control epilepsy with monotherapy or combination therapy? What should you do if combination therapy doesn’t help seizures?
aim to control with monotherapy where possible, if one drug unseccessful switch to another. If monotherapy not effective then switch to adjunctive therapy.
If adjunctive therapy does not help revert to the regime (either monotherapy or combination) that provided the best balance between toelrability and efficacy.
What MHRA advice is associated with AEDs?
How early can it be seen?
What advice should you give?
that all AEDs may be associated with small increase of suicidal thoughts and behaviour - symptoms may occur as early as 1 week of treatment.
Advice pts to seek medical advice with any mood changes/distressing thoughts/feelings
Pt should not be advised to stop/switch AEDs and to seek advice
What AEDs must be prescribed by brand (cat 1) CPPP
Carbamazepine
Phenobarbital
Phenytoin
Pirmidone
Name cat 2 AEDs (there’s 10) - only switch on clinical judgement POTZER CCVL
- clobazam
- clonazepam
- lamotrigine
- oxacarbazepine
- perampanel
- rufinamide
- topiramate
- valproate
9 zonisamide - eslicarbazepine
name cat 3 AEDs (there’s 8) PLLEB GVT
- tigabine
- vigabatrin
- gabapentin
- pregabalin
- lacosamide
- levetiracetam
- ethosuximide
- bivaracetam
What drugs are assocaited with antiepileptic hypersenstivity syndrome? (theres 8 - CPPP + LOLR)
carbamazepine
phenytoin
primidone
phenobarbital
lacosamide
oxcarbazepine
lamotrigine
rufinamide
how long must a pt be siezure free to consider drug withdrawal?
2years
how would you go about withdrawing drugs?
one at a time and very slowly (over the course of 3 months) - longer for benzodiazepines and barbituates due to drug related withdrawal symptoms
what happens if a driver has a seizure?
what happens if pts have a 1st unprovoked siezure or single isolated seizure?
when can a pt with epilepsy drive?
- they must stop driving and inform the DVLA
- they must not drive for 6 months, driving can be resumed if pt is assessed by a specialist as fit to drive
- pts must be seizure free for at least one year (or have pattern of siezures established for one year where there is no influence on their level of consiousness or ability to act). They must also not have a history of unprovoked seizures.
How long is a pt not allowed to drive for if they have a seizure whilst asleep?
What are the exceptions?
Cannot drive for one year from date of seizure
unless
a history/pattern of sleep siezures occuring only ever while asleep has been established over the course of at least one year from the date of first sleep siezure
or
an established patterns of purely asleep siezures can be demonstrated over the course of 3 years if the patient has preiously had seizures whilst awake
what does the DVLA recommened arounf meducation changes or withdrawal of AEDs?
what happens if a pt has a seizure during medication change/withdrawal of treatment?
patient should not drive during medication changes and for 6 months after their last dose
if a seizure occurs during med changes/withdrawal they will have their license revoked for 1yr. Relicensing may be considered earlier if treatment has been reinsanted for 6 months and no further seizures have occurred.
when are the risks of teratogenicity greatest during pregnancy?
first trimester
whats the most teratogenic drug and what sort of effects can it have on the baby?
sodium valproate
congential malformation (10% risk)
neurodevelopmental disorders (30 - 40% risk)
what must females be part of if they need treatment with valproate?
pregnancy prevention programme
what are the safest AEDs to use during pregnancy
lamotrigine and levetiracetam
can carbamazepine, phenobarbital, phenytoin, zonisamide and toperimate be used safely in pregnancy?
no
increased risk of congenital malformations (dose dependent with carbamazepine, phenobarb, topiramate.
adverse neurodevelopmental effects with phenobarbital and phenytoin
increased risk of intra-uterine growth restriction with phenobarbital, topiramate and zonisamide
what AEDs are most affected by physiological changes druing pregnancy and post partum.
true - especially lamotrigine and phenytoin
what methods of contraception are considered highly effective?
long-acting reversible contraceptives (copper IUD, levonorgestrel intrauterine system), progesterone only implant and sterilisation.
what type of enzyme inhibitors reduce the action COC and POP
Give some AED examples.
enzyme inducers reduce the concentration of contraceptives.
carbamazepine, oxacarbzepine, phenytoin, phenobarbital, primidone, topiramate
what hormonal contraceptives can affect the efficacy of some AEDs?
what is the likelihood of a female taking AED having a baby with no malformations?
at least 90% - NB important for them not to stop taking essential treatment because of concern to harm over fetus
what should you over to pregnant women to reduce the risk of neural tube defects in the first trimester?
folate supplementation
T/F - all females taking AEDs should be encouraged to breast feed.
False - should be encouraged if on monotherapy but if on combination therapy or other risk factors such as prematre birth, close monitoring is recommended - counsel on signs of toxicity
what AEDs are readily transferred to breast milk?
ethosuximide, lamotrigine, primidone, zonisamide
what AEDs transferred by breast milk are metabolised slowly in infants increasing risk of accumulation?
phenobarbital and lamotrigine
what 3 AEDs are associated with establsihed risk of drowsiness in breast fed babies? what are the risks if a mother suddenly stop breastfeeding?
benzodiazepines, primidone, phenobarbital
risk of withdrawal in infant
what AEDs can exacerbate Dravet syndrome?
carbamazepine
gabapentin
lacosamide
lamotrigine
oxacarbzepine
phenobarbital
pregabalin
tigabine
vigabatrin
what is Dravet syndrome and what is the first line treatment?
severe form of epilepsy
1st line = sodium valproate even if female as severity of syndrome means can respond poorly
what the first and second line adjunctive therapy for Dravets syndrome?
What is the 5-HT receptor agonist that can be started under specialsit care for Dravets syndrome?
1st = sodium valproate + clobazam + stripipentol
2nd = cannabidiol + clobazam
5-HT agonist = fenfluramine
what is Lennox-Gastaut syndrome?
what’s the first and second line monotherapy/adjunct?
what are the 3rd line adjunctive therapies?
severe form of epilepsy - developmental effects
1st line = sodium valproate
2nd line = lamotrigine
3rd line adjunct = cannabidiol with clobazam or clobazam, rufinamide or topiramate
what CD schedule are cannabidiol products?
2
define status epilepticus - how does this differ from proglonged convulsive seizures?
actue medical emergency - seizure that continues for more than 5 mins or convulsive seizures that occur one after the other without recovery inbetween with no post-ictal recovery
prolonged convulsive seizures = more than 2mins longer than the patients usual seizure
what should be given if a siezure occurs and alcohol abuse is suspected?
parenteral thiamine
what should be given if status epilepticus is caused by pyridoxine deficiency?
pyridoxine hydrochloride
whats the management for brief febrile convulsions?
paracetamol to reduce fever and prevent further convulsions
