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competency 10/11 > neuro: epilepsy > Flashcards

neuro: epilepsy Flashcards

1
Q

epilepsy is a disease of the brain defined by any of the following conditions:

A
  • At least two unprovoked seizures occurring>24 h apart
  • One unprovoked seizure and a probability of further seizures similar to the general
    recurrence risk (at least 60%) after two unprovoked seizures, occurring over the next 10
    years
  • Diagnosis of an epilepsy syndrome
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2
Q

provokedseizure

A

events occurring in close temporal rs with an acute CNS insult: metabolic, toxic, structural, infectious, inflammation

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3
Q

drugs that decr seizure threshold

A

TCA, carbapenems, baclofen

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4
Q

safety considerations: phenytoin

A

a/w incr risk of serious skin reactions in people of Han Chinese or Thai family background

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5
Q

safety considerations: cbz

A

a/w incr risk of serious skin reactions in people of Han Chinese, Thai, European, Japanese family background

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6
Q

safety considerations: LT treatment with some antiseizure meds such as cbz, phenytoin, primidone and sodium valproate

A

a/w decr bone mineral density and incr risk of osteomalacia
- ca and vit D supplementation for person at risk

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7
Q

antiseizure meds for women and girls

A

teratogenic: sodium valproate, topiramate, phenytoin

impair effectiveness of hormonal contraceptives: cbz, oxcarbazepine, phenytoin, topiramate
(estrogen-containing hormonal contraceptives can imapair effectiveness of lamotrigine

breastfeeding is generally safe and should be encouraged

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8
Q

generalised tonic clonic/ grand mal: tonic phase

A

stiffening of the limbs, breathing may decr or cease altogether, cyanosis of nail beds&lips&face

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9
Q

generalised tonic clonic/ grand mal: clonic phase

A

jerking of limbs and face, lasts 1 min, after which the brain is extremely hyperpolarised and insensitive to stimuli
- incontinence may occur, along w biting of the tongue or inside of the mouth, breathing may be noisy and appear to be laboured
- following the seizure, pt may have headache and appear lethargic/confused/sleep

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10
Q

myoclonic

A

Involves rapid, brief contractions of bodily muscles,
usually occurring on both sides of the body
concurrently
- On occasion, may involve just one arm or one foot

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11
Q

absence generalised seizure / petit mal

A
  • Usually manifests as basic lapse in awareness that begins and ends
    abruptly
  • Sometimes mistaken as persistent staring
  • Lasts only a few seconds 􀂲 no warning, no after-effects
  • Often undetected even if there 50-100 attacks per day
  • More common in children than in adults
  • First onset usually occurs at 4-12 years old; rarely after 20 years old
  • May be mistaken for complex
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12
Q

absence seizures vs complex partial seizures

A

absence:
1. are never preceded by auras
2. last seconds (rather than minutes)
3. begin frequently and end abruptly
4. produce characteristic EEG pattern ‘3Hz spike waves’

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13
Q

generalised atonic seizure

A
  • most severe form is the classic drop attack (astatic
    seizure) in which all postural tone is suddenly lost,
    causing collapse to the ground like a rag doll
  • short episode and followed by immediate recovery
  • occur at any age, and are always associated with diffuse
    cerebral damage and learning disability
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14
Q

risk of second seizure is higher in the presence of:

A
  • epileptiform abnormalities on EEG
  • Prior brain insult (e.g. stroke, brain trauma)
  • Structural abnormality in brain imaging
  • Nocturnal seizure
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15
Q

non-pharmacological treatment for epilepsy

A
  • ketogenic deit
  • vagus nerve stimulation
  • responsive neurostimulator system
  • surgery
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16
Q

AED that requires slow titration

A

lamotrigine and topiramate

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17
Q

AED that undergoes autoinduction

A

carbamazepine

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18
Q

AED to use in pt w migraine

A

topiramate, valproate

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19
Q

AED to use in caution for pt w depression or anxiety

A

levetiracetam: can cause irritability and aggresion

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20
Q

women w childbearing potential

A

avoid valproate, use l/l

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21
Q

If the first AED produces an adverse drug reaction or is not tolerated at low doses or does
not improve seizures consider

A

substitution

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22
Q

if the patient tolerates the first or second AED but with a
suboptimal response, consider

A

combination

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23
Q

ketogenic diet

A

may be used for pt who cannot tolerate or have not responded well to AED treatment
􀂃 Comprises low carbohydrate, high fat in diet
􀂃 Induction of ketosis
􀂃 Prevention of seizures (used mainly in young children 􀂲 evidence)
􀂃 Challenging to adhere long term

24
Q

AED with possible cognitive adr

A

topiramate: usually speech fluency

25
Q

AED to use in hepatic impairment

A

gabapentin, pregabalin, levetiracetam, topiramate, clobazem

26
Q

AED to use in renal impairment

A

carbamazepine, phenobarbitol, phenytoin, valproate

lamotrigine

27
Q

AED with no DDI`

A

gabapentin, pregabalin, levetiracetam

28
Q

potent enzyme inducers

A

1st gen
- carbamazepine
- phenytoin
- phenobarbitol

29
Q

potent enzyme inhibitor

A

valproate

30
Q

moderate cyp inducer

A

oxcarbazepine, topiramate

31
Q

moderate cyp inhibitors

A

oxcarbazepine, topiramate

32
Q

When an enzyme inducing ASM is discontinued, activity of affected enzymes

A

return to baseline
- drugs that are metabolised by the affected enzymes may require dose adj

33
Q

issue w enzyme-induced AED: ddi

A
  • antidepressants and antipsychotics
  • immunosuppressive therapy
  • antiviral therapy
  • chemotherapeutic agent
34
Q

phenytoin correction for

A

albumin < 40g/L

35
Q

carbamazepine pk

A

􀂃 Undergoes autoinduction (induces its
own metabolism)
􀂃 Clearance increase and half-life
shorten 􀃆 carbamazepine
concentration decline and stabilize in
accord with the new clearance and
half-life
􀂃 Maximal autoinduction usually occurs
2-3 weeks after dose initiation
􀂃 Implication:
􀂃 Do not start with desired maintenance
dose at the first dose, but gradually
increase over the initial few weeks

36
Q

absence of myoclonic seizures, do not use:

A

cbz, gbt, oxcarbazepine, phenytoin, pregabalin

37
Q

AED that may cause behavioural disturbances

A

levetiracetam

38
Q

AED that can cause n/v

A

carbamazepine, valproate

39
Q

rare but serious idosyncratic reactions of AED

A

􀂃 Blood dyscrasia (Aplastic anaemia, agranulocytosis
􀂃 Hepatotoxicity (1st-generation ASMs 􀂲 phenytoin, valproate, carbamazepine)
􀂃 Pancreatitis (e.g., sodium valproate)
􀂃 Lupus-like reaction
􀂃 Exfoliative dermatitis
􀂃 Toxic epidermal necrolysis/Stevens-Johnson syndrome

40
Q

AED that has been a/w pancreatitis

A

sodium valproate

41
Q

chronic SE of phenytoin

A

gingival hyperplasia (gum enlargement): may be observed in almost half of all patients receiving chronic phenytoin therapy

hirsutism: commonly observed in children and young adults on chronic phenytoin therapy

encephalopathy: most commonly a/w prolonged phenytoin treatment at high doses
^ may also occur w phenobarbitone

peripheral neuropathy: patients on LT phenytoin treatment at high doses experience sensory loss - may or may not improve w decr in AED dose, may respond with folate supplementation
^ may also occur w phenobarbitone and cbz

osteomalacia: incr clearance of vit D, leading to secondary hyperPTH, incr bone turnover, and reducing bone density
^ often a/w phenytoin, phenobarbitone and cbz (hepatic enzyme inducers)

42
Q

chronic SE of valproate

A

alopecia

increased weight gain, gradually reverses spontaneously with discontinuation of treatment

43
Q

chronic SE of topiramate

A

anorexia and weight loss, reversible w discontinuation of drug
- actl indicated as a possible weight loss agent

44
Q

other isolated adr a/w nearly all AED

A

blood dyscrasias, megaloblastic anemia (altho predominantly in pt receiving phenytoin, but also a/w cbz and phenobarbitone)

45
Q

AEDs causing neonatal congenital defects

A

malformation risk: topiramate, phenytoin, phenobarbitone

cognition: valproate

46
Q

AED that requires pharmacogenetic testing

A

carbamazepine: HLA-B*1502 testing
- prior to starting
- strong assoc btw carriage and risk of cbz-induced sjs/ten

47
Q

lamotrigine initial dosing

A

risk of severe cutaneous reaction higher with high starting dose, rapid dose escalation, concomittant valproate
- in pt taking valproate: 25mg EOD to maintenance dose of 100-200mg/d
- in pt not taking anyth else: 25mg OD, maintenance of 225-375mg/d in 2 divided doses
- in pt taking smth else but not valproate: 50mg/d to maintenance of 300-500mg/d in 2 divided doses

48
Q

aromatic AED

A

cbz, ltg, oxcarbazepine, phenytoin, phenobarbital

49
Q

non-aromatic AED

A

val, levetiracetam, gabapentin, topiramate

50
Q

ref range of phenytoin

A

10-20mg/L

51
Q

ref range of valproate

A

50-100mg/L

52
Q

ref range of cbz

A

4-12mg/L

53
Q

ref range of phenobarbitone

A

15-40mg/L

54
Q

when can we consider discontinuing AEDs?

A

after a person has been seizure free for 2yrs

55
Q

epilepsy is considered to be resolved for indiv who had

A

an age-dependent epilepsy syndrome but are not past the applicable age

or remained seizure-free for last 10 yrs, w no seizure meds for last 5 yrs

competency 10/11 (31 decks)

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