Neurologic Conditions: Seizures/Epilepsy Flashcards
Focal seizures
start on one side of brain and can spread to the other
Generalized seizures
start on both sides of the brain
Unknown seizures
beginning is unknown, occur at night or unwitnessed
Focal aware seizure
no loss of consciousness
Focal seizure with impaired awareness
pt experiences loss of consciousness
Status epilepticus
seizure that lasts more than 5 minutes
if lasts 30min, long term damage can occur and is medical emergency
Status epilepticus txm
0-5min = stabilization phase = time seizure, start ECG, check AED lvls/electrolytes
5-20 min = initial txm phase = IV loraz or IM midaz, rectal Diastat or nasal/buccal midday if cant do IV
20-40 min = 2nd txm phase = give regular AED, IV fosphenytoin, valproic acid, keppra, if lasts longer than no clear txm
Dispensing Diastat
pharmacist has to lock syringes into appropriate dose prior to dispensing
should double check when counseling patient before med leaves pharmacy
Ketogenic for refractory seizures
high fats
normal protein
low carbs
4:1 ratio of fats to combined protein/carbs
Seizures can occur due to….
deficiency of inhibitory NT (GABA)
too much excitatory NT (Glutamate)
Which AEDs inc GABA
Benzo
Valproic Acid
Which AED enhance/potentiate GABA effect
Phenobarbital
Which AED inc GABA and CA channel blocker
Levetiracetam
Which AED is type T Ca channel blocker
Ethosuximide
Which AED are Ca channel blockers
Pregabalin
Gabapentin
Which AED block Na and Ca channels
Oxcarbazepine
Which AED block Na channels
Carbamazepine
Lamotrigine
Phenytoin/Fosphenytoin
Topiramate
Broad spectrum AED
Lamotrigine = Lamictal
Levetiracetam = Keppra
Topiramate = Topamax
Valproic acid
Divalproex = Depakote
Lamotrigine (Lamictal) boxed warnings
serious skin reactions, including SJS/TEN, risk inc if using high starting dose
Lamotrigine (Lamictal) side effects
Alopecia (supplement w/ selenium/zinc)
N/V
Somnolence
rash
tremor
How long after stopping do you have to restart dose titration for Lamotrigine
If stop for > 6 days, have to do initial dose titration
Lamictal starter kits
Orange = standard
Blue = lower dose
Green = higher dose
When to sue which Lamictal start kits
Orange = no interacting meds
Blue = if taking valproic acid, enzyme inhibitor
Green = taking enzyme inducer (carbamazepine, phenytoin, phenobarbital, primidone, ritonavir, rifampin)
Levetiracetam (Keppra) IV:PO ration
1:1
Levetiracetam (Keppra) warnings
psychiatric reactions
somnolence
fatigue
suicidal behavior
anaphylaxis
inc BP
severe skin reactions
Significant drug interactions for Keppra
No significant interactions
Topiramate (Topamax) Contraindications
Trokendi XR only = using alc 6hr before/after dose
Topiramate (Topamax) warnings
metabolic acidosis
reduced perspiration (Oligohidrosis)
kidney stones
angle-closure glaucoma
hyperammonemia
visual problems = reversible
fetal harm
Topiramate (Topamax) side effects
somnolence
memory/concentration/attention difficulty
weight loss
anorexia
Topiramate (Topamax) monitoring
Electrolytes = sodium bicarb
eye exam = intraocular pressure
Which contraception should be used with Topiramate (Topamax)
non-hormonal contraception
Valproic Acid Boxed warnings
Hepatic failure, usually during first 6 months of txm
fetal harm and dec IQ in pregnancy
Valproic Acid Contraindications
hepatic disease
urea cycle
ppx migraine pregnancy
known POLG disorder or suspected
Valproic Acid warnings
Hyperammonemia = tx w/ carnitine in symptomatic adults
dose related thrombocytopenia
DRESS reactions
Valproic Acid side effects
Alopecia = supplement selenium/zing
weight gain
N/V
HA
Valproic Acid monitoring
LFTS at BL and freq in 1st 6 months
CBC
platelets
Common narrow spectrum AED
Lacosamide = Vimpat
Carbamazepine = Tegretol
Oxcarbazepine = Trileptal
Phenytoin = Dilantin
Fosphenytoin = Cerebyx
Phenobarbital = Sezaby
Lacosamide (Vimpat) max daily dose CrCl < 30
300mg/day
Lacosamide (Vimpat) warnings
prolong PR interval and inc risk of arrhythmias
Lacosamide (Vimpat) side effects
dizziness
HA
blurred vision
ataxia
tremor
euphoria
Carbamazepine (Tegretol) boxed warnings
Serious skin reactions = test for HLAB*1502 allele in asians
aplastic anemia
agranulocytosis
Carbamazepine (Tegretol) contraindications
Myelosuppression
using MAOi within last 14 days
Carbamazepine (Tegretol) warnings
hyponatremia (SIADH)
fetal harm
hypothyroidism
Carbamazepine (Tegretol) side effects
Dizziness
drowsiness
ataxia
N/V
pruritus
photosensitivity
blurred vision
rash
inc LFTS
alopecia
Carbamazepine (Tegretol) monitoring
CBC w/ differential and platelets
LFTs
eye exam
thyroid function test
Electrolytes = Na
Oxcarbazepine (Trileptal) warnings
inc risk for serious skin reaction if HLA-B*1502 gene = test asians
Hyponatremia
Oxcarbazepine (Trileptal) side effects
Somnolence
dizziness
N/V
abdominal pain
diplopia
visual disturbances
ataxia
tremor
Oxcarbazepine (Trileptal) monitoring
serum Na lvls
thyroid functon
CBC
Oxcarbazepine (Trileptal) notes
for oral suspension, use within 7 wks of opening original container
Phenytoin (Dilantin) & Fospehnytoin (Cerebyx) boxed warnings
Phenytoin IV = no more than 50mg/min
Fosphenytoin = no more than 150 mg/min
if faster can get hypotension and cardiac arrhythmias
Phenytoin (Dilantin) & Fospehnytoin (Cerebyx) contraindications
Previous hepatotoxicity due to phenytoin
Phenytoin (Dilantin) & Fospehnytoin (Cerebyx) warnings
extravasation = lead to purple glove syndrome
avoid in HLA-B*1502 positive patients
DRESS rxn, fetal harm, bradycardia, SJS/TEN
Phenytoin (Dilantin) & Fospehnytoin (Cerebyx) side effects
dose related toxicity = nystagmus, ataxia, diplopia/blurred vision, slurred speech
chronic = gingival hyperplasia, hair growth, hepatotoxicity, skin thickening
Phenytoin (Dilantin) & Fospehnytoin (Cerebyx) monitoring
serum phenytoin concentrations, LFTs, CBC w/ differential
IV: continuous cardiac and respiratory monitoring
Phenobarbital (Sezaby) therapeutic range
20-40 mcg/mL in adults
15-40 mcg/mL in children
Phenobarbital warnings
caution in SUD = potential drug dependence, respiratory depression, fetal harm
Phenobarbital side effects
physiological dependence
tolerance
hangover effect
somnolence
cognitive impairment
dizziness
ataxia
depression
folate deficiency
Which AED is used for absence seizures
Ethosuximide (Zarontin)
Ethosuximide (Zarontin) warnings
serious skin rash (SJS/TEN)
blood dyscrasias
DRESS rxns
Felbamate (Felbatol) boxed warnings
aplastic anemia
hepatic failure
Felbamate (Felbatol) monitoring
LFTs
CBCs
serum lvls of other AEDs
Fenfluramine (Fintepla) boxed warnings
valvular heart disease
pulmonary htn = given through REMS
Fenfluramine (Fintepla) warnings
dec appetite & weight loss
serotonin syndrome
inc BP
angle closure glaucoma
Gabapentin (Neurontin) side effects
somnolence
peripheral edma
weight gain
ataxia
blurred vision
mild euphoria
Perampanel (Fycompa) boxed warning
neuropsychiatric events (dose related), including irritability, aggression, anger an paranoia, mostly in first 6 weeks
Prodrug of phenobarbital
Primidone (Mysoline)
Rufinamide (Banzel) contraindications
pts with familial short QT syndrome due to QT shortening = dose related
Stiripentol (Diacomit) warnings
loss of appetite/weight loss
delirium/hallucinations = rare
Tiagabine (Gabitril) warnings
worsening of seizures/new-onset seizures when used off-label for other indicators, serious skin reactions SJS/TEN
Vigabatrin (Sabril, Vigadrone) boxed warnings
causes permanent vision loss > 30% of patients
Vigabatrin (Sabril, Vigadrone) monitoring
eye exam at baseline, every 3 months during therapy and 3-6 months after d/c
can only get through REMS
Zonisamide (Zonegran, Zonisade) contraindications
hypersensitivity to sulfonamides
Zonisamide (Zonegran, Zonisade) side effects
similar to topiramate
including oligohidrosis/hyperthermia and risk of nephrolithiasis
Adjusting Phenytoin doses
Has Michaelis-Menten kinetics, aka saturable kinetics
if enzymes saturated, small inc in dose can cause large inc in drug lvl
Higher lvls of lamotrigine will inc the risk of….
severe rash
Concerns with AEDs
seizure frequency monitoring
many drug interactions
CNS depression
Bone loss
Suicide Risk and Rash
risks in pregnancy
