NS: Epilepsy

Question 1

Most antiepileptics, when used in the usual dosage, can be given twice daily.

Which AEDs, when given in usual doses, can be given once daily at night time? (4)

Answer 1

Lamotrigine, perampanel, phenobarbital, and phenytoin, which have long half-lives, can be given once daily at bedtime.

However, with large doses, some antiepileptics may need to be given more frequently to avoid adverse effects associated with high peak plasma-drug concentration.

Question 2

A single AED should be prescribed wherever possible.

When monotherapy with a first-line AED has failed, what should be tried next?

Answer 2

When monotherapy with a first-line antiepileptic drug has failed, monotherapy with a second drug should be tried; the diagnosis should be checked before starting an alternative drug if the first drug showed lack of efficacy. The change from one antiepileptic drug to another should be cautious, slowly withdrawing the first drug only when the new regimen has been established.

Question 3

Antiepileptic drugs have been divided into ____ risk-based categories to help healthcare professionals decide whether it is necessary to maintain continuity of supply of a specific manufacturer’s product.

Answer 3

Antiepileptic drugs have been divided into three risk-based categories to help healthcare professionals decide whether it is necessary to maintain continuity of supply of a specific manufacturer’s product.

Question 4

Category 1 AEDs are those which

Answer 4

Must be prescribed by brand:
Phenytoin
Carbamazepine
Phenobarbital 
Primidone

Question 5

What are the category 1 AEDs that must be prescribed by brand?

Answer 5

Must be prescribed by brand:
Phenytoin
Carbamazepine
Phenobarbital 
Primidone

Question 6

Category 2 AEDs are those which

Answer 6

Category 2 AEDs are those which the need for continued supply of a particular manufacturers product should be based on clinical judgement and consultation with the patient and/or carer taking into account factors such as seizure frequency and treatment history.

Sodium Valproate, lamotrigine, perampanel, rufinamide, clobazam, clonazepam, oxcarbazepine, eslicarbazepine, zonisamide, topiramate.

Question 7

Category 2 AEDs include rufinamide, lamotrigine, oxcarbazepine and what else? (5)

Answer 7

1. Perampanel
2. Clobazam
3. Clonazepa
4. Zonisamide
5. Topiramate

Question 8

Category 3 AEDs are those that

Answer 8

It is usually unnecessary to ensure that patients are maintained on a specific manufacturer’s product unless there is specific concerns such as patient anxiety, and risk of confusion or dosing errors.

Question 9

Category 3 AEDs include:

Answer 9

Levetiracetam, lacosamide, tiagabine, gabapentin,pregabalin, ethosuximide, vigabatrin.

Question 10

What is antiepileptic hypersensitivity syndrome?

Answer 10

Antiepileptic hypersensitivity syndrome is a rare but potentially fatal syndrome associated with some antiepileptic drugs (carbamazepine, lacosamide, lamotrigine, oxcarbazepine, phenobarbital, phenytoin, primidone, and rufinamide);

Question 11

Antiepileptic hypersensitivity syndrome is associated with what AEDs? (8)

Answer 11

1. Carbamazepine
2. Lacosamide
3. Lamotrigine
4. Oxcarbazepine
5. Phenobarbital
6. Phenytoin
7. Primidone
8. Rufinamide

Question 12

There is a theoretical risk of antiepileptic hypersensitivity syndrome with what AEDs?

Answer 12

Some other antiepileptics (eslicarbazepine, stiripentol, and zonisamide) have a theoretical risk.

Question 13

The symptoms of AED hypersensitivity syndrome usually start when?

What are they?

Answer 13

The symptoms usually start between 1 and 8 weeks of exposure; fever, rash, and lymphadenopathy are most commonly seen. Other systemic signs include liver dysfunction, haematological, renal, and pulmonary abnormalities, vasculitis, and multi-organ failure.

Question 14

Patients who have had a first unprovoked epileptic seizure or a single isolated seizure must not drive for __ months; driving may then be resumed, provided the patient has been assessed by a specialist as fit to drive and investigations do not suggest a risk of further seizures.

Answer 14

Patients who have had a first unprovoked epileptic seizure or a single isolated seizure must not drive for 6 months; driving may then be resumed, provided the patient has been assessed by a specialist as fit to drive and investigations do not suggest a risk of further seizures.

Question 15

Patients with established epilepsy may drive a motor vehicle provided they are not a danger to the public and are compliant with treatment and follow up. To continue driving, these patients must be seizure-free for at how long?

Answer 15

Patients with established epilepsy may drive a motor vehicle provided they are not a danger to the public and are compliant with treatment and follow up. To continue driving, these patients must be seizure-free for at least one year (or have a pattern of seizures established for one year where there is no influence on their level of consciousness or the ability to act); also, they must not have a history of unprovoked seizures.

Question 16

Patients who have had a seizure while asleep are not permitted to drive for _____ from the date of each seizure, unless certain stipulations are met.

Answer 16

Patients who have had a seizure while asleep are not permitted to drive for one year from the date of each seizure, unless:

a history or pattern of sleep seizures occurring only ever while asleep has been established over the course of at least one year from the date of the first sleep seizure; or
an established pattern of purely asleep seizures can be demonstrated over the course of three years if the patient has previously had seizures whilst awake (or awake and asleep).

Question 17

Patients who have had a seizure while asleep are not permitted to drive for one year from the date of each seizure, unless what? (2)

Answer 17

Patients who have had a seizure while asleep are not permitted to drive for one year from the date of each seizure, unless:

a history or pattern of sleep seizures occurring only ever while asleep has been established over the course of at least one year from the date of the first sleep seizure; or
an established pattern of purely asleep seizures can be demonstrated over the course of three years if the patient has previously had seizures whilst awake (or awake and asleep).

Question 18

The DVLA recommends that patients should not drive during medication changes or withdrawal of antiepileptic drugs, and for __ months after their last dose.

Answer 18

The DVLA recommends that patients should not drive during medication changes or withdrawal of antiepileptic drugs, and for 6 months after their last dose.

Question 19

f a seizure occurs due to a prescribed change or withdrawal of epilepsy treatment, the patient will have their driving license revoked for ____; relicensing may be considered earlier if treatment has been reinstated for 6 months and no further seizures have occurred.

Answer 19

f a seizure occurs due to a prescribed change or withdrawal of epilepsy treatment, the patient will have their driving license revoked for 1 year; relicensing may be considered earlier if treatment has been reinstated for 6 months and no further seizures have occurred.

Question 20

Valproate is associated with the highest risk of serious developmental disorders (up to 30–40% risk) and congenital malformations (approx. __% risk).

Answer 20

Valproate is associated with the highest risk of serious developmental disorders (up to 30–40% risk) and congenital malformations (approx. 10% risk).

Question 21

There is also an increased risk of teratogenicity with phenytoin, primidone, phenobarbital, lamotrigine, and carbamazepine. Topiramate carries an increased risk of congenital malformations (including cleft palate, hypospadias, and anomalies involving various body systems) if taken when?

Answer 21

here is also an increased risk of teratogenicity with phenytoin, primidone, phenobarbital, lamotrigine, and carbamazepine. Topiramate carries an increased risk of congenital malformations (including cleft palate, hypospadias, and anomalies involving various body systems) if taken in the first trimester of pregnancy.

Question 22

The likelihood of a woman who is taking antiepileptic drugs having a baby with no malformations is at least __%, and it is important that women do not stop taking essential treatment because of concern over harm to the fetus.

Answer 22

The likelihood of a woman who is taking antiepileptic drugs having a baby with no malformations is at least 90%, and it is important that women do not stop taking essential treatment because of concern over harm to the fetus.

Question 23

o reduce the risk of neural tube defects, folate supplementation is advised before conception and throughout the first trimester. In the case of sodium valproate and valproic acid an urgent consultation is required to reconsider the benefits and risks of valproate therapy.

What dose folic acid?

Answer 23

5mg daily

Question 24

The concentration of antiepileptic drugs in the plasma can change during pregnancy. Doses of which AEDs should be adjusted on the basis of plasma-drug concentration monitoring? (3)

Answer 24

The concentration of antiepileptic drugs in the plasma can change during pregnancy. Doses of phenytoin, carbamazepine, and lamotrigine should be adjusted on the basis of plasma-drug concentration monitoring; the dose of other antiepileptic drugs should be monitored carefully during pregnancy and after birth, and adjustments made on a clinical basis.

Question 25

Routine administration of ______ at birth minimises the risk of neonatal haemorrhage associated with antiepileptics. Withdrawal effects in the newborn may occur with some antiepileptic drugs, in particular benzodiazepines and phenobarbital.

Answer 25

Routine injection of vitamin K at birth minimises the risk of neonatal haemorrhage associated with antiepileptics. Withdrawal effects in the newborn may occur with some antiepileptic drugs, in particular benzodiazepines and phenobarbital.

Question 26

Can women taking antiepileptic monotherapy breastfeed?

Answer 26

Women taking antiepileptic monotherapy should generally be encouraged to breast-feed; if a woman is on combination therapy or if there are other risk factors, such as premature birth, specialist advice should be sought.

Question 27

What AEDs are readily transferred into breast milk?

Answer 27

Infants should also be monitored for adverse effects associated with the antiepileptic drug particularly with newer antiepileptics, if the antiepileptic is readily transferred into breast-milk causing high infant serum-drug concentrations (e.g. ethosuximide, lamotrigine, primidone, and zonisamide), or if slower metabolism in the infant causes drugs to accumulate (e.g. phenobarbital and lamotrigine).

Question 28

What three AEDs are associated with an established risk of drowsiness in breast-fed babies?

Answer 28

Primidone, phenobarbital, and the benzodiazepines are associated with an established risk of drowsiness in breast-fed babies and caution is required.

Question 29

What are the first-line options for treating newly diagnosed focal seizures with or without secondary generalisation? (2)

Answer 29

Carbamazepine and lamotrigine are first-line options for treating newly diagnosed focal seizures; oxcarbazepine, sodium valproate and levetiracetam may be used if carbamazepine or lamotrigine are unsuitable or not tolerated.

Question 30

In the treatment of focal seizures with or without secondary generalisation, if carbamazepine or lamotrigine are unsuitable or not tolerated, what other monotherapy options are there?

Answer 30

Carbamazepine and lamotrigine are first-line options for treating newly diagnosed focal seizures; oxcarbazepine, sodium valproate and levetiracetam may be used if carbamazepine or lamotrigine are unsuitable or not tolerated.

Question 31

In focal seizures with or without secondary generalisation, if monotherapy is unsuccessful with tow of the first-line antiepileptic drugs (which are?), what are the options for adjunctive treatment?

Answer 31

If monotherapy is unsuccessful with two of these first-line antiepileptic drugs, adjunctive treatment may be considered. Options for adjunctive treatment include carbamazepine, clobazam, gabapentin, lamotrigine, levetiracetam, oxcarbazepine, sodium valproate, or topiramate.

Question 32

What is the first-line treatment for newly diagnosed generalised tonic-clonic seizures? (what exceptions?)

Answer 32

Sodium valproate is the first-line treatment for newly diagnosed generalised tonic-clonic seizures (except in female patients who are premenopausal)

Question 33

What is an alternative first-line choice for newly diagnosed generalised tonic-clonic seizures if sodium valproate is not suitable? What may this alternative drug cause?

Answer 33

Lamotrigine is the alternative choice if sodium valproate is not suitable, but may exacerbate myoclonic seizures. `

Question 34

Carbamazepine and oxcarbazepine may also be considered in newly diagnosed and established tonic-clonic seizures but they may exacerbate what?

Answer 34

Carbamazepine and oxcarbazepine may also be considered in newly diagnosed and established tonic-clonic seizures, but may exacerbate myoclonic and absence seizures.

Question 35

In tonic-clonic seizures, what drugs can be used as adjunctive treatment if monotherapy is ineffective or not tolerated?

Answer 35

Clobazam, lamotrigine, levetiracetam, sodium valproate or topiramate may be used as adjunctive treatment if monotherapy is ineffective or not tolerated.

Question 36

What is/are the drugs of choice in treating absence seizures?

Answer 36

Ethosuximide, or sodium valproate (except in female patients who are premenopausal, see Valproate below), are the drugs of choice in absence seizures and syndromes;

Question 37

Which AEDs are NOT recommended for use in epilepsy? (7)

Answer 37

Carbamazepine, gabapentin, oxcarbazepine, phenytoin, pregabalin, tiagabine and vigabatrin are not recommended in absence seizures or syndromes.

Question 38

Sodium valproate should be used as the first-line drug in absence seizures if what criteria are met?

Answer 38

Sodium valproate should be used as the first choice if there is a high risk of generalised tonic-clonic seizures.

and not female pre-menopausal etc.

Question 39

What is the drug of choice in newly diagnosed myoclonic seizures? (except in female patients who are premenopausal)

Answer 39

Sodium valproate is the drug of choice in newly diagnosed myoclonic seizures (except in female patients who are premenopausal)

Question 40

Topiramate and levetiracetam are both alternate options to treat myoclonic seizures if valproate is unsuitable, which may be the better choice?

Answer 40

topiramate and levetiracetam are alternative options if sodium valproate is unsuitable but consideration should be given to the less favourable side-effect profile of topiramate

Question 41

Atonic and tonic seizures are usually seen in childhood, in specific epilepsy syndromes, or associated with cerebral damage or mental retardation. They may respond poorly to the traditional drugs. What is the drug of choice?

Answer 41

Sodium valproate is the drug of choice (except in female patients who are premenopausal, see Valproate below); lamotrigine can be added as adjunctive treatment.

Question 42

What two epileptic drugs are licensed for use in Lennox-Gastaut syndrome?

Answer 42

Lamotrigine and rufinamide

Question 43

Carbamazepine is a drug of choice in __________________ and also a first-line treatment option for what?

Answer 43

Carbamazepine is a drug of choice for simple and complex focal seizures and is a first-line treatment option for generalised tonic-clonic seizures.

Question 44

Carbamazepine can be used as an adjunctive treatment for what when monotherapy has been ineffective?

Answer 44

Carbamazepine is a drug of choice for simple and complex focal seizures and is a first-line treatment option for generalised tonic-clonic seizures. It can be used as adjunctive treatment for focal seizures when monotherapy has been ineffective.

Question 45

It is essential to initiate carbamazepine therapy at a low dose and build this up slowly.

Carbamazepine may exacerbate what four types of seizures?

Answer 45

It is essential to initiate carbamazepine therapy at a low dose and build this up slowly. Carbamazepine may exacerbate tonic, atonic, myoclonic and absence seizures and is therefore not recommended if these seizures are present.

Question 46

Ethosuximide is a first-line treatment option for absence seizures. It may also be prescribed as adjunctive treatment for absence seizures when monotherapy is ineffective.

What other form of epilepsy is ethosuximde used for

Answer 46

Ethosuximide is a first-line treatment option for absence seizures. It may also be prescribed as adjunctive treatment for absence seizures when monotherapy is ineffective. Ethosuximide is also licensed for myoclonic seizures.

Question 47

Gabapentin and pregabalin are used for the treatment of what epilepsy?

Answer 47

Gabapentin and pregabalin are used for the treatment of focal seizures with or without secondary generalisation. They are not recommended if tonic, atonic, absence or myoclonic seizures are present.

Question 48

Pregabalin is licensed for what type of anxiety disorder?

Answer 48

Gabapentin and pregabalin are used for the treatment of focal seizures with or without secondary generalisation. They are not recommended if tonic, atonic, absence or myoclonic seizures are present. Both are also licensed for the treatment of neuropathic pain. Pregabalin is licensed for the treatment of generalised anxiety disorder. Gabapentin is an effective treatment for migraine prophylaxis [unlicensed].

Question 49

Gabapentin can be used in the prophylaxis of what?

Answer 49

Gabapentin and pregabalin are used for the treatment of focal seizures with or without secondary generalisation. They are not recommended if tonic, atonic, absence or myoclonic seizures are present. Both are also licensed for the treatment of neuropathic pain. Pregabalin is licensed for the treatment of generalised anxiety disorder. Gabapentin is an effective treatment for migraine prophylaxis [unlicensed].

Question 50

Myoclonic seizures may be exacerbated by lamotrigine and it can cause serious rashes in what patient group?

Answer 50

Myoclonic seizures may be exacerbated by lamotrigine and it can cause serious rashes especially in children; dose recommendations should be adhered to closely.

Question 51

Valproate has what impact on plasma-lamotrigine concentration?

Answer 51

Valproate increases plasma-lamotrigine concentration, whereas the enzyme-inducing antiepileptics reduce it; care is therefore required in choosing the appropriate initial dose and subsequent titration.

Question 52

Phenobarbital is effective for what seizures?

Answer 52

Phenobarbital is effective for tonic-clonic and focal seizures but may be sedative in adults. It may be tried for atypical absence, atonic, and tonic seizures. Rebound seizures may be a problem on withdrawal.

Question 53

How is primidone related to phenobarbital?

Answer 53

Primidone is largely converted to phenobarbital and this is probably responsible for its antiepileptic action. A low initial dose of primidone is essential.

Question 54

Phenytoin is licensed for ____-___ and _____ seizures but may exacerbate absence of myoclonic seizures and should be avoided if these seizures are present.

Answer 54

Phenytoin is licensed for tonic-clonic and focal seizures but may exacerbate absence or myoclonic seizures and should be avoided if these seizures are present.

Question 55

Rufinamide is licensed for what?

Answer 55

Rufinamide is licensed for the adjunctive treatment of seizures in Lennox-Gastaut syndrome. It may be considered by a tertiary specialist for the treatment of refractory tonic or atonic seizures [unlicensed].

Question 56

What monitoring accompanies the use of sodium valproate?

Answer 56

Sodium valproate has widespread metabolic effects and monitoring of liver function tests and full blood count is essential.

Question 57

Valproic acid is licensed for what?

Answer 57

Valproic acid (as semisodium valproate) is licensed for acute mania associated with bipolar disorder.

Question 58

What role does Acetazolamide play in epilepsy?

Answer 58

Specific role in treating epilepsy associated with menstruation.

Question 59

Immediate measures to manage status epilepticus include positioning the patient to avoid injury, supporting respiration including the provision of oxygen, maintaining blood pressure, and the correction of any hypoglycaemia.

What should be considered if alcohol abuse is suspected?

Answer 59

Parenteral thiamine.

Question 60

Seizures lasting longer than 5 minutes should be treated urgently with IV what?

Answer 60

Seizures lasting longer than 5 minutes should be treated urgently with intravenous lorazepam (repeated once after 10 minutes if seizures recur or fail to respond).

Question 61

Seizures lasting longer than 5 minutes should be treated urgently with intravenous lorazepam, repeated once after what time period if seizures recur or fail to respond?

Answer 61

Seizures lasting longer than 5 minutes should be treated urgently with intravenous lorazepam (repeated once after 10 minutes if seizures recur or fail to respond).

Question 62

Where facilities for resuscitation are not immediately available, what benzo can be administerd as a rectal solution?

Answer 62

Diazepam or midazolam oromucosal solution can be given into the buccal cavity.

Question 63

If after initial treatment with benzodiazepines, seizures recur or fail to respond 25 minutes after onset, what drugs should be used? (3)

Answer 63

1. phenytoin sodium 
OR
2. Fosphenytoin sodium 
OR
3. Phenobarbital sodium

Question 64

If, after initial treatment with benzodiazepines, seizures recur or fail to respond 25 minutes after onset, phenytoin sodium, fosphenytoin sodium, or phenobarbital sodium should be used; contact intensive care unit if seizures continue.

If these measures fail to control seizures 45 minutes after onset, anaesthesia with what should be used?

Answer 64

If, after initial treatment with benzodiazepines, seizures recur or fail to respond 25 minutes after onset, phenytoin sodium, fosphenytoin sodium, or phenobarbital sodium should be used; contact intensive care unit if seizures continue. If these measures fail to control seizures 45 minutes after onset, anaesthesia with thiopental, midazolam, or a non-barbiturate anaestheric such as propofol [unlicensed indicaton].

Question 65

Which anticonvulsants can cause gingival enlargement?

Answer 65

Phenytoin*
Lamotrigine
Ethosuximide
Topiramate

*alongside ciclosporin accounts for 80% of cases.

(also the CCBs: nifedipine, verapamil and amlodipine)

Question 66

Which of the following is the treatment of choice in a newly diagnosed 24 year old pregnant female with generalised tonic-clonic seziures?

Sodium valproate
Carbamazepine 
Lamotrigine
Topiramate
Ethosuximide

Answer 66

Sodium valproate is the treatment of choice in newly diagnosed generalised tonic-clonic seizures: apart from women who are premenopausal or pregnant.

Lamotrigine is an alternative in those who canot take valproate but doses may need adjustment if patient becomes pregnant when already on lamotrigine.

Question 67

`Which of the following is the treatment of choice in a 17 year old male with newly diagnosed focal seizures?

Sodium valproate
Carbamazepine 
Lamotrigine
Topiramate
Ethosuximide

Answer 67

Carbamazepine is first-line treatment for newly diagnosed focal seizures with or without secondary generalisation.

Lamotrigine is also an option.

oxcarbazepine, valproate or levetiracetame may be used if carbamazepine or lamotrigine are not tolerated.

Question 68

Which of the following is the treatment of choice in a 30 year old male with absence seizures with a high risk of general tonic clonic seziures?

Sodium valproate
Carbamazepine 
Lamotrigine
Topiramate
Ethosuximide

Answer 68

Ethosuximide or sodium valproate (except female) are the drugs of choice in absence seizures and syndromes; lamotrigine is a suitable alternative if those two are ineffective.

> > Valproate should be used as the first choice if there is a high-risk of GTC<

Question 69

Which of the following would be the treatment of choice in a 40 year old pre-menopausal women with Lennox-Gastuat syndrome?

Sodium valproate
Carbamazepine 
Rufinamide
Lamotrigine
Topiramate
Ethosuximide

Answer 69

Lamotrigine and rufinamide are licensed for the use in Lennox-Gastaut syndrome.

Question 70

Which of the following would NOT be an appropriate treatment for atonic and tonic seizures in a 14 year old girl?
[ignore any age licensing issues]

Carbamazepine 
Gabapentin
Valproate
Pregabalin
Vigabatrin

Answer 70

Zero of the options are appropriate.

Valproate is first line in post-menopausal women, not a 14 year old.

Carbamazepine, gabapentin, pregabalin and vigabatin are not recommended for the treatment of atonic and tonic seizures.

The best choice AED would be lamotrigine but this was not listed.

Question 71

Which of the following is NOT appropriate for the treatment of myoclonic or absence seizures? (2)

Valproate
Lamotrigine
Carbamazepine
Oxcarbazepine

Answer 71

Carbamazepine and oxcarbazepine can be considered in newly diagnosed tonic-clonic seizures but SHOULD NOT be used in myoclonic and absence seizures as they can cause exacerbation.

Ethosuximide is first line for absence but valproate is better if there is a high risk of GTC seizures with absence.

Lamotrigine is a suitable alternative to Ethosuximide/valproate