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PHRM 845: Therapeutics III > Seizure Disorders > Flashcards

Seizure Disorders Flashcards

1
Q

What is a seizure?

A
  • Paroxysmal disorder of the CNS that is characterized by abnormal cerebral neuronal discharges with or without loss of consiousness
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2
Q

What are convulsions?

A
  • Specifc seizure type where the attack is manifested by involuntary muscle contractions
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3
Q

What is Epilepsy?

A
  • Repeated seizures doe to damage, irritation, and/or chemical imbalance in the brain which leads to a sudden, excessive, synchronous electrical discharge
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4
Q

What are the type of Generalized seizures?

A
  • Myoclonic
  • Tonic
  • Clonic
  • Atonic
  • Tonic Clonic
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5
Q

What is the one thing that really classifies a seizure?

A
  • It has to be DISORDERED, SYNCHRONOUS, RHYTHMIC firing of the brain
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6
Q

What are the different types of seizures?

A
  • Focal [Simple and complex] and Generalized
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7
Q

What is a focal seizure?

A
  • Focal: Originates in one part of the brain [temporal lobe] then eventually moves to the other parts [Focal to Generalized]
  • Due to lesion
  • Either have awareness [simple] or not [complex]
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8
Q

What is a generalized seizure?

A
  • Generalized: Occurs in both sides of the brain
  • “Primary”
  • Genetic?
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9
Q

What are the genetic tests that are used for epilepsy?

A
  • GABRA1, GABRB2, GABRB3, GABRG2
  • SCN1A, SCN1B, SCN2A, SCN8A
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10
Q

What is the pathways for the propagation of focal and generalized seizures?

A
  • Focal: Starts at one spot then moves to others
  • Focal to Generalized
  • Primary Generalized Seizures: Connections between the thalamus and the cortex
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11
Q

What is the purpose for the EEG within seizures?

A
  • Electrodes are place on the top of the head being able to show the activity of the surface of the brain
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12
Q

What is a simple focal seizure?

A
  • An AWARE type [know they had one]
  • NO loss of consciousness
  • May experience aura
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13
Q

What is a complex focal seizure?

A
  • An IMPAIRED AWARENESS type
  • LOSS of consciousness
  • MOST common
  • Aura is COMMON
  • Postictal state due to impaired awareness
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14
Q

What is the Postictal State in seizures?

A
  • The patient wont be able to remember what happened to them after the seizure.
  • SE: Confusion, disorientation, anterograde amnesia
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15
Q

What is a Absence Generalized Seizure?

A
  • Basically “Blanking Out” and coming back immediately
  • NO convulsions, aura, or postictal period
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16
Q

What is a Generalized Tonic-Clonic

A
  • Grand Mal
  • Most dramatic of all seizures
  • First Phase: Tonic - begins suddenly with diaphragm contractions [No aura]; tremor that corresponds to relaxation
  • Second Phase: Clonic - Begins as relaxation becomes more prolonged; violent jerking
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17
Q

What is Status Epilepticus?

A
  • A repetitive seizure activity in which the patient does not regain consciousness or its a single seizure lasting >30 minutes
  • GOAL is the bring seizure under control within 60 minutes
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18
Q

What are a couple of important concepts to note about Epilepsies?

A
  • One seizure =/= Epilepsy [>3 seizures]
  • Drugs can be withdrawn when patient has been seizure free for 2-5 years [stopping suddenly will make the seizure worse]
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19
Q

What is a Paroxysmal Depolarizing Shift [PDS]?

A
  • Large Depolarizations that trigger a burst of action potentials
  • Depolarization: activation of AMPA and NMDA by glutamate and voltage gated ion Ca channels; increasing cations
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20
Q

What happens after the Depolarization within PDS?

A
  • Hyperpolarization: Activation of GABA receptors by the influx of Cl- ions along with voltage and calcium-dependent K channels; decreasing K+
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21
Q

What are somethings that can aggravate or increase the risk of seizures?

A
  • Alcohol, Theophylline, CNS stimulants, Bupropion, Oral Contraceptives, Withdrawl from depressants
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22
Q

What is the MOA for the anticonvulsant drugs?

A
  • To stabilize and reduce neuronal excitability; reduce the E/I imbalence
  • Decrease in Na Influx; Reduction in Ca influx; Enhance GABA inhibition; antagonism of excitatory transmitters
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23
Q

What are the targets that affect the excitatory [glutamatergic] synapse?

A
  • Presynaptic Targets: Na & Ca Channels
  • Postsynaptic Targets: NMDA & AMPA Receptors
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24
Q

What are the targets that affect the inhibitory [GABAergic] synapse?

A
  • Presynaptic Targets: GABA Transporter [GAT-1] & GABA Transaminase [GABA-T]
  • Postsynaptic Targets: GABAa & GABAb Receptors
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25
Q

What is the function of Phenytoin in seizures?

A
  • MOA: blocks the Na gated voltage, to stop the rapid influx of Na resulting in the depolarization [not isoform: blocks Na channels in other parts of the body]
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26
Q

What are the side effects and/or drug interactions of Phenytoin?

A
  • SE: Arrhythmia [not isoform], visual, ataxia, GI Symptoms, skin rash
  • DI: Displaced from plamsa proteins & induces CYP450
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27
Q

What is the function of Carbamazepine in seizures?

A
  • MOA: blocks the Na voltage gated channels; stopping the rapid influx of Na that resulting in the depolarization
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28
Q

What are some of the side effect and/or drug interactions for Cabamazepine?

A
  • SE: blurred vision, GI issues, SJS, DRESS
  • DI: Induces CYP450
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29
Q

What is the function of Lacosamide in seizures?

A
  • MOA: enhance the blockage of the Na voltage gated channels
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30
Q

What are some of the side effects of Lacosamide?

A
  • SE: Skin Rashes, PR interval prolongation, vision problems
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31
Q

What is the function of the Barbiturates [Phenobarbital and Primidone] in seizures?

A
  • MOA: will bind to the GABAa receptor, allowing more Cl- into he neuron causing hyper-polarization in decreased excitability of the neuron
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32
Q

What is important to note about Phenobarbital?

A
  • The drug of choice for infants that are up to 2 months
33
Q

What are some of the side effects and/or drug interactions for the Barbiturates in seizures?

A
  • SE: Sedation, abuse
  • DI: induces CYP450
34
Q

What is the function of the Benzodiazepines [Diazepiam & Clonazepam] in seizures?

A
  • MOA: will bind to the GABAa receptor allowing more Cl- into the neuron resulting in hyper-polarization and decreases excitability of the neuron
35
Q

What are some afor the side effects for the Benzodiazepines?

A
  • SE: Sedation, abuse [not for chronic treatment]
36
Q

What is important to note about Diazepam for seizures?

A
  • Very useful for the Tonic-Clonic status epilepticus; often use as rectal gel
37
Q

What is important to note about Clonazepam for seizures?

A
  • Very useful for acute treatment of epilepsy and ABSENCE seizures
38
Q

What is the function of Gabapentin and Pregabalin in seizures?

A
  • MOA: Increase the GABA release which will decrease the presynaptic Ca2+ influx = a reduction in gluatmate [decreasing the excitatory response]
39
Q

What is the side effects of Gabapentin and Pregabalin?

A
  • Sedation, ataxia, behavioral changes
40
Q

What is the function of Vigabatrin?

A
  • MOA: Irreversible inhibitor of GABA Transminase [GABA-T]; decreases the breakdown of GABA
41
Q

What are the side effects for Vigabatrin?

A
  • Sedation, Depression, Visual problems
42
Q

What is the function of Tigabine?

A
  • MOA: Inhibits the GABA transporter [GAT-1]; will block the movement of GABA and increase its reuptake
43
Q

What are the side effects of Tigabine?

A
  • Sedation, Ataxia, nervousness, depression
44
Q

What is the purpose of GABA within the brain?

A
  • It is an inhibitory neurotransmitter that prevents the neurons from firing to rapidly; so a decrease in GABA could result in the neurons firing rapidly = degradation
45
Q

What does the NMDA receptor do with in the brain?

A
  • It will bind Glutamate resulting in an influx of Na and Ca and a efflux of K
46
Q

What does the AMPA receptor do within the brain?

A
  • It will bind Glutamate resulting in a trigger of Na and an efflux of K [same for kainate receptors]
47
Q

What is the function of Felbamate in seizures?

A
  • It is a NMDA receptor antagonist; decreasing the excessive amount of Ca that resulting in the neuronal damage
  • 3rd line
48
Q

What are some of the side effects that are associated with Felbamate?

A
  • severe hepatits [why its 3rd line]
49
Q

What is the function of Topiramate in seizures?

A
  • AMPA and Kainate Receptor Antagonist; decreasing the glutamate and decreasing the neuronal damage
50
Q

What are some of the side effects of Topiramate?

A
  • Confusion, cognitive dysfunction, sedation, vision loss [patient feel worse than before]
51
Q

What is the function of Ethosuximide in seizures?

A
  • Used in ABSENCE seizure that block the T-Type Ca2+ channels in the thalamic neuron; reducing the excitability of the neuron
52
Q

What is the Thalamocortical signaling mostly associated with?

A
  • Generalized seizures
53
Q

What are the side effect for Ethosuximide?

A
  • GI issues, sedation
54
Q

What is the function of Lamotrigine in seizures?

A
  • It is used as a primary or add on therapy for focal or generalized seizures [even absence] which blocks the Na and Ca voltage gated channels
55
Q

What are some of the side effect for Lamotrigine?

A
  • Sedation, Ataxia, SJS or DRESS [because it blocks Ca channel in the skin?]
56
Q

What is the function of Valproate in seizures?

A
  • Used in focal and generalized seizures [even absence] by inhibiting Na and Ca channel and increasing GABA levels
57
Q

What are some fo the side effect and/or drug interactions with Valproate?

A
  • SE: GI issues, Hpyerammonemia, Hepatotoxicity [fatal?]
  • DI: displaces phenytoin from plasma, inhibits the metabolism of Phenytoin, Carbamazepine, Phenobarbital, lamotrigine
58
Q

What is the function of Levetiracetam in seizures?

A
  • used in focal and generalized seizures that binds to the synaotic vesicular protein [SV2A] and thus will interfere with the synaptic vesicle release and neurotransmission; may also interfere with Ca entry
59
Q

What drugs affect what targets within the EXCITATORY [glutamatergic] Synapse?

A

Presynaptic Targets:
- Na Channels: Phenytoin, Carbamazepine, Lasoamide, Lamotrigine, Valproate
- Ca Channels: Ethozuximide, Lamotrigine, Levetiracetam, Valproate
Postsynaptic:
- NMDA Receptors: Felbamate
- AMPA Receptors: Topiramate

60
Q

What drugs affect what targets within the INHIBITORY [GABAergic] Synapse?

A

Presynaptic Targets:
- GABA Transporter: Tiagabine
- GABA Transaminase: Vigabatrin
Postsynaptic Targets:
- GABAa Receptors: Phenobarbital, Benzodiazepines
* Gabapentin and Pregabalin

61
Q

What are some of the known seizure causes?

A
  • Withdrawal, toxicity, Medical conditions, Stroke, Lowering seizure threshold
62
Q

What are some of the medications that lower the seizure threshold?

A
  • Bupropion, Clonazapine
  • OTHERS: Varenicline, Carbapenems, Lithium, Tramadol
63
Q

What are some of the quailty of life monitoring that we should focus on in seizures?

A
  • Frequency, Functional Status, Social Functioning, Emotional Status, Cognition, Number of doses of drug per day, $$$$
64
Q

Is/should life long treatment for serizure be necessary?

A
  • NO: medication removeal after 2-5 years?
    Seizure Recurrence
  • < 2 years seizure free, Onset after 12yo, 2-6 years before control, number of seizures before control, abnormal EEG…
65
Q

What is Status Epilepticus in seizures?

A
  • Continuous seizure activity lasting 5 minutes or more OR two or more discrete seizures with incomplete recovery between seizures
  • Treatment: Benzo; IV Lorazapem or IM Midazolam
66
Q

What are the steps in treating Status Emilepticus in seizures?

A
  • Stablization Phase [0-5mins]: Time to seizure, Start ECG, Check Meds [to see if anything causes it]
  • Initial Treatment Phase [5-20mins]: IV Lorazepam or IM Midazolam
  • Second Treatment Phase [20-40mins]: IV Fospheytoin, IV Valproic Acid, IV Levetiractam
67
Q

What is the phenytoin/fosphenytoin loading dose for seizures?

A
  • Phenytoin: 20mg/kg IV up to 50mg/min IV
    [can cause hypotension]
  • Fosphenytoin: 20mg PE/kg IV up to 150mg/min IV [Prodrug with better tolerance]
68
Q

What is important to note about the Oral Phenytoin dosing within Seizures?

A
  • MUST obtain both a phenytoin serum concentration and serum albumin concentration in the same blood draw
  • Serum range: 10-20 mcg/ml
69
Q

What is the Valproate loading dose for seizures?

A
  • 15-30 mg/kg; subsequent doses = 1/2 LD up to 60mg/kg/day
  • Loading Calc: Vd [0.2-0.3] x Serum Concentration [80mcg/mL] x kg
70
Q

What is the seizure classifcations?

A
  • Partial [Focal] & Generalized
71
Q

What are the subclasses within Focal Seziures?

A
  • Simple: are AWARE and conscious
  • Complex: is NOT AWARE and looses consciousness
72
Q

What are medications affect what CYP enzymes in seizures?

A
  • 1A2 INDUCERS: Carbamazepine, Phenobarbital, Phenytoin,
  • 2C9 INDUCERS: Carbamazepine, Phenobarbital, Phenytoin
  • 3A4 INDUCERS: Carbamazepine, Lamotrigine, Oxcarbaepine, Phenobarbital, Phenytoin, Topiramate
  • UGT INHIBITORS: Valproate
73
Q

Why should we adjust the dosing of Lamotrigine and what/when should we change it to in seizures?

A
  • Can cause SJS and/or DRESS
  • WITHOUT UGT: 25 mg x14 d -> 50mg x14d -> 100mg x7d -> 200mg
  • WITH UGT INHIBITOR [Valproate]: Same as WITHOT UGT but every other day
  • WITH UGT INDUCER [Carbamazepine & Phenytoin]: Same as WITHOUT UGT but doubled
74
Q

What patients are more associated with developing DRESS syndrome within seizures?

A
  • If taking Cabamazepine, Cenboamate, Lamotrigine, Phenobarbital, Phenytoin, Valproate, Zoinsamide
    • HLA-A*3101 Allele
75
Q

What medications should not be used in pregnancy in seizures?

A
  • Carbamazepine, Clonazepem, Fosphenytoin, Phenobarbital, Phenytoin, Primiodone, Topiramate = Teratogentic
  • Valproate = Decrease in IQ
  • SHOULD be given Folic Acid
76
Q

What is VERY important to note about using any contraceptive with antiseizure medications?

A
  • Will decrease the effectiveness of the contraceptive; MUST counsel
  • Really only effects the Estrogen compounds
  • COULD use progestin only
77
Q

What are some of the Cardiovascular adverse effect associated with seizure medications?

A
  • Arrhythmias [Lamotrigine, Phentyoin/Fosphenytoin]
  • QTc Shortening [Rufinamide & Cenobamate]
  • PR Interval Changes [Lasocsamide & Pregabalin]
  • Heart Block [Lacosamide]
  • Valvular Heart Disease [Fenfluramine]
78
Q

What are some of the electrolyte abnormalities caused my seizure medications?

A
  • Hyponatremia: Carbamzepine, Oxcerbazepine, Eslicarbazeipine
  • Decrease Ca = Ostroprosis: Phenytoin
  • Decrease bicarb = Heat Stroke: Topiramate
79
Q

What are some of the Psychiatric Side effects for Antisezure medications?

A
  • Levetiracetam: Mood issues in children
  • Perampanel: Serious Neruopsychiatric event
  • Valproate: Hyperammonemia
  • Topiramate: cognitive disfunction is dosed to fast

PHRM 845: Therapeutics III (25 decks)

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