Seizures Flashcards
Etiology of Seizures : Single seizure causes
1. C,A,T,M,M,M,M
- Meds associated with seizures?
- CNS depressant withdrawal
◦ Acute illness
◦ Toxicity
◦ Medical conditions
◦ Metabolic disturbances
◦ Medical procedures
◦ Medications - Anticholinergics
-Anticholinesterases
-Antidepress
-Antiemetics
-Antiseizure meds
-Antihistamines
-Antimalarials
-Antimicrobials
-Antineoplastics
-Antipsychotics
-Contrast agents
-Baclofen
-Beta blockers
-CNS stims
-Oxytocin
-Estrogen
-Lithium
-Anesthetics
-Opioids
-Sympathomimetics
Etiology
1.Chronic seizure disorders :
-S, I, N, Other such as ? (4)
- Other etiology such as ___
Risk factors
1. Congenital : ___ during gestation/early life, abnormal ___ at birth, and abnormal ____/___, cerebral palsy
2. Childhood/devel : seizures in ___, serious __ or ___, intellectual ___, intractable ___
3. Illness/Trauma such as?
- Stroke, other vascular abnorms
-Intellectual disability
-Neurodevel/birth injury
-CNS neoplasms, Cerebral palsy, genetic predisposition, head trauma - Genetics
- Underweight, brain structure, blood vessel structure/function in brain
- 1st month of life, brain injury , lack of oxygen to brain , disability , febrile seizures
- brain tumors, infections of brain, encephalitis, stroke, seizures within days after head injury, family history of epilepsy or fever-related seizures,
advanced Alzheimer’s disease
Focal Seizures :
1. Formerly known as?
2. Focal Motor - sx’s ?
3. Focal Non motor -Sx’s?
4. A__
- partial
- involuntary body movement (twitching, jerking, stiffening) or automatisms (automatic movements such as lip smacking, rubbing hands, walking, running)
- other symptoms occur before seizure, such as somatic (paresthesia), sensory (visual, auditory, olfactory, gustatory hallucinations), psychological symptoms (detachment, déjàvu, fears, illusions)
- Auras
Generalized Motor :
1. Formerly known as?
2. Tonic refers to , clonic refers to
3. Prodromal sx’s in some patients such as?
4. Postictal phase ?
5. EEG will show what ?
- Tonic clonic or grand mal
- Stiffening, jerking
- Irritability , decr concentration
- Unarousable at first, then lethargic, confused, sleepy
- generlized spike and wave discharges, generalized poly-spike discharges
Generalized Non-Motor
1. Formerly known as
2. Ages ?
3. Momentary lapse in awareness lasting ?
4. Sx’s?
5. No ____
6. Atypical non motor has __ and __ components
7. EEG will show?
- Absence or Petit mal
- 5-15 yrs, first peak 6-7 yrs, second peak ~12 yrs
- 10-30 secs
- motionless staring, arrest of any activity , mild motor facial jerks, automatisms, rapid blinking
- postictal period
- tonic, autonomic
- 2-3 Hertz Spike and wave discharge on EEG
Generalized Other motor
1. Myoclonic : sx’s?
2. Atonic (Akinetic) sx’s?
- Rapid, lightning -like jerk movements of entire body
- can affect small, isolated muscle groups of face, arms or may involve larger areas of head, limbs, trunk - Drop attacks, sudden loss of muscle tone
-fragmentary (head drop) or generalized (usually resulting in fall)
Treatment :
1. Initiate ASM therapy if your pt at incr risk of ? Such as ?
- TX goal?
- Non pharm tx options ?
- Recurrent seizures (Sleep deprivation, fever, substance use)
- Seizure free without AE’s, monotherapy desirable
- Vagus nerve stim, responsive neurostim, surgery , ketogenic diet in pt’s w/refractory epilepsy who have failed >=2ASMs
Carbamazepine (Tegretol)
1. Indications ? (5)
- Metabolism with enzyme? (DDI)
- Autoinduction will complete when ?
- BBW? (3)
- 10 fold incr risk of TEN/SJS in which individuals?
- ADRs?
-CNS such as
GI such as
__ and __ deficiency –> incr osteoporosis risk
Dose related such as (4)
Idiosyncratic such as ? - RIsk of hypersensitivity rxn may be INCR with variant ___
- Monitor ?? (3)
- Discontinue if?
- What do u have to repeat every 3 months for 6 months and then annually? (4)
- Focal onset, gen tonic clonic, mixed seizures, trigeminal neuralgia, bipolar disorder
- CYP3A4
- 20-30 days, max 4 weeks
- aplastic anemia and agranulocytosis
- SJS, TEN - Asian descent , test for HLA-B*1502 Allele and avoid use if positive
- Dizzi, drowsiness, HA, fatigue
- N/V
- Vitamin D, Calcium
- Diplopia, drowsy, nausea, sedation
-Rash, SJS, aplastic anemia, anemia, leukopenia, SIADH, Cholestatic jaundice - HLA-A*3101 allele
- LFTs, CBC, CMP
- WBC or ANC < 3000/mm^3 or 1500 /mm^3
- LFTS, CBC, Carbam levels, CMP
Oxcarbazepine (Trileptal)
1. Monotherapy or adjunctive in what types of seizures and for what ages?
- CYP interactions?
- Warnings : cog/neuropsych rxns such as?
- Avoid use if positive for HLA-B*1502 because of?
- Cross hypersensitivity rxn to ___
- AE’s ? CNS, Dose related, Idiosyncratic
- Need to Monitor ?
- Monother or adjunctive in focal onset seizure in adults. Mono for 4-16, Adjunct for 2-16
- Strong CYP3A4 inducer
- concentration difficulties, speech/language problems, and psychomotor slowing, somnolence or fatigue, coordination problems such as ataxia and gait disturbances
- SJS, TEN
- Carbamazepine (25-30%)
- Drowsy, ataxia , diplopia
-N/HA
-Hyponatremia!, Blood dyscrasias - CBC , CMP every 3 months then annually
Comparing Carbamazepine Vs Oxcarbazepine
- Autoinduction ?
- Hyponatremia?
- DDI’s?
- Better tolerated due to NO metabolism to epoxide?
- Measure drug levels?
- Dosage of oxcarb compared to carb ?
- Carb
- Low risk with carb, high risk with oxcarb
- Carb has more DDI’s
- Oxcarb
- Carb = measure levels , Oxcarb = measure MHD levels! (its metabolite)
- oxcarb = 1.2-1.5x daily dose of carbam
Ethosuximide (Zarontin) :
1. Indicated for ?
2. Metabolized by ?
3. Warnings for ? (4)
4. AE’s CNS, Dose related, Idiosyncratic
5. Monitoring Baseline , every 3 months then annually? (3)
- Gen non-motor (absence) seizures
- CYP 3A4 (CYP3A4 substrate)
- Blood dyscrasias
* Avoid in renal AND hepatic dysfunction
* Systemic lupus erythematosus (SLE)
* Dermatologic reactions, including SJS and TEN - CNS : Drowsy, fatigue
DR : Anorexia, weight loss, GI upset, AB cramps
Idio : Leukopenia, eosinophilia, Psych disturbances, sleep disturbances, aggression, hiccups - CBC, CMP, Ethosuximide levels
Gabapentin (Neurontin)
1. Indications: ADJUNCTIVE for ___ +/- secondary generlization in >=3yrs, postherpetic neuralgia
- Warnings such as :
- Neuropsych ae’s in ____ w/ seizures ages __
-T ___ potential
-Sudden, unexplained ___ in pt’s w/epilepsy
-_____ including serious, life threatening, fatal
-Concomitant use with ___ - AE”s : CNS, Other, Concentration related ?
- What needs to be monitored q3months + annually?
- Focal onset seizures
- pediatric pt’s, 3-12 yrs
- Tumorigenic
- death
-Respiratory depression
-Opioids
- Dizzy!, somnolence, ataxia!
- Peripheral edema!, weight gain!
- Drowsy, sedation! - baseline CBC , CMP
Lacosamide (Vimpat)
1. Indications : adjunctive therapy for?
2. metabolized by ? (3 enzymes)
3. Warnings for ___ and ___, including dose dependent prolonged ___, Atrial __ and ___
-S__
- AE’s CNS, GI, Other, Idiosyncratic
- Need to monitor ___ at baseline and steady state maintenance dose recc if underlying ___, severe ___ or taking concomitant meds that affect conduction
- Focal onset seizures in >17 yrs
- CYP3A4, 2C9, 2c19
- cardiac rhythm, conduction abnorms, PR interval, fib, flutter
-syncope - CNS : Dizzi, HA, Somnolence, ataxia/shakiness
-Nausea
-Diplopia
-Hepatic impairment, 1st degree AV Block - ECG at baseline, proarrhythmic conditions, cardiac disease
Lamotrigine (Lamictal) :
1. Indications for adjunctive therapy in >= 2 yrs with ____, primary ____, generalized seizures of ___, and ___ (>=18yrs)
- Boxed warnings?
- Increased risk of boxed warning with concomitant use of ___, initial doses exceeding __, and dose escalations exceeding recc’s
- What should we do at first sign of rash ?
- When should you re-titrate the medication?
- WHich drugs affect the dosing titration of Lamictal?
- Warnings for ? (2)
- AE”s : CNS, DR, Idiosyncratic
- Monitoring for ? (3)
- focal onset seizures, gen tonic clonic seizures, LGS, bipolar
- serious skin rashes, including SJS, TEN
- Valproate !!
- recommendations - DISCONTINUE unless its clearly not medication related
- If medication missed for > 5 half lives
- Valproate, Carb, Phenytoin, Phenobarb, Primidone
- Cardiac rhythm and conduction abnorms
- Concomitant use w/oral contraceptives (They incr clearance of drug, lower lamictal) - Dizzy, ataxia, blurred vision
-Rash, N/V
-Life threatening rash, hepatic failure, hemophagocytic lymphohistiocytosis - Baseline CBC, CMP, and rash q3months then annually
Levetiracetam (Keppra) :
1. Indications : Mono or adjunctive for ___ in >=1 month, adjunctive for ___ in >=12yrs w/juvenile ___, adjunctive for primary ___ in >=6yrs w/idiopathic epilepsy
- Warnings for :
Behavioral abnorms such as ?
-CNS depression including ? (3)
-Derm rxns such as ?
-C___ difficulties
-Blood ___
-Incr in ___
-Seizure control during ___ - AE’s : CNS, DR, Idiosyncratic
- Monitoring baseline, q3months, annually
- focal onset seizures, myoclonic seizures , myoclonic epilepsy, gen tonic-clonic seizures
- psychotic sx’s (psychosis, aggression,anger)
- somnolence, fatigue, ataxia
- SJS, TEN
-Coordination
-Dyscrasias
-BP
-Pregnancy - CNS : Drowsiness, ataxia
DR: Nausea /HA
Idio: Cog and mood changes, depression!, irritablity - CBC, CMP
Phenytoin (Dilantin) :
1. Indicated for ?
- Metabolism by which enzymes?
- BOXED WARNINGS for ?
- WARNINGS : S,T, B,H,B,A,Exacerbation of P__ , R or H impairment, Hypo__, Hyper___
- Chronic use associated with ?
- T___
- Sustained phenytoin serum levels above thera range may produce ?
- AE”s : CNS , DR, Idisocyncratic
- AE’s IV related ?
- Monitoring baseline, q3months, annually
- Does what to oral contraceptives?
- Gen tonic clonic seizures, prevention and tx post neurosurgery, status epilepticus
- CYP 2C9, 2C19, 3A4–> CYP inducer !!!
- Cardiovasc events w/IV infusion >50mg/min
-Peds should not exceed 1-3mg/kg/min to decr risk of severe hypotension, cardiac arrhythmias (or just avoid in children) - SJS, TEN (Test for HLAB*1502 allele , avoid if possitive) , Blood dyscrasias, hepatic injury, bradycardia/cardiac arrest, angioedema, porphyria, renal , hepatic, albuminemia, glycemia
- Decr bone mineral density , fractures
- Teratogenicity
- Confusional states including delirium, psychosis, enceph, or rarely , irreversible cerebellar dysfunction and or cerebellar atrophy
- CNS : Nystagmus, ataxia, diplopia, cerebral atrophy (chornic use)
DR : N/V/C
Idio : Blood dyscrasias, hepatotoxic, hirutism, gingival hyperplasia, acne, arrhythmias, SJS, alt of Vitamin D metab, folate deficiency - Phlebitis, seevre soft tissue damage (purple glove syndrome), hypotension and bradycardia related to propylene glycol
- CBC, CMP, PHENYTOIN LEVELS
- Decr their levels
Fosphenytoin (Cerebyx)
1. Indications for?
2. metab?
3. Boxed warning : rate of admin should not exceed ?
-Whats associated w/RAPID INFUSION?
- Warnings: B, D, D, Local toxicty such as __. S, H, A,P, R or H or H, Exacerbation of __, Hyper ___
- AE’s such as ? (2)
- Gen tonic clonic status epilepticus, prevention and tx of seizures during neurosurgery
- Rapidly via hydrolysis to PHENYTOIN –> CYP 2c9, 2c19, 3a4
- 150mg PE/min in adults, 2mgPE/kg/min in peds
-Cardiovasc events - Blood dyscrasias, dosing errors, derm rxns (SJS and TEN) , Pruple glove syndrome (Less common than phenytoin) , Sensory disturbances (burning, itching paresthesia), hepatic injury, angioedema, phosphate load (caution w/severe renal impairment), renal, hepatic disease, hypoalbum, porphyria , Glycemia
- Hypotension, Perianal pruritus
See chart on Phenytoin vs Fosphenytoin
See chart
Phenobarbital (Luminal ) :
1. Indications?
2. Metabolism by ?
3. Warnings :
__ and __depression
-Derm rxns such as ?
-___ stim response
-may reduce potency of __ and other __
- AE’s ? CNS,DR, ___ in children, Decr ___ w/chronic use
- Monitoring at baseline, q3months, annually? (3)
- Gen seizures, focal onset, status epilepticus
- CYP 2C19, 2C9, 2E1 –> its an enzyme inducer
- CNS, respiratory
SJS , TEN
Paradoxical
-Warfarin, anticoags - CNS : somnolence, confusion, cog impair
DR : HTN, respiratory depression, coma
Hyperactivity
- Bone mineral density - CBC, cmp, phenobarb levels!
Valproate (Depakote )
1. Indications for mono and adjunctive in ___? (4)
2. Metabolism by which enzymes?
3. Boxed warnings for ? (3)
4. Warning for
-Hyper ___ , incr risk with concomitant ___
-___ disorders
-Hypo___
-DR ____
-Use in women of ___
-False positive for ____ and altered ___
-Reduced ___ w/concomitant ___ abx
-Medication residue in __
- AE’s : CNS, Dose related, Idiosyncratic
- Monitoring baseline, q3months, annually?
- VALPLATE ?
- Focal onset impaired awareness seizures, gen non motor (absence) seizures in >10yrs, mania, migraine prophylaxis
- CYP 2A6, 2B6, 2C9 –> CYP inhibitor !!!
- Hepatic failure, Pancreatitis, Structural birth defects
- Ammonemia, topiramate use
-urea cycle
-thermia
-thrombocytopenia
-childbearing age
-urine ketone test, thyroid function test
-Valproate serum concentrations , carbapenem
-Stool - tremor, somnolence, reversible and irreversible
cerebral and cerebellar atrophy
- N/V/weight gain, reversible thrombocytopenia, alopecia
-Hepatotoxic, Idiopathic thrombocytopenia, rash - CBC, CMP, Valproic acid levels !!!!
- Vomiting (N/D) , Alopecia, Levels, Pancreatitis, liver toxic, albumin/ammonia levels , thrombocytopenia/tremor, enzyme inhibition
Topiramate (Topamax)
- Indications for ? (5)
- Inducer of __ which may cause interactions with ?
- Warnings for Cog effects such as ?
- Acute __ and secondary ___ . Visual ____.
- Metabolic ___, Oligo___ and hyper____
- Fetal ___, serious skin rxns including ___ (2)
- N
- Hyper ___ and E___
- Hypothermia with concomitant ___
- AE’s : CNS, DR
- Monitoring of baseline __ ,___, ___ every 3months then annually
- Focal onset or primary gen tonic clonic seizures in >2yrs, adjunctive for focal seizures, primary gen tonic clonic, seizures associated with LGS in >2yrs, migraine prophylaxis in >12 yrs
- Enzymes , birth control
- confusion, psychomotor slowing, difficulty with concentration, word-finding difficulties, neuropsychiatric effects –depression, mood swings, fatigue, somnolence
- Myopia, angle close glaucoma. Field defects
- ACidosis, oligohidrosis, hyperthermia
- Toxicity , SJS, TEN
- Nephrolithiasis
- Hyperammonemia, enceph
- Valproic acid use
- Cog impairment, psychomotor slowing, somnolence and fatigue
- N/Dyspepsia, weight LOSS, hyperchloremic non anion gap metab acidosis, neprholithiasis - CBC, CMP, urinalysis
Zonisamide (Zonegran)
1. Indications such as adjunctive therapy in ?
2. Metabolism by?
3. Warnings for C/N, M,N,Serious ___, Serious ___
4. O__, hyperthermia in peds
5. Acute __ and secondary ___
6. Increased ___
7. Hyper__ and E___
8. S____!!!!!!
9. T____
- AE’s such as CNS and Dose related ?
- Monitoring baseline , q3months, annually?
- focal onset seizures in adults
- CYP3A4 –> lots of DDI’s
- Cog/neuropsych effects (Confusion, psychomotor slowing, depression psychosis, somnolence , fatigue)
-metab acidossis
-Nephrolithiasis
-serious hematologic events
-Skin rashes (SJS and TENS) - Oligohidrosis
- Myopia, angle closure glaucoma
- renal dsyfunction
- Ammonemia, encephalopathy
- Sulfonamide rxns
- Teratogenicity
- Drowsy, dizzy, confusion, tremor, cog dulling
- N/V/WEIGHT LOSS, paresthesias - CBC, CMP
Status Epilepticus -Initial ASM TX : Diazepam
- what form of diazepam?
- What other formulations could you use of Diazepam if IV is not available, and IV Loraz/IM Midaz is not available either?
- COnsiderations for the drug ?
- IV
- Rectal Diazepam (Level B evidence)
- has active metabolite, short duration, IV contains propylene glycol
Status Epilepticus - Initial ASM TX Lorazepam and Midazolam
- What form of lorazepam?
- COnsiderations?
- What form of Midazolam is 1st line?
- What 2 other forms are level B evidence ?
- Considerations?
- IV, IV push
- IV contains propylene glycol
- IM
- Intranasal and Buccal
- Active metab, short duration , renal elim
Enzyme Inducing ASMS :
1. List the 5 drugs
For each of the affected drug classes, give examples :
2. ASMs
3. ANticoags
4. Antipsychs
5. BZD’s
6. Steroids
7. Antidepress
- Carbamazepine, Cenobamate (mod dose), Phenobarb, Phenytoin, Primidone
- CArbamazepine, felbamate, lamotrigine, Oxcarb, Tiagabine, Topiramate , Valproate, Zonisamide
- warfarin (reduced inr)
- Chlorpromazine, clozapine, haloperidol, olanzapine, quetiapine, risperidone
- Alpraz, CLobaz, Clonaz, Diaz, midaz
- Dexameth, hydrocort, methylpred, pred , prednisolone
- Wellbutrin, citalopram, paroxetine, TCA’s, mirtazapine
Which Enzyme inducing ASMs have an interaction with oral contraceptives? (7)
- Carbamazepine
- Cenobamate (moderate)
- Oxcarbazepine
- Phenobarb
- Phenytoin
- Primidone
- Topiramate with >=200 mg/day
ASM Enzyme Inhibition
1. Valproic acid can increase plasma levels of?
2. Valproic acids inhibition of glucoronidation is associated with ?
3. May potentiate ____
- Oxcarb can incr ___ at doses of ___
- Phenobarb, phentoin, carbamazepine 10,11-epoxide
- incr risk of derm ae’s in combination with lamictal
- CNS effects of BZD’s
- Phenytoin plasma levels at doses >1200 mg/day