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Pharm III - Exam 2 > Seizures > Flashcards

Seizures Flashcards

1
Q

Define seizure

A
  • Paroxysmal event caused by excessive electrical discharge of neurons
  • May disturb consciousness, sensory or motor systems
  • Discharges seen as spikes on EEG
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2
Q

Define epilepsy

A

Group of chronic neuro disorders characterized by unprovoked recurrent seizures (usually idiopathic)

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3
Q

Define status epilepticus

A

Prolonged seizures without recovery in between

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4
Q

Describe simple partial seizures

A

NO LOC

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5
Q

Describe complex partial seizures

A

With LOC, may prgoress to GTC

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6
Q

Describe secondarily generalized partial seizure

A

Begins as partial and has LOC

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7
Q

Describe absence seizures

A
  • Sudden onset, blank stare
  • Typically young children
  • LOC but returns instantly
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8
Q

Describe generalized tonic-clonic seizures

A
  • Muscle rigidity followed by sharp contractions

- LOC and confusion upon return to consciousness

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9
Q

Describe myoclonic seizures

A
  • Generalized
  • Brief sudden muscle contractions
  • Face, trunk, extremities
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10
Q

Describe atonic seizures

A
  • Generalized

- Complete loss of muscle tone

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11
Q

Describe tonic seizures

A

Uncontrolled extension of muscle groups

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12
Q

Describe clonic seizures

A

Repeated rhythmic jerking of arms and legs

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13
Q

Indications of phenytoin

A

Primary generalized

Partial

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14
Q

Advantages of phenytoin

A
  • Well studied

- Many dosage forms

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15
Q

Disadvantages of phenytoin

A
  • Challenging to dose (PK)
  • DIs (CYP inducer, highly protein bound)
  • Close monitoring required
  • Extensive SE profile
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16
Q

Which formulation of phenytoin results in more active drug in the body?

A

Phenytoin ACID

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17
Q

Monitoring of phenytoin

A
  • Risk of suicidal ideation
  • CBC, LFTs, albumin
  • Serum concentration due to narrow TI
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18
Q

Pregnancy category of phenytoin

A

D

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19
Q

Notable ADRs of phenytoin

A
  • Gingival hyperplasia
  • Hirsutism
  • Osteomalacia
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20
Q

Why does phenytoin interact with other drugs?

A

Highly protein bound - other highly protein bound drugs can displace phenytoin

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21
Q

Drugs that increase phenytoin levels

A
  • Acute ETOH intake
  • Salicylates
  • Estrogens
  • H2 blockers
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22
Q

Drugs that decrease phenytoin levels

A
  • Carbamazepine
  • Chronic ETOH abuse
  • Antacids w/Ca
  • Phenobarbital
  • Rifampin
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23
Q

How does phenytoin initially interact with warfarin?

A

Immediately, phenytoin can displace warfarin which may INCREASE INR

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24
Q

How does phenytoin interact with warfarin after prolonged administration?

A

CYP2C9 induction - phenytoin induces the metabolism of warfarin which may DECREASE INR

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25
Q

Phenytoin and warfarin are both ___ for CYP2C9

A

Substrates

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26
Q

How are Vit K dependent clotting factors affected by phenytoin and warfarin interacting? How is INR affected?

A
  • Warfarin inhibits synthesis of clotting factors
  • Phenytoin may also deplete them
  • INR INCREASES
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27
Q

Main factors of phenytoin and warfarin interactions

A
  1. Protein binding
  2. CYP2C9 induction
  3. Competitive inhibition
  4. Depletion of Vit K clotting factors
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28
Q

Indications for carbamazepine

A
  • Primary generalized (non-emergent)

- Partial seizures (newly diagnosed)

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29
Q

Advantages of carbamazepine

A

Well studied

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30
Q

Disadvantages of carbamazepine

A
  • Active metabolite
  • Auto-inducer (DIs)
  • CNS side effects
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31
Q

What should be monitored when using carbamazepine?

A

WBC and ANC

  • Idiopathic blood dyscrasias
  • Mild persistent leukopenia
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32
Q

Contraindications to carbamazepine

A
  • Hypersensitivity to TCAs

- BM suppression

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33
Q

Black box warning of carbamazepine

A

Blood dyscrasias

-Asians should be screened for HLA-B*1502 beforehand

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34
Q

Pregnancy category of Carbamazepine

A

D

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35
Q

Oxcarbazepine indications

A
  • Partial (mono or adjunct)

- GTC

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36
Q

Advantages of oxcarbazepine

A

Comparable efficacy to phenytoin, valproic acid and CBZ but may be better tolerated

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37
Q

Disadvantages of oxcarbazepine

A
  • Hyponatremia

- DIs

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38
Q

Dosing of oxcarbazepine compared to CBZ

A

Oxcarbazepine doses may need to be 50% higher in order to obtain equivalent seizure control

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39
Q

Pregnancy category of oxcarbazepine

A

C

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40
Q

Eslicarbazepine acetate indications

A

Partial (mono or adjunct)

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41
Q

Metabolism of eslicarbazepine acetate

A

Metabolized to eslicarbazepine (active metabolite of oxcarbazepine)

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42
Q

What is the significance of eslicarbazepine acetate metabolism?

A

Converted to active metabolite of oxcarbazepine (better tolerated bc more exposure to active vs. inactive metabolites)

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43
Q

When should eslicarbazepine acetate be avoided?

A

Severe hepatic dysfunction

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44
Q

Topiramate indications

A
  • Partial

- GTC

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45
Q

Advantages of topiramate

A
  • Few DIs

- Wt loss?

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46
Q

Disadvantages of topiramate

A
  • Cognitive functioning impairment
  • Kidney stones
  • Wt loss?
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47
Q

How should dosing of topiramate be adjusted?

A

50% dose reduction in CrCl less than 50

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48
Q

Common ADRs of topiramate

A
  • Poor concentration, confusion, word finding difficulties
  • Somnolence
  • Wt loss
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49
Q

DIs of topiramate

A
  • OCPs
  • Digoxin
  • Valproic acid
  • Phenytoin, CBZ, barbiturates
  • CNS depressants
50
Q

How are OCPs affected by topiramate?

A

May be less effective (higher estrogen doses may be required)

51
Q

How is digoxin affected by topiramate?

A

Decreased concentration

52
Q

How does topiramate interact with valproic acid?

A

Increased risk of hyperammonemia

53
Q

Lamotrigine indications

A
  • Partial (mono or adjunct)
  • GTC
  • Absence
54
Q

Advantages of Lamotrigine

A
  • Not highly protein bound

- Does not cause wt gain

55
Q

Disadvantages of Lamotrigine

A
  • Rash

- DIs

56
Q

Dosing of Lamotrigine

A

Varies based on other meds

57
Q

Major ADR of Lamotrigine

A

Hypersensitivity reaction presenting as rash can lead to SJS

58
Q

Which AED can cause a hypersensitivity rash leading to SJS?

A

Lamotrigine

59
Q

DIs of Lamotrigine

A
  • Anticonvulsants

- OCPs

60
Q

Drugs that cause visual abnormalities

A
  • CBZ
  • Eslicarbazepine
  • Oxcarbazepine
  • Lamotrigine
  • Phenytoin
  • Pregabalin
61
Q

Anticonvulsants that cause weight loss?

A
  • Ethosuximide
  • Felbamate
  • Topiramate
  • Zonisamide
62
Q

Anticonvulsants that cause weight gain?

A
  • Gabapentin
  • Pregabalin
  • Valproic acid
  • Vigabatrin
63
Q

Indications for valproic acid

A
  • Primary generalized (myoclonic, atonic, absence)
  • Partial
  • Mixed disorders
64
Q

Advantages of valproic acid

A
  • Well studied

- Multiple dosage forms

65
Q

Disadvantages of valproic acid

A
  • Side effect profile

- DIs (enzyme inhibitor)

66
Q

What is the active form of valproic acid?

A

Valproate ion

67
Q

Half life of valproic acid?

A

9-18 hours

68
Q

PK of valproic acid

A
  • 90% protein bound

- Undergoes glucuronidation (inhibits glucuronidation of other agents)

69
Q

Pregnancy category of valproic acid

A

D

70
Q

Notable ADRs of valproic acid

A
  • Sedation, fine hand tremor
  • Hair loss, hepatotoxicity
  • Thrombocytopenia
71
Q

Indications for gabapentin

A

Partial (with or w/o secondary generalization)

72
Q

Advantages of gabapentin

A

No known DIs

73
Q

Which AEDs have no known drug interactions?

A

Gabapentin
Levetiracetam (Keppra)
Pregabalin

74
Q

Disadvantages of gabapentin

A
  • Very high doses required for seizure control

- Increased frequency of dosing

75
Q

PK of gabapentin

A
  • Not metabolized (renally excreted unchanged)

- Does NOT induce hepatic enzymes

76
Q

Half life of gabapentin

A

5-8 hours

77
Q

Pregnancy category of gabapentin

A

C

78
Q

ADRs of gabapentin

A
  • Somnolence
  • Ataxia
  • Tremor
  • Dizzy
  • HA
79
Q

Indications for Levetiracetam (Keppra)?

A
  • Partial (with or w/o secondary generalization)

- Adjunctive for myoclonic or primarily generalized

80
Q

Advantages of Levetiracetam (Keppra)?

A
  • No known DIs
  • Various dosage forms
  • Pediatric use
81
Q

Disadvantages of Levetiracetam (Keppra)?

A

Limited indications

82
Q

Pregnancy category of Levetiracetam (Keppra)

A

C

83
Q

ADRs of Levetiracetam (Keppra)

A
  • Somnolence
  • Asthenia
  • Dizzy
  • Vertigo
  • HA
  • Not dependent on dose or titration
84
Q

Indications for pregabalin

A

Partial (with or w/o secondary generalization)

85
Q

Advantages of pregabalin

A

No known DIs

86
Q

Disadvantages of pregabalin

A
  • Brand name only (expensive)

- Schedule V

87
Q

Which AED is expensive because it is available brand only?

A

Pregabalin

88
Q

Pregnancy category of pregabalin

A

C

89
Q

Common ADRs of pregabalin

A
  • Dizzy
  • Ataxia
  • Somnolence
  • Peripheral edema
  • HA
90
Q

Indications for tiagabine

A

Partial (adjunct)

91
Q

PK (half life and metabolism) of tiagabine

A

6.7 hours

CYP3A4 metabolism

92
Q

Drug interactions of Tiagabine

A

Highly protein bound but NO significant displacement of other protein bound agents

93
Q

Pregnancy category of Tiagabine

A

C

94
Q

Notable ADRs of tiagabine

A
  • Generalized muscle weakness
  • Depression
  • Aphasia
  • Encephalopathy
95
Q

Indications for Zonisamide

A

Partial (adjunct)

96
Q

Drug interactions of Zonisamide

A

CYP3A4

97
Q

Pregnancy category of Zonisamide

A

C

98
Q

Indications for phenobarbital

A

All seizure disorders

99
Q

Advantages of phenobarbital

A
  • Oldest anti-epileptic drug

- Broad spectrum

100
Q

Disadvantages of phenobarbital

A
  • Pan-inducer

- Toxicity

101
Q

What does acute intoxication of phenobarbital cause?

A
  • Unsteady gait
  • Slurred speech
  • Sustained nystagmus
102
Q

Signs of chronic intoxication of phenobarbital?

A
  • Confusion
  • Poor judgment
  • Irritability
  • Insomnia
  • Somatic complaints
103
Q

Phenobarbital and ETOH interaction?

A

Lethal dose is LESS if taken with ETOH (circulatory collapse and respiratory depression)

104
Q

ADRs of phenobarbital

A
  • Dependence

- CNS depression

105
Q

Use phenobarbital with caution in which patients?

A

Renal OR hepatic dysfunction

106
Q

What are the withdrawal symptoms of phenobarbital?

A

Convulsions and delirium

107
Q

DIs of phenobarbital

A
  • Pan inducer of CYP450
  • Increases Vit D metabolism (osteomalacia)
  • CNS depressants (additive effect)
108
Q

Pregnancy category of phenobarbital

A

D

109
Q

Describe primidone

A

Converted to phenobarbital via hepatic oxidation

110
Q

Pregnancy category of primidone

A

D

111
Q

Indications for ethosuximide

A

Absence seizures

112
Q

DIs of ethosuximide

A

Clearance is decreased by valproic acid

113
Q

Indications for felbamate

A

Partial seizures (reserved for refractory cases)

114
Q

ADRs of felbamate

A

Aplastic anemia

Severe hepatitis

115
Q

When can AED therapy be discontinued?

A

Once a patient has been seizure free for 2-4 years

116
Q

Treatments of status epilepticus

A
  • 0-10 mins: IV lorazepam
  • 10-30 mins: IV phenytoin or fosphenytoin
  • 30-60 mins: additional dose of hydantoin, IV phenobarbital
117
Q

Which GCSE treatment contains propylene glycol?

A
  • IV Phenytoin (40%, can cause hypotension and cardiac arrhythmias)
  • Fosphenytoin does NOT have propylene glycol
118
Q

How should fosphenytoin be prepared?

A

Diluted in 5% dextrose or NS

119
Q

Side effects of fosphenytoin

A

Paresthesia and pruritus of face and groin

120
Q

Nonpharm therapy of GCSE

A
  • IV thiamine
  • IV glucose
  • Vital signs
  • Airway, ventilation
121
Q

Describe midazolam

A
  • Diffuses rapidly into brain

- Extremely short half life (give via continuous infusion)

Pharm III - Exam 2 (3 decks)

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