Seizures Flashcards
Lamotrigine [Lamictal®]
- 25 mg daily (slow titration to 375 mg/day); differs in presence of CYP enzyme inhibitors/inducers – PO only
- Consider for severe impairment (renal)
- Broad-Spectrum
- 40-50% Protein binding
- Focal Seizure; tonic-clonic; absence, atonic
Keppra
Levetiracetam
- Renal Adjustment
- Broad-Spectrum
- < 10 %
- No significant DDI’s
- Focal, Tonic-Clonic, Myoclonic
- SE : psychosis (elderly population)
- Use cautiously in pt’s with pre-existing psychosis
Topiramate
(Topamax)
- Renal Adjustment
- Broad Spectrum / Myoclonic Seizures
- 15% protein binding
- 3A4 inducer at doses ≥ 200 mg/day)
- SE: weight loss ; Reduced Cognition; acute angle glaucoma; oligohydrosis; Nephrolithiasis
- Teratogenic - cleft lip and/or palate
Valproate/Divalproex/ Valproic Acid Derivatives [Depakote, Depakote ER, Depakote Sprinkles, Depakene]
- Broad Spectrum- Focal, Tonic-Clonic, Absence, Myoclonic, Atonic
- Hepatic Adjustment
- 90-95% protein binding **significant**
- 10-15 mg/kg/day (max 60 mg/kg/day) – PO and IV
- ER formulation – increase dose by 10-20%
- the extended release formulation has a lower bioavailability compared to the IR, IV, and DR formulations, meaning that if the same dose of valproic acid is ingested, only 80-90% of the ER formulation is absorbed and reaches the systemic circulation to have an effect in the body.
- DDI’s with Capapennems (inducers)
- Inhibits Lamotrigine Metabolism
SE: Hepatotoxicity (Monitor LFTs at baseline and periodically (q 6 months), Weiht Gain; Blood Dyscrasias (anemia, leukopenia) ; Osteoporosis
- o Fatal pancreatitis
- o Hyperammonemia (treat with levocarnitine or lactulose in symptomatic patients)
- o Polycystic ovary-like syndrome (increased incidence in females <20 years or overweight)
- o Menstrual cycle irregularities, hirsutism, alopecia, acne
- Tertogenic - Reduced IQ and neural tube defects
Zonisamide (Zonegran®)
- Consider slower titration/ frequent monitoring for renally and hepatic adjustment
- 40-60% protein binding
- SE : Weight Loss; Skin rash ( with sulfa drugs); Reduced Cognition; Oligohydrosis, Nephrolithiasis;
Carbamazepine [Tegretol®, Tegretol XR®, Carbatrol®, Epitol®]
- Narrow-Spectrum; Focal; Tonic-Clonic
- Hepatically adjustment
- 40-90% (could be significnt) protein binding
- Auto-inducer
- SE: Skin Rash (consider testing for HLA-A* 3101 in for carbamazepine) ; Osteoporosis ; Diplopia ; Hyponatremia
- Teratogenic
Fosphenytoin [Cerebyx®]
-prodrug of phenytoin
- Consider adjustments for severe impairment (hepa, renal)
- 95-99%
- -only used short-term when oral phenytoin is not possible
- Inducers
- SE: Hepatotoxicity; Blood Dyscrasias (anemia, leukopenia) ;Skin rash (**Test for HLA-B* 1502 gene in Asian patients ); Reduced Cognition; Blurry Vision;
o Cerebellar syndrome (occurs with high serum levels; monitor for gait and muscle coordination changes)
o Connective tissue changes
o Skin thickening (more common in children), gingival hyperplasia
o Folate deficiency
o Hirsutism, acne, coarsening of facial features
- Teratogenic
Gabapentin [Neurontin®, Gralise®, Fanatrex®]
- Renal Adjustment
- 0 protein binding
- no significant DDI
- SE: weight gain
Lacosamide [Vimpat®]
- -more evidence for focal seizures
- Renal/heptatotoxic Adjustment
- <15% protein binding
- Focal Seizures( Narrow)
- No significant DDIs
- SE : ECG changes ( PR interval increase)
Oxcarbazepine (Trileptal®, Oxtellar XR®)
- prodrug of carbamazepine
- Focal; Tonic- Clonic (Narrow)
- Do not use ER with severe hepatic impairment
- Renal Adjustment
- 40% PB
- SE: Skin Rash (**Test for HLA-B* 1502 gene in Asian patients ); Osteoporosis ; Diplopia ;Hyponatremia
Eslicarbazepine Acetate [Aptiom®]
- -prodrug of oxcarbazepine
- Use not recommended for severe hepatic impairment
- Renal Adjustment
- < 40% PB
- Skin rash; Osteoporosis; Diplopia; Hyponatremia
Phenobarbital C-IV
- 50% PB
- Renal/ Hepato Adjustment
- Hepatotoxicity ;Blood Dyscrasias (anemia, leukopenia) ; Skin Rash ; Reduced Cognition ; Osteoporosis
- Teratogenic
Phenytoin and Phenytoin ER (Dilantin®, Phenytek®)
- 90% PB - significant
- Renal/ Hepatic Adjustment
- Inducer
- Similar SE as Fosphenytoin
- Hepatotoxicity
- Blood Dyscrasias (anemia, leukopenia)
- Skin Rash
- Reduced Cognition
- Osteoporosis
- Vision Changes
- Teratogenic
Pregabalin (Lyrica®) C-V
- 0% PB
- Renal Adjustment
- SE: Weight Changes; Blood Dyscrasias (anemia, leukopenia) ; Vision Changes ; ECG Changes (PR interval increase)
- No Significant DDI’s
Ethosuximide (Zarontin®)
- Absence Seizure;
- Avoid with severe impairment (renal/hepatic)
- 0% PB
- Inhibited by Valproate
- SE: weight loss; Blood Dyscrasias (anemia, leukopenia) ;Skin Rash