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Pharm > Seizures > Flashcards

Seizures Flashcards

1
Q

Causes of seizures

A 
Congenital defects (cerebral palsy)
Hypoxia
Trauma (incl. brain surgery)
Cancer (tumors)
Alcohol or drugs (incl. withdrawal)
Elevated body temp (febrile)
Electrolyte disturbances 
Drugs: Meperidine
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2
Q

Partial seizures

A

Simple
Complex
Secondarily generalized

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3
Q

Generalized seizures

A 
Absence
Tonic
Clonic
Tonic-clonic (grand mal)
Myoclonic
Atonic
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4
Q

Seizure type guidelines

A

Identification is very important
Initial drug choice depends on what type
If you give the wrong med you could induce MORE seizures

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5
Q

Meds for all partial seizures

A

Valproate**
Carbamazepine
Phenytoin

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6
Q

Meds for generalized tonic-clonic

A

Valproate**
Carbamezepine
Phenytoin

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7
Q

Meds for absence seizures

A

Valproate

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8
Q

Meds for myoclonic seizures

A

Valproate

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9
Q

Meds for atonic seizures

A

Valproate

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10
Q

Anti-epileptic drugs (AEDs)

A

Most pts respond to 1-2 AEDs

Rarely do they require more than 2

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11
Q

What % of pts are controlled with AED monotherapy?

A

50-70%

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12
Q

What % of pts require combination AED therapy

A

30%

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13
Q

What % of pts are poorly controlled despite AED therapy

A

5%

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14
Q

Pseudoresistance to AEDs

A

Wrong diagnosis
Wrong drug(s)
Wrong dose
Lifestyle issues (compliance, alcohol, drugs)
**MUST be ruled out to consider tx failure

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15
Q

Goals of AED therapy

A

Prevent seizures
Maintain normal function
Improve quality of life
**All w/ fewest side effects

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16
Q

Principle of AED therapy

A

Select recommended drug for seizure type

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17
Q

When augmenting AED therapy, what should you do?

A

Choose a drug w/ an alternative mechanism

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18
Q

When do you start AED therapy?

A

Depends on the pt
Rarely needed after single episode
Start in pts at risk for recurrent seizures
Generally start after >2 unprovoked seizures

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19
Q

Is AED therapy lifelong?

A

Not necessarily

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20
Q

AED withdrawal

A

Should be gradual/tapered

Sudden could lead to status epilepticus

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21
Q

When is AED relapse more likely

A

When withdrawn over 1-3 months

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22
Q

When is AED relapse less likely

A

If withdrawn over 6 months

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23
Q

What 2 standalone drugs do AEDs interact with?

A

Oral contraceptives

Warfarin

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24
Q

Significant CYP450 inducers

A

Phenytoin (Phenobarbital)
Carbamezepine
Primidone

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25
Q

Less significant CYP450 inducers

A

Oxycarbazepine

Topiramate

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26
Q

Much less significant CYP450 inducers

A

Newer (2nd generation) agents

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27
Q

Common AED side effects

A

Suicidal ideation (2 fold risk over general population)
CNS issues
Osteomalacia
Osteoporosis
Vision changes
Correlate drug levels to sx before changing meds

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28
Q

CNS side effects

A

Slowed thinking
Sedation
Ataxia
Dizziness

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29
Q

Why is AED monotherapy preferred

A

Increases adherence
Provides wider therapeutic index
More cost effective

30
Q

Combination AED therapy guidelines

A

Combinations promote drug-drug interactions
No controlled studies comparing drug combos
Choose add-on w/ different MOA and/or SE profile

31
Q

Big 3 AED meds

A

Phenytoin
Carbamezepine
Valproic acid

32
Q

Phenytoin

A

IV or PO dosing

33
Q

SE of phenytoin

A 
Gingival hyperplasia
Rash
Acne
Nystagmus
Hirsutism
Osteomalacia
Folate deficiency
34
Q

Carbamazepine

A

PO
SE: hyponatremia
Advantage = less cognitive impairment

35
Q

Valproic Acid

A

IV and PO dosing

SE: fatal hepatotoxicity

36
Q

Divalproex

A

Derivative of valproic acid
Depakote, Depakote ER
1:1 dimer in enteric coated tablet
Less GI effects

37
Q

Phenobarbital

A 
Rarely used except for in pregnancy
More SE than other drugs
Abrupt stopping may cause seizures
Taper slowly
Primidone -> metabolized to phenobarbitol
38
Q

Benzodiazepines for seizures

A

Long term use not practical due to tolerance

39
Q

Benzo agents for seizures

A

Clonazepam
Diazepam
Lorazepam

40
Q

Agent for absence seizures

A

Ethosuximide

41
Q

Felbamate

A

Use cautiously

Can cause fatal aplastic anemia and hepatotoxicity

42
Q

Topiramate

A

Can cause temporary or permanent vision loss

Decreases sweating

43
Q

Zonisamide

A

Chronic side effects similar to topiramate

44
Q

Levetiracetam

A

Newer agent
Few drug interactions
IV and PO dosing

45
Q

Gabapentin and Pregabalin

A

GABA analog
No interactions
Not first line AED

46
Q

What AED do you give in pregnancy

A

Phenobarbital-D
Anticonvulsant of choice during pregnancy
Apparently this isn’t true

47
Q

American Academy of Neurology stance on generic stubsitution

A

Opposes generic substitution of anticonvulsant drugs for tx of epilepsy w/o physician approval

48
Q

What AEDs are used for neuropathic pain

A

Gabapentin

Pregabalin

49
Q

Other uses for AEDs

A

Bipolar disorder

Migraine

50
Q

Status Epilepticus

A

Life-threatening emergency

Mortality = 20%

51
Q

Status etiology

A 
AED noncompliance/discontinuation
Withdrawal syndromes (alcohol/barbiturates)
Brain injury (tumor/stroke)
Metabolic abnormalities (decreased glucose, Na, Ca, Mg, etc.)
Drug use/overdoes that lowers seizures threshold
52
Q

Drugs that lower seizure threshold

A

Imipenem
High dose penicillin G (IV PCN)
Lidocaine

53
Q

Tx of status

A 
Diazepam
Lorazepam
Phenytoin
Fosphenytoin
Phenobarbital
54
Q

Diazepam for status

A

Inject directly -> diluting causes precipitation
Typically provides 30-40 minute seizure free interval
(often <20 mins due to redistribution into adipose)

55
Q

Advantages of lorazepam for status

A

More effective than phenytoin

Easier to use than diazepam + phenytoin or phenobarbitol

56
Q

Lorazepam for status

A

Most effective in terminating seizures w/in 20 mins and maintaining seizure free state in first 60 mins after tx
Longer lasting than diazepam
May be diluted w/ equal volume of 0.8% NaCl

57
Q

Phenytoin for status

A

15-20 mg/kg IV load (better results at higher end 18-20)

Infuse no faster than 50 mg/min (may need to slow if pt becomes hypotensive)

58
Q

Fosphenytoin for status

A

Pro-drug of phenytoin

59
Q

How is fosphenytoin dosed?

A

Phenytoin equivalents (PEs)

60
Q

How many mgs of fosphenytoin to phenytoin?

A

1.5 mg fosphenytoin to 1 mg phenytoin

61
Q

Can you infuse fosphenytoin faster or slower than phenytoin

A

Faster

150 mg/min

62
Q

Advantage of fosphhenytoin

A

Highly water soluble so it likely won’t precipitate
Allows for IM administration
Less hypotension
Can be mixed in any solution

63
Q

Phenobarbital dosing for status

A

If refractory:

IV 15-20 mg/kg @ 50 mg/min

64
Q

Phenobarbital for status

A

Not 1st line due to: Slow administration
Prolonged sedation (half life 80-100 hours)
Greater risk of hypotension and hypoventilation
Little used -> not quickly available

65
Q

How much folate do you supplement in young females on AEDs

A

1-4 mg/day

66
Q

Who should you contact if you have questions about a pregnant pt on AEDs

A

AED Pregnancy registry

67
Q

When do you discontinue AEDs?

A

Depends on seizure type, seizure free duration, EEG, etc.

68
Q

Do you abruptly stop AEDs?

A

NO!!!

69
Q

What does optimal AED tx require?

A

INDIVIDUALIZATION

70
Q

% of fetal malformations w/ Levetiracetam (Keppra®)

A

2.4%

71
Q

% of fetal malformations w/ Lamotrigine (Lamictal®)

A

2.0%

Pharm (32 decks)

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