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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
Less significant CYP450 inducers
Oxycarbazepine | Topiramate
26
Much less significant CYP450 inducers
Newer (2nd generation) agents
27
Common AED side effects
Suicidal ideation (2 fold risk over general population) CNS issues Osteomalacia Osteoporosis Vision changes Correlate drug levels to sx before changing meds
28
CNS side effects
Slowed thinking Sedation Ataxia Dizziness
29
Why is AED monotherapy preferred
Increases adherence Provides wider therapeutic index More cost effective
30
Combination AED therapy guidelines
Combinations promote drug-drug interactions No controlled studies comparing drug combos Choose add-on w/ different MOA and/or SE profile
31
Big 3 AED meds
Phenytoin Carbamezepine Valproic acid
32
Phenytoin
IV or PO dosing
33
SE of phenytoin
``` Gingival hyperplasia Rash Acne Nystagmus Hirsutism Osteomalacia Folate deficiency ```
34
Carbamazepine
PO SE: hyponatremia Advantage = less cognitive impairment
35
Valproic Acid
IV and PO dosing | SE: fatal hepatotoxicity
36
Divalproex
Derivative of valproic acid Depakote, Depakote ER 1:1 dimer in enteric coated tablet Less GI effects
37
Phenobarbital
``` Rarely used except for in pregnancy More SE than other drugs Abrupt stopping may cause seizures Taper slowly Primidone -> metabolized to phenobarbitol ```
38
Benzodiazepines for seizures
Long term use not practical due to tolerance
39
Benzo agents for seizures
Clonazepam Diazepam Lorazepam
40
Agent for absence seizures
Ethosuximide
41
Felbamate
Use cautiously | Can cause fatal aplastic anemia and hepatotoxicity
42
Topiramate
Can cause temporary or permanent vision loss | Decreases sweating
43
Zonisamide
Chronic side effects similar to topiramate
44
Levetiracetam
Newer agent Few drug interactions IV and PO dosing
45
Gabapentin and Pregabalin
GABA analog No interactions Not first line AED
46
What AED do you give in pregnancy
Phenobarbital-D *Anticonvulsant of choice during pregnancy* Apparently this isn't true
47
American Academy of Neurology stance on generic stubsitution
Opposes generic substitution of anticonvulsant drugs for tx of epilepsy w/o physician approval
48
What AEDs are used for neuropathic pain
Gabapentin | Pregabalin
49
Other uses for AEDs
Bipolar disorder | Migraine
50
Status Epilepticus
Life-threatening emergency | Mortality = 20%
51
Status etiology
``` 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
Drugs that lower seizure threshold
Imipenem High dose penicillin G (IV PCN) Lidocaine
53
Tx of status
``` Diazepam Lorazepam Phenytoin Fosphenytoin Phenobarbital ```
54
Diazepam for status
Inject directly -> diluting causes precipitation Typically provides 30-40 minute seizure free interval (often <20 mins due to redistribution into adipose)
55
Advantages of lorazepam for status
More effective than phenytoin | Easier to use than diazepam + phenytoin or phenobarbitol
56
Lorazepam for status
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
Phenytoin for status
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
Fosphenytoin for status
Pro-drug of phenytoin
59
How is fosphenytoin dosed?
Phenytoin equivalents (PEs)
60
How many mgs of fosphenytoin to phenytoin?
1.5 mg fosphenytoin to 1 mg phenytoin
61
Can you infuse fosphenytoin faster or slower than phenytoin
Faster | 150 mg/min
62
Advantage of fosphhenytoin
Highly water soluble so it likely won't precipitate Allows for IM administration Less hypotension Can be mixed in any solution
63
Phenobarbital dosing for status
If refractory: | IV 15-20 mg/kg @ 50 mg/min
64
Phenobarbital for status
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
How much folate do you supplement in young females on AEDs
1-4 mg/day
66
Who should you contact if you have questions about a pregnant pt on AEDs
AED Pregnancy registry
67
When do you discontinue AEDs?
Depends on seizure type, seizure free duration, EEG, etc.
68
Do you abruptly stop AEDs?
NO!!!
69
What does optimal AED tx require?
INDIVIDUALIZATION
70
% of fetal malformations w/ Levetiracetam (Keppra®)
2.4%
71
% of fetal malformations w/ Lamotrigine (Lamictal®)
2.0%

Pharm (32 decks)

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