Seizures/Epilepsy Flashcards by Tinos Worksew

Valproic Acid:

BBW
Warnings
ADE

Hepatic failure
Pancreatitis
Pregnancy category X

Hyperammonemia
Thrombocytopenia

Alopecia
Weight gain

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Why is Brivaracetam better than Levetiracetam?

It has less incidence of mood, psychotic ADE

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Seizure pathophysiology

Deficiency of Gamma-aminobutyric acid (GABA)

Excess of Glutamate, NA, and Ca channels

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When do we treat epilepsy with meds?

Consider early treatment if a seizure is clearly unprovoked and :

an epileptiform EEG
structural lesions
history of status epileptics
variable known to prove a seizure that cannot be modified due to clinical necessity

(note: Patients are allowed to have 1 seizure without having to be treated long term if there is no reoccurrence)

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What are the common ADE of all anti-epileptic drugs?

Anti-epileptic drugs are depressants.
Cause:
Dizziness
Confusion
Sedation 
Ataxia/Coordination difficulties
Bone loss
Suicide risk

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Why is Clobezam better than Clonazepam?

Less sedating

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What drug is closely related to Topamax

Zonisamide

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Carbamazepine
Oxcarbazepine
Eslicarbazepine

ADE

Hyponatremia

Rash

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Phenobarbital clinical peral

Has a few days of half life and therefore may need a loading dose
Also used in neonates

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Which anti-epileptic drugs are inducers and which are inhibitors?

Enzyme inhibitor : Valproic acid

Enzyme inducers : All other anti-epileptic drugs

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Which anti-epileptic drugs cause an increase in GABA?

Benzodiazepines
Valproic acid
Phenobarbital

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Lacosamide warning

Prolongs PR interval

Increase risk of arrhythmias

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What is the brand name of Lacosamide and what is the schedule?

Vimpat

Class V

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In the treatment of Status Epileptics, what is the usually dose for IV loading dose of anti-epileptic drugs?

20mg/kg

Except for Keppra

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Which anti-epileptic drugs can cause SJS/TEN?

Lamotrigen
Carbamazepine
Oxcarbazepine
Eslicarbazepine

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Which anti-epileptic drugs have a high risk of causing neural tube defects in utero?

Valproic acid

Carbamazepine

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Status Epileptics (SE) treatment?

0-5 min: Stabilization Phase

Time the seizure
Start EEG, O2 prn
Check AED levels, electrolytes, BG

5 - 20 min: Initial treatment phase (if seizure continues)

Give IV Lorazepam (perferred)
Or IV Medazolam
OR PR Diazepam

20 - 40 min: Second treatment phase (if seizure continues)
- Give regular AED, IV fosphenytoin, Valproic acid, Levetiracetam (or phenobarbital if others are unavailable)

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What is the BBW and special ADE of Lamotrigine?

Serious skin reaction (SJS/TEN)

Alopecia (treatment: supplement selenium and zinc)

Remember: D-D interaction with Valproic acid

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What is the guideline in starting meds in treating epilepsy?

Start with mono therapy
Titrate up slowly.

If patient is experiencing too much ADE or not working then slowly titrate down while titrating up on another mono therapy.
Titrate up on the 2nd mono therapy.

If still uncontrolled, start add on agents

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What is it called when patient has a focal seizure with awareness and without awareness?

With awareness:
Focal aware seizure aka Simple Partial seizure

Without awareness:
Focal seizure with impaired awareness aka Complex Partial seizure

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Which anti-epileptic drugs are Ca channel blockers?

Pregabalin

Gabapentin

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What electrolyte can cause seizures

Sodium (hypo or hyper )

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What is the prodrug of Phenobarbital?

Primidone (Mysoline)

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Clinical peril of Topamax

Dopamax

make people dumb

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What kind of seizure is characterized with brief, subtle momentary loss of awareness?

Absence Seizure Always are categorized as general Can sometimes be misdiagnosed for ADHD

Phenobarbital Warning ADE

Habit forming Respiratory depression Pregnancy category X Physiological dependence Tolerance Hangover effect

What kind of seizure is characterized with rigid or tense muscle and rhythmical uncontrolled jerking movement?

Tonic-Clonic Seizure | the violent seizures with falls and jerks

Phenytoin/Fosphenytoin BBW Warnings ADE

These drugs are non-linear IV administration of Phenytoin should not exceed 50mg/minute and Fosphenytoin should not exceed 150 PE/minute Fast infusion can cause cardiac arrhythmias Extravastion leading to Purple Glove Syndrome HLA-B*1502 in Asian due to metabolism changes Pregnancy category X Dose related: Nystagmus Ataxia Diplopia/blurred vision Long term use: Gingival hyperplasia Hair growth Hepatotoxicity

What are some non med, alternative treatments for seizures?

Marijuana Ketogenic diet Vagal nerve stimulation Surgical intervention

Which anti-epileptic drugs cause Hyperammonemia?

Valproate | Topiramate

Which anti-epileptic drugs are considered broad-spectrum?

Lamotrigine Levetiracetam Topiramate Valproic Acid

Phenytoin/Fosphenytoin therapeutic range?

1 - 2.5 mcg/ml (free level) 10 -20 mcg/ml (total level)

What is the dose adjustment formula for phenytoin?

Phenytoin correction = total phenytoin measured/ ((0.2 * albumin) + 0.1)

What kind of seizure is characterized with muscle twitching or jerking ?

Myoclonus

Valproic Acid therapeutic range?

50 - 100 mcg/ml

Dose Phenytoin or Fosphenytoin have a lower risk of purple-glove syndrome? Which one can be infused faster?

Fosphenytoin for both

What with the difference b/w Cabamezapine and Oxcarbazepine?

Oxcarbazepine doesn't auto-induce. | Not a prodrug

What drug has a very narrow spectrum of activity and is only used in the treatment of one type of seizure?

Ethosuximide = Absence seizures

Which anti-epileptic drugs cause alopecia and what is the treatment?

Lamotrigine Valproic Acid Treatment: supplement selenium and zinc

What is Epilepsy?

A chronic seizure disorder Def for diagnosis: - 2 unprovoked seizures separated by 24 hours - 1 unprovoked seizure if the chance of reassurance is over 60% per physician

What is the starting and maintenance dose of Lamotrigine?

Initial: 25mg PO QD Maintenance: 300 - 400mg PO QD or divided BID Starter kit color coding: Orange: standard dose with no d-d interaction Blue: lower dose with d-d interaction with valproic acid Green: Higher dose with enzyme inducers

Which anti-epileptic drugs are Na channel blockers (usually used for focal seizure)?

``` Carbamezepine Lacosamide Lamotrigine Phenytoin/Fosphenytoin Topiramate ```

Which anti-epileptic drugs are considered narrow-spectrum?

``` Carbamazepine Oxcarbazepine Lacosamide (Vimpat) Phenobarbital Phenytoin/Fosphenytoin ```

How are epilepsy diagnosed?

EEG

What kind of seizure is characterized with limp or weak muscles?

Atonic

What vitamins or supplements do we need to consider taking when on anti-epileptic drugs?

With all AED: Calcium and Vitamin D Women of childbearing age: Folate Valproic acid: possibly carnitine Lamotrigine and Valproic acid: if alopecia, supplement with selenium and zinc

Levetiracetam warning?

***Mood is one big problem to watch for with Keppra Psychiatric reactions, including psychotic symptoms, somnolence, fatigue

What are Status Epileptics (SE) seizures?

Seizures which last more than 5 minutes If more than 30 min, can cause brain injury

Phenobarbital therapeutic range?

20 - 40 mcg/ml

Carbamazepine therapeutic range?

4 - 12 mcg/ml

What are Focal seizures?

Seizures which start on one dose of the brain but can spread to the other side.

Oxcarbazepine warning

Serious skin reaction (SJS/TEN) HLA-B*1502 in Asian due to metabolism changes (which can cause SJS/TEN) Hyponatremia

What anti-epileptic drugs is an auto- inducer?

Cabamezapine

Which anti-epileptic drugs cause permanent vision loss?

Vigabatrin (Sabril, Vigadrone)

Topiramate , Zonisamide ADE

Weight loss Metabolic acidosis Nephrolithiasis Oligohidrosis/hyperthermia (in children)

Clinical peril with Gabapentin?

Needs renal dose adjustments and can cause peripheral edema

Which anti-epileptic drugs cause blocking of both Na and Ca channels?

Oxcarbazepine

Which anti-epileptic drugs cause both an increase in GABA and blocks Ca channels?

Levetiracetam

What are Generalized seizures?

Seizures which start on both sides of the brain Always has a loss of conciseness

What are some drugs which can decrease the threshold of seizure? (10)

``` Bupropion Clozapine Theophylline Varenicline Carbepenems (esp. Imipenem) Lithium Meperidine Penicillin Quinolones Tramadol ```

Other than for epilepsy, what other condition is Topiramate used for?

Migraine prophylaxis

Topiramate Warnings ADE

``` Metabolic acidosis Oligohidrosis (reduced perspiration/hyperthermia Nephrolithiasis (kidney stones) Angle-closure glaucoma Hyperammonemia Fetal harm ``` Memory/concentration/attention loss Weight loss Anorexia

What are generalized seizures with non motor symptoms called?

Absence seizures

Pregabalin Gabapentin ADE

Weight gain Peripheral edema Mild euphoria Usually used for neurotic pain

Which anti-epileptic drugs has a sulfa allergy attached to it?

Zonisamide (Zonegran)

``` Phenobarbital Primidone (prodrug of Phenobarbital) ``` ADE

Dependence/tolerance/overdose risk

At what point can anti-epileptic drugs be discontinued?

If patient is without a seizure for 1 to 2 years

Carbamazepine BBW Contraindication Warning

Serious skin reaction (SJS/TEN) HLA-B*1502 in Asian due to metabolism changes (which can cause SJS/TEN) Aplastic anemia Agranulocytosis Myelosuppression Hyponatremia (SIADH) Pregnancy category X