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Clinical Pharmacology & Intro to Prescribing > Session 13: Epilepsy > Flashcards

Session 13: Epilepsy Flashcards

1
Q

Define seizure.

A

A transient occurrence of signs or symptoms due to abnormal electrical activity in the brain which leads to a disturbance of conscious, emotion, behaviour, motor function and sensation.

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2
Q

What happens if you stimulate glutamate and NMDA receptors?

A

They are channels that let Na+ and Ca2+ in and K+ out leading to depolarisation and increased excitation of the neurons.

This means the neuron is more likely to fire and action potential.

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3
Q

Explain what happens if you stimulate GABA and GABAa receptors?

A

They open channels that let Cl- in which will hyperpolarise the membrane and lead to a less likelihood of an action potential firing.

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4
Q

Give general causes of a seizure.

A

Genetic differences in brain chemistry and receptor structure i.e. genetic epilepsy syndrome.

Drugs that stimulate receptors

Drug withdrawal or metabolic changes leading to an acquired change in brain chemistry.

Strokes/Tumours

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5
Q

Signs and symptoms of a seizure

A

Often an aura before seizure begins.

Shaking

Loss of consciousness with changes in muscle tone and biting (generalised seizure)

In a tonic-clonic seizure there is an initial hypertonic phase followed by rapid clonus (shaking/jerking)

Post-ictal phase which can last from minutes to hours.

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6
Q

Defintion of epilepsy.

A

Seizure does not mean epilepsy

It is diagnosed by a specialist.

At least two unprovoked seizures occurring more than 24 hours apart.

One unprovoked seizure and a probability of further seizures similar to the general recurrence risk after two unprovoked seizures.

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7
Q

What is a reflex seizure?

A

A seizure brought on by stimulus.

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8
Q

Give examples of reflex seizures.

A

Photogenic

Phonogenic/Musicogenic

Thinking

Eating

Hot water immersion

Reading

Orgasm

Movement

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9
Q

What type of onsets of seizures are there?

A

Focal onset

Generalised onset

Unknown onset

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10
Q

How can focal onset be subdivided?

A

Aware focal onset

Impaired awareness focal onset

Motor onset or nonmotor onset

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11
Q

How can generalised onset be subdivided?

A

Motor onset (tonic-clonic)

Or nonmotor onset (absence)

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12
Q

What is focal to bilateral tonic-clonic?

A

A focal onset seizure that becomes a generalised tonic-clonic seizure.

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13
Q

Which types of generalised motor onset seizures are there?

A

Tonic-clonic

Myoclonic

Atonic

and many more…

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14
Q

Explain the spread of a generalised seizure.

A

Originate at some point within and rapidly engage bilaterally distributed networks.

This can include cortical and subcortical structures but not necessarily the entire cortex.

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15
Q

Explain the origin and spread of a focal seizure.

A

Originate within networks limited to one hemisphere.

May be discretely localised or more widely distributed.

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16
Q

What is a grand mal?

A

A generalised seizure

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17
Q

What is a petit mal?

A

An absence seizure

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18
Q

What is a partial seizure?

A

A focal seizure

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19
Q

Give examples of provoked seizures.

A

Drug use or withdrawal

Alcohol withdrawal

Head trauma and intracranial bleeding

Hyponatraemia/hypoglycaemia

Meningitis and encephalitis

Febrile seizures in infants

Uncontrolled hypertension

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20
Q

Differential diagnoses of seizures

A

Vasovagal syncope

Reflex anoxic seizures

Arrhythmias

Parkinson’s

Huntington’s

TIAs

Migraines

Non-epileptic attack disorders

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21
Q

Initial management of a seizure.

A

A-E assessment

Airways

Breathing - sats reading

Circulation (expect a high HR and be wary of the BP as drugs might drop BP)

Disability - consciousness state

Exposure

22
Q

Why should you set a timer for 5 minutes at the onset of a seizure?

A

Because the majority of seizures will self-terminate without the use of drugs.

Therefore a timer is set for 5 minutes and if it is still going give seizure terminating drugs.

23
Q

Define status epilepticus.

A

A seizure lasting more than 5 minutes or more, or multiple seizures without a complete recovery between them.

Has a mortality of around 20% after 30 days.

24
Q

Explain the pharmacological approach to a seizure.

A

Wait 5 minutes.

Give benzodiazepines

If that doesn’t work give benzodiazepines again.

If that doesn’t work give a loading dose of phenytoin or levetiracetam.

If that doesn’t work call intensive care/anaesthetics to give thiopentone or other anaethesia. This must be done by a specialist.

25
Q

Explain the mechanism of action of benzodiazepines.

A

GABAa agonist.

Increases the Cl- conductance leading to a more negative resting potential and the neuron less likely to fire.

No firing nuerones = no seizure.

Benzos work best when membrane positive like in a seizure.

26
Q

Other uses for benzos.

A

Anxiolytics

Sleep aids

Alcohol withdrawal

27
Q

ADRs of benzos

A

Addiction

Cardiovascular collapse

Airway issues

28
Q

Give benzodiazepine options and what to give in status epilepticus.

A

Intravenous lorazepam

Rectal diazepam (can be difficult)

Buccal or intranasal midazolam - beware of biting - might be easier to give if no cannula.

29
Q

Investigations of epilepsy

A

EEG - Electroencephalography

Imaging such as MRI

30
Q

Explain how EEGs are performed.

A

Record of electrical pattern of activity in the brain.

It relies on catching an episode in the act or an abnormal pattern.

Also a lot of people without epilepsy have abnormal EEGs.

Usually done by a sleep deprived EEG

31
Q

Give examples of Anti-Epileptic drugs.

A

Carbamezapine

Phenytoin

Valproate

Lamotrigine

Levetiracetam

Benzodiazepines (for seizure termination)

32
Q

Why are anti-epileptic drugs important?

A

Because of sudden unexplained death in epilepsy (SUDEP)

33
Q

Explain the mechanism of action of carbamezepine.

A

Sodium channel blocker (also used in bipolarity and sometimes in chronic pain)

34
Q

Side-effects of carbamezepine.

A

Suicidal thoughts

Joint pain

Bone marrow failure

35
Q

Explain the mechanism of action of phenytoin.

A

Sodium channel blocker used mainly in status epilepticus or as an adjunct in generalised seizures.

36
Q

Side effects of phenytoin

A

Bone marrow suppression

Hypotension

Arrhythmias

37
Q

Why is it important to monitor the administration of phenytoin?

A

Because it exhibits zero order kinetics meaning that it doesn’t decrease via half-life but linearly instead.

This means that giving a larger dose will exhibit the same metabolism.

38
Q

Explain the mechanism of action of sodium valproate.

A

A mix of GABAa effects and sodium channel blockade.

The 1st line for generalised epilepsies.

39
Q

Specific side effects of sodium valproate.

A

Liver failure

Pancreatitis

Lethargy

40
Q

Explain the action of lamotrigine

A

Sodium channel blocker and also affects calcium channels.

It is especially good for focal epilepsy and often used where valproate is contraindicated in generalised epilepsy.

41
Q

Explain mechanism of action of levetiracetam.

A

Synaptic vesicle glycoprotein binder that stops the release of neurotransmitters into the synapse and reduces neuronal activity.

This is a good option for focal seizures and generalised seizures.

Safe in pregnancy

42
Q

Side effects of anti-epileptic drugs.

A

Tiredness/Drowsiness

Nausea and vomiting

Mood changes and suicidal ideation

Osteoporosis

Steven-Johnson syndrome/Rashes

Anaemia, thrombocytopenia, bone marrow failure

43
Q

Carbamezepine and phenytoin DDIs.

A

May decrease the effectiveness of oral contraceptive pills.

May decrease the effectiveness of some antibiotics

44
Q

Valproate DDIs

A

Can increase the plasma concentration of other AEDs.

45
Q

AEDs that are inducers of CYP 450 enzymes

A

Phenytoin

Carbamazepine

Barbituates

46
Q

AEDs that are inhibitors of CYP 450 enzymes

A

Valproate

47
Q

How do you start someone on AEDs?

A

Look at guidelines.

Start at a low dose and build up.

Trial of drug and see how patient responds. Look for the efficacy of the drug and the side effects.

Aim for the patient to be seizure free with minimal or acceptable side-effects.

Transition to a new agent should be done carefully.

48
Q

What are the risks of AEDs and especially valproate in pregnancy?

A

Risk of congenital malformations (10%)

Valproate should not be prescribed to any woman of childbearing age unless they meet the conditions of a pregnancy prevention programme.

49
Q

Which are the safest AEDs in pregnancy?

A

Lamotrigine and particularly levetiracetam.

50
Q
A

Clinical Pharmacology & Intro to Prescribing (24 decks)

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