- levetiracetam - lamotrigine - valproate - topiramate - clobazam - felbamate - perampanel - rufinamide

therapeutics Flashcards by Tim Pulleyn

epilepsy treatment goals

complete elimination of seizures
no medication adverse effects
optimal quality of life

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main reason seizure drugs fail

nonadherance

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common comorbidities of epilepsy

depression
anxiety
suicide risk

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patient quality measures pharmacist is involved in

evaluation of seizure frequency
querying and counseling about ASD side effects
counseling about epilepsy safety issues
counseling women of childbearing age

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what can trigger seizures

metabolic disturbances
cerebral trauma
intracranial hemorrhage
tumor
stroke
medication nonadherance

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risk of seizure in diabetes

diabetic ketoacidosis and hypoglycemia can trigger seizure activity

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drugs that may induce seizures

bupropion
theophylline
meperidine
tramadol
antipsychotics
antibiotics
amphetamines, cocaine

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drugs that may cause seizures after withdrawal

alcohol
barbiturates
benzodiazepines
ASDs

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when is greatest risk of 2nd seizure following an unprovoked seizure

in the first 2 years after the 1st unprovoked

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drug of choice for absence seizures

ethosuximide

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drug of choice for infantile spasms

vigabatrin

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broad spectrum ASD

levetiracetam
lamotrigine
valproate
topiramate
clobazam
felbamate
perampanel
rufinamide

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broad spectrum ASD can be used to treat

focal and generalized seizures

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how to start patient on a new ASD

start at the low dose and titrate up, following dosing guidelines

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ethosuximide adverse effects

nausea/vomiting, depression, rash

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how to change from one drug to another

titrate the 2nd drug to its max dose and then taper off the 1st drug

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common CYP450 inducers

phenytoin
carbamazepine
oxcarbazepine
phenobarbital

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common CYP450 inhibitor

valproate

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autoinduction

the process of a drug inducing a CYP enzyme that then metabolizes the drug, causing levels to become subtherapeutic

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drugs associated with skin reactions

carbamazepine
phenytoin
lamotrigine
oxcarbazepine
eslicarbazepine

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drug associated with autoinduction

carbamazepine

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drug associated with protein binding

phenytoin

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highest risk of bone loss tied to which drugs

phenytoin

phenobarbital

special considerations for elderly

drug interactions
hypoalbuminemia
body mass changes
neurocognitive AEs
may need lower serum conc.

special considerations for young

- increased body water - may require higher doses - rapid changes in metabolism

special considerations for women

- hormones may affect electrical excitability - estrogen (proconvulsant)/progesterone (anticonvulsant) - DDI with oral contraceptives - catamenial seizures

catamenial seizure

seizure before/during menstrual flow and at times of ovulation

seizures in pregnancy

- not contraindicated - increased seizures by 25-30% - must have adequate folic acid

drugs that have risk of neural tube defect

valproic acid | carbamazepine

risk of teratogenic effects with which ASDs

phenobarbital phenytoin topiramate

avoid valproic acid and ASD polypharmcy when

1st trimester of pregnancy

when can you stop ASDs

- seizure free for 2-5 years - history of single type of seizure - normal neuro exam and IQ - EEG normalized

how to stop an ASD

always taper

most seizures last how long

<2 minutes

status epilepticus

seizure lasting over 5 minutes

status epilepticus associated with

brain damage or death

types of status epilepticus

- generalized convulsive status epilepticus (tonic/clonic) | - nonconvulsive status epilepticus (altered consciousness/behavior)

most generalized convulsive status epilepticus seizures occur in who

individuals with no history of epilepsy

highest risk of status epilepticus

< 1 y/o and over 60 y/o

phase I of GCSE

- increased BP and HR - muscular contraction+hypoxia = lactic acid release and acidosis - airway obstruction - aspiration pneumonia risk

phase II of GCSE

- hypotensive - decreased cerebral blood flow - hypoglycemia - hyperthermia

treatment steps of patient undergoing status epilepticus

1. stabilize airway 2. note onset time, get vitals, identify precipitating factors 3. terminate seizure 4. prevent recurrence

drugs used for termination of status epilepticus

benzodiazepines | possibly phenytoin or barbiturates

benzodiazepine that can be given nasally

midazolam

initial hospital care for seizures

-assess airway and heart function -IV access -begin IV fluids o Thiamine 100 mg for adults o pyridoxine 50-100 mg for infant -glucose if BG <60 -naloxone if suspected narcotic OD -antibiotic if suspected infection

benzodiazepine given in hospitals for seizure

IV lorazepam

why are benzo's used to terminate seizures

- work very quickly (2-3 mins) | - shorter half life in CNS

after benzo is given in hospital what to we give after

IV phenytoin or fosphenytoin

benefits of phenytoin in termination of seizures in hospital

- long half life | - less respiratory depression and sedation

problems in using phenytoin in termination of seizures in hospital

- cannot be given rapidly - must be diluted to 5mg/ml in NS - max rate of 50 mg/min

fosphenytoin

- water soluble phenytoin prodrug - no propylene glycol - converts 100%

how do we dose fosphenytoin

in phenytoin equivalents

drugs for refractory seizures (>60 minutes) in hospital

IV midazolam IV pentobarbital IV propfol

when do refractory seizures occur

when adequate doses of benzo's, hydantoin, or barbiturate have failed

what drug can be given rectally to terminate a seizure

diazepam