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701 Neuro/Psych/Sub Abuse > Week 1 > Flashcards

Week 1 Flashcards

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1
Q

Epilepsy

A
  • Neurological disorder of brain resulting in 2 or more unprovoked seizures
  • Requires professional diagnosis from neurologist
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2
Q

Simple Partial Seizure

A
  • NO loss of consciousness
  • Motor signs (jerking, lip smacking)
  • Parathesis (numbness)
  • Autonomic signs (sweating, flushing)
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3
Q

Complex Partial Seizure

A
  • Impaired consciousness
  • Purposeless behavior, glassy stare
  • Hallucinations, aggressive behavior (sometimes appears psychiatric)
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4
Q

Secondary Generalized Seizure

A
  • Partial onset which further evolves to generalized tonic-clonic seizures
  • Involves entire cerebral cortex (vs portion of brain in other partial-focal seizures)
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5
Q

Absence Seizures

A
  • Exclusively in childhood and early adolescence
  • Brief LOC, higher frequency
  • Attacks last for a few seconds and often go unrecognized
  • Sometimes diagnosed by teachers with worsening grades
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6
Q

Generalized tonic-clonic Seizures

A

“Grand Mal” seizure
- Sudden LOC
- Tonic: tensed up, loud noises, incontinence
- Clonic: convulsing/shaking

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7
Q

Atonic Seizures

A

“Drop attack”
- Occurs mainly in children
- Associated with sudden loss of postural tone (falls to ground)

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8
Q

Risk Factors (breakthrough seizures for pts with epilepsy)

A
  • Sleep deprivation
  • Missed doses of AEDs
  • Alcohol withdrawal
  • Physical/Mental exhaustion
  • Flickering lights
  • Intercurrent infections
  • Metabolic disturbances
  • Uncommon reasons (loud noise, hot bath, etc.)
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9
Q

Should patients be treated with lifelong AEDs after 1 seizure? Or multiple seizures if provoked by external factors?

A

NO

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10
Q

Predictors of favorable outcomes

A
  • Seizure free >3 years (unless structural abnormality)
  • Monotherapy
  • Normal EEG (careful)
  • NO psychomotor retardation
  • No juvenile myoclonic epilepsy
    **Longer seizure free = better prognosis
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11
Q

EEG

A

Measure of electrical activity in brain (from far perspective)
- Abnormal ONLY DURING a seizure (not in between)
***EEGs are NOT indications for confirming NOR to stop AED therapy for seizure free pts

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12
Q

Polytherapy considerations

A
  • Refractory pts
  • Inadequate response to 1st AED
  • Underlying structural abnormalities
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13
Q

Goals of Antiepileptic therapy

A

To significantly limit the frequency of seizures and manageable side effects (NOT to eliminate any chance of seizure recurrence)

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14
Q

When to consider AED withdrawal?

A
  • Normal neuro exam, IQ and EEG
  • Seizure free for at least 3 years
  • No juvenile myoclonic epilepsy
    **Must still titrate down from medication to avoid abrupt withdrawal (may provoke seizure)
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15
Q

Phenytoin (Dilantin)

A
  • Used for partial and generalized tonic-clonic (NOT absence seizures)
  • Na Channel blocker (blocks Na/Ca influx)
  • potent CYP inducer
  • *Rarely used due to narrow therapeutic index (only in developmentally disabled)
  • PO/IV
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16
Q

Phenytoin ADEs

A

Dose related: GI upset, nystagmus (rapid eye movement), sedation, potential VTE (rate injection <50 mg/min)

Non-dose related: *Gingival hyperplasia, Hirsutism, Hydantoin syndrome

17
Q

Carbamazepine (Tegretol)

A
  • MoA/clinical use similar to Phenytoin
  • *Additionally used for mania and trigeminal neuralgia
  • **Extremely potent CYP inducer of numerous drugs including autoinduction
  • 200-800 mg/day given BID
18
Q

Carbamazepine ADEs

A
  • **Hyponatremia and water intoxication (rare)
  • GI upset, drowsiness, ataxia and headache
  • Congenital deformations (avoid in pregnancy)
  • **Blood dyscrasias as fetal aplastic anemia (D/C)
  • **Mild leukopenia (Monitor dosing)
19
Q

Carbamazepine affects on WBC

A

Transient DECREASE WBC count
- Baseline CBC required prior to initiation
- Repeat CBC in 6 weeks post-initiation
- Normal to see low WBC (monitor dose)
- **If decreased counts of other cells or labs including WBC - D/C STAT

20
Q

Valproic Acid (Divalproex/Depakote)

A
  • Very effective in absence and myoclonic seizures (also gen tonic-clonic)
  • Less effective for partial seizures
  • **Beneficial for migraine ppx
  • Increases GABA content in brain
  • CYP inhibitor
  • PO (caps/syrup) or IV
21
Q

Valproic Acid ADEs

A
  • GI issues (most common due to insolubility)
  • Increased appetite/Weight gain
  • Hepatotoxicity
  • **Neural Tube Defects (contraindicated in pregnancy) – pts on VPA must visit neurologist prior to pregnancy
22
Q

Gabapentin (Neurontin)

A
  • Used in adjunct to other AED therapies
  • **Beneficial for pain due to diabetic neuropathy or postherpetic neuralgia
  • Increases GABA activity
  • Does not inhibit/induce CYP
23
Q

Gabapentin ADEs

A
  • Somnolence, dizziness, ataxia, fatigue and nystagmus
  • **Concern for abuse potential
24
Q

Lamotrigine (Lamictal)

A
  • Used as adjunct or monotherapy
  • **Beneficial for vertigo/chronic dizziness
  • Na channel blocker -> blocks excitatory neurons such as Glutamate (similar to Phenytoin)
  • **Requires SLOW titration
  • Does not inhibit/induce CYP
  • 24 hour half life (long)
25
Q

Lamotrigine ADEs

A
  • **Skin rash (potential SJS/TEN)
  • **Somnolence (requires slow titration)
  • Blurred vision, ataxia, aggression, influenza-like syndrome
26
Q

Topiramate (Topamax)

A
  • Na channel blocker as well as potentiates inhibitory effect of GABA (increased levels)
  • **Beneficial for migraine ppx and mood
  • Good absorption (80%), food has no effect
  • 18-24 hour half life
  • **Requires SLOW titration
27
Q

Topiramate ADEs

A
  • **Psychological or cognitive dysfunction (constant feeling of intoxication)
  • **Weight loss
  • **Bilateral Paresthesia (numb/tingling) – NOT unilateral (potential stroke)
  • Urolithiasis and retinal issues (increased risk with dehydration)
  • Sedation, dizziness, fatigue
  • Long flights pose potential issue…?
28
Q

Levetiracetam (Keppra)

A
  • Commonly used for most seizure types (typical drug of choice)
  • Non-competitive antagonist at AMPA glutamate receptor
  • Generally well tolerated with little ADEs (potential weight gain)
  • Enhances CNS depressants
29
Q

Levetiracetam Dosing

A

IR (tabs, sol, susp): 500mg BID
- increase every 2 weeks by 500mg based on tolerability to max dose 1.5g BID

ER (*only approved for focal (partial) onset seizures): 1,000mg QD
- increase every 2 weeks by 1g based on tolerability to max dose 3g QD

30
Q

Oxcarbazepine (Trileptal)

A
  • Very similar mechanism to CBZ (Na channel blocker)
  • **Good alternative for those on Carbamazepine and well controlled (encouraged transition) due to decreased ADEs
31
Q

Vigabatrin (Sabril)

A
  • Drug of choice for infantine spasms
  • Inhibits GABA metabolizing enzyme and increases GABA in brain (similar to VPA)
  • Alternative AED option (works well, significant ADE profile)
32
Q

Vigabatrin ADEs

A
  • **Visual field defects
  • **Psychosis and depression (continue to gradually worsen)
33
Q

Zonisamide (Zonegran)

A
  • Add on therapy for partial seizures
  • Prolongation of Na channel inactivation
  • No CYP enzyme affects
  • 50-68 hour half life
  • ADEs: Drowsiness, ataxia, loss of appetite, N/V, somnolence
34
Q

Tiagabine (Gabitril)

A
  • Adjunctive therapy in partial and generalized tonic-clonic seizures
  • Inhibits GABA uptake and increases levels of GABA in brain
  • ADEs: Asthenia (weakness/lack of energy), sedation, dizziness, mild memory impairment, abdominal pain
35
Q

Clinical Advices for AED use in Epilepsy

A
  1. Essential to have accurate and comprehensive diagnosis by neurologist
  2. Must treat underlying causes of seizures (hypoglycemia, infection, tumors, etc.)
  3. Description of symptoms from both patient and witness of seizure
  4. EEG’s are ONLY SUPPORTIVE (not for confirmation)
36
Q

First Aid for Seizures

A
  • **Record time of seizure onset (call 911)
  • Prevent pt from hurting themself (soft object under head)
  • Do not force objects in pt’s mouth
  • Turn pt on side to allow saliva drainage
  • Do not pour liquid or offer any food/medications until pt is fully awake
  • Give CPR if pt does not begin breathing ~2mins after convulsions (common to stop breathing during tonic-clonic)

701 Neuro/Psych/Sub Abuse (2 decks)

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