26 - Seizures/Epilepsy

Question 1

non-pharms for seizure

Answer 1

• avoid sleep deprivation
• keep alcohol consumption to a minimum
• avoid cocaine and amphetamines
• ketogenic or atkins diet may decrease seizure frequency
• yoga or mildfulness-based therapy may help

Question 2

if sensitive to phenytoin, avoid _____

Answer 2

carbamazepine

Question 3

first line for absence seizures

Answer 3

ethosuximide

Question 4

What is primidone’s active metabolite?

Answer 4

phenobarbital

Question 5

Definition of epilepsy?

Answer 5

-either 2 unprovoked seizures occurring more than 24 hours apart, 1 unprovoked seizure at a high (>60%) probability of further seizures over the next 10 years or 1 unprovoked seizure and a clearly identifiable epilepsy syndrome

Question 6

An aura indicates the onset of what type of seizure?

Answer 6

focal (partial) seizure

Question 7

What is a simple partial seizure?

Answer 7

• focal seizures without impairment of awareness

- usually brief, less than 60 seconds

Question 8

What is a complex partial seizure?

Answer 8

focal seizures with impairment of awareness

-usually last 1-2 mins

Question 9

List the 4 types of generalized seizures

Answer 9

• Absence
• Generalized tonic-clonic
• Atonic
• Myoclonic

Question 10

Describe an absence seizure (petit-mal)

Answer 10

• usually lasts only 5-10 seconds
• can recur daily
• no warning signs
• onset in childhood

Question 11

Describe a generalized tonic-clonic seizure (grand-mal)

Answer 11

• tonic/clonic phases

- can begin as a focal seizure or can involve entire brain at onset

Question 12

Describe an atonic seizure

Answer 12

• abrupt loss of consciousness and muscle tone

- return to awareness in seconds

Question 13

Describe myoclonic seizures

Answer 13

-“shock-like” jerks

Question 14

Which AEDs can we measure serum levels for

Answer 14

phenytoin, phenobarbital, primidone, CBZ, VPA

Question 15

First choice monotherapy for generalized tonic-clonic

Answer 15

• CBZ
• lamotrigine
• levetiracetam
• phenytoin
• VPA/divalproex

Question 16

First choice montherapy for absence seizures

Answer 16

ethosuximide

Question 17

First choice monotherapy for myoclonic and atonic seizures

Answer 17

VPA/divalproex

Question 18

First choice monotherapy for focal (partial) seizures with or without secondary generalization

Answer 18

• CBZ
• lamotrigine
• levetiracetam
• phenytoin

Question 19

Women of childbearing age taking an AED should receive what daily supplementation to prevent neural tube defects?

Answer 19

folic acid 1 mg daily

Question 20

_____ may be better tolerated than CBZ and have similar effectiveness in obtaining long-term seizure freedom

Answer 20

lamotrigine

Question 21

____ may be superior to lamotrigine and topiramate

Answer 21

VPA

Question 22

For childhood absence epilepsy, ____ and _____ are similarly effective in preventing seizures and both meds are superior to lamotrigine

Answer 22

ethosuximide and BPA

Question 23

Ethosuximide is associated with lower rates of ______ difficulties than VPA so it is first choice for childhood absence epilepsy

Answer 23

attention

Question 24

For patients with traumatic brain injury, AEDs prevent seizures in the first ___ days after the injury but have no effect on development of later seizures

Answer 24

7

Question 25

What are some dose-related adverse effects of AEDS? | How do you manage them?

Answer 25

- dizziness, sedation, fatigue, cognitive and psychiatric symptoms, nausea - try reducing the dose or slow release formulation or more frequent administration with lower doses of IR AED

Question 26

What is an idiosyncratic reaction to AED?

Answer 26

skin rash

Question 27

Which AEDs are most likely to cause skin rash

Answer 27

phenytoin, CBZ, lamotrigine

Question 28

When is rash most likely to occur?

Answer 28

within 6 weeks but can occur at any time

Question 29

If a definite drug rash develops, how do you manage this?

Answer 29

stop AED. Continuation can result in SJS

Question 30

What type of people are at higher risk for CBZ-associated rash?

Answer 30

Han Chinese descent with certain human leukocyte antigen (HLA) status *consider checking HLA status in these patients before starting CBZ therapy

Question 31

AEDs can also cause other idiosyncratic reactions such as ?

Answer 31

hematopoiesis or hepatic toxicity

Question 32

Long-term use of enzyme-inducing AEDs and VPA have been associated with what?

Answer 32

increased risk fo low bone density and fracture

Question 33

Pre-pregnancy considerations: | Ideally if patient on COC, how much estrogen should it have if they're on enzyme inducing AED?

Answer 33

> 50 mcg EE but no COC products currently available with EE > 35 mcg

Question 34

Pre-pregnancy considerations: | What are some options for women to prevent pregnancy on enzyme inducing AEDs?

Answer 34

- depot shot - IUD (hormonal and non-hormonal) - barrier contraception (less effective)

Question 35

Pre-pregnancy considerations: | Which AED is actually decreased by COCs?

Answer 35

lamotrigine * levels can be expected to drop by at least 50% after starting COC * consider doubling lamotrigine dose after starting a COC

Question 36

If they are pregnant and on an anti-epileptic drug that will not be stopped, how much folic acid and when do they need it?

Answer 36

- Ideally 1mg folic acid daily at least 3 months prior to conception until 12 weeks gestation - Then from 12 weeks gestation continuation through pregnancy and for 4-6 weeks postpartum or as long as breastfeeding continues, they need folic acid 0.4-1mg daily.

Question 37

Which AEDs are associated with low rates of teratogenicity?

Answer 37

lamotrigine, levetiracetam and oxcarbazepine

Question 38

Levels of AEDs can ____ when pregnancy due to increased clearance

Answer 38

decrease

Question 39

If a pregnant person is controlled on an AED that may cause teratogenic effects do you switch?

Answer 39

No, the risk of congenital malformations is highest in 1st trimester when many women don't even know they are pregnant A change in controlled therapy puts person at risk of another seizure which can harm the mom and fetus

Question 40

What vitamin is routinely given to all newborns of a mom on an AED?

Answer 40

vitamin K bc enzyme-inducing AEDs can potentially increase the degradation of vitamin K in the fetus

Question 41

Do you still recommend breastfeeding while on AED?

Answer 41

Yes

Question 42

Infants whose mothers are taking _____ may be sedated

Answer 42

barbiturates

Question 43

AED levels may _____ after delivery

Answer 43

increase

Question 44

If a patient is controlled but they are below the serum target range, do you increase the drug.

Answer 44

no - "treat the patient, not the serum level"

Question 45

Is CBZ a pro drug?

Answer 45

yes

Question 46

100 mg phenytoin sodium = ___ mg phenytoin base

Answer 46

92