Dr.Ott Seizure disorder

Question 1

Risk factors for seizure recurrence

Answer 1

<2 years seizure free
onset of seizure after age 12
2-6 years before good seizure control in treatment
withdrawal of phenytoin or valproate

Question 2

What is status epilepticus and what can we use to treat it

Answer 2

A continuous seizure lasting 5 minutes or more, or two seizures back to back with incomplete recovery between them
Treatment
- benzodiazepines: lorazepam, midazolam

Question 3

Treatment of status epilepticus treatment

Answer 3

0-5 minutes
- start ECG and oxygen
5-20 minutes
- IV lorazepam or IV midazolam
20-40 minutes
- if not controlled IV fosphenytoin, IV valproic acid

Question 4

Oral phenytoin dosing considerations

Answer 4

must obtain both phenytoin serum concentration and serum albumin in the same blood draw
therapeutic serum concentration range - 10-20

Question 5

Valproate dosing

Answer 5

IV to PO conversion 1;1mg/mg
desired serum concentration = 80mcg/mL

Question 6

First line treatment for Partial onset (focal onset)

Answer 6

Carbamazepine
Lamotrigine
Levetiracetam
Oxcarbazepine
Phenytoin
Pregabalin
Valproate

Question 7

First line treatment for Tonic- Clonic (generalized)

Answer 7

Carbamazepine
Lamotrigine
Oxcarbazepine
Phenobarbital
Phenytoin
Valproate

Question 8

First line treatment for Absence Generalized

Answer 8

Ethosuximide
Lamotrigine
Valproate

Question 9

First line treatment for Myoclonic (Focal or generalized)

Answer 9

Levetiracetam
Topiramate
Valproate

Question 10

First line treatment for Lennox-Gastaut Syndrome

Answer 10

Felbamate
Lamotrigine
Rufinamide
Topiramate
Valproate

Question 11

First line treatment for Atonic (generalized)

Answer 11

Valproate
Lamotrigine
Rufinamide
Topiramate

Question 12

Cyp1A2 inducers

Answer 12

Carbamazepine
phenobarbital
phenytoin

Question 13

Cyp2C9 inducers

Answer 13

Carbamazepine
phenobarbital
phenytoin

Question 14

Cyp3A4 inducers

Answer 14

Carbamazepine
phenytoin
Lamotrigine
oxcarbazepine
topiremate
phenobarbital

Question 15

UGT inhibitors

Answer 15

Valproate

Question 16

DRESS syndrome

Answer 16

life threatening
generally occurs 2-6 weeks after initiation of drug therapy
increase risk in patients who are positive for the HLA-A*3101

Question 17

which drugs are associated with causing DRESS syndrome

Answer 17

Carbamazepine, Cenobamate, lamotrigine, phenobarbital, phenytoin, valproate, zonisamide

Question 18

Anti-seizure drug therapy in pregnancy

Answer 18

Drug serum concentration may change during pregnancy due to volume of distribution

Valproate not used in pregnancy because may lower IQ of fetus
Supplemental folic acid (5mg daily) should be considered during pregnancy
Infants should receive vitamin K 1mg IM at birth to decrease risk of hemorrhagic disease

Question 19

Antiseizure drug withdrawal syndrome

Answer 19

abrupt discontinuation
may cause recurrence of seizures, doses of antiseizure medication should always be tapered for discontinuation

Question 20

Contraceptive drug interaction

Answer 20

This interaction can be minimized by using higher dose estrogen contraceptives- warning for increased thromboemoblism
can use progestin only contraceptives- depot forumulation
estrogen can significantly decreased lamotrigine serum concentration (50%) and lamotrigine decreased estrogen concentration

Question 21

Psychiatric side effects of anti-seizure medications

Answer 21

Levetiracetam - psychosis, suicidal thoughts, unusual mood changes, worsening depression
Perampanel - boxed warning - dose related serious and life theratening neuropsychiatric events
Valproate - acute mental status changes related to hyperammonemia
Topiramate - associated with cognitive dysfunction if the dose is increased too rapidly, use a slow dose titration

Question 22

Visual abnormalities

Answer 22

Topiramate - post marketing warning for vision loss, myopia, retinal detachment
vigabatrin is contraindicated in patients who have other risk factors for irreversible vision loss.

Question 23

Carbamazepine interactions

Answer 23

Carbamazepine: strong P450 (1A2, 2C9, 2C19, 3A4) and p-glycoprotein inducer (induces own metabolism)
Oxcarbazepine induces 3A4

Question 24

Valproate clinical pearl

Answer 24

valproate can cause thrombocytopenia - monitor CBC/Platelets can cause PCOS, Weight gain, sedation