epilepsy

Question 1

what is the aim of epilepsy control

Answer 1

prevent the occurrence of seizures by maintaining an effective dose of one or more antiepileptic drugs

Question 2

what should you consider when choosing an antiepileptic drug

Answer 2

• first the presenting epilepsy syndrome
• If the syndrome is not clear, the seizure type should determine the choice of treatment
• note you should also take into account patients other medication, co-morbidity, age, and sex*

Question 3

what determines the dosage frequency of antiepileptic drugs

Answer 3

The plasma half life.

- frequency of doses should be kept as low as possible to encourage adherence to meds

Question 4

which antiepileptics can be given once daily due to their long half life

(acronym: LPPP)

Answer 4

• Lamotrigine
• perampanel
• phenobarbital
• phenytoin

Question 5

how do you switch a patient from one antiepileptic to another

Answer 5

• if first line monotherapy has failed, check the diagnosis again and then consider starting a second drug (monotherapy)
• slowly withdraw the first drug only when the new regimen with the second drug has been established

Question 6

what are the disadvantages of combination therapy with antiepileptics

Answer 6

increased risk of:

• adverse reactions
• drug interactions

note monotherapy with antiepileptics should be prescribed whenever possible

Question 7

why should patients/carers be advised to report any mood changes, distressing thoughts/feelings when taking antiepileptics

Answer 7

because all antiepileptics are associated with an increased risk of suicidal thoughts and behaviours

note this can be seen as early as 1 week into treatment

Question 8

Should a patient taking antiepileptics stop treatment if they are experiencing suicidal thoughts/behaviours

Answer 8

No, do not stop or switch antiepileptic treatment. Seek advice from a healthcare professional if concerned

Question 9

why are antiepileptic drugs categorised into 3 risk-based categories

Answer 9

to help healthcare professionals decide whether it is necessary to supply a specific manufacturers version of antiepileptic drug

Question 10

what are the 3 risk-based categories of antiepileptics

name examples of antiepileptic drugs in each category

Answer 10

• CATEGORY 1: ensure patient is maintained on a specific manufacturer’s product.
  e. g Carbamazepine, phenobarbital, phenytoin, primidone
• CATEGORY 2: need to supply a specific manufacturers product based on clinical judgement + consultation with the patient and/or carer taking into account factors such as seizure frequency, treatment history, and potential implications to the patient of having a breakthrough seizure.

E.g clobazam, clonazepam, eslicarbazepine acetate, lamotrigine, oxcarbazepine, perampanel, rufinamide, topiramate, valproate, zonisamide

• CATEGORY 3: it is usually unnecessary to ensure that patients are maintained on a specific manufacturer’s product as therapeutic equivalence can be assumed.
  e. g Brivaracetam, ethosuximide, gabapentin, lacosamide, levetiracetam, pregabalin, tiagabine, vigabatrin

Question 11

name the antiepileptic drugs (category 1) that you need to make sure a patient stays on a specific manufacturer’s brand

Answer 11

• Carbamazepine
• phenobarbital
• phenytoin
• primidone

Question 12

what are the symptoms of Antiepileptic hypersensitivity syndrome

name some antiepileptics are associated with this

Answer 12

fever, rash, and lymphadenopathy (enlarged lymph node) are most commonly seen. other signs could be liver dysfunction, renal/pulmonary abnormalities, multi-organ failure.

antiepileptics associated with this: carbamazepine, lamotrigine, oxcarbazepine, phenobarbital, phenytoin, primidone, and zonisamide

note symptoms can start between 1-8 weeks of starting treatment

Question 13

what should happen if a patient shows symptoms of antiepileptic hypersensitivity syndrome

Answer 13

the drug should be withdrawn immediately, the patient must not be re-exposed, and expert advice should be sought

Question 14

what normally causes interactions between antiepileptic drugs

Answer 14

hepatic enzyme induction or inhibition

note interactions between antiepileptics are varibale + unpredictable

Question 15

how do you withdraw a patient taking an antiepileptic

Answer 15

• should be withdrawn under specialist supervision
• Avoid abrupt withdrawal (particularly of barbiturates and benzodiazepines)
• In patients receiving several antiepileptic drugs, only one drug should be withdrawn at a time

Question 16

why must you avoid abrupt withdrawal especially when a patient is taking barbiturates (e.g phenobarbital) and benzodiazepines (e.g clonazepam, clobazam)

Answer 16

because abrupt withdrawal in these can cause severe rebound seizures

note withdrawal of barbiturates can take months

Question 17

what are the rules around epilepsy + Driver and Vehicle Licensing Agency (DVLA).

Answer 17

• If a driver has a seizure (of any type) they must stop driving immediately and inform DVLA
• DVLA recommends not to drive during medication changes or withdrawal. if a seizure occurs during this, driving license revoked for 1 year
• after first unprovoked epileptic seizure or a single isolated seizure do not drive for 6 months. Then assessed by specialist as fit to drive
• those with established epilepsy can drive as long as not danger to public + compliant with treatment. Must be seizure-free for at least one year or have no history of unprovoked seizures
• if a seizure occurs whilst asleep, stop driving for 1 year from last seizure date. unless pattern established that seizures only occur during sleep over 1 year

Question 18

what is the risk of taking antiepileptic drugs whilst pregnant

when is this risk the highest

Answer 18

increased of teratogenicity

highest risk:

• during first trimester
• if patient is taking 2 or more antiepileptic drugs

Question 19

when is the only time sodium valporate can be used in women of childbearing age

Answer 19

• conditions of the Pregnancy Prevention Programme are met

- alternative treatments are ineffective or not tolerated

Question 20

name the 2 safest antiepileptic drugs to take during pregnancy

Answer 20

lamotrigine and levetiracetam

Question 21

what advice would you give to epileptic women planning a pregnancy

Answer 21

• not to stop their antiepileptic treatment without discussing this with their doctor (treatment based on clinical condition + circumstance)
• urgently referred to a specialist for advice and offered folic acid

Question 22

which contraception is part of the pregnancy prevention programme

Answer 22

The long-acting reversible contraceptives (LARC):

• copper intrauterine device (Cu-IUD),
• levonorgestrel intrauterine system (LNG-IUS)
• progestogen-only implant (IMP)

note some antiepileptic drugs can reduce the efficacy of hormonal contraceptives, and the efficacy of some antiepileptics may be affected by hormonal contraceptives

Question 23

what is given during the first trimester to reduce neural tube defects from antiepileptics

Answer 23

folate supplementation (folic acid) is advised throughout the first trimester

Question 24

how do you minimise the risk of neonatal haemorrhage associated with antiepileptics

Answer 24

Routine injection of vitamin K at birth

Question 25

which antiepileptics can cause withdrawal effects in newborns

Answer 25

some antiepileptic drugs, in particular benzodiazepines (e.g clonazepam, clobazam) and phenobarbital.

Question 26

TRUE OR FALSE women taking antiepileptics should not breastfeed

Answer 26

False. Women taking antiepileptic monotherapy should generally be encouraged to breastfeed. if on combination therapy- seek specialist advice *note withdrawal effects can occur if a mother suddenly stops breastfeeding*

Question 27

what should all breastfed infants from women taking antiepileptics be monitored for

Answer 27

- monitored for: sedation, feeding difficulties, adequate weight gain, and developmental milestones - if breast-fed infants are suspected of having adverse drug effects, monitor serum-drug concentration

Question 28

what is the treatment options for Focal seizures with or without secondary generalisation mnemonic: foCAL

Answer 28

- Carbamazepine and lamotrigine are first-line options. (oxcarbazepine, sodium valproate and levetiracetam can be used if first-line intolerated) extra info: - if monotherapy unsuccessful with first line options, consider adjunctive therapy with clobazam, gabapentin, lamotrigine, levetiracetam, oxcarbazepine, sodium valproate, or topiramate - if adjunctive therapy isn't successful a tertiary epilepsy specialist should be consulted

Question 29

what are the treatment options for generalised tonic-clonic seizures

Answer 29

- sodium valproate | - lamotrigine is the alternative if sodium valproate unsuitable (e.g women of childbearing age)

Question 30

what are the treatment options for absence seizures and syndromes mnemonic: SEAL

Answer 30

- first line: Ethosuximide, or sodium valproate lamotrigine is the alternative is both unsuitable - A combination of any two of these drugs may be used if monotherapy is ineffective

Question 31

what are the treatment options for Myoclonic seizures (myoclonic jerks) mnemonic: SALT

Answer 31

first line: sodium valproate - topiramate (has less favourable side effects) and levetiracetam are alternative options - A combination of two of these drugs may be used if monotherapy is ineffective or not tolerated

Question 32

which type of seizures are usually seen in childhood or associated with cerebral damage or mental retardation what is the treatment for them mnemonic: SLART

Answer 32

Atonic and tonic seizures Treatment: - first line: sodium valproate - lamotrigine can be added as adjunctive treatment

Question 33

what are epilepsy syndromes name the 2 type of epilepsy syndromes

Answer 33

specific types of epilepsy that are characterised based on the number of features including seizure type, age of onset, and EEG characteristics - Dravet syndrome - Lennox-Gastaut syndrome

Question 34

Name the 6 types of seizures/syndromes where sodium valproate is the first-line treatment

Answer 34

- generalised tonic-clonic seizures - absence seizures and syndromes - Myoclonic seizures - Atonic and tonic seizures - Dravet syndrome - Lennox-Gastaut syndrome

Question 35

what are Gabapentin and Pregabalin used to treat

Answer 35

- focal seizures with or without secondary generalisation | - neuropathic pain

Question 36

which antiepileptics should NOT be used in tonic, atonic, myoclonic and absence seizures

Answer 36

- Carbamazepine - Oxcarbazepine - Gabapentin - Pregabalin *this is because these drugs exacerbate these types of seizures*

Question 37

which antiepileptic causes a cleft palate in newborns if taken during pregnancy

Answer 37

topiramate

Question 38

which antiepileptic increases the plasma concentration of lamotrigine

Answer 38

sodium valproate

Question 39

which antiepileptic is converted to phenobarbital in the body

Answer 39

Primidone. It is largely converted to phenobarbital which causes it's antiepileptic effect

Question 40

Phenytoin has a narrow therapeutic index and the relationship between dose and plasma-drug concentration is non-linear. How does this affect dosage

Answer 40

- small dosage increases in some patients may produce large increases in plasma concentration with acute toxic side-effects - Similarly, a few missed doses or a small change in drug absorption may result in a marked change in plasma-drug concentration * note non-linear dose and plasma-drug concentration means that the plasma concentration does not correlate with the dose*

Question 41

which antiepileptic is used to treat Lennox-Gastaut syndrome (an epilepsy syndrome)

Answer 41

Rufinamide - topiramate can also be used in adjunctive treatment

Question 42

what needs to be monitored in patients taking sodium valproate

Answer 42

- liver function tests and full blood count this is because it has widespread metabolic effects

Question 43

what is Convulsive status epilepticus

Answer 43

- when a seizure lasts for 5+ minutes OR - One tonic-clonic seizure follows another without the person regaining consciousness in between

Question 44

what are the immediate measures to manage Convulsive status epilepticus

Answer 44

- positioning the patient to avoid injury - supporting respiration including the provision of oxygen - maintaining blood pressure - correction of any hypoglycaemia

Question 45

how do you treat seizures lasting more than 5 minutes during Convulsive status epilepticus

Answer 45

- intravenous lorazepam (a benzodiazepine) .repeated once after 10 minutes if seizures recur or fail to respond. - monitor patients for respiratory depression and hypotension *note Intravenous diazepam is effective but it carries a high risk of thrombophlebitis (blood clot formation).*

Question 46

how do you treat seizures lasting more than 5 minutes during Convulsive status epilepticus if there are no facilities for resuscitation

Answer 46

- diazepam can be administered as a rectal solution or | - midazolam oromucosal solution can be given into the buccal cavity

Question 47

what can be used to treat Convulsive status epilepticus if benzodiazepines have failed to treat it after 25 minutes

Answer 47

phenytoin sodium, fosphenytoin sodium, or phenobarbital sodium should be used; contact intensive care unit if seizures continue