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Epilepsy Flashcards

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1
Q

What are the MHRA warnings for anti-epileptics

A
  1. Risk of suicidal thoughts
  2. Some anti-epileptics should not be switched between different manufacturers products.
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2
Q

What are the category 1 drugs?

A

Carbamazepine, Phenytoin, Primidone, Phenobarbital

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3
Q

What does category 1 mean

A

They need to be maintained on a specific manufacturers brand.

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4
Q

What is anti-epileptic hypersensitivity syndrome?

A

Rare and potentially fatal syndrome that is associated with some anti-epileptics

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5
Q

What drugs are associated with anti-epileptic hypersensitivity syndrome?

A

Carbamazepine, Phenytoin, Primidone, Phenobarbital, Laccosamide, Lamotrigine, Oxecarbazepine and Rufinamide (cat 1 and LLOR)

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6
Q

When do symptoms show of anti-epileptic hypersensitivity syndrome?

A

Usually start between week 1 and 8 of exposure and can be fever, rash and lymphadenopathy
Withdraw drug immediately, do not restart and seek expert advice immediately.

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7
Q

What are the main interactions associated with anti-epileptics?

A

Complex and may cause toxicity without added anti-epileptic effect
Caused by hepatic enzyme induction or inhibition, displacement from protein binding sites is not usually a problem.

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8
Q

How do you withdraw an anti-epileptic drug?

A

Avoid abrupt withdrawal especially in barbituates and benzodiazepines.
In the case of barbituates it can take months. (primidone, phenobarbital)

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9
Q

How long can you not drive for if you have one single isolated seizure?

A

6 months

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10
Q

How long must a patient be seizure free for or established pattern so they can drive again?

A

1 year

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11
Q

If the patient has had seizures whilst being awake but now only has them when they are asleep, how long must this happen for so they can drive again?

A

Establish the pattern for 3 years

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12
Q

How long can a patient not drive for if they have a medication change or withdrawal?

A

6 months

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13
Q

if a patient has a seizure whilst their medication has changed or withdrawn, how long must they go without driving?

A

1 year (if medication restarted and they remain seizure free it may be considered after 6 months)

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14
Q

What are the first and second line anti-epileptics for focual seizures?

A

First line: Lamotrigine or Levetiracetam
Second line: Carbamazepine, Oxcarbazepine, Zonisamide

Got to take 2 L’s to get you focused COZ

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15
Q

Whats the first and second line for tonic clonic seizures

A

1st: Sodium Valproate
2nd: Lamotrigine or Levetiracetam

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16
Q

Whats the first and second line for absence seizures

A

1st: Ethosuximide
2nd: Sodium Valproate

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17
Q

Whats the first and second line for absence and another seizure

A

1st: Sodium valproate
2nd: Lamotrigine or Levetiracetam

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18
Q

Whats the first and second line for myoclonic seizures

A

1st: sodium valproate
2nd: Levetiracetam

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19
Q

Whats the first and second line for Atonic seziures

A

1st: sodium valproate
2nd: Lamotrigine

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20
Q

Whats the first and second line for tonic seizures

A

1st: sodium valproate
2nd Lamotrigine

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21
Q

What other two anti-epileptics can be used in tonic seizures?

A

Carbamazepine and Vigabatrin

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22
Q

Whats the definition of Status epilepticus

A

A seizure lasting for longer than 5 minues

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23
Q

Whats the different treatment options for Status epilepticus depending on where you are?

A

In the community: Buccal Midazolam 10mg or Rectal diazepam 10-20mg
If resus facilities available: IV lorazepam 4mg

if the seizure doesn’t stop within 5-10 minutes then give another dose

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24
Q

What do you give if the status epilepticus seizure fails to respond after 2 benzodiazepine doses?

A

Give Levetiracetam, Phenytoin, Sodium valproate

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25
What do you do if the status epilepticus fails to respond to the benzodiazepines and the anti-epileptics?
Give Phenobarbital or General anaesthesia
26
What are the drug interactions for Carbemazepine?
Drugs that cause hepatotoxicity: Amiodarone, Itraconazole, Macrolides, Alcohol It's an enzyme inducer Drugs that lower seizure threshold e.g. Tramadol, Theophylline, Quinolones Drugs that cause hyponatraemia e.g. SSRI's, diuretics DOAC's Oral contraceptives
27
What are the drug interactions for Phenytoin?
Drugs that cause hepatotoxicity: Amiodarone, Itraconazole, Macrolides, Alcohol It's an enzyme inducer Drugs that lower seizure threshold e.g. Tramadol, Theophylline, Quinolones Anti-folates e.g. Methotrexate, Trimethoprim doac, carbamazepine, oral contraceptive pill, ulipristal.
28
What are the drug interactions for Sodium Valproate ?
Drugs that cause hepatotoxicity: Amiodarone, Itraconazole, Macrolides, Alcohol It's an enzyme inhibitor Drugs that lower seizure threshold e.g. Tramadol, Theophylline, Quinolones
29
What effect does phenobarbital have on CYP enzymes?
It's an inducer
30
Side effects of Carbamzepine
Depression and suicide Hepatotoxicity Hypersensitivity Blood dyscrasias Vit D deficiency- bone pain Hyponatraemia Oedema Nausea vomiting sedation dizziness and ataxia are dose related and are most common at the start of treatment Hyponatraemia, eucopenia and thrombocytopenia are very common. carbamazepine known to be an enzyme inducer and induces its down metabolism
31
Side effects of Phenytoin
Depression and suicide Hepatotoxicity Hypersensitivity Blood dyscrasias Vit D deficiency- bone pain Coarsening appearance and facial hair Gingival hyperplasia, agranulocytosis, thrombocytopenia, altered taste
32
Side effects for Sodium Valproate
Depression and suicide Hepatotoxicity Hypersensitivity Blood dyscrasias Vit D deficiency- bone pain Pancreatities Teratogenicity
33
How long can a hypersensitivity reaction take to develop?
8 weeks
34
What are the symptoms of a hypersensitivity reaction?
Abdominal pain Jaundice Dark urine Rash LIVER, RASH, FEVER, SOB then Multi organ failure
35
What anti-epileptics cause hypersensitivity reactions
carbamzepine phenobarbital phenytoin primidone lamotrigine Lacosamide Rufinamide Oxecarbazepine CP3L2RO
36
What anti-epileptics cause skin rash
Lamotrigine- steven johnson syndrom
37
What anti-epileptics cause Bloody dyscrasias
Carbamazepine, Valproate, Ethosuximide, Topiramzte, Phenytoin, Lamotrigine, Zonisamide C VET PLZ
38
What anti-epileptics cause eye disorders
Vigabatrin (reduced visual field) Topiramate (secondary glaucome)
39
What anti-epileptics cause Encephalopathy
Vigabatrin
40
What anti-epileptics cause respiratory depression
Gabapentin and Pregabalin
41
What's carbamazepine's therapeutic range?
4-12 mg/L
42
Whats the signs of carbamazepine toxicity?
HANDBAG Hyponatraemia, Ataxia, nystagmus, Drowsiness, Blurred vision, Arrhythmias, GI disturbances
43
Whats the therapeutic range of phenytoin?
10-20 mg/L
44
Whats the signs of Phenytoin toxicity?
SNACHD Slurred speech, Nystagmus, Ataxia, Confusion, Hyperglycaemia, Double vision
45
Key points of anti-epileptics during pregnancy
The risks of harm to mother and baby from a convulsive seizure outweighs the risk of continued therapy. Folic acid can reduce the risk of neural tube defects Vit K injection administered at brith to minimise risk of neonatal haemorrhage Most risk: Sodium valproate Topiramate can cause cleft palate
46
Key points of anti-epileptics and breastfeeding
Encouraged to breastfeed High presence in milk: Primidone, Ethosuximide, Lamotrigine, Zonisamide Risk of drowsiness: Primidone, Phenobarbital, Benzydiazepines Withdrawal effects: Phenobarbital, primidone, Benzodiazepines and lamotrigine
47
Enzyme inducing anti-epileptics:
Carbamazepine Oxcarbazepine Phenobarbital Phenytoin/Fosphenytoin Primidone Topiramate
48
Definition of an absence seizure
Abrupt loss of awareness for a short period
49
Definition of a myoclonic seizure
Seizure involving a group of muscles causing jerking motions
50
Definition of a tonic clonic seizure
Seizures involving stiffening (tonic) or sudden relaxation (atonic) of muscles
51
Definition of focal seizures
Start in one part of the brain and affect the corresponding side of the body
52
What are the MHRA warnings for carbamazepine?
Prescribe a specific brand Risk of suicidal thoughts Risk of congenital malformations in pregnancy Risk of steven johnsons syndrome in presence of certain allele that can be found in chinese or thai origin - should always test patients from malaysia and phillipines.
53
Key points of phenytoin
Narrow therapeutic index drug and follows non linear kinetics. Small change in dose can result in a large change in blood levels. Drug monitoring in patients with epilepsy is not routinely performed. Anti-folate
54
What is the optimum plasma levels for phenobarbital?
15-40mg/L
55
Patient and carer advice for phenobarbital?
28 days to collect prescription from the date prescribed Consider vitamin D supplementation for immobilised patients or those who have inadequate sun exposure or dietary intake of calcium
56
What is the % risk of someone on sodium valproate having teratogenicity?
30-40%
57
What teratogenicity can topiramate cause?
Neurodevelopmental disabilities Cleft lip
58
What are the two benzodiazepines licensed in epilepsy?
Clonazepam and Clobazam
59
What type of seizure can lamotrigine exacerbate?
Myoclonic
60
What drugs exacerbate generalised seizures?
Carbamazepine, Pregabalin, Gabapentin
61
What other indications is carbamazepine licensed for?
Trigeminal neuralgia Bipolar if unresponsive to lithium Diabetic neuropathy Alcohol withdrawal

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