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Epilepsy Flashcards

1
Q

What are the 2 types of seizures?

A

Generalised and Focal

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2
Q

What is the definition of a seizure

A

Abnormality in the flow of electrical activity in the brain

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3
Q

What are the different types of generalised seizures

A

MATA
Myoclonic
Atonic/tonic
Tonic-clonic
Absence

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4
Q

What are the different types of Focal seizures

A

simple and complex

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5
Q

What are the drug treatments of choice for Atonic/Tonic seizures

A

SLaRCT (a= alternatively)

(1st line) S: sodium valporate (Males, Girls under 10 years old or unable to have children)

(2nd line) L: Lamotrigine
alternatively (used as add on therapy)
R= Rufinamide
C= clobazam (new to guidance)
T= Topiramate

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6
Q

What are the drug treatments of choice for Tonic- Clonic seizures

A

SaLL
1) Sodium valporate
alternatively
2) Lamotrigine or Levetiracetam (lev= unlicensed)

potential add ons: Clobazam, perampanel, Topiramate

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7
Q

What are the drug treatments of choice for Absence seizures

A

ESaLL
1) Ethosuximide
2) Sodium valporate
alternatively
3) Lamotrigine or Levetiracetam (lev= unlicensed)

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8
Q

What are the drug treatments of choice for Myoclonic seizures

A

SaLE
1) sodium valporate (Males, Girls under 10 years old or unable to have children)

2) Levetiracetam

Add ons:
brivaracetam, clobazam, clonazepam, phenobarbital, piracetam,topiramate,zonisamide.

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9
Q

Which antiepileptic can exacerbate Myoclonic seizures?

A

Lamotrigine

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10
Q

What are Category 1 antiepileptics? What are their additional requirements?

A

CPr3
Carbamazepine
Phenytoin
Phenobarbital
Primidone

Brand continuity

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11
Q

Category 2 antiepileptics

A

Clonazepam, Clobazam, valproate, Topiramate, Lamotrigine

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12
Q

Category 3 antiepileptics

A

Levetiracetam, gabapentin, Pregabalin, Vigabatrin, Ethosuximide, Tigabine, Brivaracetam

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13
Q

What Generalised seizure can carbamazepine and vigabatrin be used in?

A

Tonic clonic (exacerbates all other types of generalised seizures)

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14
Q

What are the drug treatments of choice for Focal seizures seizures

A

1) Lamotrigine or levetiracetam
alternatively
2) Zonisamide
oxcarbazepine
carbamazepine

3) Lacosamide

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15
Q

What antiepileptics have a long half life (can have OD dosing)

A

LP3
Lamotrigine
perampanel
phenobarbital
phenytoin

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16
Q

What antiepileptics have an increased risk of causing hypersensitivity syndrome?

A

CPr3 (Carbamazepine, Phenytoin,Phenobarbital, Primidone) Lamotrigine, lacosamide and Rufinamide

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17
Q

what are the symptoms of hypersensitivity syndrome?

A

Fever, rash, liver dysfunction (abdo pain, jaundice, dark urine), pulmonary abnormalities (SOB), multi-organ failure.
STOP drug and refer

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18
Q

What are the MHRA warnings associated with antiepileptics?

A

Sodium Valproate- teratogenicity (PPP)

ALL antiepileptics= Risk of suicidal thoughts, brand switching and use in pregnancy

Topiramate= Increased risk of neurodevelopmental disabilities in children and prenatal exposure. (also can cause Cleft lip if used in pregnancy)

Benzos (clonazepam/Clobazam) + Gabapentinoids: risk of respiratory depression

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19
Q

What is the % risk of teratogenicity associated with sodium valproate

A

30-40%

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20
Q

How long should patients not drive for if they have a first unprovoked seizure/single isolated seizure?

A

6 months

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21
Q

How long does a patient have to be seizure free for before they continue driving?

22
Q

How long should patients stop driving if they have had a dose change or are withdrawing a medication?

23
Q

If a seizure occurs during dose change or withdrawal how long will their license be revoked for?

24
Q

SODIUM VALPROATE- PPP
What are the contraceptive requirements?

A

at least ONE highly effective contraception method

or at least TWO complementary forms plus the barrier method

25
SODIUM VALPROATE- PPP What are the highly effective contraceptions?
IUD (CU, Levonogestrel only), or progesterone implant
26
SODIUM VALPROATE- PPP What are the complementary/user dependent forms of contraception that should be used?
Condom, cap, diaphragm, COC, fertility awareness methods
27
What can be given in pregnancy to prevent neuronal tube defects, and what is the dose?
folic acid 5mg
28
What are the antiepileptics of choice during pregnancy?
lamotrigine and levetiracetam
29
What can be given for the management of status epilepticus?
Iv lorazepam (where there are resuscitation facilities. e.g., hospital) No resus facilities= buccal midazolam (oral solution into buccal cavity- 1st line in community) OR Rectal diazepam
30
How would you manage status epilepticus?
- protect head - maintain BP, correct hypoglycemia (could be the cause), support respiration (give ox) - parenteral thiamine if alcohol related - Give pyridoxine (B6) if cause
31
Drug management of status epilepticus
1st dose of benzo- if no response call 999 2) no response= refer to emergency management plan OR give second dose of benzo after 5-10 minutes 3) No response after 2 benzo doses= second line treatment (levetiracetam, phenytoin or sodium valproate) 4) no response= 3rd line option (general anesthesia or phenobarbital (thiopental- 75–125 mg for 1 dose)
32
Carbamazepine indications (epileptic and non epileptic)
Focal seizures, tonic clonic seizures, Prophylaxis of bipolar (unresponsive to lithium), trigeminal neuralgia (licensed) acute alcohol withdrawal + diabetic neuropathy (unlicensed)
33
Carbamazepine Patient and carer advice
can cause Blood, hepatic and skin disorders. medical attention if fever, rash, sore throat, mouth ulcers, bleeding or bruising.
34
Carbamazepine What is the therapeutic range?
4-12mg/L (20-50mcmol/L) measured 1-2 weeks after dosing
35
Carbamazepine Side effects?
HANDBAG HYPONATRAEMIA Ataxia Nystagmus (involuntary movement of the eyes) Drowsiness/Dizziness Blurred vision Arrhythmias Gastro (N&V) common at the start of treatment and can be reduced by giving MR preps
36
Carbamazepine Cautions
Cardiac disease; history of haematological reactions to other drugs; presence of HLA-B*1502 or HLA-A*3101 allele (chinese or Han Thai origin) ; seizures (Dravet syndrome, Lennox-Gastaut syndrome. also may be exacerbated- generalised except tonic clonic); skin reactions- SJS ; susceptibility to angle-closure glaucoma
37
Carbamazepine Treatment cessation (withdrawing for bipolar)
withdraw gradually over a period of 4 weeks
38
Carbamazepine Interactions
- DOAC- Apixaban (reduces efficacy of apix by 50%) - CYP enz inducers and inhibitors (macrolides, some antifungals, omep, metronidazole) - Clozapine - contraceptives/progestogens - decrease efficacy of COC/deso/norethist/ ulipristal (avoid for 4 weeks after stopping) - Isoniazid - Lithium (inc neurotox) - Ticagrelor (decrease exposure of Tic) - Tramadol (decrease conc) - rate limiting CCB- inc conc of carbamazepine and decreases exposure to CCB - atorv/amlod decrease exposure
39
How long should you avoid Ulipristal after stopping carbamazepine
4 weeks
40
MHRA warnings for sodium valproate?
ALL antiepileptics= risk of suicidal thoughts Sod Val= teratogenic
41
Sodium valporate indications
epilepsy, mania and migraine prophylaxis
42
Sodium valporate Side effects
V Appetite increase Liver failure Pancreatitis Reversible hair loss (alopecia) Oedema Ataxia Teratogenicity and tremor Encephalopathy + Hyponatraemia
43
When should Sodium valproate be withdrawn?
Liver dysfunction (particularly children <3) - persistent vomiting, abdo pain, anorexia, jaundice, oedema, malaise, drowsiness, or loss of seizure control pancreatitis- pain in abdomen, N&V, fever, chills, tachycardia, SOB
44
Serious Sodium Valproate interactions
Lamotrigine- Increases exposure= increase risk of SJS Olanzapine Phenytoin- monitor conc Topiramate- increased risk of toxicity Pivmecillinam- avoid Carbapenems- imipenem, etrapenem and meropenem (AVOID)
45
Phenytoin indications
Tonic clonic seizures, focal seizures, status epilepticus
46
Phenytoin What route should be avoided?
IM- slow and erratic absorption
47
Phenytoin Target range
10-20mg/L (40-80micromol/L) PhenyTEN= pneumonic
48
Phenytoin Toxicity symptoms
Nystagmus slurred speech ataxia confusion hyperglycaemia Blood and skin disorders- Med attention Rash= discontinue
49
Phenytoin serious interactions
Amiodarone DOACs (all) Bupropion and buspirone carbamazepine ciclosporin Oral contraceptives- COC, desogestrel, ulipristal,levonogestrel miconazole valproate Folic acid (phenytoin= enzyme inducer)
50
Phenytoin Side effects
P-450 INDUCER Hair changes- hirsutism (thick and dark body hair) Enlarged gums (gingival hyperplasia) NYstagmus and ataxia Teratogenicity Osteopenia (loss in bone density) Insomnia, Immune system- agranulocytosis, thrombocytopenia. Neuropathy
51
What antiepileptic needs to be endorsed with SLS?
Clobazam
52
What is the most common side effect of vigabatrin
Visual disturbances (VIgabatrin- VIsual) - REPORT test 6 months before treatment and at 6 monthly intervals

Pre-reg (13 decks)

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