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3703 > Epilepsy > Flashcards

Epilepsy Flashcards

1
Q

What is epilepsy?

A

Neurological disorder where sudden recurrent episodes of sensory disturbance, behavioural change and/or convulsions occur

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2
Q

What occurs when a seizure happens?

A

Abnormally high excitability of neurons in one or more parts of the brain

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3
Q

What is a focal seizure and examples?

Simple

Complex - loss of consciousness

A

A seizure where the excitation occurs in one section of the brain

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4
Q

What is a generalised seizure?

A

Excitation starts from a focal point and spreads to majority of the brain

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5
Q

What are examples of a generalised seizure?

A

Motor:

Myoclonic - clonic to atonic

Tonic-clonic - tonic to clonic

Non-motor:
absence seizure

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6
Q

How does a generalised tonic-clonic seizure present?

A

Begins with a tonic phase with muscle stiffness that causes falls

Clonic phase with rhythmic jerking and convulsions

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7
Q

How does an absence seizure look?

A

Patient stares with a blank expression for a few seconds

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8
Q

What are the features of a myoclonic seizure?

A

Less dangerous with rapid, jerking of limbs

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9
Q

What are the features of atonic seizures and safety measures?

A

Loss of muscle tone and strength suddenly causing falls

Protective head gear worn by patients

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10
Q

What are seizures called if they begin as focal and become generalised?

A

Focal to generalised secondary seizure

Starts with focal symptoms

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11
Q

What are the signs and symptoms of focal seizures?

A

Motor - lip smacking, jerking, hand rubbing, repetitive chewing/swallowing

ANS (peripheral) - Sweating, gastointestinal changes, flushing and tachycardia

Sensory - Smelling/tasting things, hearing things, seeing things, feeling pins and needles

Cognitive - Intense feeling of fear, fiddling with objects, intense joy, behavioural changes like aggression

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12
Q

What is temporal lobe epilepsy (TLE)?

A

Most common type of focal seizure

Clouds consciousness and alters perception, which gets confused with mental health

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13
Q

What are the common epilepsy syndromes?

A

Occur during childhood

West syndrome

Lennox-Gastaut Syndrome (LGS)

Dravet Syndrome

Juvenile Myoclonic Epilepsy

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14
Q

What are the causes of epilepsy classified as?

A

Idiopathic - genetic component

Symptomatic - underlying cause such as an abnormality

Cryptogenic - unknown cause on investigation

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15
Q

What is reflex epilepsy?

A

Patients have a predisposition for seizures that are triggered by photic, auditory or environmental changes

Example:
Heat/cold

Loud sounds

Thinking/reading

Eating/chewing

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16
Q

How is epilepsy diagnosed?

A

Detailed history and account of events from a witness

EEG for diagnosis and to classify the type of epilepsy

Difficult to diagnose as it could be confused with other conditions that cause loss of consciousness

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17
Q

What is a confirmed diagnosis of epilepsy?

A

2 or more unprovoked or reflex seizures, more than 24 hours apart

1 unprovoked of reflex seizure with a probability of 60% of recurrence over the next 10 years

Diagnosis of an epilepsy syndrome

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18
Q

What is seizure freedom?

A

Go 12 months without having a seizure

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19
Q

What is a therapeutic effect?

A

3 x the longest previous interval between seizures on the drug

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20
Q

What are the therapeutic objectives for epilepsy?

A

Reduce the length of time of seizures

Reduce or control frequency of seizures

Improve impact to quality of life

Minimise risk of ADRs with anti-epileptic drugs

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21
Q

What is the likelihood of success with AED?

A

50% of patients are seizure free within 12 months of starting monotherapy

10-20% success of seizure freedom with 2nd AED after failure with 1st drug

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22
Q

What considerations are there for carbamazepine?

A

Plasma levels can take up to 2 weeks to reach a steady state

Start low, go slow

Drug toxicity side effects can be reduced by using modified release

Bioequivalence varies with formulation

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23
Q

What are the monitoring requirements for carbmazepine?

A

Urea and electrolytes - hyponatraemia

Liver function

FBC

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24
Q

What considerations are there for sodium valproate?

A

Does not need therapeutic drug monitoring, has no defined therapeutic range

Can increase levels of other antiepileptic drugs - inhibits hepatic enzymes

Can cause hepatotoxicity or worsen it

25
Q

What is the monitoring for sodium valproate?

A

Liver function - hepatotoxic

FBC - low WBC and platelets

26
Q

What are the risks of valproate in pregnancy?

A

Can cause congenital malformations (spina bifida, cleft palate)

risk of neurodevelopment disorders in childhood

27
Q

What is included in the PPP?

A

Risk form signed annually by patient

Patient put on a LARC <1% failure rate and pregnancy excluded

Treatment reviewed by specialist once a year

28
Q

What are the considerations for phenytoin?

A

Narrow therapeutic index, likely to cause toxicity

Start low, go slow

Poor side effect profile

Many drug interactions

Bioequivalence varies with formulation

Third line for focal and used in status epilepticus

29
Q

What is the monitoring for phenytoin?

A

Liver function

FBC

ECG and BP (IV) - cardiovascular issues (brady and hypo)

30
Q

What are the considerations for lamotrigine?

A

Rash can occur so titrate dose slowly

Synergistic effect with valproate for reducing seizures

Less side effects and interactions

31
Q

What are the considerations for levetiracetam?

A

No monitoring required

Few ADRs and well tolerated

Can mask cognitive and behavioural issues related to brain injury

32
Q

What are considerations for gabapentinoids (pregabalin and gabapentin)?

A

Mainly used for neuropathic pain

No monitoring involved, few ADRs

Renally excreted so dose adjustments for impairment is key

33
Q

What are the considerations for benzodiazapines?

A

Pam and lam drugs

Used to terminate seizure activity or status epilepticus

Leads to dependency and tolerance

Can be used when switching from one AED to another (short-term)

Sedation effect - diazepam has a long half-life

Clabazam - least sedating

34
Q

What is the treatment for status epilepticus in community and hospital?

A

Buccal midazolam or rectal diazepam

IV lorazepam

35
Q

What are the next steps if the patient does not respond to status epilepticus treatment?

A

Call 999

Give a second dose of benzos if the seizure does not stop within 5 to 10 minutes of first dose

If second dose does not work give:

IV levetiracetam (least side effects)

IV phenytoin

or IV sodium valproate

36
Q

What are the non-pharmacological treatment options?

A

Drug-resistant epilepsy on max. doses of AED:

Resective epilepsy surgery

or vagus nerve stimulation with antiepileptic drugs

37
Q

What is the treatment for generalised tonic-clonic seizure?

A

First-line: sodium valproate

Boys/men, girls under 10 unlikely to need treatment when older

Alternative: Lamotrigine or levetiracetam

Girls and women of child-bearing age

Second-line add-on: Any of the above or clobazam

38
Q

What is the treatment for focal seizures?

A

First -line: Lamotrigine or levetiracetam

Second-line: carbamazepine or oxcarbazepine

Third line: Lacosamide

39
Q

What is the treatment for absence seizures?

A

First-line: Ethosuxamide

Second-line: sodium valproate

Third: Lamotrigine or levetiracetam

40
Q

What is the treatment for myoclonic seizures?

A

First-line: sodium valproate

Second-line: Levetiracetam

Third-line: Add-on with lamotrigine

41
Q

Which AEDs reduce the effectiveness of hormonal contraceptives?

A

Carbamazepine

Phenytoin

COC with 50micrograms or more is recommended

Avoid progesterone-only

42
Q

Which drugs for women reduce the effect of lamotrigine?

A

Oestrogen-containing contraceptives

HRT

43
Q

Which supplement reduces the chance of neural tube defects with AEDs?

A

Folate supplements

44
Q

What should be done for patients if monotherapy or combination fails?

A

Allow the patient to choose the regimen that was most comfortable for them

In terms of seizure control vs ADRs

45
Q

What is refractory epilepsy?

A

Drug-resistant or intractable

Failure to respond to two attempts with AED to achieve sustained seizure freedom

High seizure burden

46
Q

Which drugs are therapeutic drug monitoring useful for?

A

Carbamazepine and phenytoin

Plasma levels correlate to efficacy

47
Q

When is therapeutic drug monitoring conducted?

A

Starting treatment- to get a baseline

Monitor adherence

Toxicity

Manage PK interactions

Pregnancy, organ failure and status

48
Q

What is status epilepticus?

A

When a seizure lasts for 5 minutes or longer

Repeated convulsions without recovery of consciousness

49
Q

What are the complications of status epilepticus?

A

Brain death or injury

Catecholamine surge: arrhythmias, tachycardia, high BP

Hypoglycaemia

Lactic acidosis

50
Q

What must you do if someone is having refractory status epilepticus?

A

Admit them into the ICU

Induce a coma

51
Q

Which AEDs have to be given for a specific brand?

A

Carbamazepine, phenytoin and phenobarbital

Primidone

52
Q

How should treatment be switched for intolerance or ADRs?

A

Gradually reduce and stop 1st AED then start 2nd AED with a gradual increase

53
Q

How should treatment be switched for poor seizure control with no interaction?

A

Start 2nd AED and gradually increase, then gradually reduce and stop 1st AED

54
Q

How should treatment be switched for poor seizure control with possible interaction?

A

Start 2nd AED and gradually increase and at the same time gradually reduce and stop the 1st

55
Q

How long should it take for AEDs to be stopped?

A

2-3 months

Longer for phenobarbital and benzos

56
Q

What drug interactions are important for AEDs?

A

Older AEDs are inducers of CYP450 enzymes

Lower the plasma concentration of many drugs

57
Q

Which drugs lower seizure threshold?

A

Tricyclic antidepressants - amitriptyline (SSRI)

Tramadol - SNRI

Ciprofloxacin

58
Q

What are the signs of anti-epileptic hypersensitivity?

A

Occur within 2-8 weeks of exposure

Rash, fever, swollen lymph nodes and organ failure

Stop drug immediately

3703 (13 decks)

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