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Patient Semester 2 > Epilepsy > Flashcards

Flashcards in Epilepsy Deck (141):

Incidence/prevalence of epilepsy?

50 per 100,000 diagnosed each year
approx 1 in 100 people in the UK have it

most commonly presents in children and the elderly


Prognosis of epilespy?

up to 70% can become seizure free
50% can withdraw medicatiom
20-30% will continue to have seizures despite treatment


Mortality of epilepsy?

2-3x higher than general population
can be due to accidents not just the disease (indirect)
sudden unexpected death in epilepsy (more common in generalised tonic clonic and poor seizure control)


How many different types of epilepsy?

over 40


Definition of a seizure?

episode of neurological dysfunction of abnormal firing of neurones manifesting as changes in motor control


Definition of epilepsy?

Condition of recurrent, spontaneous seizures arising from abnormal, synchronus and sustained electrical activity in the brain


Aetiology of epilepsy?

- idiopathic epilepsy: genetic cause
- symptomatic epilepsy: e.g. head injury or stroke
- up to 50% have no apparent cause


What is the first step of epilepsy diagnosis?

establish if paroxysmal event was actually a seizure

acute symptomatic seizure? e.g. head injury, infection, imbalance etc

Non-epileptic attack from syncope, encephalitis, migraine?

witnesses are very helpful


Updated NICE guidelines on diagnosis of epilepsy?

must be made by a specialist (i.e. neurologist) as other doctors had an even worse misdiagnosis rate


What is the clinical decision of epilepsy diagnosis based on?

- desrcription of attack (footage, witness)
- family history (genetic cause)
- blood tests
- ECG (cardiac cause/syncope?)
- Medication history - illegal drugs can cause seizures, overdose of some drugs can cause seizures, many commonly prescribed drugs can lower seizure threshold)


Tongue biting pattern of seizures?

tonic clonic seizures - patients tend to bite the sides of their tongue

tip of tongue - generally non-epileptic attack disorder


Which drugs can lower seizure threshold?

SSRIs, tricyclics, quinolones, tramadol


Importance of imaging in epilepsy diagnosis?

MRI preferrred to CT - can see structural abnormalities

important in <2s and adults who develop seizures (see a treatable cause)
should be performed within 4 weeks


Role of EEGs in epilepsy diagnosis?

should never be used in isolation
main use is to classify the epilepsy for correct treatment

however: 10% epileptics have normal EEGs, and 2-4% healthy people have abnormal EEGs


Principles of classification of seizures?

- depend on the location and focus on the pathway involved
- patients can have more than one type of seizures
- failure to classify correctly can lead to inappropriate treatment and therefore treatment failure


Two main types of seizures?

Partial and generalised seizures


Types of partial seizures?

- simple partial seizures (maintain consciousness)
- complex partial seizures (lose consciousness)
- with secondary generalisation


Types of generalised seizures?

- tonic/clonic (muscles spasm in tonic, then limb shaking in clonic)
- absence
- myoclonic
- atonic


Common seizure triggers?

fatique, lack of sleep, stress, excess alcohol, flashing lights, excitement, menstruation, missing meals, some medications


NICE guidelines for treatment of epilepsy?

- always intiated by a specialist after diagnosis
- monotherapy to start (low and slow)
- adjunctive treamtent only if monotherapy has failed
- AEDs are not usually started after first seizure


Ideal epilepsy therapy aim?

Single drug
lowest possible dose
minimum side effects


Patient factors that contribute to choice of drug for epilepsy?

- epilepsy syndrome
- seizure type
- co-morbidity
- lifestyle
- gender, age
- preferences of individual/carers


Drug factors that contribute to choice of drug epilepsy?

- side effect profile
- dose
- formulation
- treatment schedule
- interactions


First line drugs for tonic-clonic seizures?

carbamazepine, lamotrigine, sodium valproate, oxcarbazepine


Adjunctive drugs for tonic-clonic seizures?

Clobazam, lamotrigine, levetiracetam, sodium valproate, topiramate


Drugs that may worsen tonic-clonic seizures?

Carbamazepine, gabapentin, oxcarbazepine, phenytoin, pregabalin


First line drugs for tonic or atonic seizures?

Sodium valproate


Adjunctive drugs for tonic or atonic seizures?



Drugs that may worsen tonic or atonic seizures?

Carbamazepine, gabapentin, oxcarbazepine, pregabalin


First line drugs for absence seizures?

Ethosuximide, lamotrigine, sodium valproate


Adjunctive drugs for absence seizures?

Ethosuximide, lamotrigine, sodium valproate


Drugs that may worsen absence seizures?

Carbamazepine, gabapentin, oxcarbazepine, phenytoin, pregabalin


First line drugs for myoclonic seizures?

Levetiracetem, sodium valproate, topiramate


Adjunctive drugs for myoclonic seizures?

Levetiracetem, sodium valproate, topiramate


Drugs that may worsen myoclonic seizures?

Carbamazepine, gabapentin, oxcarbazepine, phenytoin, pregabalin


First line drugs for partial seizures?

carbamazepine, lamotrigine, sodium valproate, oxcarbazepine, levetiracetem


Adjunctive drugs for partial seizures?

carbamazepine, lamotrigine, sodium valproate, oxcarbazepine, levetiracetem, clobazam, gabapentin, topiramate


Dosing info for sodium valproate?

600mg/day in 1-2 divided doses gradually increased every 3 days


Dosage forms of sodium valproate?

EC tablets, MR tablets, liquid, granules, IV

IV is equivalent to oral doses


Monitoring requirements for sodium valproate?

signs of liver, blood and pancreatic disorders


Side effects of sodium valproate?

nausea, gastric irritation, diarrhoea, weight gain, hair loss


Who is sodium valproate not suitable for?

Women of childbearing age, risk of serious neurodevelopment effects


Dosing info for carbamazepine?

Initially 100-200mg 1-2 times daily, increased slowly every 2 weeks


Monitoring requirements for carbamazepine?

blood liver and skin disorders


Dosage forms of carbamazapine?

oral and PR

125 suppository is equiv to 100mg orally


How is carbemazepine metabolised?

CYP3A4 - so susceptible to DDIs. potent inducer


Side effects of carbamazepine?

Headache, nausea/vomiting, drowsiness, dizziness, rash, ataxia, hyponatraemia


How can the side effects of carbamazepine be managed?

They are dose related and can be dose limiting

can be reduced using MR tabs


Dosing info for lamotrigine?

Initially, 25mg/day and slowly titrated every 2 weeks


Side effects of lamotrigine?

Nausea/vomiting, diarrhoea, dry mouth, skin reactions


How to manage the skin reactions with lamotrigine?

more common in the first 8 weeks or when also on valproate
increase dose slowly


Use of lamotrigine in pregnancy?

Considered the safest AED for pregnancy


Dosage forms of lamotrigine?

Oral only


Dosing info for levetiracetam?

250mg/day, increased every 1-2 weeks to max 1.5g BD


How is levetiracetam metabolised?

very little, so no CYP450 interaction


Dosage forms of levetiracetam?

oral and IV
good oral bioavailability, so no dose adjustment required between the two


Side effects of levetiracetam?

Nasopharyngitis, somnolence, fatigue, dizziness, headache
Low mood, irritability, depression are common reasons for discontinuation


Dosing info for phenytoin?

Initially 3-4mg/kg/day (usual dose 200-500mg/day)
Dose adjusted according to levels and effect


Place of phenytoin in epilepsy treatment?

Not recommended by NICE for first line


Pharmacokinetics of phenytoin?

- Narrow therapeutic index with saturable kinetics
- Half life 4-72 hours (depends on dose)
- Steady state reached after 7-10days
- Extensive hepatic metabolism
- Strong inducer of CYP450 - interactions
- Highly protein bound – albumin
- Interactions with enteral feeding


Phenytoin dosage forms and how to interchange?

Capsules and IV - phenytoin sodium
Liquid and chewable tablets - phenytoin base

92mg phenytoin = 100mg phenytoin sodium


Side effects of phenytoin?

N+V, constipation, drowsiness, parasthesia, gingival hyperplasia, acne, hirsuitism, coarsening of facial features


Signs of phenytoin overdose?

Nystagmus (involuntary eye movements), ataxia, diplopia (double vision), slurred speech, confusion, hyperglycaemia


What is the desired phenytoin plasma concentration?



MHRA categories for antiepileptics for supply - category 1?

Includes phenytoin, carbamazepine, phenobarbital,
Specific measures are necessary to ensure consistent supply of a particular product


MHRA categories for antiepileptics for supply - category 2?

Includes sodium valproate, lamotrigine, oxcarbazepine
The need for continued supply based on clinical judgement


MHRA categories for antiepileptics for supply - category 3?

Includes levetiracetam, lacosamide, gabapentin
No specific measures required


Important points when giving antiepileptics to women?

- Antiepileptics interact with hormonal medications
Can reduce effectiveness as enzyme inducers
E.g. Carbamazepine, phenytoin
Oral contraceptives and EHC can reduce effectiveness of lamotrigine.
May need to increase dose of lamotrigine

- Some AEDs are teratogens/can cause birth/developmental defects
- These drugs are to be avoided in women of childbearing potential and pregnant women
- Pharmacokinetics can be altered in pregnancy
- All women on AEDs should be offered folic acid 5mg OD before any possibility of pregnancy
- Some women have increased seizure frequency around menstruation
- Side effects of some AEDs may be undesirable


Risks when giving antiepileptics to the elderly?

Pharmacokinetic and pharmacodynamic issues
- Polypharmacy
- Co-morbidity

Consider using lower doses of AEDs

If on carbamazepine, this should be modified release


What is status epilepticus?

Medical emergency associated with significant morbidity and mortality

Generalised Convulsive Status Epilepticus is defined as a tonic clonic seizure which lasts longer than 30 minutes or repeated tonic clonic seizures within 30 minutes with little or no recovery in between


Treatment aims for status epilepticus?

Efficient and effective treatment is key
Aim of treatment is seizure termination


Treatment for status epilepticus?

- IV Lorazepam 0.1mg/kg (usually 4mg), repeated once after 10-20 minutes if seizure continues
- Give usual AEDs if already on treatment
- Alternatives to lorazepam are IV diazepam or buccal midazolam
- then Phenytoin IV 20mg/kg over 20 minutes (or phenobarbital if already on phenytoin) if still no success

last resort - general anaesthesia


What to check if treatment is failing?

- compliance
- change in brand/formulation?
- diagnosis - wrong drug for their epilepsy type
- brain tumour?
- alcohol/drug misuse


How to change drug in case of treatment failure?

- change to second line therapy
- initiate new drug, titrate up, then wean off old drug
- never abruptly stop AEDs, risk of rebound seizures


What to do if combination therapy doesn't work?

revert to the regimen that provided the best balance of tolerability and efficacy (could me mono or combination therapy)


What are the issues with combination therapy in epilepsy?

- drug interactions (many are potent inducers)
- increased toxicity
- identifying ADRs
- non-compliance (increased pill burden and side effects)


When is treatment withdrawal suitable?

- seizure free for at least two years
- joint decision by patient, carers and under guidance of specialist


How is treatment withdrawal carried out?

- slowly over months
- one drug at a time if combination therapy
- plan in place if seizures recur: reverse last dose reduction and seek specialist help


What counselling points are important to patients on epilepsy treatment?

- Importance of compliance explained – even when seizure free
- Dosing schedule and dose titration
- Signs and symptoms of adverse effects (Blood disorders, Liver dysfunction, Skin disorders)
- Brands and formulations


What are some of the social impacts of epilepsy?

- Employment: cannot be refused but must consider health and safety
- Driving: must be one year seizure free to drive (also consider side effects)
- Alcohol: interaction with drugs, can trigger seizures


How is childhood epilepsy diagnosed?

Same as adults
- history (description, video, witness)
- exclusion of other causes (cardiac, structural, metabolic)


Non-epileptic causes of childhood seizures?

- febrile seizures
- trauma
- metabolic


Epileptic causes of childhood seizures?

- primary idiopathic (genetic)
- secondary (tumour, structural abnormality)
- neurodegenerative disorders


What are paroxysms?

'fully turns'
- anoxic tonic-clonic seizures
- breath holding attacks, dramatic tantrums

reflex anoxic seizures arise from cold food, trauma or fright


What are febrile seizures?

- often a strong family history
- high incidence (3% of 3 months to 5 years)
- generalise tonic-clonic
- short lived, self resolving, associated with high body temperature


How to treat febrile seizures?

- reassure and comfort parents
- cool the child (remove clothing, bedding, reduce heaitng)
- antipyretics don't prevent them, cold swabbing no longer recommended
- maintenance AEDs are not appropriate as will resolve by age 5
- management of prolonged seizures should follow status epilepticus pathway


What is Dravets Syndrome?

80% have a mutation in SCN1A gene


Characteristics of Dravets Syndrome?

- Intractable seizures
- developmental delay
- failure to thrive
- dysregulated autonomic nervous system (thermoregulation, sweating)

15-20% mortality - as it doesn't respond to any AEDs


Management of Dravets Syndrome?

- Sodium valproate, plus clobazam, plus stiripentol if the first two doesn't work


Treatment goals for Dravets Syndrome?

Reduce frequency and severity of seizures
Reduce doses of valproate and clobazam


What must we do to valproate and clobazam if steripentol is initiated?

Reduce dose - potent inhibitors of CYP2C19, 2D6 and 3A4


Mode of action of Stiripentol?

- increase amount of GABA, inhibit metabolism of other AEDs


Who is stiripentol licensed in?

>3 years with Dravets Syndrome


Formulations fo stiripentol?

Oral suspension (sachet) and capsule

sachet has greater bioavailability, so not bioequivalent


Starting dose for stiripentol?

10mg/kg BD for a week
then 15mg/kg BD for a week


Max dose for stiripentol <6 years?

increase over three weeks to max 25mg/kg BD


Max dose for stiripentol 6-12 years?

increase over four weeks to max 25mg/kg BD


Max dose for stiripentol >12 years?

increase slowly to maximum tolerated dose


Why can we increase stiripentol dose quicker in under 6s than 6-12s?

Different pharmacokinetics in children


How does drug absorption vary between children and adults, and relate to AEDs?

- children have higher gastric pH (5-6 vs 2-3)
- lower bioavailability of phenytoin than adults (<75% vs 95%)
- slower gastric motility (reduced peak levels of phenobarbitone, which is rapidly absorbed through the GI tract - increase dose). also slower time to reach peak levels of carbemazepine
- milk based diets react with AEDs (phenytoin absorption reduced by 35% if administered with enteral feed)


How does drug metabolism vary between children and adults, and relate to AEDs?

- Hepatic extraction ratio is much higher - liver surface area is larger relative to their size
- increased first pass metabolism
- higher mg/kg dose for carbemazepine and sodium valproate required compared to adults
- higher expression of 1A2, 2C9 and 3A4 so lower F of substrates of these


Results of varying pharmacokinetics on dosing in children of AEDs?

Usually higher doses mg/kg than adults


Child vs adult dose of valproate?

10mg/kg for BD childen
300mg BD for adults - approx 3.8mg/kg


Child vs adult dose of clobazam?

5mg/kg daily for child
100mg BD for adult - approx 1.3mg/kg


Child vs adult dose of phenytoin?

5mg/kg/day child
3mg/kg/day adult


What is Lennox-Gastaut syndrome?

- most common form of intractable epilepsy
- characterised by 'drop attacks' - generalised absense seizures, atypical focal absence seizures (floppy and unresponsive), tonic seizures (jerking)
- developmental delays


Why does epilepsy cause development delays?

large amount of calorie expenditure on seizures


Treatment options for Lennox-Gastaut syndrome?

1st line: valproate
2nd line: lamotrigine, topiramate, clobazam, phenytoin

corticosteroids to reduce inflammation and neuronal damage
surgery to remove the affected area of the brain


Properties of valproate?

short chain fatty acid that inhibits uptake of GABA in the CNS


Why is valproate so commonly used in epilepsy?

- broad spectrum
- well tolerated
- cheap
- range of formulations


Toxicity profile of valproate?

1. Liver (monitor LFTs, bilirubin, ALT etc) - fatty liver
2. Pancreatitis (10% of patients)
3. Haemotological (pancytopaenia, thrombocytopoenia)
4. Metabolic derangement (urea cycle disorders)


Pharmacokinetics of valproate?

- half life 4-8 hours (8-20 hours in adults)
- 90% protein bound
- 65% renally cleared
- therapeutic level 40-100mg/L
concentration not correlated with therapeutic efficacy, only useful if concerned about toxicity


Valproate and teratogenicity?

- should not be used in women of childbearing age
- 1 in 10 risk of birth defects
- 4 in 10 risk of developmental delays (memory impairment, lower IQ, delay in walking/talking)


Why is valproate still on the market despite the risks?

Patient centred assessment, risk vs benefit


Counselling for children on valproate

Make parents/carers aware of risk of valproate and epilepsy in pregnancy
At a suitable time for the patient, discuss suitable contraception
When the child reaches child bearing age, review valproate and consider a change


What to do in unplanned pregnancy whilst taking valproate?

- review treatment and risk assess
- remind her to continue therapy until a decision is made
- use smallest dose possible, consider prolonged release formulation
- check understanding of risks and consider further counselling
- refer to specialist obstetrician for specialist guidance


Mode of action of carbemazepine?

- dose dependent voltage gated sodium channel antagonist: prevents repetitive action potentials, downregulates seizureactivity at the nerve
- also a GABA agonist


When is carbemazepine contraindicated?

Epilepsy seizures with sodium channel involvement, as it makes them worse
- Dravets Syndrome
- Myoclonic seizure disorders


Pharmacokinetic information on carbamazepine?

- half life 30 hours after a single dose (15 hours after repeated dosing) (2-12 hours if with phenytoin)
- 65% protein bound
- hepatically metabolised by CYP3A4
- therapeutic level 4-12mg/L - seldom correlates with efficacy


Mode of action of lamotrigine?

Direct effect on voltage gated sodium channels
- interacts with other AEDs (valproate, increased level. carbemazepine, decreased level)


Uses for lamotrigine?

1st line for focal seizures
1st line for generalised tonic clonics (good alternative to valproate)


What is the dynamic target of seizure control?

Balance between factors that influence excitatory and inhibitory post synaptic potentials


What factors influence excitatory post synaptic potential?

- sodium influx
- calcium influx
- paroxysmal depolarisation


What factors influence inhibitory post synaptic potential?

- potassium efflux
- chloride influx
- low pH


At what levels does physiological protection against repetitive firing occur?

cellular (e.g. sodium channel inactivation)
network (e.g. GABA mediated inhibition)


What are the main categories of anticonvulsants?

1. drugs that inhibit sodium channels
2. drugs that inhibit calcium channels
3. drugs that enhance GABA mediated inhibition
4. drugs that inhibit glutamate


How do the drugs that inhibit the sodium channels work?

prevent the return of these channels to active state by stabilising them in the inactive state


How do the drugs that inihibit the calcium channels work?

inhibit T-calcium channels (particularly useful in absence seizures)
high voltage activated channels - involved in neurotransmitter release


How is GABA synthesised?

mediated by glutamic acid decarboxylase (GAD)


How is GABA stored?

GABA is packaged into presynaptic vesicles by a transporter (VGAT)


How is GABA released?

In response to an action potential and the presynaptic elevation of intracellular Ca2+, GABA is released into the synaptic cleft by fusion of GABA-containing vesicles with the presynaptic membrane


Reuptake of GABA?

Neurons and glia take up GABA via specific GABA transporters (GATs). Four GATs have been identified, GAT-1, GAT-2, GAT-3 and GAT-4, each with a characteristic distribution in the CNS


How is GABA broken down?

widely distributed mitochondrial enzyme GABA-transaminase (GABA-T) metabolises GABA


Types of drugs that enhance GABA mediated inhibition?

GABA receptor agonists, GABA reuptake inhibitors, GABA-transaminase inhibitors


What do glutamate receptors do?

glutamate is a major excitatory neurotransmitter in the brain


What are the sites on ionotropic glutamate receptors?

AMPA, kainate, NMDA


How do AMPA and Kainate receptor sites regulate glutamate response?

oopen a channel that allows small amounts of sodium and calcium ions through


How do NMDA receptor sites regulate glutamate response?

open a channel that allows large amounts of calcium to enter alongside the sodium


What facilitates the opening of the NMDA rececptor channel?



What mediates and regulates the metaobtropic receptors?

Regulated by complex reactions and response mediated by second messengers


Why do NMDA receptor agonists have limited use?

produce psychosis and hallucinations
can also impair learning and memory