Epilepsy Flashcards
What is the MHRA advice surrounding switching between different manufacturers’ products in epilepsy?
Antiepileptic drugs have been divided into three risk-based categories to help healthcare professionals decide whether it is necessary to maintain continuity of supply of a specific manufacturer’s product.
Category 1:
Carbamazepine, phenobarbital, phenytoin, primidone. For these drugs, doctors are advised to ensure that their patient is maintained on a specific manufacturer’s product.
Category 2
Clobazam, clonazepam, eslicarbazepine acetate, lamotrigine, oxcarbazepine, perampanel, rufinamide, topiramate, valproate, zonisamide. For these drugs, the need for continued supply of a particular manufacturer’s product should be based on clinical judgement and consultation with the patient and/or carer taking into account factors such as seizure control
Category 3
Brivaracetam, ethosuximide, gabapentin, lacosamide, levetiracetam, pregabalin, tiagabine, vigabatrin. For these drugs, it is usually unnecessary to ensure that patients are maintained on a specific manufacturer’s product as therapeutic equivalence can be assumed
What is antiepileptic hypersensitivity syndrome?
Rare but potentially fatal syndrome associated with some antiepileptic drugs
The symptoms usually start between 1 and 8 weeks of exposure; fever, rash, and lymphadenopathy are most commonly seen.
What is the MHRA advice regarding antiepileptic drugs and psychological side effects?
Associated with a small increased risk of suicidal thoughts and behaviour (can occur as early as one week after starting treatment)
Seek medical advice if they develop mood changes
What is 1st line for newly diagnosed focal seizures?
Carbamazepine or Lamotrigine
What is 1st line for tonic-clonic seizures?
What would be an alternative if this is unsuitable? What is the problem with this?
Sodium valproate
Lamotrigine, carbamazepine is an alternative however may exacerbate myoclonic seizures
What is 1st line for absence seizures?
What would be an alternative?
Ethosuximide or sodium valproate
Lamtorogine is an alternative
What is 1st line for myoclonic seizures?
What would be alternative options?
Sodium valproate
Topiramate or levetiracetam
Atonic and clonic seizures are usually seen in which patient group?
What is the drug of choice for this?
Childhood or associated with cerebral damage or mental retardation
Sodium valproate
Lamotrigine can be added
Which benzodiazepines can be used in epilepsy management (not status epilepticus)?
Clobazam
Clonazepam
Seizures lasting longer than 5 minutes should be treated with what benzodiazepine?
What should you monitor?
IV lorazepam - can repeat once after 10 minutes if response fails
Monitor for hypotension and respiratory depression
IV diazepam is effective in seizures but carries a high risk of what?
Thrombophlebitis
True or false:
Diazepam IM or suppositories should be used for status epilepticus
False- absorption is too slow
If after initial treatment of IV lorazepam and there is no response after 25 mins, what should be used?
Phenytoin/phenobarbital/fosphenytoin
If this does not work- anaesthesia
Do brief febrile convulsions need any treatment?
No, may give paracetamol to reduce fever
However, if prolonged (>5 mins) or recurrent, treat as epileptic seizure.
Is long term anticonvulsant prophylaxis recommended?
Rarely indicated
If an epileptic patient becomes pregnant, what supplement is recommended alongside their pregnancy, especially in the first trimester?
Folate supplementation to prevent neural tube defects (folic acid)
High dose 5mg OD
Pregnant patients who are taking what antiepileptics should have fetal growth monitoring?
Topiramate or levetiracetam
What conditions can lamotrigine exacerbate?
Parkinson’s Disease
Myoclonic seizures
What is a main side effect of lamotrigine?
What are the risk factors of this?
Hypersensitivity syndrome. Serious skin reactions including Stevens-Johnson syndrome and toxic epidermal necrolysis have developed (especially in children); most rashes occur in the first 8 weeks.
Risk factors include concomitant use of valproate, too high dose or too rapid dose increase
What is the patient advice surrounding lamotrigine?
- Don’t suddenly stop treatment as needs to be tapered off gradually
- Contact doctor immediately if any rash or signs of hypersensitivity
- Rare - be alert for symptoms and signs suggestive of bone-marrow failure, such as anaemia, bruising, or infection.
What vitamin supplementation should you consider if a patient is on carbamazepine?
Vitamin D
Especially if immobilised for long periods, or who have inadequate sun exposure/dietary intake of calcium
What are the main side effects to look out for if a patient is on carbamazepine?
Blood or skin disorders
Antiepileptic hypersensitivity syndrome
Seek medical help if fever, rash, mouth ulcers etc occur
ALSO can cause hepatotoxicity so report signs of dark urine, nausea, vomiting
What is the MHRA advice regarding gabapentin?
Risk of severe respiratory depression
What are the serious side effects of lamotrigine?
Skin reactions: these develop within 1-8 weeks. They include serious skin reactions i.e. Steven-
Johnson syndrome and toxic epidermal necrolysis
Blood disorders - Patients and their carers should be alert for symptoms and signs suggestive of bone-marrow failure, such as anaemia, bruising, or infection
