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Flashcards in Epilepsy/ Seizures Deck (140):
0

What's epilepsy?

Unprovoked seizures or abnormal "electrical storms" in the brain

1

Name the 2 basic grps that seizures are gen classified into.

Partial seizures

Generalized seizures

2

What's a partial seizure? Diff btw simple partial and complex partial seizures?

Starts in 1 part of the brain where the pt is either conscious or unconscious.

Simple partial= if there's NO loss of consciousness

Complex partial = if there's loss of consciousness

3

Are partial seizures (PS) only confirmed to 1 part of the brain?

No!

PS can spread to the other hemisphere of the brain resulting in "secondarily generalized tonic-sonic seizures"

Note: simple and complex PS stays in the hemisphere where the seizures start

4

What's generalized seizures (GS)?

GS begins in BOTH hemispheres of the brain where consciousness is impaired

5

What's the difference btw Secondarily generalized tonic-clonic seizures and Generalized seizures

Secondarily generalized tonic-clonic seizures = starts in 1 hemisphere and spreads to another hemisphere

Generalized seizures = starts in both hemisphere at the same time

6

What's a status epilepticus?

Seizures that last longer than 5 minutes

OR

>= 2 seizures btw which the pt doesn't regain consciousness

7

Which type of seizure/epilepsy is a medical emergency?

Status Epilepticus

8

List anticonvulsants/antiepileptic drugs/AEDs that are category D?

Carbamazepine

Clonazepam

Phenobarbital/Primidone

Phenytoin/Fosphenytoin

Topiramate

Valproate


All others are pregnancy category C

9

Which AEDs is assigned cat. X? Why?

Valproate used in migraine prophylaxis

10

Which AEDs is thot to have the highest risk of fetal harm?

Valproate

11

Whats the most common types of SE AEDs users experience?

CNS SEs e.g. Dizziness, somnolence and cognitive dysfunction (not surprising as AEDs penetrate CNS to work)

12

Most AEDs are strong inducers/ inhibitors/ substrates?

Most AEDs are strong INDUCERS

13

List the main AEDs that are strong inducers

Carbamazepine

Oxcarbazepine

Fosphenytoin

Phenytoin

Phenobarbital

Primidone

Topiramate (>= 200mg/d)

14

Effects of strong inducers (most AEDs)?

They can lower the blood conc of many drugs, as they increase their metabolism, so the other drugs are removed quickly from the body

15

What supplement should all pts on enzyme-inducing AEDs be on? Why?

Vit. D and Calcium

Bcuz bone loss can occur as soon as 2 yrs after starting AEDs, making pts prone to osteoporosis

16

Do all AEDs require MedGuide?

Yes.

All AEDs require a MedGuide due to risk of suicidality

17

How should seizure meds be d/c?

Taper off med slowly

Never d/c seizure meds abruptly due to seizure risk

18

When do u call 911 if u witness seizure?

Time seizure with ur watch, if longer than 5 mins without signs of slowing down, or

if person has trouble breathing afterwards, or

Appears to be inured, in pain, or

Recovery is unusual in some way

19

How can u keep the airway of the person experiencing seizures clear?

Turn the person gently onto 1 side

20

What's the tx of status epilepticus?

Rapid-acting BZD first e.g. Lorazepam (BZD of choice in status)

Followed by AED therapy (LD followed by MD)

21

List BZD used to treat Status Epilepticus. Which is drug of choice?

Lorazepam (Ativan) - drug of choic

Diazepam

Rectal diazepam (Diastat Acudial)

22

What's the dose of lorazepam used in status epilepticus?

Lorazepam (Ativan): 4mg given by slow IV (adult)
Max rate - 2mg/min
May repeat in 5-10 minutes, if no response

23

What's the 2nd line tx in status epilecticus?

AEDs

24

List 1st line tx in Partial, including secondarily generalized

Carbamazepine

Lamotrigine

Levetiracetam

Oxcarbazepine

25

List 1st line tx in Primarily Generalized Tonic-Clonic ONLY (type of partial seizure)

Lamotrigine

Levetiracetam

Valproate

26

List 1st line tx in Absence seizures

Ethosuximide

Valproate

27

List 1st line tx in Atypical Absence, Myoclonic, Atonic seizures

Ethosuximde

Lamotrigine

Levetiracetam

Valproate

28

List 1st gen AEDs

Benzodiazepines (BZD)

Carbamazepine (CBZ)

Ethosuximide

Phenobarbital/Primidone

Phenytoin/Fosphenytoin

Valproic acid/Valproate

29

MOA of BZD (1st generation AED)

BZDs enhance the activity of gamma-aminobutyric acid (GABA)

GABA is an inhibitory neurotransmitter

30

List agents under BZDs (1st generation AED)

Clonazepam (Klonopin)

Clobazam (Onfi)

31

SEs of BZDs (1st generation AED)

Drowsiness

Ataxia

Behavior disorder

Dizziness

Lethargy

Cognitive impairment (limit other CNS depressants)

Depression

Physiological dependence

Tolerance

Retrograde amnesia

32

Which BZD used as aces is pregnancy cat. C? D?

Preg cat. C = Clobazam (Onfi)

Preg cat. D = Clonazepam (Klonopin)

33

Is Clonazepam a major 3A4 inducer, inhibitor or substrate?

Clonazepam is a major 3A4 substrate

34

MOA of carbamazepine? (1st generation AED)

Fast Na channel blocker

Stimulates release of anti diuretic hormone (ADH) => reabsorption of water

35

What's the brand name of Carbamazepine? (1st generation AED)

Tegretol; Tegretol XR

Carbatrol

Epitol - used for Bipolar

36

What's the therapeutic range of CBZ (Tegretol, Tegretol XR, carbatrol) (1st generation AED)?

4-12 mcg/mL

37

What's the black box warning of CBZ (Tegretol; XR, Carbatrol) (1st generation AED)?

Serious skin rxns, including SJS and TEN

Fatal blood cell abnormalities (including aplastic anemia and agranulocytosis)

38

What MUST be done b4 a pt of Asian descent use CBZ (Tegretol; XR, Carbatol) (1st generation AED)?

Must be tested for HLA-B*1502 allele PRIOR to therapy

If positive CBZ can't be used

39

If a pt of Asian descent tests positive for HLA-B*1502, can they still use CBZ (Tegretol; XR, Carbatrol) (1st generation AED)?

No!

Unless benefit clearly outweighs the risk

40

What's the warning associated with CBZ (Tegretol; XR, Carbatrol) (1st generation AED) use?

Serious skin rxns (onset usually 2-8 wks after initiation)

41

SEs of CBZ (Tegretol; XR, Carbatrol) (1st generation AED)?

Nausea

Vomiting

Dizziness

Drowsiness

Headache

Ataxia

Fatigue

Vit. D and Calcium deficiency (bone loss)

SIADH/hyponatremia

Hepatotoxicity

42

Is CBZ an inhibitor, substrate/ inducer?

Potent CYP 450 INDUCER and autoinducer of many enzymes (1A2, 2C19, 2C8/9, 3A4)

T4 LOWERS the level of many drugs and of itself

And a major 3A4 Substrate (t4 inh will increase its level)

43

What supplementation is req with the use of carbamazepine (Tegretol; XR, Carbatrol) (1st generation AED)?

Calcium and Vit. D

44

Generally, should OCPs be used concurrently with AEDs?

No!

Use alternative, nonhormonal contraceptive

45

What seizure type is CBZ (Tegretol; XR, Carbatrol) (1st gen AEDs) used for?

Partial (simple and complex), including secondarily generalized

46

MOA of Ethosuximide?

T-type Ca channel blocker that increase seizures threshold and suppresses paroxysmal spike-and-wave pattern in absence seizures

47

What's the brand name of Ethosuximide (1st gen AEDs)?

Zarontin

48

SEs of Ethosuximide (1st gen AEDs)?

GI upset (weight loss, abdominal pain, nausea & vomiting)

Hiccups

49

Types of seizure Ethosuximide (1st gen AEDs) is used for?

Absence seizure

Atypical Absence, Myoclonic, Atonic seizures

50

Is Ethosuximide a substrate, inducer/ inhibitor?

Major 3A4 substrate

T4 strong inducers like CBZ, Fosphenytoin, phenytoin, phenobarbital, Primidone may LOWER Ethosuximide levels

51

Which AEDs may INCREASE the level of Ethosuximide (1st gen AEDs)? (Most other AEDs lowers it's level)

Valproic acid

52

MOA of phenobarbital/Primidone? (1st gen AEDs)

Enhance gamma-aminobutyric acid (GABA)- mediated chloride influx

53

What's the brand name of phenobarbital?

Luminal

54

What's Primidone (Mysoline)?

Prodrug of phenobarbital and phenylethylmalonamide (PEMA)

55

What's the therapeutic range of phenobarbital (Luminal) and Primidone (Mysoline) in adults? (1st gen AEDs)

20-40 mcg/mL

56

What's the therapeutic range of phenobarbital (Luminal) and Primidone (Mysoline) in children? (1st gen AEDs)

15-30 mcg/mL

57

SEs of phenobarbital (luminal) / Primidone? (1st gen AEDs)

Drowsiness

Cognitive impairment (limit other CNS depressants)

Dizziness/ataxia

Physiological dependence

Tolerance

Hang-over effect

Depression

Vit. D and calcium bone deficiency (bone loss)

Hepatotoxicity (rare)

58

How do u d/c phenobarbital (luminal) / Primidone? (1st gen AEDs). True for all AEDs also.

Taper slowly

59

Supplement with phenobarbital (luminal) / Primidone? (1st gen AEDs)? True for all AEDs.

Calcium and Vit. D

60

Are phenobarbital (luminal) / Primidone (1st gen AEDs), inhibitors, substrate, inducers?

Strong CYP 450 enzyme inducer

61

MOA of phenytoin/Fosphenytoin? (1st gen AEDs)

Fast Na channel blockers

62

What's the brand name of Phenytoin (1st gen AEDs)?

Dilantin

Phenytek

63

What's Fosphenytoin? (1st gen AEDs)

Prodrug of phenytoin

IV/IM Injection only

64

What's the max rate for Phenytoin (Dilantin, Phenytek) infusion? (1st gen AEDs)

50 mg/min

65

What's the max rate for Fosphenytoin infusion? (1st gen AEDs)

150 mg PE/min

66

How's Fosphenytoin dosed?

In Phenytoin Equivalents (PE)

1mg PE = 1mg phenytoin

67

Phenytoin (Dilantin, Phenytek) and Fosphenytoin (1st gen AEDs) exhibits Michaelis-Menten kinetics. What does that mean?

They exhibit saturable

That means a small change in dose can cause a big change in serum level

68

What's the relationship btw low albumin and phenytoin levels?

Low albumin (< 3.5g/dL) results in a false low phenytoin level (t4, PHT will appear artificially LOW)

T4 it's corrected using this formula

PHT measure
Divided by
(0.2 x albumin) + 0.1

Or

Can measure a fre PHT level

69

What's the value deemed to be low albumin?

Low albumin < 3.5g/dL

70

Since low albumin (< 3.5 g/dL) results in a false LOW PHT levels, whats the formula used to correct PHT?

PHT correction = PHT measured
Divided by
(0.2 x alb) + 0.1

71

What's the therapeutic range of total PHT level measured?

Total PHT: 10-20 mcg/mL

72

T/F? PHT ER caps contains 8% less drug than chewable and suspension?

True!

T4 adjust dose if changing formulations

73

What's the black box warning associated with Phenytoin (Dilantin, Phenytek) and Fosphenytoin (1st gen AEDs)?

PHT admin: NOT to exceed 50mg/minute

FosPHT admin: NOT to exceed 150mg PE/min

To avoid hypotension and cardiac arrhythmias

74

What's the warning associated with IV PHT?

Vesicant: can cause venous irritation and

Purple glove syndrome (discoloration with edema & pain of distal limb)
Inject into large vein slowly & follow with saline flush

75

Dose-related SEs of Phenytoin (Dilantin, Phenytek) and Fosphenytoin (1st gen AEDs)?

Dose-related toxicity

-Ataxia
-Dizziness
-Drowsiness
-HA
-Nystagmus
-Slurred speech

76

Chronic SEs of Phenytoin (Dilantin, Phenytek) and Fosphenytoin (1st gen AEDs)?

Skin thickening (children)

Gingival hyperplasia

Hirsutism

Vit. D and Calcium deficiency (bone loss)

Connective tissue changes

Coarsening of facial features

Folate deficiency

Hepatoxicity

77

What's unique about the supplementation of Phenytoin (Dilantin, Phenytek) and Fosphenytoin (1st gen AEDs)?

In addition to Vit. D and calcium,

Folic acid and Vit. B12 are also used?

78

What's PHT compatible with only during IV?

NS only

Req a filter and is stable for 4 hrs only

79

Enteral feedings and PHT?

Enteral feedings may LOWER PHT absorption

T4 must separate!

80

Protein binding and Phenytoin (Dilantin, Phenytek) and Fosphenytoin (1st gen AEDs)?

Phenytoin (Dilantin, Phenytek) and Fosphenytoin (1st gen AEDs) are HIGH protein binding activity

PHT: 90-95%
FosPHT: 95-99%

Can displace other highly-protein bound drugs

81

What's the brand name of Valproate/Valproic acid? (1st gen. AEDs)

Depakene - capsule, solution, syrup

Stavzor - delayed-release capsule

Depacon - IV

82

What's the brand name of Divalproex? (1st gen. AEDs)

Depakote - delayed release tablet

Depakote ER - ext-release tablet

Depakote Sprinkle

83

What's the usual therapeutic range of Valproic acid/Valproate?

50-100 mcg/ml

Some pts req higher levels

84

Effect of low albumin (< 3.5 g/dL) on valproate levels?

Same as PHT (results in a false LOW valproate levels) .

T4 low albumin = low PHT and valproate levels

Adjust using the same formula

Valproate correction formula =
Valproate measured
Divided by
(0.2 x albumin) + 0.1

85

Black box warnings of Valproate/Valproic acid and Divalproex? (1st gen. AEDs)

Hepatic failure

Teratogenicity

Pancreatitis

86

Who's at the highest risk of hepatic failure as a result of Valproate/Valproic acid and Divalproex use? (1st gen. AEDs)

During 1st 6 months of use

Pts with mitochondrial disorders (at highest risk)

Children under the age of 2 yrs

87

What's the sx of teratogenicity that occurs in Valproate/Valproic acid and Divalproex use? (1st gen. AEDs)

Neural tube defects e.g. Spina bifida

88

SEs of Valproate/Valproic acid and Divalproex use? (1st gen. AEDs)

GI upset (n/v)

Abdominal pain

Dizziness

Asthenia

Tremor

Alopecia (treat with a multivitamin containing selenium and zinc)

Somnolence

Weight gain

Polycystic ovary syndrome (PCOS)

Vit. D and calcium deficiency (bone loss)

Pancreatitis

Lower IQ in children if exposed in-utero

89

Dose-related SEs of Valproate/Valproic acid and Divalproex use? (1st gen. AEDs)

Thrombocytopenia

90

What may alleviate stomach ache?

Switch from Valproic acid to delayed-release Divalproex may reduce stomach upset

91

What's unique about the role of Valproic acid (1st gen. AEDs)

Inhibitor of 2C9

Most AEDs are inducers

92

List 2nd generation anticonvulsants

Lamotrigine

Levetiracetam

Oxcarbazepine

Pregabalin/Gabapentin

Topiramate

Zonisamide

93

What's the brand name of Lamotrigine (2nd generation AEDs)?

Lamictal

94

Black box warning of Lamotrigine (Lamictal) (2nd generation AEDs)

Serious skin rxn: including SJS and TENS

95

What's the titration schedule of Lamotrigine (Lamictal) (2nd generation AEDs) based on?

It's based on whether pt is:

On valproate (inhibitor)

On Inducer AEDs

Or, no concomitant AEDs

96

SEs of Lamotrigine (Lamictal) (2nd generation AEDs)?

Nausea

Insomnia

Drowsiness

Rash

97

What's the brand name of Levetiracetam (2nd generation AEDs)?

Keppra

Keppra XR

98

SEs of Levetiracetam (Keppra) (2nd generation AEDs)?

Somnolence

Dizziness

99

What's unique about Levetiracetam (Keppra), Pregabalin (Lyrica), Gabapentin (Neurotin) (2nd generation AEDs) and Rufinamide use?

No significant drug interactions

100

What's the brand name of Oxcarbazepine (2nd generation AEDs)?

Trileptal

Oxtellar XR

101

Warnings associated with Oxcarbazepine (Trileptal, Oxtellar XR) (2nd generation AEDs) use?

Serious skin rxns

102

SEs of Oxcarbazepine (Trileptal, Oxtellar XR) (2nd generation AEDs)?

Somnolence

Dizziness

HA

GI effects (n/v/ abdominal pain)

Diplopia

Nystagmus

Abnormal vision

Ataxia

Tremor

Vit. D and Ca deficiency (bone loss)

103

Which SE should be monitored, esp in the 1st 3 months of Oxcarbazepine (Trileptal, Oxtellar XR) use?

Hyponatremia

Monitor serum Na levels esp during the first 3 months (more common than with CBZ)

104

What's the same as all other AEDs?

Strong inducer

Supplement with Vit. D and Ca

105

MOA of pregabalin/Gabapentin

Bind to the alpha-2-delta subunit of voltage-dependent Ca channels within CNS

106

What's the brand name of Pregabalin (2nd generation AEDs)?

Lyrica

107

SEs of Pregabalin (Lyrica) and Gabapentin (Neurotin) (2nd generation AEDs) use?

Dizziness

Somnolence

Peripheral edema

Weight gain

Ataxia

Diplopia

Blurred vision

Xerostomia

108

Whats the brand name of Gabapentin (2nd generation AEDs)?

Neurotin

109

Brand name of Topiramate (2nd generation AEDs)?

Topamax

110

Warning associated with Topiramate (Topamax) (2nd generation AEDs) use?

Metabolic acidosis

Oligohydrosis (reduced perspiration)/ Hyperthermia - mostly in kids

Neohrolithiasis - keep hydrated

111

What's different in the SE of Topiramate (Topamax), compared to other AEDs?

Weight loss

112

What can be caused in newborn, if mother uses Topiramate (Topamax) while pregnant?

Cleft lip and/or palate in newborn

113

What's the CI to Zonisamide (Zonegran) (2nd generation AEDs) use?

Hypersensitivity to Sulfonamides

114

What AEDs cause weight loss?

Topiramate (Topamax)

Zonisamide (Zonegran)

115

What's warning associated with Zonisamide (2nd generation AEDs) use?

Serious skin rxns, including SJS/TEN

Oligohydrosis (reduced perspiration)/ hyperthermia - mostly in kids - try to limit sun and hydrate

Nephrolithiasis (kidney stones) - keep hydrated

Metabolic acidosis

116

SEs of Zonisamide use?

Drowsiness

Dizziness

Weight loss

Vit. D & Ca deficiency (bone loss)

117

List other AEDs

Eslicarbazepine Acetate (Aptiom)

Ezogabine (Potiga)

Felbamate (Felbatol)

Lacosamide (Vimpat)

Rufinamide (Banzel)

Tiagabine (Gabitril)

Vigabatrin (Sabril)

Perampanel (Fycompa)

118

Which AEDs has Retinal abnormalities and Blue skin discoloration as SEs (unique)?

Ezogabine (Potiga)

119

Unique SEs of Ezogabine (Potiga)?

Retinal abnormalities

Skin discoloration - typically blue

Urine to turn orangish/reddish/brown

120

Black box warnings of Felbamate (Felbatol)?

Hepatic Failure

And

Aplastic Anemia

121

What do I look out for if I see Felbamate being used in a case in exam?

There's likely a reason why it should NOT be used.

T4 use at LFTs, other concomitant drugs that are hepatotoxic and the CBC

122

What's unique SE of Rufinamide (Banzel) use?

QT shortening

123

What's AEDs cause Teratogenicity?

CBZ, Clonazepam

Phenobarbital, PHT

Topiramate

Valproic acid

124

What's AEDs cause Hepatoxicity?

CBZ

Felbamate

Phenobarbital/Primidone, PHT

Valproic acid

125

What's AEDs cause decreased effects of OCPs?

CBZ, Clobazam

Oxcarbazepine

Perampanel, Phenobarbital, PHT, Primidone

Topiramate (>= 200mg/day)

126

What's AEDs cause Fatal Pancreatitis?

Valproic acid

127

What's AEDs cause Aplastic Anemia?

CBZ (also cuz Agranulocytosis)

Felbamate

128

What's AEDs cause Skin rash (SJS)?

CBZ

Lamotrigine

Oxcarbazepine

Phenobarbital, PHT/Fosphenytoin

Tiagabine

Zonisamide

129

What's AEDs cause:
Oligohydrosis - inability to sweat, risk of heat stroke - highest risk in kids

Nephrolithiasis (kidney stones)

Topiramate

Zonisamide

130

What's AEDs cause weight gain?

Valproic acid

Gabapentin

Pregabalin

131

What's AEDs cause Weight loss?

Felbamate

Ethosuximide

Topiramate

Zonisamide

132

What's AEDs cause Hyponatremia?

CBZ

Oxcarbazepine (more common)

133

What should women in Teratogenic causing AEDs be encouraged to do, once they're pregnant and still in med?

Enrol in North American Antiepileptic Drug (NAAED) pregnancy registry

134

What natural pdt should be avoided with AEDs?

St. John's wort

135

List drugs/conditions that may lower the seizure threshold

Antipsychotics e.g, clozapine, phenothiazines, butyrophenones

Antivirals e.g, Amantadine, Rimantadine, Foscarnet, Ganciclovir, and
Acyclovir IV

Bupropion

Carbapenems (in poor renal fxn, esp. Imipenem)

Cephalosporin

Fluoroquinolones

Lindane

Lithium and Theophylline (in toxicity)

Mefloquine

Meperidine (in poor renal fxn)

Metoclopramide

Natural pdts such as dendrobium, evening primrose oil, gingko, melatonin, St. John's wort

Penicillins

Sleep deprivation, alcohol intoxication, menstruation, infection, and fever (esp, in children) can worsen seizure

136

Look at pt counseling pts on pg 934-938

Look!

137

List sx PHT toxicity

Shakiness/walking unsteady

Double vision

Nystagmus

138

If PHT is used long-term, what can occur without proper supplementation?

Osteoporosis

Anemia

139

List some of the steps that can be taken if pt is found having seizures

Turn pt on their side

Remove sharp or hard objects away from the pt seizing and support their head

Loosen pts clothes

Time seizure

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