Flashcards in Epilepsy/ Seizures Deck (140):
Unprovoked seizures or abnormal "electrical storms" in the brain
Name the 2 basic grps that seizures are gen classified into.
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
Are partial seizures (PS) only confirmed to 1 part of the brain?
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
What's generalized seizures (GS)?
GS begins in BOTH hemispheres of the brain where consciousness is impaired
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
What's a status epilepticus?
Seizures that last longer than 5 minutes
>= 2 seizures btw which the pt doesn't regain consciousness
Which type of seizure/epilepsy is a medical emergency?
List anticonvulsants/antiepileptic drugs/AEDs that are category D?
All others are pregnancy category C
Which AEDs is assigned cat. X? Why?
Valproate used in migraine prophylaxis
Which AEDs is thot to have the highest risk of fetal harm?
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)
Most AEDs are strong inducers/ inhibitors/ substrates?
Most AEDs are strong INDUCERS
List the main AEDs that are strong inducers
Topiramate (>= 200mg/d)
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
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
Do all AEDs require MedGuide?
All AEDs require a MedGuide due to risk of suicidality
How should seizure meds be d/c?
Taper off med slowly
Never d/c seizure meds abruptly due to seizure risk
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
How can u keep the airway of the person experiencing seizures clear?
Turn the person gently onto 1 side
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)
List BZD used to treat Status Epilepticus. Which is drug of choice?
Lorazepam (Ativan) - drug of choic
Rectal diazepam (Diastat Acudial)
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
What's the 2nd line tx in status epilecticus?
List 1st line tx in Partial, including secondarily generalized
List 1st line tx in Primarily Generalized Tonic-Clonic ONLY (type of partial seizure)
List 1st line tx in Absence seizures
List 1st line tx in Atypical Absence, Myoclonic, Atonic seizures
List 1st gen AEDs
MOA of BZD (1st generation AED)
BZDs enhance the activity of gamma-aminobutyric acid (GABA)
GABA is an inhibitory neurotransmitter
List agents under BZDs (1st generation AED)
SEs of BZDs (1st generation AED)
Cognitive impairment (limit other CNS depressants)
Which BZD used as aces is pregnancy cat. C? D?
Preg cat. C = Clobazam (Onfi)
Preg cat. D = Clonazepam (Klonopin)
Is Clonazepam a major 3A4 inducer, inhibitor or substrate?
Clonazepam is a major 3A4 substrate
MOA of carbamazepine? (1st generation AED)
Fast Na channel blocker
Stimulates release of anti diuretic hormone (ADH) => reabsorption of water
What's the brand name of Carbamazepine? (1st generation AED)
Tegretol; Tegretol XR
Epitol - used for Bipolar
What's the therapeutic range of CBZ (Tegretol, Tegretol XR, carbatrol) (1st generation AED)?
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)
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
If a pt of Asian descent tests positive for HLA-B*1502, can they still use CBZ (Tegretol; XR, Carbatrol) (1st generation AED)?
Unless benefit clearly outweighs the risk
What's the warning associated with CBZ (Tegretol; XR, Carbatrol) (1st generation AED) use?
Serious skin rxns (onset usually 2-8 wks after initiation)
SEs of CBZ (Tegretol; XR, Carbatrol) (1st generation AED)?
Vit. D and Calcium deficiency (bone loss)
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)
What supplementation is req with the use of carbamazepine (Tegretol; XR, Carbatrol) (1st generation AED)?
Calcium and Vit. D
Generally, should OCPs be used concurrently with AEDs?
Use alternative, nonhormonal contraceptive
What seizure type is CBZ (Tegretol; XR, Carbatrol) (1st gen AEDs) used for?
Partial (simple and complex), including secondarily generalized
MOA of Ethosuximide?
T-type Ca channel blocker that increase seizures threshold and suppresses paroxysmal spike-and-wave pattern in absence seizures
What's the brand name of Ethosuximide (1st gen AEDs)?
SEs of Ethosuximide (1st gen AEDs)?
GI upset (weight loss, abdominal pain, nausea & vomiting)
Types of seizure Ethosuximide (1st gen AEDs) is used for?
Atypical Absence, Myoclonic, Atonic seizures
Is Ethosuximide a substrate, inducer/ inhibitor?
Major 3A4 substrate
T4 strong inducers like CBZ, Fosphenytoin, phenytoin, phenobarbital, Primidone may LOWER Ethosuximide levels
Which AEDs may INCREASE the level of Ethosuximide (1st gen AEDs)? (Most other AEDs lowers it's level)
MOA of phenobarbital/Primidone? (1st gen AEDs)
Enhance gamma-aminobutyric acid (GABA)- mediated chloride influx
What's the brand name of phenobarbital?
What's Primidone (Mysoline)?
Prodrug of phenobarbital and phenylethylmalonamide (PEMA)
What's the therapeutic range of phenobarbital (Luminal) and Primidone (Mysoline) in adults? (1st gen AEDs)
What's the therapeutic range of phenobarbital (Luminal) and Primidone (Mysoline) in children? (1st gen AEDs)
SEs of phenobarbital (luminal) / Primidone? (1st gen AEDs)
Cognitive impairment (limit other CNS depressants)
Vit. D and calcium bone deficiency (bone loss)
How do u d/c phenobarbital (luminal) / Primidone? (1st gen AEDs). True for all AEDs also.
Supplement with phenobarbital (luminal) / Primidone? (1st gen AEDs)? True for all AEDs.
Calcium and Vit. D
Are phenobarbital (luminal) / Primidone (1st gen AEDs), inhibitors, substrate, inducers?
Strong CYP 450 enzyme inducer
MOA of phenytoin/Fosphenytoin? (1st gen AEDs)
Fast Na channel blockers
What's the brand name of Phenytoin (1st gen AEDs)?
What's Fosphenytoin? (1st gen AEDs)
Prodrug of phenytoin
IV/IM Injection only
What's the max rate for Phenytoin (Dilantin, Phenytek) infusion? (1st gen AEDs)
What's the max rate for Fosphenytoin infusion? (1st gen AEDs)
150 mg PE/min
How's Fosphenytoin dosed?
In Phenytoin Equivalents (PE)
1mg PE = 1mg phenytoin
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
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
(0.2 x albumin) + 0.1
Can measure a fre PHT level
What's the value deemed to be low albumin?
Low albumin < 3.5g/dL
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
(0.2 x alb) + 0.1
What's the therapeutic range of total PHT level measured?
Total PHT: 10-20 mcg/mL
T/F? PHT ER caps contains 8% less drug than chewable and suspension?
T4 adjust dose if changing formulations
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
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
Dose-related SEs of Phenytoin (Dilantin, Phenytek) and Fosphenytoin (1st gen AEDs)?
Chronic SEs of Phenytoin (Dilantin, Phenytek) and Fosphenytoin (1st gen AEDs)?
Skin thickening (children)
Vit. D and Calcium deficiency (bone loss)
Connective tissue changes
Coarsening of facial features
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?
What's PHT compatible with only during IV?
Req a filter and is stable for 4 hrs only
Enteral feedings and PHT?
Enteral feedings may LOWER PHT absorption
T4 must separate!
Protein binding and Phenytoin (Dilantin, Phenytek) and Fosphenytoin (1st gen AEDs)?
Phenytoin (Dilantin, Phenytek) and Fosphenytoin (1st gen AEDs) are HIGH protein binding activity
Can displace other highly-protein bound drugs
What's the brand name of Valproate/Valproic acid? (1st gen. AEDs)
Depakene - capsule, solution, syrup
Stavzor - delayed-release capsule
Depacon - IV
What's the brand name of Divalproex? (1st gen. AEDs)
Depakote - delayed release tablet
Depakote ER - ext-release tablet
What's the usual therapeutic range of Valproic acid/Valproate?
Some pts req higher levels
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 =
(0.2 x albumin) + 0.1
Black box warnings of Valproate/Valproic acid and Divalproex? (1st gen. AEDs)
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
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
SEs of Valproate/Valproic acid and Divalproex use? (1st gen. AEDs)
GI upset (n/v)
Alopecia (treat with a multivitamin containing selenium and zinc)
Polycystic ovary syndrome (PCOS)
Vit. D and calcium deficiency (bone loss)
Lower IQ in children if exposed in-utero
Dose-related SEs of Valproate/Valproic acid and Divalproex use? (1st gen. AEDs)
What may alleviate stomach ache?
Switch from Valproic acid to delayed-release Divalproex may reduce stomach upset
What's unique about the role of Valproic acid (1st gen. AEDs)
Inhibitor of 2C9
Most AEDs are inducers
List 2nd generation anticonvulsants
What's the brand name of Lamotrigine (2nd generation AEDs)?
Black box warning of Lamotrigine (Lamictal) (2nd generation AEDs)
Serious skin rxn: including SJS and TENS
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
SEs of Lamotrigine (Lamictal) (2nd generation AEDs)?
What's the brand name of Levetiracetam (2nd generation AEDs)?
SEs of Levetiracetam (Keppra) (2nd generation AEDs)?
What's unique about Levetiracetam (Keppra), Pregabalin (Lyrica), Gabapentin (Neurotin) (2nd generation AEDs) and Rufinamide use?
No significant drug interactions
What's the brand name of Oxcarbazepine (2nd generation AEDs)?
Warnings associated with Oxcarbazepine (Trileptal, Oxtellar XR) (2nd generation AEDs) use?
Serious skin rxns
SEs of Oxcarbazepine (Trileptal, Oxtellar XR) (2nd generation AEDs)?
GI effects (n/v/ abdominal pain)
Vit. D and Ca deficiency (bone loss)
Which SE should be monitored, esp in the 1st 3 months of Oxcarbazepine (Trileptal, Oxtellar XR) use?
Monitor serum Na levels esp during the first 3 months (more common than with CBZ)
What's the same as all other AEDs?
Supplement with Vit. D and Ca
MOA of pregabalin/Gabapentin
Bind to the alpha-2-delta subunit of voltage-dependent Ca channels within CNS
What's the brand name of Pregabalin (2nd generation AEDs)?
SEs of Pregabalin (Lyrica) and Gabapentin (Neurotin) (2nd generation AEDs) use?
Whats the brand name of Gabapentin (2nd generation AEDs)?
Brand name of Topiramate (2nd generation AEDs)?
Warning associated with Topiramate (Topamax) (2nd generation AEDs) use?
Oligohydrosis (reduced perspiration)/ Hyperthermia - mostly in kids
Neohrolithiasis - keep hydrated
What's different in the SE of Topiramate (Topamax), compared to other AEDs?
What can be caused in newborn, if mother uses Topiramate (Topamax) while pregnant?
Cleft lip and/or palate in newborn
What's the CI to Zonisamide (Zonegran) (2nd generation AEDs) use?
Hypersensitivity to Sulfonamides
What AEDs cause weight loss?
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
SEs of Zonisamide use?
Vit. D & Ca deficiency (bone loss)
List other AEDs
Eslicarbazepine Acetate (Aptiom)
Which AEDs has Retinal abnormalities and Blue skin discoloration as SEs (unique)?
Unique SEs of Ezogabine (Potiga)?
Skin discoloration - typically blue
Urine to turn orangish/reddish/brown
Black box warnings of Felbamate (Felbatol)?
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
What's unique SE of Rufinamide (Banzel) use?
What's AEDs cause Teratogenicity?
What's AEDs cause Hepatoxicity?
What's AEDs cause decreased effects of OCPs?
Perampanel, Phenobarbital, PHT, Primidone
Topiramate (>= 200mg/day)
What's AEDs cause Fatal Pancreatitis?
What's AEDs cause Aplastic Anemia?
CBZ (also cuz Agranulocytosis)
What's AEDs cause Skin rash (SJS)?
What's AEDs cause:
Oligohydrosis - inability to sweat, risk of heat stroke - highest risk in kids
Nephrolithiasis (kidney stones)
What's AEDs cause weight gain?
What's AEDs cause Weight loss?
What's AEDs cause Hyponatremia?
Oxcarbazepine (more common)
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
What natural pdt should be avoided with AEDs?
St. John's wort
List drugs/conditions that may lower the seizure threshold
Antipsychotics e.g, clozapine, phenothiazines, butyrophenones
Antivirals e.g, Amantadine, Rimantadine, Foscarnet, Ganciclovir, and
Carbapenems (in poor renal fxn, esp. Imipenem)
Lithium and Theophylline (in toxicity)
Meperidine (in poor renal fxn)
Natural pdts such as dendrobium, evening primrose oil, gingko, melatonin, St. John's wort
Sleep deprivation, alcohol intoxication, menstruation, infection, and fever (esp, in children) can worsen seizure
Look at pt counseling pts on pg 934-938
List sx PHT toxicity
If PHT is used long-term, what can occur without proper supplementation?