Exam 3 Flashcards by Maryam Rauf

Seizure begins at a single site in the cortex (only a few electrodes show synchronous activity)

Partial seizure

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Seizure in both hemispheres of the brain (all electrodes go off simultaneously)

Generalized seizure

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Type of seizure:
No loss in consciousness
Short duration (20-60 seconds)
Ex: one side of face may twitch

Simple seizure (partial)

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Type of seizure:

Sudden loss of consciousness
Less than 30 seconds
Person may be staring and blinking (3 blinks per second)
More common in children than adults

Petit mal (absence seizure) (generalized)

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Gradual loss of consciousness (30seconds to 2 minutes)

Starts with simple seizure and hallucinations then there are strong automatisms (lip smacking)

Complex seizure (partial)

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Sudden loss of consciousness (1.5-2.5minutes)

20 seconds of muscle rigidity, then 1-2 minutes of rhythmic muscle contractions

Tonic-clinic (generalized)

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Single shock like contraction in the whole body that lasts less than 1 second
More in children than in adults

Myoclonic (generalized)

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Starts with a partial seizure and progresses to generalized seizure

Secondarily generalized seizure

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Sodium and potassium bromide Use

Less seizures because of severe sedation

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Sodium and potassium bromide ADRs

Severe sedation

Severe skin rash and/or lesions

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First anti seizure drug (1912)

Phenobarbital (Luminal)

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Barbiturate metabolized to phenobarbital and PEMA

Primidone

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Animal model where repeated low intensity, electrical stimulation to the amygdala

Kindling model for partial and generalized seizures

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Animal model where there were injections of excitatory neurotransmitters

Model for tonic clonic seizures

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MOA: Potentiation of synaptic inhibition via GABAa receptor

Use: Monotherapy used for generalized tonic-clonic and partial seizures

Phenobarbital (Luminal)

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MOA: Potentiation of synaptic inhibition via GABAa receptor

Use: Monotherapy for generalized tonic clonic, partial and adolescent Myoclonic seizures (*less effective than phenobarbital)

Primidone

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MOA: prolong rate of recovery for voltage gated Na channels from inactivation (inactivated for longer)

Use: Monotherapy for generalized tonic clonic and partial seizures

Phenytoin (Dilantin)

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Drug concentration for this drug increases disproportionately as the dosage is increased and is bound 90% to plasma protein

Phenytoin (Dilantin)

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Side effects for phenobarbital

*Induction of CYP3A4 so increased drug metabolism of certain drugs like oral contraceptives
Sedation in adults
Hyperactivity/irritation in children

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Side effects for Primidone

Induction of CYP3A4 so increased drug metabolism of certain drugs like oral contraceptives
Sedation in adults
Hyperactivity/irritation in children

PLUS 
dizziness 
Nausea
Nystagmus 
Ataxia

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Side effects for phenytoin

Increases drug metabolism of drugs that are metabolized by the same enzyme (CYP2C9) because these enzymes are saturable (warfarin)
Induces CYP3A4 so increased metabolism of drugs like contraceptives
Gingival hyperplasia
Steven johns syndrome

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Adverse immune reaction

Blistering of skin and mucous membranes after flu like symptoms and a persistent fever

Steven johns syndrome

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Treatment for Steven johns syndrome

*Discontinuation of drug

Possible immunosuppressants

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MOA: Inhibit T-type Ca channels

* Uses: Monotherapy for absence seizures

Ethosuximide

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MOA: prolong the rate of recovery of Na channels from inactivation Uses: Monotherapy for generalized Tonic clonic and partial seizures Also for Manic depressive patients

Carbamazepine

MOA: prolong rate of recovery of Na channels from inactivation Uses: Monotherapy in treatment of partial seizures 4-16 years old Adjunctive treatment for partial seizures

Oxcarbazepine

Not bound to plasma protein so few drug-drug interactions

Ethosuxomide

Induces own metabolism so have to wait 3 weeks to get a good steady level to be reached

Carbamazepine

A prodrug that is converted to active metabolite in the Iiver *does not autoinduce like carbamazepine

Oxcarbazepine

Phenobarbital, phenytoin, and valproic acid increase the metabolism for this drug

Carbamazepine

Side effects for carbamazepine

Chronic side effects *induces drug metabolism of OCs from CYP3A4 Drowsiness, vertigo, ataxia, blurred vision Acute side effects: Stupor, coma, hyper irritability convulsions

Side effects for oxcarbazepine

*Increases drug metabolism of CYP3A4 enzyme like OCs. Not as much as carbamazepine though Dizziness, nausea, ataxia

Side effects for ethosuximide

Nausea, vomiting, anorexia CNS drowsiness, lethargy, euphoria SJS, aplastic anemia

MOA: *inhibits T-type Ca channels prolongs inactivation of Na and increases GABA synthesis Use: *used as monotherapy for absence, myoclonic, partial, and tonic-clonic seizures. "broad spectrum" anti epileptic

Valproic acid (Depakote)

ADRs for Valproic Acid (Depakote)

increase in hepatic blood enzymes, increases hepatic toxicity inhibits CYP2C9 so increased concentration of phenytoin & phenobarbital

MOA: starts synaptic inhibition via GABAa receptors Use: adjuncitve treatment for absence seizures and juvenile myoclonic seizures

benzodiazepines (clonazepam and clorazepate)

ADRs for benzodiazepines

Drowsiness, lethargy In children, aggression, hyperactivity, irritability

MOA: unknown...even though binds to Ca channels, nothing happens and nothing happens with GABA either Use: adjunctive treatment for partial with and without secondary generalized seizures

Gabapentin (Neurontin)

this drug is not metabolized but excreted unchanged in the urine so renal function must be determined before dosing

gabapentin (Neurontin)

Gabapentin side effects

fatigue and ataxia

GABA molecule bound to lipophilic hexane ring but doesnt interact with GABA receptors at all

gabapentin (Neurontin)

GABA molecule bound to isobutane

pregabalin (Lyrica)

MOA: unknown Use: adjunctive therapy for partial onset seizures and fibromyalgia

pregabalin (Lyrica)

MOA: inhibits Ca, Na, NMDA, and AMPA-kainate receptors Use: monotherapy and adjunctive therapy for LGS, partial and generalized seizures in adults

felbamate (Felbatol)

Felbatol side effects

GI upset, anorexia, and insomnia | may have aplastic anemia and hepatotoxicity

childhood onset of epilepsy that can causes severe cognitive dysfunction multiple seizure types including atonic or "drop" seizures and is resistant to drug therapy

LGS (Lennox-Gustaut syndrome)

this drug was taken off the market for causing hepatotoxicity and aplastic anemia but was later brought back as a last resort drug for resistant seizures

flebamate (Felbatol)

MOA: prolongs the rate of recovery of Na channels from inactivation. To a small extent, inhibits Ca Use: *a monotherapy and adjunctive treatment for partial and generalized tonic/clonic seizures like LGS. considered a broad spectrum anti epileptic

Lamotrigine (Lamictal)

when used with other anti epileptics, can get rash and SJS

Lamotrigine (Lamictal)

Lamotrigine side effects

dizziness, ataxia, blurred vision, nausea | rash and SJS when combined with other anti epileptics

MOA: inhibit Na channels and AMPA-kainate receptors enhance GABA receptors Use: *monotherapy and adjunctive treatment for partial and tonic clonic seizures (LGS). considered a broad spectrum anti epileptic

Topiramate (Topamax)

side effects for Topiramate:

ataxia, fatigue, somnolence, weight loss

Reduces plasma levels of OCs and estradiol

Topiramate (Topamax)

MOA: inhibit GABA reuptake at synapse and prolong GABA action Use: treats partial with and without secondarily generalized tonic clonic seizures

Tiagabine (Gabitril)

side effects for tiagabine (Gabitril)

dizziness, somnolence, tremor (mild after initial treatment)

MOA: unknown Uses: *adjunctive treatment for partial and tonic clonic seizures in adults * myoclonic seizures in children. * IV prep for status epilepticus

Levitracatem (Keppra)

highest safety of margin in animal studies | rapid dose titration makes this drug useful in adjunctive therapy

Levitracatem (Keppra)

MOA: prolong rate of recovery for Na channels. inhibit T-type Ca channels Uses: adjunctive treatment for partial seizures in adults

Zonisamide

Side effects for Zonisamide

somnolence, dizziness, anorexia, fatigue | 1% get renal calculi

What are the following drugs used to treat? Lacosamide (Vimpat) Rufinamide (Benzel) Vigabatrin (Sabril) Egozabine (Potiga)

epilepsy

drug of choice for a partial seizure secondarily generalized

carbamazepine and phenytoin

alternative drugs for partial secondarily generalized seizures

lamotrigine and valproic acid

drugs of choice for generalized absence seizures

ethosuximide and valproic acid

alternative drug of choice for generalized absence seizures

clonazepam

drug of choice for generalized tonic clonic seizures

carbamazepine, phenytoin, valproic acid

alternative drug of choice for generalized tonic clonic seizures

lamotrigine and topiramate

a disease in which there are a series of seizures and where a full recovery doesnt occur before there is an onset of second seizure

status epilepticus

how to treat status epilepticus

give either diazepam or lorazepam IV (lorazepam is preferred). avoid hypoventilation and hypotension. then give IV fosphenytoin (water soluble prodrug for phenytoin) or Levitracatem, phenobarbital or valproic acid

what do long term use of AEDs cause?

osteoporosis

true/false women on OCs have a higher failure rate. if yes, by what 3?

true. they have a 3X higher failure rate.

AEDs are safe to take while pregnant true or false

false. there is a 2-3X higher increase in birth defects

how to reduce the likelihood of neuronal rube defecfts from AEDs?

0.4mg/day of folate throughout pregnancy give vitamin K during the last month

which drug to completely avoid during pregnancy

valproic acid...teratogenic

are generic drugs ok to give for seizures?

No because switching even from brand to generic can cause major seizures

what are the 4 phases of migraines?

premonitory, aura, headache, and resolution

what is the premonitory phase of a migraine?

can have neurologic symptom (photophobia and phonophobia), psychological symptoms (anxiety and depression), constitutional symptoms (stiff neck, yawning, thirst, food cravings)

when is the premonitory phase?

hours to days before the actual migraine

what is the aura phase of a migraine?

an aura refers to focal, neurological symptoms (vision or other sensations) occurs in ~31% of people with migraine

how do migraines work (the headache part)

start from a dull ache in frontotemporal region and extends to the back of the skull and goes on to intense pulsations (usually unilateral) and these worsen over time. ~90% of patients have GI symptoms as well like nausea, vomiting and also photphobia and phonophobia

how long does a migraine normally last?

4-72 hours

what is a tension headaches

a muscle contraction headache. a dull persisting, non pulsating and non debilitating bilateral pain. no nausea/vomiting and no aura or photophobia/phonophobia

what is a cluster headache

brief episodes of extremely excruciating unilateral pain that come in clusters with periods of remission (months to years)

what to migraines result from?

inappropriate dilation of intracranial extracerebral blood vessels

what is the serotonergic abnormality theory for migraines?

drugs that deplete serotonin from tissue stores can induce migraines and so an intravenous injection of 5-HT can abort spontaneous migraines

name a couple drugs that are known to deplete serotonin levels from the tissue stores thus causing migraines

reserpine and fenfluramine

what is a rebound headache and why does it occur?

a rebound headache is a medication overuse headache and occur if you use the drug too much which induces a higher headache frequency

what does the abortive therapy include?

combination analgesics, opiates, ergotamine tartrates, and triptans

how do you avoid rebound headaches?

use abortive therapy no more than 2 times a week

possible triggers for migraines (food)

alcohol chocolate (phenylethylamine) beer, red wine, cheese (tyramine) frozen dinners, canned food, chinese food (MSG) processed meats and fish (sodium nitrate)

possible triggers for migraines (general)

irregular sleep pattern stress environmental changes hormonal changes

what is the first line therapy for mild to moderate migraines?

analgesiscs (NSAIDS, Midrin, Opiates)

MOA: blocks prsotaglandin synthesis which prevent inflammation in the trigeminovascular system and lessens pain sensitization

NSAIDS

a combination therapy that is as effectice as oral ergotamine in some patients with lower side effects

Midrin

what are the 3 ingredients used in midrin?

Isomethoheptene, dichlorophenazone acetaminophen

this drug should be used with extreme caution in patients with peptic ulcer disease, renal disease or hypersensitivity to aspirin

NSAIDS

what is isomethoheptene do?

Mild vasocontrictor activity

what does dichlorophenazone do?

sedative action

this drug is used for severe, infrequent headaches where conventional therapies either do not work or are contraindicated so a rescue medication is needed

opiates (Butorphanol...a nasal spray)

what are the ADRs for butorphanol?

dizziness, nauseam vomiting, drowsiness, and bad taste

what are ergotamine tartrates used for?

they are used in the acute treatment of moderate to severe migraines

where are ergot-like compounds found in nature?

found in rye contaminated with the fungus claviceps purperea

what is ergotism?

gangrenous mummified limbs and spontaneous abortions

what are the 3 dosage forms ergotamine are available in?

oral, sublingual and suppository

what is the maximum dose of oral/sublingual ergotamine?

not to exceed 6mg/attack or 10mg/week

___ is added to some ergotamine containing products for vasoconstriction and to help it absorb in the intestines

caffeine

why is ergotamine called a dirty drug?

it interacts with serotonin, dopamine, and adrenergic receptors

how do ergotamines work?

activation of 5-HT1b receptors and by causing vasoconstriction. in addition, it may reduce neurologic inflammation by decreasing vasodilators

___ is a powerful vasoconstricor and a contraindication in patients with peripheral vascular disease ___ may potentiate the vasoconstriction that is caused by ergotamines

ergotamine B blocker

one of the side effects of ergotamines include GI upset. How does this happen and what needs to be added to counteract it?

there is an activation of central dopamine receptors in the chemoreceptor trigger zone. we need to add metoclopramide to the regimen as an antiemetic

___ (antibiotic) can interferew with the liver metabolism of ergotamine and cause ergot toxicity

erythromycin

Aside from peripheral vascular disease, what is one contraindication of ergotamine?

cardiovascular disease

MOA: direct vasoconstriction of dilated intracranial arteries, reduced neurologic inflammation by decreasing the release of vasodilators and proinflammatory neuropeptide transmitter (works like ergotamine)

Dihydroergotamine (DHE45)

true/false DHE45 needs to be administered parenterally

true it is not absorbed in the GI tract at all

1st line treatment for the acute treatment of moderate to severe migraines

Dihydroergotamine (DHE45)

what is the only thing that is different between ergotamine and DHE45 (dihydroergotamine) regarding ADRs

DHE45 is less likely to have vasospasms because of less arterial vasoconstrictor activity. with DHE45 there is more alpha blocking activity

what are triptans used for?

they are used for the acute treatmetn of moderate to severe migraines

sumatriptan is a derivative of _____ and can be administered by _____, _____, and _____ (routes). it is metabolized by _____ can be administered up to ____ hours after onset of attack and be effective

serotonin (5-HT) SQ injection, oral tablets, or nasal spray MAO-A 4 hours

how does sumatriptan work?

causes constriction of inflamed/dilated intracranial arteries and inhibits the release of vasodilator/proinflammatory mediators

what side effects of migraines does sumatriptan relieve?

nausea, vomiting, photophobia, and phonophobia

what is the one huge contraindication in using sumatriptan and why?

contraindicated in pateints with cardiovascular disease. many fatalities are reported in patients who have cardiovascular disease and use SQ sumatriptan. High chance of getting MIs so do not give IV

True/false it is ok to give sumatriptan and another ergot-type compound together

false!!!! do not give them within 24 hours of each other!!

common triptan symptoms

chest and throat tightness, difficulty breathing, panic/anxiety

this drug is contraindicated with the use of an MAO inhibitor

sumatriptan

these have a greater bioavailability than triptans they act at the peripheral components of the trigeminovascular system act centrally to inhibit pain transmission in he trigeminal nucleus (greater lipid solubility)

second generation triptans

Exam 3 Flashcards

(124 cards)