Neurologic Conditions: Seizures/Epilepsy Flashcards by Patryk Lasiuk

Focal seizures

start on one side of brain and can spread to the other

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Generalized seizures

start on both sides of the brain

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Unknown seizures

beginning is unknown, occur at night or unwitnessed

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Focal aware seizure

no loss of consciousness

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Focal seizure with impaired awareness

pt experiences loss of consciousness

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Status epilepticus

seizure that lasts more than 5 minutes

if lasts 30min, long term damage can occur and is medical emergency

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Status epilepticus txm

0-5min = stabilization phase = time seizure, start ECG, check AED lvls/electrolytes

5-20 min = initial txm phase = IV loraz or IM midaz, rectal Diastat or nasal/buccal midday if cant do IV

20-40 min = 2nd txm phase = give regular AED, IV fosphenytoin, valproic acid, keppra, if lasts longer than no clear txm

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Dispensing Diastat

pharmacist has to lock syringes into appropriate dose prior to dispensing
should double check when counseling patient before med leaves pharmacy

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Ketogenic for refractory seizures

high fats
normal protein
low carbs

4:1 ratio of fats to combined protein/carbs

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Seizures can occur due to….

deficiency of inhibitory NT (GABA)
too much excitatory NT (Glutamate)

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Which AEDs inc GABA

Benzo
Valproic Acid

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Which AED enhance/potentiate GABA effect

Phenobarbital

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Which AED inc GABA and CA channel blocker

Levetiracetam

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Which AED is type T Ca channel blocker

Ethosuximide

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Which AED are Ca channel blockers

Pregabalin
Gabapentin

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Which AED block Na and Ca channels

Oxcarbazepine

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Which AED block Na channels

Carbamazepine
Lamotrigine
Phenytoin/Fosphenytoin
Topiramate

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Broad spectrum AED

Lamotrigine = Lamictal
Levetiracetam = Keppra
Topiramate = Topamax
Valproic acid
Divalproex = Depakote

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Lamotrigine (Lamictal) boxed warnings

serious skin reactions, including SJS/TEN, risk inc if using high starting dose

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Lamotrigine (Lamictal) side effects

Alopecia (supplement w/ selenium/zinc)
N/V
Somnolence
rash
tremor

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How long after stopping do you have to restart dose titration for Lamotrigine

If stop for > 6 days, have to do initial dose titration

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Lamictal starter kits

Orange = standard
Blue = lower dose
Green = higher dose

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When to sue which Lamictal start kits

Orange = no interacting meds
Blue = if taking valproic acid, enzyme inhibitor
Green = taking enzyme inducer (carbamazepine, phenytoin, phenobarbital, primidone, ritonavir, rifampin)

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Levetiracetam (Keppra) IV:PO ration

1:1

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Levetiracetam (Keppra) warnings

psychiatric reactions somnolence fatigue suicidal behavior anaphylaxis inc BP severe skin reactions

Significant drug interactions for Keppra

No significant interactions

Topiramate (Topamax) Contraindications

Trokendi XR only = using alc 6hr before/after dose

Topiramate (Topamax) warnings

metabolic acidosis reduced perspiration (Oligohidrosis) kidney stones angle-closure glaucoma hyperammonemia visual problems = reversible fetal harm

Topiramate (Topamax) side effects

somnolence memory/concentration/attention difficulty weight loss anorexia

Topiramate (Topamax) monitoring

Electrolytes = sodium bicarb eye exam = intraocular pressure

Which contraception should be used with Topiramate (Topamax)

non-hormonal contraception

Valproic Acid Boxed warnings

Hepatic failure, usually during first 6 months of txm fetal harm and dec IQ in pregnancy

Valproic Acid Contraindications

hepatic disease urea cycle ppx migraine pregnancy known POLG disorder or suspected

Valproic Acid warnings

Hyperammonemia = tx w/ carnitine in symptomatic adults dose related thrombocytopenia DRESS reactions

Valproic Acid side effects

Alopecia = supplement selenium/zing weight gain N/V HA

Valproic Acid monitoring

LFTS at BL and freq in 1st 6 months CBC platelets

Common narrow spectrum AED

Lacosamide = Vimpat Carbamazepine = Tegretol Oxcarbazepine = Trileptal Phenytoin = Dilantin Fosphenytoin = Cerebyx Phenobarbital = Sezaby

Lacosamide (Vimpat) max daily dose CrCl < 30

300mg/day

Lacosamide (Vimpat) warnings

prolong PR interval and inc risk of arrhythmias

Lacosamide (Vimpat) side effects

dizziness HA blurred vision ataxia tremor euphoria

Carbamazepine (Tegretol) boxed warnings

Serious skin reactions = test for HLAB*1502 allele in asians aplastic anemia agranulocytosis

Carbamazepine (Tegretol) contraindications

Myelosuppression using MAOi within last 14 days

Carbamazepine (Tegretol) warnings

hyponatremia (SIADH) fetal harm hypothyroidism

Carbamazepine (Tegretol) side effects

Dizziness drowsiness ataxia N/V pruritus photosensitivity blurred vision rash inc LFTS alopecia

Carbamazepine (Tegretol) monitoring

CBC w/ differential and platelets LFTs eye exam thyroid function test Electrolytes = Na

Oxcarbazepine (Trileptal) warnings

inc risk for serious skin reaction if HLA-B*1502 gene = test asians Hyponatremia

Oxcarbazepine (Trileptal) side effects

Somnolence dizziness N/V abdominal pain diplopia visual disturbances ataxia tremor

Oxcarbazepine (Trileptal) monitoring

serum Na lvls thyroid functon CBC

Oxcarbazepine (Trileptal) notes

for oral suspension, use within 7 wks of opening original container

Phenytoin (Dilantin) & Fospehnytoin (Cerebyx) boxed warnings

Phenytoin IV = no more than 50mg/min Fosphenytoin = no more than 150 mg/min if faster can get hypotension and cardiac arrhythmias

Phenytoin (Dilantin) & Fospehnytoin (Cerebyx) contraindications

Previous hepatotoxicity due to phenytoin

Phenytoin (Dilantin) & Fospehnytoin (Cerebyx) warnings

extravasation = lead to purple glove syndrome avoid in HLA-B*1502 positive patients DRESS rxn, fetal harm, bradycardia, SJS/TEN

Phenytoin (Dilantin) & Fospehnytoin (Cerebyx) side effects

dose related toxicity = nystagmus, ataxia, diplopia/blurred vision, slurred speech chronic = gingival hyperplasia, hair growth, hepatotoxicity, skin thickening

Phenytoin (Dilantin) & Fospehnytoin (Cerebyx) monitoring

serum phenytoin concentrations, LFTs, CBC w/ differential IV: continuous cardiac and respiratory monitoring

Phenobarbital (Sezaby) therapeutic range

20-40 mcg/mL in adults 15-40 mcg/mL in children

Phenobarbital warnings

caution in SUD = potential drug dependence, respiratory depression, fetal harm

Phenobarbital side effects

physiological dependence tolerance hangover effect somnolence cognitive impairment dizziness ataxia depression folate deficiency

Which AED is used for absence seizures

Ethosuximide (Zarontin)

Ethosuximide (Zarontin) warnings

serious skin rash (SJS/TEN) blood dyscrasias DRESS rxns

Felbamate (Felbatol) boxed warnings

aplastic anemia hepatic failure

Felbamate (Felbatol) monitoring

LFTs CBCs serum lvls of other AEDs

Fenfluramine (Fintepla) boxed warnings

valvular heart disease pulmonary htn = given through REMS

Fenfluramine (Fintepla) warnings

dec appetite & weight loss serotonin syndrome inc BP angle closure glaucoma

Gabapentin (Neurontin) side effects

somnolence peripheral edma weight gain ataxia blurred vision mild euphoria

Perampanel (Fycompa) boxed warning

neuropsychiatric events (dose related), including irritability, aggression, anger an paranoia, mostly in first 6 weeks

Prodrug of phenobarbital

Primidone (Mysoline)

Rufinamide (Banzel) contraindications

pts with familial short QT syndrome due to QT shortening = dose related

Stiripentol (Diacomit) warnings

loss of appetite/weight loss delirium/hallucinations = rare

Tiagabine (Gabitril) warnings

worsening of seizures/new-onset seizures when used off-label for other indicators, serious skin reactions SJS/TEN

Vigabatrin (Sabril, Vigadrone) boxed warnings

causes permanent vision loss > 30% of patients

Vigabatrin (Sabril, Vigadrone) monitoring

eye exam at baseline, every 3 months during therapy and 3-6 months after d/c can only get through REMS

Zonisamide (Zonegran, Zonisade) contraindications

hypersensitivity to sulfonamides

Zonisamide (Zonegran, Zonisade) side effects

similar to topiramate including oligohidrosis/hyperthermia and risk of nephrolithiasis

Adjusting Phenytoin doses

Has Michaelis-Menten kinetics, aka saturable kinetics if enzymes saturated, small inc in dose can cause large inc in drug lvl

Higher lvls of lamotrigine will inc the risk of....

severe rash

Concerns with AEDs

seizure frequency monitoring many drug interactions CNS depression Bone loss Suicide Risk and Rash risks in pregnancy