OHCM - Epilepsy: Management Flashcards Preview

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Flashcards in OHCM - Epilepsy: Management Deck (32):
1

Absence seizures - Give:

1. Valproate.
2. Lamotrigine.
3. Ethosuximide.

2

Tonic, atonic, and myoclonic seizures - Give:

As for generalized tonic-clonic seizures, but avoiding carbamazepine and oxcarbazepine, which may worsen seizures.

3

Partial seizures +/- secondary generalization - Give:

1st line = Carbamazepine.
2nd line = Valproate, lamotrigine, oxcarbamazepine or topiramate.
Others: Levetiracetam, gabapentin, tiagabine, phenytoin, clobazam.

4

Treat seizures with one ... and one ... .

ONE DRUG - ONE DOCTOR IN CHARGE.

5

To switch drugs:

Introduce the new drug, and only withdraw the 1st drug once established on the 2nd.

6

Dual therapy is necessary in

Consider if all appropriate drugs have been tried singly at the optimum dose.

7

EEG:

Cannot exclude or refute epilepsy!

8

Non-epileptic attack disorder (pseudo- or psychogenic seizures):

These are NOT INFREQUENT.
Suspect this if there are uncontrollable symptoms, no learning disabilities, and CNS exam, CT, MRI, and EEG are normal.

9

Non-epileptic attack disorder (pseudo- or psychogenic seizures) - May coexist with ...?

TRUE EPILEPSY!

10

If drugs don't work ...?

If a single epileptogenic focus can be identified such as hippocampal sclerosis or small low-grade tumor, neurosurgical resection offers up to 70% chance of seizure freedom, depending on the location of the focus, with the risk of causing focal neurological deficits such as memory impairment, dysphasia, or hemianopia.
--> An alternative is VAGAL nerve stimulation, which can reduce frequency and severity in 33%.

11

When it all goes wrong ...?

Sudden unexpected death in epilepsy (SUDEP) is more common in uncontrolled epilepsy, and may be related to nocturnal seizure-associated apnea or asystole.

12

Those with epilepsy have a mortality rate ...?

3-fold that of controls.

13

>... epilepsy-related deaths are recorded/yr in the UK.

700 (17% are SUDEPs).

14

Carbamazepine (as slow release):

Initially 100mg/12h --> increase by 200mg/d every 2wks up to max 1000mg/12h.

15

Carbamazepine - SE:

1. Leukopenia.
2. Diplopia/blurred vision.
3. Impaired balance.
4. Drowsiness.
5. Mild generalized erythematous rash.
6. SIADH.

16

Lamotrigine - Doses:

As monotherapy, initially 25mg/d --> incr. by 50mg/d every 2wks up to 100mg/12h (max 250mg/12h).
--> Halve monotherapy dose if on valproate; double if on carbamazepine or phenytoin (max 350mg/12h).

17

Lamotrigine - SE:

1. Maculopapular rash - occurs in 10% (but 1/1.000 develops SJS or TEN) typically in first 8wks, especially if on valproate; warn patients to see a doctor at once if rash or flu symptoms develop; also associated with hypersensitivity (fever, incr. LFTs and DIC).
2. Diplopia/blurred vision.
3. Photosensitivity (SLE-like).
4. Tremor, agitation.
5. Vomiting.
6. Aplastic anemia.

18

Levetiracetam - Doses:

If >16yrs, initially 250mg/24h --> increase by 250mg/12h every 2wks up to max 1.5g/12h (if eGFR >80).

19

Levetiracetam - SE:

1. Depression.
2. Agitation.
3. D&V.
4. Dyspepsia.
5. Drowsiness.
6. Diplopia.
7. Blood dyscrasias.

20

Phenytoin:

Effective and well-tried, but no longer 1st-line for generalized or partial epilepsy due to toxicity.

21

Phenytoin - SE:

1. Nystagmus/diplopia.
2. Tremor.
3. Dysarthria.
4. Ataxia.
5. Decr. intellect/depression.
6. Coarse facial features.
7. Acne.
8. Gum hypertrophy.
9. Polyneuropathy.
10. Blood dyscrasias.

22

Phenytoin - Doses:

Difficult - do blood levels.

23

Valproate - Doses:

Initially 300mg/12h --> Increase by 100mg/12h every 3 days up to max 30mg/kg (or 2.5kg) daily.

24

Valproate - Why take with food?

Nausea is very common.

25

Valproate - SE:

vALPROATE:

Appetite UP, weight gain.
Liver failure (watch LFTs esp. during 1st-6months).
Pancreatitis.
Reversible hair loss (grows back curly).
Oedema.
Ataxia.
Teratogenicity, tremor, thrombocytopenia.
Encephalopathy (due to hyperammonemia).

26

Vigabatrin:

Only used in infantile spasms (due to high incidence of visual field defects).

27

Teratogenicity of anti-epileptic drugs - Women of child-bearing age should ...?

Folic acid 5mg/d.
Avoid valproate (use lamotrigine).

28

Breastfeeding:

Most AEDs are present in breast milk, carbamazepine and valproate.
Lamotrigine is NOT thought to be harmful to infants.

29

Most patients are seizure-free within a few years of starting the drugs. More than ...% remain so when the drugs are withdrawn.

More than 50%.

30

Withdrawal may be tried, if the patient meets the criteria:

1. Normal CNS exam.
2. Normal IQ.
3. Normal EEG prior to withdrawal.
4. Seizure-free for >2yrs.
5. No juvenile myoclonic epilepsy.

31

One way to withdraw drugs in adults is to decrease the dose by ...?

10% every 2-4wks - for carbamazepine, lamotrigine, phenytoin, valproate, and vigabatrin.
10% every 4-8wks - for phenobarbital, benzodiazepines, ethosuximide.

32

Generalized tonic-clonic seizures - Give:

1st line = Valproate or Lamotrigine (often better tolerated, and less teratogenic).
2nd line = Carbamazepine or topiramate.
Others: levetiracetam, oxcarbamazepine, clobazam.