Seizure disorders

Question 1

define seizure

Answer 1

abnormal/excessive firing of CNS neurons

Question 2

define epilepsy

Answer 2

chronic condition recurrent seizure which are not provoked by neurologic insults
2unprovoked more than 24hr apart or
1 unprovoked and probability of further seizures

Question 3

status epilepticus

Answer 3

seizure lastin >30min or 2 without return to normal mental baseline

Question 4

focal vs generalised

Answer 4

focal is in one small part or whole hemisphere

general is in two hemispheres

Question 5

5 things in the evaluation of a seizure

Answer 5

history and physical exam 
lab tests, screen for drugs as well 
lumbar puncture if CNS infection suspected 
EEG 
CT/MRI brain scan

Question 6

what is electroencaphalography

Answer 6

electrodes placed on scalp

records electrical activity of the brain

Question 7

inhibitory neurons

Answer 7

GABA

Question 8

how does inhibitory transmission work

Answer 8

gaba binds to post synaptic receptor to open chloride ion channels and allowing influx making it hyperpolarized

Question 9

excitatory neurons

Answer 9

glutamate

Question 10

how does excitatory transmission work

Answer 10

glutamate binds to NMDA receptor

Na/Ca influx, K efflux

Question 11

targets for antiepileptic drugs

Answer 11

enhanced excitation (glutamate)
membrane depol 
reduced inhibition (GABA)

Question 12

epilepsy there is an imbalance in

Answer 12

excitatory and inhibitory processes, more excitation is happening

Question 13

goals of therapy

Answer 13

eliminate seizures
min side effects
optimize quality of life

Question 14

remission is

Answer 14

complete cessation of seizures for at least one year

Question 15

refractory is

Answer 15

2 or more AEDs failed to control seizures

Question 16

how do you initiate an AED

Answer 16

start low and go slow but if needed push to max tolerated dose

Question 17

indication for an AED

Answer 17

once diagnosed with epilepsy

Question 18

first line for adult focal seizure

Answer 18

carbamazepine

levetiracetam

Question 19

first line for adult generalized tonic clonic

Answer 19

carbamazepine

lamotrigine

Question 20

first line for absence

Answer 20

valproic acid

ethosuximide

Question 21

SE for all AEDs

Answer 21

CNS- drowsy, dizzy
GI
toxicities additive

Question 22

side effects are

Answer 22

dose related

reversible on lowering or discontinuing AED

Question 23

gingival hyperplasia caused by

Answer 23

phenytoin

Question 24

describe idiosyncratic reactions

Answer 24

more serious and life threatening
not dose related
no lab test identifies risk

Question 25

some rare idiosyncratic reactions

Answer 25

SJS toxic epidermal necrosis DRESS fever and rash

Question 26

risk factors for idiosyncratic reactions

Answer 26

history of previous drug reactions liver/kidney dysfunction hematopoisesis or metabolic disorders

Question 27

idosyncratic reactions rare with

Answer 27

``` gabapentin pregabalin topiramate OXC LEV ```

Question 28

highest risk of idiosyncratic reaction occurence

Answer 28

first 2 months of therapy

Question 29

more common idiosyncratic reactions

Answer 29

``` agranulocytosis aplastic anemia thrombocytopenia hepatotoxicity pancreatitis connective tissue disorder ```

Question 30

AEDs have two fold increased relative risk of what

Answer 30

suicidal behaviour or idealation

Question 31

what med do we absolutely avoid in pregnancy and in women of childbearing age

Answer 31

VALPROIC ACID

Question 32

supplement for pregnant women on AEDs

Answer 32

folic acid 1-3 month prior to conception becuase theres an increased risk of neural tube defects

Question 33

inducers

Answer 33

``` carbamaxepine phenytoin phenobarb topiramate oxcarbazepine ```

Question 34

inhibtors

Answer 34

valproic acid

Question 35

when should you monitor serum levels

Answer 35

``` assess non adherence suspected toxicity adjustment of phenytoin dose manage PK interactions status elipticus ```

Question 36

what should patients record

Answer 36

seizure frequency adverse effects precipitating factors

Question 37

labs to monitor

Answer 37

CBC electrolytes LFT before starting AED and at regular intervals during the first months of use

Question 38

managing AE for new AEDs

Answer 38

use test dose at bed time if SE delay next dose if they recur reduce dose increase as tolerated

Question 39

managing AE due to peak blood levels

Answer 39

administer with food change dosing interval give larger dose at bedtime smaller during the day extended release formulation

Question 40

monitoring parameters

Answer 40

seizure frequency, CNS effects, AE daily | CBC, LFT, electrolytes baseline then every 6 months

Question 41

should see improvment in

Answer 41

1-2 weeks | sig benefit in 1 month

Question 42

when could you consider discontinuing AEDs

Answer 42

eizure free for 2 years control easily achieved at low dose no previous unsuccessful attempts normal neurologic exam

Question 43

how do you discontinue an AED

Answer 43

one drug at a time | slowly for at least 2-3 months

Question 44

immediate emergency care required if

Answer 44

seizure lasts >5min | repeated convulsive seizures

Question 45

first line treatment for status epilepticus

Answer 45

benzo | if doesnt work use and anticonvulsant

Question 46

what is a keotgenic diet

Answer 46

high fat low protein very low carbs

Question 47

what does the ketogenic diet do

Answer 47

mimics biochemical changes during starvation so body burns fat producing ketones which are structurally similar to GABA

Question 48

advantage of ketogenic diet

Answer 48

fewer SE and sometimes more effective

Question 49

disadvantage of ketogenic diet

Answer 49

need dietician compliance unhealthy ?