Seizure/Epilepsy

Question 1

Seizure Causes

Answer 1

• Fever (Children/Infants!)
• Alcohol withdrawal
• Hypoglycemia
• Electrolyte abnormalities
• (CNS) infections!

Question 2

Epilepsy Causes

Answer 2

• Brain tumors
• Dementia
• Brain damage
• Genetic

Question 3

Epilepsy vs Seizure

Answer 3

• Seizure can be one time event
• Epilepsy: chronic seizure disorders
• One seizure isn’t necessarily epilepsy

Question 4

Diagnosis

Answer 4

• EEG mainly
• CT/MRI (damage)
• Spinal tap/CSF (infectious)

Question 5

Focal

Answer 5

• Focused area

- One side of the brain

Question 6

Awareness

Answer 6

• Subtype of focal seizure
• Aware seizure: maintain awareness (simple in the past)
• Impaired awareness: loss/reduced awareness (complex in the past)

Question 7

Generalized

Answer 7

Both sides of the Brain

Question 8

Movement Types

Answer 8

• Subtypes of generalized seizure
• Tonic: rigid muscles
• Clonic: rhythmical/jerking movements
• Atonic: limp muscles
• Myoclonus: muscle twitching

Question 9

First Aid for Seizure

Answer 9

• Lower to floor gently
• Lie patient on the side
• Keep track of the time (>5 min = medical emergency)
• Remove tight clothing, don’t put anything in mouth

Question 10

Status Epilepticus Tx

Answer 10

• 0-5 min: Check BG, electrolytes, AED levels IF possible
• 5-20 mins: IV benzo (lorazepam) OR IM midazolam or rectal diazepam if IV access not available
• 20-40 mins: IV AEDs

Question 11

IV AED Options

Answer 11

• Fosphenytoin
• Levetiracetam
• Valproic Acid

Question 12

Diastat AcuDial Dispensement

Answer 12

• Dial to correct dose before giving to patient (lock once set)
• Instruct pts/caregivers to confirm that dose is correct when they leave pharmacy
• Green “ready band” should be showing when locked

Question 13

Chronic Seizure Management

Answer 13

• AEDs are first line
• Avoid meds that lower seizure threshold
• Don’t abruptly stop any seizure medication
• Non-Rx Tx: Medical marijuana, ketogenic diet (4:1 fat:other diet, usually recommended in refractory pts)
• Decreases hormonal birth control efficacy

Question 14

Drugs that Lower Seizure Threshold

Answer 14

• Carbapenems (imipenem esp!)
• Lithium
• Meperidine
• Penicillin
• Quinolones
• Theophylline
• *^^High doses/renal impairment increase risk in meds above**
• Clozapine
• Bupropion
• Tramadol
• Varenicline

Question 15

General AED Risk/Monitoring

Answer 15

• ALL increase risk for fracture
• ALL have increased risk in suicidal ideation/risk (CNS depression)
• Most have fetal harm to some degree
• Monitor seizure freq (efficacy), mental status, blood levels (if applicable)
• Supplement with vitamin D/calcium

Question 16

AEDs that Increase GABA

Answer 16

• Benzos
• Valproic Acid
• Levetiracetam (2 MoA)
• Deficiency in GABA can cause seizures

Question 17

Ca-Channel Blocker AEDs

Answer 17

• Ethosuximide: T-Type Ca Channel Blocker
• Levetiracetam (2 MoA)
• Reducing Ca+ reduces neuronal firing

Question 18

Na-Channel Blocker AEDs

Answer 18

• Carbamazepine
• Phenytoin/Fosphenytoin
• Lamotrigine
• Topiramate
• Reducing Na+ reduces neuronal firing rate

Question 19

AED Inhibitor vs Inducer

Answer 19

• Valproic acid is the only notable INHIBITOR

- Otherwise, assume they are an inducer

Question 20

AEDs Requiring Blood Levels

Answer 20

• Phenytoin**
• Valproic Acid
• Carbamazepine
• Phenobarbital

Question 21

Phenytoin Doses

Answer 21

• Michaelis-Mentin kinetics
• Small increases in doses can cause large increases in drug level
• Only increase in 30-50 mg dose adjustments
• IF albumin low, correct total phenytoin level: total measured/[(0.2*Albumin) + 0.1]

Question 22

Valproic Acid

Answer 22

-Severe fetal harm (category X): neural tube defects, decreased IQ (prevent with folate)

Question 23

Kids + AED

Answer 23

• CNS depression is a concern (need to be awake/pay attention in school
• Topiramate/Zonisamide: hypohydrosis ( reduced sweating, limit outside play, hydrate)
• Lamotrigine: increases risk of severe rash

Question 24

Carbamazepine Cousins

Answer 24

• Oxcarbazepine
• Eslicarbazepine
• Hyponatremia, rash, enzyme inducers

Question 25

Topiramate Cousin

Answer 25

Zonisamide - Weigh loss, metabolic acidosis - Kidney stones, oligohidrosis/hyperthermia (esp. kids)

Question 26

Lamotrigine

Answer 26

- SERIOUS skin reactions (SJS, TEN) - SE: aespetic meningitis, nausea - Dose: Start low and slowly titrate up - Give BLUE starting dose pack if also using valproic acid - GREEN starter pack: if taking with enzyme inducers and/or not taking valproic acid - ORANGE: standard starting dose, no DDI

Question 27

Keppra

Answer 27

- Levetiracetam - No significant DDI - Less toxicity/SE - SE: psych. rxns, irritability, dizzy, weakness - IV: PO is 1:1

Question 28

Topamax

Answer 28

- Topiramate - Warning: kidney stones, oligohidrosis, acute angle closure glaucoma, metabolic acidosis (nonanion), hyperammonia, hetal harm - SE: Weight LOSS, anorexia, CNS depression (cognitive problems, "Stupamax")

Question 29

Depakote

Answer 29

- Valproic Acid - Box Warning: hepatic failure, fetal harm, pancreatitis - Warning: HYPERammonia * Can treat hyperammonia with carnitine in severe cases* - SE: alopecia (use selenium/zinc), weight GAIN - Therapeutic levels: 50-100 mcg/mL * *Can correct the same way as phenytoin if albumin is low**

Question 30

Tegretol Information

Answer 30

- Carbamazepine: NARROW SPECTRUM - Hyponatremia - Rash: SJS/TEN (test for HLA-B*1502) - Strong inducer (AUTOinducer) - Can also be used for bipolar disorder (Equetro) and trigeminal neuralgia - Therapeutic Levels: 4-12 mcg/mL

Question 31

Trileptal

Answer 31

- Oxcarbazepine: NARROW spectrum - Hyponatremia - Rash 25-30% cross-sensitivity (HLA*B-1502 testing recommended, but not req. like carbamazepine) - Inducer

Question 32

Gabapentin Cousin

Answer 32

- Pregabalin - Weight gain, peripheral edema, euphoria - More common for neuropathic pain

Question 33

Phenobarbital Cousin

Answer 33

- Primidone (prodrug of Phenobarbital) | - Sedating, dependence/tolerance/overdose risk, enzyme inducer

Question 34

Vimpat

Answer 34

- Lacosamide - Prolongs PR level: baseline ECG and cont. to monitor - CV - Risk of arrhythmias - Otherwise similar to other AEDs

Question 35

Phenobarbital

Answer 35

- CI: hepatic impairment, previous addiction, intraarterial administration (extravasation) - Warning: habit forming, resp. depression, fetal harm - SE: dependence/tolerance/hangover effects - Strong inducer - Therapeutic Range: 20-40 mcg/mL

Question 36

Dilantin

Answer 36

- Phenytoin - 1 mg PE = 1 mg phenytoin (used to dose Fosphenytoin - Cerebyx, IV prodrug) - Strong inducer - Therapeutic: 10-20 mcg/mL total; 1-2.5mcg/mL free levels

Question 37

Phenytoin AE

Answer 37

- Time related: gingival hyperplasia, hirsutism, hepatotoxicity - Dose-related: ataxia, nystagmus, diplopia/blurred vision * *Due to kinetics, only increase by 30-50 mg at a time**

Question 38

Phenytoin Vs Fosphenytoin

Answer 38

- Phenytoin max: 50 mg/min; Fosphenytoin: 150 mg PE/min or 2 mg PE/kg/min - Arrhythmia risk at fast inf., purple glove syndrome - Less purple glove syndrome in fosphenytoin - Phenytoin: requires filter, dilute with NS, stable for 4 hours - Separate tube feedings from phenytoin by 1-2 hours (decreases absorption)

Question 39

Zarontin

Answer 39

- Ethosuximide | - Indication: absence seizures

Question 40

Felbatol

Answer 40

- Felbamate - Hepatic failure - Aplastic anemia

Question 41

Sabril

Answer 41

- Vigabatrin - Vision loss (30%) - REMS