Seizure/Epilepsy Flashcards by Jessica Weaver

drugs that can lower the seizure threshold

bupropion
clozapine
metoclopramide
theophylline
beta lactams
lithium
meperidine
FQs
tramadol
methadone

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first line for acute seizure management

***if sz lasts >5 min

for 5-20 min
IV ativan or IV midazolam (versed) or rectal diazepam (Diastat)

for 20-40 min
give regular AEDs
keppra
VPA
IV fosphenytoin
IV phenytoin
phenobarbital

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what doses does diastat (PR diazepam) come in

2.5mg
10mg
20mg

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what is the device that can monitor sz in patients >6 yo

Embrace 2 smart watch

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what type of diet can possible help with epilepsy

ketogenic
4:1 fats : carbs + proteins

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what are the general coverage AEDs

keppra
lamotrigine
VPA
topiramate

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how is lamotrigine dosed upon initiation for patients not on CYP inducers or inhibtors

week 1-2: 25mg po qd
week 2-4: 50mg po qd
week 5+: increase daily dose by 50mg q1-2 weeks

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why is lamotrigine titrated slowly

risk of SJS/TEN

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ADE of lamictal

SJS/TEN, DRESS, blood dyscrasias, arrhythmia, HLH, alopecia, N/V, somnolence, tremor, blurred vision

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what color lamotrigine starter kit would be used for a patient on VPA

blue with a lower starting dose

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what color lamotrigine starter kit would a patient use if they are not on any CYP inducers or inhibitors that affect lamotrigine

orange

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what color lamotrigine starter kit would a patient be started on if they were taking a drug that induces CYP enzymes that affect lamotrigine concentrations and no VPA

green with a higher start dose

(phenobarbital, phenytoin, rifampin, SJW, primidone, carbamazepine)

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levetiracetam dosing
start dose
MDD
renal adjustments?
what is the IV:PO ratio

start 500mg IR BID
MDD 3000mg
CrCl <80 –> dec dose
1:1

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ADE of keppra

irritability, HTN, SJS/TEN, psych reactions, somnolence

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levetiracetam DDI

no significant DDI :)

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topiramate dosing
start dose
MDD
renal adjustments?
what is the IV:PO ratio

week 1: 25mg IR BID
week 2:-4: inc TDD by 50mg
week 5+: inc by 100mg weekly
MDD 400mg
CrCl <79 –> dec dose 50%
not available IV!

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when is topiramate contraindicated

Er formulations are CI with alcohol and metformin

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topiramate SE and monitoring

metabolic acidosis, nephrolithiasis, angle-closure glaucoma, memory issues, psychomotor slowing, anorexia, fetal harm

monitor bicarb, s/sx kidney stones, renal function (dec dose 50% if CrCl <80), hydration, eye exams for glaucoma

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topiramate and CYP DDI

topiramate is a 3A4 inducer
3A4 inducers also dec topiramate levels

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topiramate decreases efficacy of

estrogen-containing oral contraceptives and warfarin

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what is the starting dose of VPA

15-20 mg/kg/day

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MDD of VPA

60mg/kg/day

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VPA concentrations are reported as

A. free
B. bound
C. total

C. total

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VPA TDM goal

50-100mcg/mL of total VPA

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what is the nuance with TDM of VPA

dec albumin will inc unbound VPA while VPA level stays the same bc it is total VPA

BBW of VPA

hepatic failure, fetal harm and neural tube defects

when is VPA contraindicated

hepatic disease

VPA SE and monitoring

SE: hyperammonemia, thrombocytopenia, DRESS monitor: LFTs, CBC w diff, plts, TDM

T or F carbapenems increase VPA concentrations

false, carbapenems dec VPA concentrations by induction

T or F estrogen containing oral contraceptives decrease VPA concentrations

true, carbapenems do as well

T or F VPA inhibits 2C9

true

T or F VPA inhibits 2C19

false, VPA is a substrate of 2C19

what are the common inducers of VPA metabolism

phenytoin phenobarbital rifampin carbamazepine

T or F SJ Wort induces VPA metabolism

false, does not affect

which AEDs are metabolized by 2C19

VPA lacosamide phenytoin

esomeprazole and omeprazole will increase or decrease VPA concentrations? Which enzyme is involved?

esomeprazole and omeprazole inhibit CYP2C19 and will increase VPA concentrations

VPA will increase plasma concentrations of... via 2C19 inhibition SATA A. warfarin B. lacosamide C. rifampin D. phenytoin E. amiodarone F. statins

A. warfarin B. lacosamide D. phenytoin

which are the narrow spectrum AEDs

phenytoin, fosphenytoin, lacosamide, oxcarbazepine, carbamazepine, phenobarbital

lacosamide isa control - _____

pregabalin is a control - ____

lacosamide brand name control - ___

vimpat V

phenobarbital is a control - ____

lacosamide starting dose MDD renal adjustments? IV:PO

50-100mg BID MDD 400mg MDD if CrCl <30 = 300mg 1:1

major lacosamide ADE

porolongs PR interval --> arrhythmias *caution with BB, CCB, and other drgs that prolong PR interval

carbamazepine brand name TDM goal

tegretol goal is 4-12 mcg/mL

tegretol (carb) ADE and monitoring

DRESS SJS/TEN, liver damage, fetal harm, hyponatremia

what should be done prior to tegretol or trileptal initiation and for which patient population?

patients of asain ancestry should be tested for the HLA-B*1502 allele

what is a major concern with tegretol and trileptal

hyponatremia (SIADH)

how do we convert between oxcarbazepine and carbamazepine

carb x 1.2 or 1.5 = oxcarb

carbamazepine is CI in

myelosuppression MAO-i in last 14 days TCA hypersensitivity reaction

what is unique about carbamazepine metabolism

auto inducer enzyme inducer and induces its own metabolism

oxcarbazepine dosing MDD renal adjustments warnings

300mg BID MDD 2400mg CrCl <30 -- start at 300mg qd warnings: SJS/TEN, hyponatremia

carbamazepine/tegretol dosing MDD renal adjustments warnings

200mg BID MDD 1600mg no renal dose adjustments warnings: SJS/TEN, hyponatremia

phenytoin dosing target in TDM

LD = 15-20mg/kg LD TDM 10-20 total 1-2.5 free

corrected pheny equation

corr pheny = pheny measured (0.2 x alb) + 0.1

IV:PO phenytoin

1:1

admin of IV phenytoin should not exceed

50mg/min

Fosphenytoin is a ____________ of phenytoin

prodrug

how to convert btwn Fosphenytoin and phenytoin

1.5mg Fosphenytoin = 1mg phenytoin

admin of IV Fosphenytoin should not exceed

150mg of phenytoin equivalent/min

s/sx of phenytoin dose-related toxicity

nystagmus, ataxia, diplopia, lethargy

s/sx of chronic phenytoin use

gingival hyperplasia hair growth liver tox inc BG metallic taste

what should be monitored with phenytoin use

ECG (arrhythmias) CMP respiratory TDM LFTs

phenytoin induces/inhibits which enzymes?

strong inducer 3A4, 1A2, 2C9, 2C19

patients on which AEDs should use non-hormonal contraceptives

phenytoin topiramate VPA

how should phenytoin be administered in patients with an NG tube

tube feeds should be held for 1-2 hours before and after

phenobarb dosing

50-100mg BID-TID

phenobarb is contraindicated in

hepatic imp, dyspnea, PMH sed/hypnotic addiction, IA adminsitration

warnings for phenobarbital

drug dependency resp depression SJS/TEN tolerance and hangover effects fetal harm

phenobarb DDI

strong inducer do not use with estrogen-containing OCs

what can happen with phenytoin drug concentrations and metabolism with time

phenytoin metabolism can become saturated over time where a small inc in dose can cause a large inc in Cp need to correct for albumin

common concerns with AEDs

bone loss, CNS dep, suicide risk, SJS/TEN

which AEDs are NOT safe in pregnancy and are considered teratogenic

phenytoin oxcarbazepine carbamazepine phenobarbital primidone clonazepam

what supplementation should be given to patients who are on AEDs and are of child bearing potential / aer pregnant

folate, vitamin D, Ca

what supplementation should be given to all patients on AEDs

Ca and Vit D

what SE are children more susceptible to and which AEDs cause this

more susceptible to hypohidrosis from topiramate and zonisamide limit sun exposure

what supplementation can be given with VPA

carnitine

what can be given to patients on lamotrigine and VPA if they develop alopecia

selenium and zinc

which AEDs should not be used with estrogen-containing OCs and are recommended to use with non-hormonal contraceptives instead

phenytoin topiramate VPA phenobarbital

which AEDs can cause SJS/TEN

lamotrigine levetiracetam oxcarbazepine carbamazepine

benzo MOA

potentiate GABA

VPA MOA

potentiates GABA

phenobarb MOA

potentiates GABA

levetiracetam (keppra) MOA

CA channel blocker and potentiates GABA

pregabalin/gabapentin MOA

Ca channel blocker

oxcarbazepine MOA

Na and Ca channel blocker

carbamazepine MOA

Ca channel blocker

lamotrigine MOA

Ca channel blocker

phenytoin/fosphenytoin MOA

Ca channel blocker

topiramate MOA

Ca channel blocker

Seizure/Epilepsy Flashcards

acute management, chronic management, monitoring, DDI, ADE, pregnancy, peds, counseling points (90 cards)