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Pharm I > Seizures > Flashcards

Seizures Flashcards

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1
Q

Most common causes of medication-induced seizures

A 
Tramadol
Bupropion
Venlafaxine
Theophylline
High-dose phenothiazines
Benzodiazapene or AED withdrawal
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2
Q

Partial seizures

A

Cause asymmetric manifestations
Begin in one hemisphere of the brain
Also called focal or localization related

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3
Q

General seizures

A

Begin in both hemispheres- diffusely throughout the cerebral cortex
Tonic- rigidity
Clonic- rhythmic jerks
Atonic- loss of muscle tone

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4
Q

Partial seizure sx

A

Motor
Sensory- visual, auditory, olfactory, gustatory
Autonomic- pallor, flushing, vomiting, sweating, vertigo, tachycardia
Psychic- hallucinations, emotional changes, dysphasia, cognitive changes

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5
Q

Partial seizure subtypes

A

Simple partial- no LOC
Complex- impaired consciousness
Secondarily generalized seizures

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6
Q

Types of generalized seizures

A

Myoclonic
Infantile spasms
Absence (petit mal)
Tonic-clonic (grand mal)

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7
Q

Myoclonic seizures

A

Brief jerking movements of whole body or upper body, occasionally lower extremities

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8
Q

Absence (petite mal) seizures

A

Nonconvulsive
Short LOC (10-30 secs)
Pt seems to stare, motionless, with distant facial expression

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9
Q

Tonic-clonic (grand mal) seizures

A

Convulsive motor activity with LOC

5 phases- flexion, extension, tremor, clonic, postictal

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10
Q

Non-pharmacologic interventions- seizure

A 
Surgery
Ketogenic diet
-High diet
-Low carbohydrate, low protein
Pt education
-Disease and drug education is crucial
Vagus nerve stimulation
-Implantable, programmable pulse generator
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11
Q

Criteria for attempting discontinuation of seizure meds

A

2-5 yrs seizure free
Single seizure type
Nl neurologic exam and IQ

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12
Q

Process of discontinuation of AEDs

A

Go slow (6 weeks to 3 mos per drug)
Remove one agent at a time
Seizure activity may not indicate failure of withdrawal

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13
Q

Interaction of AEDs with OCPs

A

Enzyme inducers decrease estrogens and/or progestins
No interaction seen (yet) with valproate and levetiracetam
OCPs decrease lamotrigine concentration

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14
Q

AEDs in women of childbearing age

A

Increased incidence of menstrual dysfunction, infertility, birth defects, perinatal infant death

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15
Q

Mechanism of teratogenicity and AEDs

A

Major congenital malformations with AED exposure may be 2-3x the general population
Folic acid metabolism- supplementation is necessary

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16
Q

Side effects of carbamazepine

A 
Pregnancy category D
Spina bifida
Facial changes
Nail hypoplasia
Small head circumference
Developmental delay
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17
Q

Side effects of phenytoin

A 
Category D
Hydantoin syndrome (growth deficiency, craniofacial anomalies, mental retardation, nail/digital hypoplasia)
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18
Q

Valproic acid side effects

A

Category D

Spina bifida, craniofacial abnormalities, developmental delay, external ear anomalies

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19
Q

Phenobarbital pregnancy side effects

A

Category D

similar to phenytoin

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20
Q

Topiramate pregnancy side effects

A

Category D

Growth retardation and limb agenesis in animals

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21
Q

Felbamate pregnancy side effects

A

Category C

Negative findings in animals

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22
Q

Gabapentin pregnancy side effects

A

Category C

Fetal toxicity in high doses in rodents

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23
Q

Tiagabine pregnancy side effects

A

Category C

Growth retardation in animals

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24
Q

Lamotrigine pregnancy side effects

A

Category C

Does affect folate metabolism

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25
Zonisamide pregnancy side effects
Category C | Animal problems
26
How do AEDs work in general?
Raise seizure threshold via stabilization of neuronal membranes Limit seizure propagation via depression of synaptic transmission and/or reduction of nerve conduction
27
AEDs and serious rash
Serious rashes are rare though very severe idiosyncratic reactions -Fever -Mucocutaneous lesions Risk is highest in the first 2 mos and those with HLA-B 1502 allele
28
Stevens Johnson Syndrome
Exfoliative rash with fever and hepatitis
29
AEDs and bone density
Chronic administration of enzyme inducing AEDs of valproate has been associated with decreases in bone mineral density
30
Hepatic enzyme inhibitors
Valproate
31
Hepatic enzyme inducers
``` Phenytoin Topiramate Phenobarbital Oxacarbazepine Carbamazepine ```
32
Initial drugs for partial seizures
Lamotrigine Levetiracetam Oxcarbazepine Carbamazepine
33
Alternative drugs for partial seizures
``` Valproate Ezogabine Pregabaline Phenytoin Topiramate Gabapentin Zonisamide Lacosamide ```
34
Initial drugs for primary generalized tonic-clonic seizures
Valproate Lamotrigine Levetiracetam
35
Alternate drugs for generalized tonic-clonic seizures?
Phenytoin Topiramate Zonisamide
36
Initial drugs for generalized absence seizures
Valproate | Ethosuximide
37
Alternative drugs for generalized absence seizures
Zonisamide Lamotrigine Clonazepam Levetiracetam
38
Drugs to avoid in generalized absence seizures
Phenytoin Vigabatrin Phenobarbital Carbamazepine
39
Initial drugs for generalized myoclonic seizures
Valproate Lamotrigine Levetiracetam
40
Alternative drugs for generalized myoclonic seizures
Felbamate Topiramate Zonisamide Clonazepam
41
Pros of first gen AEDs
Familiar, known ADRs, low cost, broad seizure coverage | Proven efficacy because of experience/data (but equal efficacy to 2nd gen)
42
Cons of first gen AEDs
Overlapping MOAs PK- lab monitoring for toxicity and efficacy CNS ADRs: Dizzy, drowsy, ataxia, cognitive dysfunction, slurred speech Reproductive endocrine disorders: pcos- irregular menses, weight gain, hirsutism/hyperandrogenism
43
Drug interactions with first gen AEDs
Inducers and inhibitors with vit D- calcium and vit D supplements Inducers with oral contraceptives- adjust contraceptives (except with VPA)
44
1st gen AEDs
``` Valproate Phenytoin Ethosuximide Carbamazepine Phenobarbital Primidone ```
45
Additional uses of carbamazepine
Toni-clonic | Bipolar and trigeminal neuralgia
46
Dosing of carbamazepine
Initiate at 200-400 mg/day to allow tolerance to develop to CNS side effects and increase by 200 mg increments every 2-4 weeks
47
Side effects of carbamazepine
GI Rash and pruritis Idiosyncratic- bone marrow suppression (d/c if wbc < 2500/mm cubed or ANC < 1000/mm cubed) Dose related: drowsiness, double vision, dizziness, ataxia Monitor CBC, Na, LFT
48
Carbamazepine instructions
Store in dry conditions Must test for HLA-B 1502 in Asians May exacerbate absence or myoclonic seizures
49
Use for ethosuximide
Absence seizures only
50
Dosing of ethosuximide
Titrate over 1-2 weeks to a max dose of 20 mg/kg/day given qd-bid
51
Adverse effects of ethosuximmide
Low toxicity potential - Concentration dependent: N/V, drowsiness, unsteadiness, hiccups - Rare, idiosyncratic: rash, blood dyscrasia, lupus-like syndrome, psychosis
52
Drug interactions of Ethosuximide
Increased serum levels when given with valproic acid - Strong inhibitors of CYP3A4 - Decreased serum levels when given with carbamazepine - Strong inducers of CYP3A4
53
Monitoring with Ethosuximide
Periodically monitor serum levels, CBC, urinalysis, LFTs
54
Use of phenytoin
Partial, secondarily generalized
55
Dosing of Phenytoin
Initial oral dose is 15 mg/kg in 3 divided doses followed by a maintenance dose of 5 mg/kg in 1-2 divided doses Begin 300 mg/day in 1-3 doses, increase by 30-100 mg/day every 10-21 days using serum levels
56
Dose-related adverse effects of Phenytoin
Ocular-diplopia, nystagmus, blurred vision CNS- lethargy, fatigue, incoordination, drowsiness Cardiovascular- hypotension, bradycardia, cardiac arrhythmias
57
Toxicity adverse effects of Phenytoin
20 mcg/mL: nystagmus, slurred speech, ataxia dizziness 30 mcg/mL: drowsiness, diplopia, behavioral changes, cognitive impairment > 40 mcg/mL: mental status changes, coma, seizures, status epilepticus
58
Chronic adverse effects of Phenytoin
Hirsutism Gingival hyperplasia Coarsening of facial features
59
Additional uses of valproic acid/valproate
Broadest activity of AEDs Mood disorders Behavior disorders- dementia pts
60
Therapeutic serum levels of valproic acid/valproate
50-100 mcg/mL
61
Oral dosing of valproic acid/valproate
Bedtime administration to minimize effects of CNS depression | Minimize GI irritation by giving with food, slowly increasing the dose, using delayed-release preparation
62
IV dosing of valproic acid/valproate
Administer over 60 mins (less than or equal to 20 mg/min)
63
Drug interactions of valproic acid/valproate
Enzyme inhibitor Increases levels of phenytoin, carbamazepine, lamotrigine Its levels are affected by anticonvulsants ASA increases the activity of VPA Does not interfere with OCPs It is affected by inducers and inhibitors
64
Dose-related adverse effects of valproic acid/valproate
``` Weight gain Hair loss Tremor Menstrual irregularitiesGI irritation Insulin resistance ```
65
Idiosyncratic adverse effects of valproic acid/valproate
Liver failure Pancreatitis Thrombocytopenia
66
Uses of Gabapentin
Adjunctive therapy for partial seizures Neuropathic pain RLS and other neurological conditions
67
Side effects of Gabapentin
Common: fatigue, somnolence, dizziness, ataxia | Worsening edema
68
Counseling for Gabapentin
Do not take with antacids, take with food
69
Other considerations for Gabapentin
Can exacerbate myoclonic seizures
70
Use of Lacosamide (Vimpat)
Add on therapy for partial seizures in adults
71
Adverse effects of Lacosamide (Vimpat)
CNS effects Euphoria PR interval prolongation
72
Additional uses of Lamotrigine
Pediatrics | Maintenance tx for bipolar disorder
73
Dosing for Lamotrigine
Depends on drug interactions Dose is increased by inhibitors Dose is decreased by inducers
74
Monitoring for valproic acid/valproate
Esp in kids < 2 yo, congenital metabolic disorders, severe seizure disorders, organic brain disease, multiple anticonvulsants, Monitor for loss of seizure control, malaise, weakness, lethargy, facial edema, anorexia, N/V Monitor LFTs frequently in first 6 mos
75
Lamotrigine dosing with enzyme-inducing AEDs and no valproic acid
Weeks 1 and 2: 50 mg (once a day) Weeks 3 and 4: 100 mg (two divided doses) Usual maintenance dose: 300-500 mg/day (two divided doses) Escalate dose by 100 mg/day every week
76
Lamotrigine dosing with enzyme-inducing AEDs and valproic acid
Weeks 1 and 2: 25 mg (every other day) Weeks 3 and 4: 25 mg (once a day) Usual maintenance dose: 100-150 mg/day (two divided doses) Escalate dose by 25-50 mg/day every 1-2 weeks
77
Drug interactions for Lacosamide (Vimpat)
No known clinically significant drug interactions
78
Lamotrigine drug interactions
Acetaminophen decreases lamotrigine levels
79
Life-threatening rash in lamotrigine
Titrate dose slowly to minimize | More common in pediatrics and with valproic acid
80
Additional uses for levetiracetam
Neuropathic pain
81
Adverse effects of levetiracetam
CNS: sedation, fatigue, coordination difficulties Behavioral: Some agitation, irritability, depression Small risk for dermatological rxns
82
Additional uses for oxcabazepine
Bipolar disorder | Neuropathic pain
83
Adverse effects of oxcarbazepine
25-30% cross-reactivity of carbamazepine rash Less CNS effects and allergic skin rxns More frequent hyponatremia
84
Pregabalin use
Adjuvant for partial onset seizures Neuropathic pain Fibromyalgia syndrome
85
Adverse effects of pregabalin
Classic CNS side effects Thiazolidinedione: additive fluid retention/weight gain Classified as a C-V due to risk of euphoria
86
Use of topiramate
Second line for partial seizures Weight loss (in combination) Prophylaxis of migraine HAs
87
Drug interactions of topiramate
Variable effect on phenytoin | It is decreased by carbamazepine and phenytoin
88
Adverse effects of topiramate
Dose-related: Speech and language problems, fatigue, dizziness, HA, birth defects (cleft lip and cleft palate) Chronic: Kidney stones, weight loss Idiosyncratic: Acute narrow-angle glaucoma, oligohydrosis, metabolic acidosis

Pharm I (10 decks)

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