Seizures/Epilepsy Flashcards by Hannah Lapos

What is a seizure?

Excitatory neurons produce a sudden surge of uncontrolled electrical activity in brain

Excess in glutamate (excitatory) and deficiency in GABA (inhibitory)

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Drugs that reduce the seizure threshold

Opioids (tramadol, meperidine)
GQ
Carbapnems
Cephalosproin
Penicillins
Mefloquine
Bupropion
ANipsychotics
Lithium
TCA

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What is a focal seizure

One side of the brain but can spread to the other side

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What are generalized seizures

Starts on both sides of the brain

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What is focal aware seizure

The patient experiences no loss of consciousness

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What is focal seizure with impaired awareness:

Loss in consciousness during seizure

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Clonic

Jerking movement

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Atonic

Limp or weak muscles

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Myoclonus

Muscle twitching

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Tonic

Rigid or tense muscles

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What is status epilepticus

A seizure that lasts 5 minutes or more

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Treatment of status epilepticus

0-5 min (stabilization): Stabilize circulation, airway, breathing, start ECG, Check ASM levels and electrolytes,
- If glucose low → dextrose

5-20 min (Initial): IV lorazepam, IM midazolam, IV diazepam
- Alt: rectal diazepam, in or buccal midazolam

20-40 min (Second): Give non-bzd, IV fosphenytoin, valproic acid, levetiracetam
- Alt: phenobarbital

> 40 min (refractory): Repeat 2nd line therapy or midazolam, phenobarbital, or propofol

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Counseling on DiaStat AcuDial

Hold barrel of the syringe in one hand facing down
Grab the cap and turn to adjust dose
Confirm dose in window. Had the locking ring at the bottom of the barrel and push upward
Once locked the green band should say ready (can’t be unlocked)
Repeat with second syringe

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Diet used for refractory seizures

Ketogenic diets
4:1 fat to protein/carb

Ketosis → reduction of seizure frequency

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Marijuanna indicated for chronic seizures

Cannabidiol ((CBD), Epidiolex

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What are broad spectrum ASM

Treats focal and generalized seizures

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Drug for absence seizures

Ethosuximide

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ADR of all ASM

CNS depression, sedation, confusion, cognitive impairment, falls

↑ fracture risk

SJS/TEN/DRESS

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Vitamins for ASM

All: Calcium and Vit D
Women: folate
Valproic acid: carnitine
Lamotrigin and valproate: alopecia → biotin, selenium, zinc

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MOA of BZD

Enhances GABA

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Phenobarbital MOA

Enhances GABA

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MOA of valproate

Blocks Na and ↑ GABA

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MOA of Levetiracetam

Inhibits vesicle fusion by binding to SVA2 protein

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ASMs that block Na channels

Carbamazepine
Phenytoin/Fosphenytoin
Topiramate
Valproate
Lamotrigine

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MOA of Lamotrigine

Blocks Na and decreases glutamate

MOA of ethosuximide

Blocs T-type Ca channels

What are your broad spectrum ASM

Lamotrigine Levetiracetam Topiramate Valproate

Lamotrigine

Lamictal

BBW of Lamictal

Serious skin reactions (SJS/TEN)

ADR of Lamitcal

DRESS, SJS, TEN, alopecia (biotin, selenium, zinc)

Counseling upon Lamictal discontinuation

≥5 half lives (>6 days) → restart initial dosing titration

Indications for Lamictal starter kits

Blue: lower dose → taking valproate Orange: standard dose Green: higher dose → taking with inducers and not taking valproate

Levetiracetam

Keppra

ADR of Keppra

Psychiatric reaction (psychotic sx, smonolensce, fatigue)

IV to PO Keppra

1:1

Initial dose of Lamictal

25 mg PO QD

Topiramate

Topamax

Indication for Lamictal

Bipolar

Indication for Topamax

Migraine prophylaxis

ADR of Topamax

Metabolic acidosis, oligohidrosis, nephrolithiasis, angle closure glaucoma, hyperammonia, visual problems, fetal harm ADR: somnolence, dz, memory/concentration/attention difficulty, anorexia, weight loss

Monitoring for topiramate

Eyes, intraocular pressure, bicarb

DDI of topiramate

↓ effectiveness of PO contraceptives Inducers ↓ levels

Valproate therapeutic range

50-100

Divalproex

Depakote

BBW of Valproate

Hepatic failure, fetal harm, pancreatitis

ADR of valproate

Alopecia (biotin, selenium, zinc), N/V, weight gain, somnolence, tremors, hyper ammonia (carnitine), thrombocytopenia

Monitoring for valproate

LFT Q6M, platelets

DDI of valproate

↑ levels of lamotrigine, warfarin

ASMs that are narrow spectrum

Lancosamide Carbamazepine Oxacarbazepine Phenytoin/Fosphenytoin Phenobarbital

Lancosamide schedule

ADR of lancosamide

Prolonged PR interval (arrhythmia) DRESS

LAcosamide

Vimpat

Carbamazepine

Tegretol

BBW of Carbamazepine

HLA-H*1502 → serious skin reactions in Asians Aplastic anemia and agranulocytosis

ADR of carbamazepine

Myelosuppressium, hyponatremia, fetal harm

DDI of carbamazepine

Enzyme inducer and autoinducer

Oxcarbazepine

Trileptal

Carbamazepine level

4-12

Waring of Oxcarbazepine

HLA-B-1502 → skin reactions in Asians Hyponatremia

DDI of oxcarbazepine

Inducer but not autoinducer

Phenytoin

Dilantin, Infatabs

Level of phenytoin

Total: 10-20 Free: 1-2

IV to PO phenytoin

1:1

BBW of phenytoin

IV rate should not be >50mg/min Fosopheyntoin should not be >150 mg PE/min Faster leads to arrythmias

ADR of fos and phenytoin

Extravasation (purple glove syndrome) Avoid in patient with HLA-B*1502 Fetal harm Dose-related: nystagmus, ataxia, diplopia Chronic: gingivianal hyperplasia, hepatotoxicity

Fosphenytoin and phenytoin conversion

Fosphytoin 1.5 mg = 1 mg PE

Counseling on IV phenytoin

Don't exceed 50 mg/min Montior BP, respiratory, ECH Require filter Dilute NS → stable for 4 hrs, don't regrigerate

Counseling of NG phenytoin

Enteral feedings → ↓ pheytoin absorption Hold feedings 1-2 hrs before or after administration

When do you correct phenytoin levels

Albumin ≤3.5 CrCl ≥10 Phenytoin corrected = Total phenytoin measured/ (0.2x albumin) + 0.1

Schedule of phenobarbital

CIV

Level of phenobarbital

20-40 mcg/mL

ADR of phenobarbital

Physiological dependence, tolerance, residual sedation SUB

Gabapentin and pregabalin ADR

Weight gain, peripheral edema, mild eupharia

ADR of topiramate and zonisamide

Weight loss, metabolic acidosis Nephrolithiasis, oligohidrosis/hyperthermia

Schedule for BZD

CIV

BBW of BZD

opioids use with BZD →respiratory depression and death

Lorazipam

Ativan

Clobazam

Onfi

Indication of clobazam

Lennox-Gastaut syndrome or refractory epilepsy

Cannabidiol

Epidiolex

What is eslicarbazepine

Active metabolite of Oxcarbazine (monitor Na)

Ethosuximide

Zarontine

ADR of Ethosuximide

SJS/TEN

BBW of felbamate

Aplastic anemia

BBW of fenfluramine

Valvular Heart disease, pulmonary HTN ↓ appetite → weight los

ADR of Gabapentin

Somnolence, peripheral edema, weight gain, mild euphoria

What is primidone

Prodrug of phenobarbital and PEMA

BBW of vigabatrin

Permanent vision loss

CI fo zonisamide

Sulfonamide allegy

Highest risk in pregnacy

Valproate

Recommended ASM for pregnancy

Keppra and Lamictal

Recommendations in pediatrics

Lamotrigine and Lamictal ODT

Reduced sweating in children

Zonisamide, topiramate

Induces rashes in children

Lamotrigine

Seizures/Epilepsy Flashcards

(94 cards)