Therapeutics - Epilepsy Flashcards by amanda kastel

define epilepsy

RECURRENT seizures (2 or more) that are NOT provoked by neurologic insults (ie - no infection, no previous stroke, no electrolyte imbalance)

just happened unprovoked. electrical activity in brain is inherently abnormal

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is a febrile seizure considered an unprovoked seizure

there’s a reason behind it

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____ withdrawal can cause a seizure

benzodiazepine

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name 2 drug overdoses that can cause a seizure

alcohol
barbiturates

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hypo ___ and hypo ___ can cause a seizure

hypoglycemia and hypocalcemia

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name a particular antidepressant that is a risk factor for seizures

buproprion

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the presentation of a seizure depends on what 3 things

-location of onset

-comorbid diseases

-concurrent meds

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most people who have a ____ seizure lose consciousness

generalized

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what are the 3 types of seizures based on onset

focal
generalized
unknown - dont know if generalized or focal

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“focal onset” seizure

starts on ONE SIDE of the brain and may spread to the other side

generalized is on both sides of the brain and the pt tends to lose consciousness

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true or false

antiepileptics cannot just be stopped

TRUE - will induce a seizure

must TAPER DOWN

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name some drugs that can lower the seizure threshold

antidepressents
neuroleptics
phenothiazines

clozapine, theophylline, isoniazid, cyclosporine, meperidine

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name a muscle relaxant that if stopped, can induce a seizure

meprobamate

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can antipsychotic withdrawal induce a seizure

yes - particularly the early generations

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what is QOLIE-31

what does a HIGH SCORE MEAN

quality of life estimator for epilepsy patients

high score means they have a good quality of life

(low score = low QOL)

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true or false

drugs dont cure epilepsy

TRUE - only thing that actually cures epilepsy is surgery

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true or false

most epilepsy patients are not on drugs for their life

false - they’re typically on for their whole life

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___ is the mainstay of epilepsy treatment

antiseizure drug therapy

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when a patient presents after a single, isolated seizure, do we typically treat?

typically observe them, see if something induced the seizure

but if the patient has 2 or more UNPROVOKED - that’s when you need to start on antiepileptics

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as mentioned, if a patient presents with just 1 seizure we typically dont start antiepileptics.
when may a physician consider starting drugs tho even if they only had 1 seizure

if there is a definite abnormal MRI or EEG

some others tho wait to see if a 2nd one will happen

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3 nonpharm options for epilepsy

vagal nerve stimulator (implanted medical device)

ketogenic diet (high fat, low carb)

surgery

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vagal nerve stimulator is really only for…

kids who have failed antiepileptic drugs

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*when choosing antiepileptic therapy, you ALWAYS start with what

MONOTHERAPY

never start with more than 1

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when starting antiepileptic therapy, we should increase the dose until _______

either the seizures stop or CLINICAL toxicity occurs - NOT THE LAB

treat the patient not the level!!!! doesnt matter how low the level is as long as patient doesnt have seizures

everyone has very different antiepileptic medication and dose

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___ gen antiepileptics are typically indicated for generalized seizure

early gen

only time ethosuximide is used

absence seizure

name 7 1st gen antiepileptics

carbamazepine benzos ethosuximide phenytoin phenobarbital primidone valproic acid

true or false the 1st gen antiepileptics are teratogenic

true

true or false the 1st gen antiepileptics have a wide TI

false - narrow TI

true or false an advantage of 1st gen antiepileptics is that there are IV formulations available

true

true or false 1st gen are more likely to have DDI, and also need lab monitoring

true

____ has non linear pharmacokinetics

phenytoin big issue

true or false 1st gen AEDs have less SE than the newer gens

FALSE - more SE

pregnancy cetegory of NEWER antiepileptics

C - good to use in women planning pregnancy

true or false newer antiepileptics have superior efficacy to older

FALSE - similar but newer dont need lab monitoring and have better SE profile

true or false a disadvantage of newer antiepileptics is that there are limited IV formulations

true

**patient has been diagnosed with epilepsy ONE AED is chosen based on what?

the seizure classification side effects insurance are they male or female? - teratogenicity of the 1st gen

*patient with epilepsy has been started on ONE antiepileptic drug we send them home, and they come back to follow up what 2 questions do we ask

are you seizure free? do you have intolerable side effects?

*pt has been started on 1 AED and they are now following up when we ask if they are seizure free, they say yes when we ask if they have intolerable side effects, they say YES what do we do?

decrease the dose of the drug, and assess them again with the 2 questions later

*patient has been started on 1 AED and they're now following up when we ask if they are seizure free, they say yes. when we ask if they have intolerable side effects, they say no explain what we do now

assess their QOL questionairre if optimal, continue the current treatment. if they get to be seizure free for over 2 years, can consider withdrawing the drug (TAPER). if cant get to be seizure free for over 2 years. go back to box 3 if QOL NOT optimal - explore QOL issues and fix them. reassess in a little bit and ask the 2 prime questions again

*patient is started on 1 AED and they're now being reassessed we ask if they are seizure free and if they are having intolerable side effects they are NOT seizure free and they are NOT having intolerable side effects what do we do?

increase the dose and reassess with the same 2 questions later

*patient is started on 1 AED and are now following up they are NOT seizure free and ARE having intolerable side effects what do we do

decrease the dose of the drug and add a second then we reassess later and ask the same 2 questions if they're seizure free, can consider removing the first drug if they're not seizure free and having intolerable side effects, remove the least effective drug and add another, and reassess later. if still not seizure free, reconfirm diagnosis and consider nonpharm if they're not seizure free and NOT having intolerable SE, increase dose of the 2nd drug and assess compliance

name 3 antiepileptic that really dont inhibit or induce enzymes

gabapentin lamotrigine levitiracetam

carbamazepine is a potent CYP3A4 ____

inducer also an autoinducer- takes like 3-4 weeks to show in lab

true or false the dosage forms of carbamazepine (chewable/ER/IR) are NOT interchangeable

true

AE of carbamazepine

drowsiness lethargy rash hyponatremia aplastic anemia osteoporosis

counseling point of something that may happen when carbamazepine is first started

a benign rash on trunk/legs that goes away

monitoring requirements for carbamazepine

CBC and LFT at baseline, and monthyl for 2-3 months then annually thereafter

BBW carbamazepine

SJS

something you must check before initiating carbamazepine and what to do if positive

HLA-B*1502 allele DO NOT TREAT IF POSITIVE only test if certain at risk populations like asians (including south asian indians)

ethosuxamide is only used for what

absence seizures in a3 yrs of age and up can be mono or adjunct therapy

monitoring for ethosuxamide

CBC (leukopenia, pancytopenia), hepatic and renal function

true or false the different dosage forms of valproic acid are not interchangeable

true - have diff kinetics

true or false both valproic acid and carbamazepine are CI in pregnancy

true

BBW valproic acid

hepatotoxicity

advantage of keppra

minimal DDI and comes in XR formulation

SE keppra

worsening depression, anxiety behavioral changes - aggression

dose keppra need dose adjustment in renal failure

yes

there is cross sensitivity between oxcarbazepine and ____

carbamazepine so must also check for the allele! to predict SJS

gabapentin usual place in therapy

adjunct therapy

BBW lacosamide

avoid in 3rd degree heart block, and caution in patients with proarrhythmic conditions

true or false lacosamide has minimal DDI

true

___ is contraindicated in those with sulfa allergy

zonisamide

BBW zonisamide

metabolic acidosis - need to monitor look for tachycardia, excess fatigue, losing weight

advantage of eslicarbazepine over carbamazepine and oxcarbazepine

longer t1/2 so QD dosing

eslicarbazepine should not be used with...

oxcarbazepine or carbamazepine

if a patient has intolerable psychiatric keppra side effects, what may they be switched to to help

brivaracetam

true or false perampenal is not a controlled substance

false - it is

BBW perampenal

aggression, homicidal ideation

the IV formulation rate of phenytoin has a max infusion rate why

hypotension

nystagmus, ataxia, drowsiness, and cognitive impairment are dose-related or non dose related SE?

dose-related

therapeutic range of phenytoin free drug range

therapeutic range - 10-20mcg/L free drug - 1-2mg/L

fosphenytoin is the prodrug of phenytoin what are advantages of using it

minimize problems of IV phenytoin can be given more rapidly - doesn't have to be given slowly like IV phenytoin does not cause hypotension, bradycardia, pain, thrombophlebitis

true or false fosphenytoin is only given IV

true

BBW felbamate

irreversible fatal aplastic anemia, esp in women

general FDA warning about antiepileptic drugs

suicide risk in epileptic patients from 1 week-24 weeks after starting treatment

**3 drugs that have the lowest incidence of congenital malformations are any 1 of these better than the other?

lamotrigine levetiracetam gabapentin lamotrigine has an advantage because it can be used as monotherapy the other 2 are typically adjuncts

if possible ____ is preferred to ____ in women

monotherapy preferred to polytherapy

true or false in epileptic pregnant patients, you may need to use higher doses

true

2 considerations of things that can be affected in patients on antiepileptics

bone health - osteopenia and osteoporosis. treat with high dose vitamin D and calcium supplements sexual dysfunction

even if a patient has been seizure free for over 2 years, why might we still want to keep them on therapy

if they have factors associated with recurrent seizures like a known structural lesion, EEG abnormal, seizure onset during adolescence, neurologic abnormalities, etc

if we decide to take a patient off AED, explain the general rule

~25% taper down every 4 weeks - VERY SLOW the risk of withdrawal is much lower if we taper down over a whole 6 months rather than just 1-3

brand vs generic considerations AED

not same bioequivalence!!!!!! even different manufacturers of generics can be a problem - stay consistent

Therapeutics - Epilepsy Flashcards

(84 cards)