Treatment of Epilepsy (Week 5--Degiorgio) Flashcards Preview

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Flashcards in Treatment of Epilepsy (Week 5--Degiorgio) Deck (17):
1


When should we initiate treatment for epilepsy?


Definitely after 2 or more unprovoked seizures

Consider treatment after first seizure if abnormal MRI (cyst, tumor, etc) or EEG

Early treatment reduces risk of second seizure in first 2 years

2


When should we stop treatment for epilepsy?


If seizure free for at least 1-2 years

Best candidates have normal MRI and EEG and excellent response to initial treatment

3

What should we use as first line therapy for epilepsy?

Carbamazepine (however, has rash, preg class D, requires monitoring)

Levetiracetam (however, has insomnia, depression)

4


Treatment for partial seizures


Lamotrigine better tolerated than carbamazepine

Lamotrigine and carbamazepine equivalent for long term efficacy

Both better than gabapentin

Answer: lamotrigine, carbamazepine, oxcarbazepine (maybe levetiracetam)

5


Treatment for generalized epilepsy


Valproate is the best but must consider birth defects

(Valproate better than lamotrigine and topiramate)

Answer: valproate and lamotrigine

6


Treatment for absence (petit mal) seizures


Ethosuximide or valproate better than lamotrigine

Ethosuximide less cognitive side effects

Answer: ethosuximide and valproate

7


Drugs to avoid if you have a history of rash


Lamotrigine

Carbamazepine

Phenytoin

8


Drugs to avoid if you want to get pregnant


Valproate

Carbamazepine

Phenytoin

(take lamotrigine or levetiracetam instead)

9


Drugs to avoid if you have a history of behavior problems


Levetiracetam

Topiramate

Zonisamide

Lacosamide

10


Drugs to try if you have a history of previous drug failures


Topiramate

Levetiracetam

Lacosamide

11


Teratogenicity of AEDs


Fetal malformations in 6%

Higher risk with polytherapy

Highest risk with class D: phenytoin, valproate, phenobarbital, carbamazepine

Lower risk class C: lamotrigine, levetiracetam, gabapentin

Can prevent these birth defects by taking folic acid

12


Sudden death in epilepsy


3-9/1,000

Highest risk for 18-40 yo and long duration of epilepsy; frequent grand mal seizures, on multiple AEDs

Etiology: hypoxia, cardiac arrhythmias

Prevention: nighttime supervision, listening device, control grand mal seizures

13


How do we use DBS as treatment for epilepsy?


If drugs don't work

Anterior thalamic DBS

Not yet FDA approved

Seizure frequency reduced by 66%

14


Direct cortical stimulation


NeuroPace device

29% seizure reduction

Senses electrical activity then delivers a pulse and stops the seizure

15


Vagus nerve stimulation


Right vagus projects to SA node

Left vagus projects to AV node

16


Trigeminal nerve stimulation


3 divisions of trigeminal nerve

Brainstem: NTS, locus coeruleus, vagus nerve nuclei

Thalamus

Cortex

17


Summary about epilepsy treatment


Use valproate and lamotrigine for generalized seizures

Use ethosuximide and valproate for absence seizures in children

Use lamotrigine, carbamazepine, oxcarbazepine and others for partial seizures

Use topiramate, levetiracetam and lacosamide for drug resistant epilepsy

Avoid valproate, carbamazepine, phenytoin in pregnancy

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