Wk 32 - Epilepsy in practice

Question 1

What are the causes of epilepsy?

Answer 1

• Structural: stroke, trauma, malformation
• Genetic: dravet syndrome
• Infection: TB, malaria, HIV
• Metabolic: porphyria, pyridoxine deficiency
• Immune: anti-NMDA receptor encephalitis

Question 2

What are some complications of epilepsy?

Answer 2

• Sudden unexpected death in epilepsy
• Injuries: cause trauma
• Depression + anxiety
• Absence from work/school

Question 3

What is the treatment for status epilepticus outside of hospital (had previous seizures)?

Answer 3

• Rectal diazepam 10-20mg
• Buccal midazolam 10mg
• Repeat once after 15 mins

Question 4

What is the treatment for early status (hospital or ambulance)?

Answer 4

• IV lorazepam 4mg

- Repeat once after 10-20 minutes

Question 5

What is the treatment for established status?

Answer 5

• IV phenytoin infusion 15-18mg/kg

- Other: fosphenytoin + phenobarbital

Question 6

What is the treatment for refractory status (60 - 90 mins after initial treatment)?

Answer 6

• Anaesthesia eg, midazolam

- Until seizure free for 12-24hrs then taper

Question 7

What are general measures to make?

Answer 7

• Secure airway + resuscitate
• Administer oxygen
• Establish IV access

Question 8

What are emergency investigations that could be made?

Answer 8

• Bloods: glucose, renal and liver function, calcium and magnesium, full blood count (including platelets), blood clotting, AED drug levels
• Chest x-ray: possibility of aspiration

Question 9

What should be monitored?

Answer 9

• Regular neurological obs
• Pulse, BP, temp, ECG, bloods
• EEG for refractory status

Question 10

When should AEDs be discontinued?

Answer 10

• Seizure free for 2 years

- Taper slowly over 2-3 months

Question 11

What is under category 1?

Answer 11

• Phenytoin, carbamazepine, phenobarbital + primidone

- Maintain on specific manufacturers prod

Question 12

What is under category 2?

Answer 12

• Valproate, lamotrigine, retigabine, rufinamide, clobazam, clonazepam, oxcarbazepine, zonisamide, topiramate
• Continued supply of particular brand based on clinical judgement + consultation/ patient + carer - take into account freq. + history

Question 13

What is under category 3?

Answer 13

• Lacosamide, tiagabine, gabapentin, pregabalin, vigabatrin
• Unnecessary to ensure patients maintained on specific brand

Question 14

Outline the MHRA advice on risk of suicidal thoughts + behaviours

Answer 14

• ALL AEDs associated w/ inc risk of suicidal thoughts
• Occur 1 week after starting
• Seek medical advice if mood changes but don’t stop treatment

Question 15

Which drugs cause antiepileptic hypersensitivity syndrome?

Answer 15

• Carbamazepine
• Lacosamide
• Lamotrigine
• Phenobarbital
• Phenytoin
• Primidone
• Symptoms starts 1-8 wks

Question 16

What should be done if antiepileptic hypersensitivity syndrome occurs?

Answer 16

W/draw immediately + must not be re-exposed

Question 17

What are the symptoms of antiepileptic hypersensitivity syndrome?

Answer 17

• Start 1-8 wks
• Fever, rash + lymphadenopathy common
• Liver dysfunction, haematological, renal, + pulmonary abnormalities, vasculitis, + multi-organ failure

Question 18

Outline the MHRA advice on adverse effects on bones

Answer 18

• LT use: carbamazepine, phenytoin, primidone, + sodium valproate = dec bone mineral density
• Leads to: osteopenia, osteoporosis + inc fractures
• Consider: Vit D

Question 19

What contraceptives are not recommended when taking AEDs?

Answer 19

Progestogen only pill + implant

Question 20

What are the effects of AEDs on pregnancy + give examples of drugs that cause such effects

Answer 20

• Inc risk of major congenital malformations: 1st trimester
• Highest: valproate
• Risk: carbamazepine, phenobarbital, phenytoin, + topiramate
• Lamotrigine = safer