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98 Cards in this Set
- Front
- Back
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T/F: are all seizures epilepsy
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False
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Causes of seizures
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CNS depressants withdrawal, acute illness, toxic condition, fever
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Epilepsy
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recurrent seizures
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Types of epileptic seizures
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partial
generalized |
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Types of partial seizures
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simple
complex |
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Partial seizure
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focal seizures that begin in 1 hemishphere with asymmetric manifestation
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Simple partial seizure
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no loss of consciousness
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complex partial seizure
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loss of consciousness
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Types of generalized seizures
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absence
myoclonic tonic clonic tonic-clonic atonic |
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MC generalized seizures
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absence, tonic-clonic
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Generalized seizures
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begins in different hemishperes at once with bilater motor manifestation and loss of consciousness
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Secondary generalized seizure
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partial seizure that becomes generalized
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Absence seizure
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sudden onset interruption of ongoing activity-stare-pt is absent-children (petit mal)
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Myoclonic seizure
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Myoclonic-sudden brief jerking movements
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Tonic seizure
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all over stiffening
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Clonic seizure
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rhythmic jerking
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Tonic-clonic seizure
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all over stiffness then progress to rhythmic jerking
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Atonic seizure
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sudden loss in muscle tone-falls
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Seizure Tx Goals
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no seizure, no side effect from meds, optimal quality of life, driving
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Partial seizure DOC
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carbamazepine, phenytoin, lamotrigine, oxcarbazepine, topiramate, valproate, gabapentin, pregabalin, levetiracetam
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Absence seizure DOC
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valproate, ethosuximide
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Absence seizure alternate drugs
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lamotrigine, zonisamide, clonazepam, levetiracetam
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Myoclonic seizure DOC
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valproic acid, lamotrigine, phenytoin, oxcarbazepine, topiramate
"LOT of VP" |
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Tonic-clonic seizure DOC
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phenytoin, carbamazepine, valproic acid, gabapentin, lamotrigine, topiramate
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Metabolism of Carbamazepine (Tegretol)
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liver by CYP 3A4
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Acute adverse effects of Carbamazepine (Tegretol)
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Diplopia
Dizziness Drowsiness Nausea Unsteadiness Lethargy |
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Chronic adverse effects of Carbamazepine (Tegretol)
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hyponatremia
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Idiosyncratic adverse effects of Carbamazepine (Tegretol)
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bone marrow suppression (aplastic anemia, thrombocytopenia, anemia, leukopenia - d/c drug)
rash (mc Asians) |
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Drug interactions of Carbamazepine (Tegretol)
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increased by valproic acid, enzyme inhibitors (INH, fluoxetine, erythromycin, clarithromycin, cimetidine)
increases metabolism of theophylline, warfin, ethosuximide, OCP |
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Therapeutic range of Carbamazepine (Tegretol)
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4-14 mcg/ml
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metabolism of Ethosuximide (Zarontin)
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liver
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Acute adverse effects of Ethosuximide (Zarontin)
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Ataxia
Drowsiness GI distress Unsteadiness Hiccups |
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Idiosyncratic adverse effects of Ethosuximide (Zarontin)
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rash
Lupus blood dyscrasias |
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Chronic adverse effects of Ethosuximide (Zarontin)
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behavioral changes
HA |
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Drug interactions of Ethosuximide (Zarontin)
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increased by carbamazepine
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Dosing of Ethosuximide (Zarontin)
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slow to max 20mg/kg/day
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Therapeutic range of Ethosuximide (Zarontin)
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40-80 mcg/ml
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Metabolism of Gabapentin (Neurontin)
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renal elimination
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Acute adverse effects of Gabapentin (Neurontin)
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Dizziness
Fatigue Somnolence Ataxia "SAD and Fatigue" |
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Chronic adverse effects of Gabapentin (Neurontin)
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weight gain
pedal edema |
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Drug interactions of Gabapentin (Neurontin)
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no induction/inhibition of liver enzymes
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Dosing of Gabapentin (Neurontin)
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2400-4800 mg/d (reduce for renal insufficiency)
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Metabolism of Lamotrigine (Lamictal)
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liver, <10% renal elimination
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Acute adverse effects of Lamotrigine (Lamictal)
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Diplopia
Dizziness Unsteadiness Headache |
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Idiosyncratic adverse effects of Lamotrigine (Lamictal)
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rash
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Drug interactions of Lamotrigine (Lamictal)
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no inhibition/induction of liver enzymes
inhibited by valproic acid decreased by enzyme inducers (OCP) |
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Metabolism of Levetiracetam (Keppra)
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<10% protein binding, 66% renal elimination, non hepatic hydolysis
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Adverse effects of Levetiracetam (Keppra)
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sedation, fatigue, coordination difficulties, agitation, irritability, depression
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Drug interactions of Levetiracetam (Keppra)
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none!
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Dosing of Levetiracetam (Keppra)
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500 mg bid (starting 1000 mg/d increase to 3000 mg/d)
adjust for age and renal |
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Metabolism of Oxycarbazepine (Trileptal)
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glucuronidated and renally eliminated
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Acute adverse effects of Oxycarbazepine (Trileptal)
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Sedation
Dizziness Ataxia nausea "SAND" |
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Idiosyncratic adverse effects of Oxycarbazepine (Trileptal)
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rash
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Chronic adverse effects of Oxycarbazepine (Trileptal)
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hyponatremia (>carbamazepine)
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Drug interactions of Oxycarbazepine (Trileptal)
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decreases OCP
increases phenytoin increased by enzyme inducers |
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Dosing of Oxycarbazepine (Trileptal)
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2400 mg/day max
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What is Primidone (Mysoline) metabolized to?
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Phenobarbital
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Acute adverse effects of Phenobarbital
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Fatigue
Drowsiness Sedation Depression Ataxia Headache Hyperactivity in children |
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Idiosyncratic adverse effects of Phenobarbital
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Rash
Blood dyscrasias Behavioral changes Connective tissue disorders Intellectual blunting Osteomalacia Mood changes |
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Drug interactions of Phenobarbital
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potent inducer of liver enzymes
inhibited by valproic acid, phenytoin, felbamate, cimetidine increased by ethanol |
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Therapeutic range of Phenobarbital
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10-40 mcg/ml
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Dosing of Phenobarbital
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once daily, bedtime, steady state in 3-4 weeks
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Metabolism of Phenytoin (Dilantin)
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duodenum
CYP 2C9 and 2C19 |
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Is there an oral dosage form bioequivalent to Dilantin Kapseals?
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no
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What is the kinetics of Phenytoin (Dilantin)?
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Michaelis Menten Kinetics (non linear kinetics)
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how to correct for therapuetic Phenytoin (Dilantin)?
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c(calc) = c(obs)/0.2xalbumin + 0.1
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Dose related adverse effects of Phenytoin (Dilantin)
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Nystagmus
Ataxia Drowsiness Cognitive impairment |
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Non-dose related adverse effects of Phenytoin (Dilantin)
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Gingival hyperplasia
Hirsutism Acne Rash Hepatotoxicity Coarsening of facial features Bone issues |
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Drug interactions of Phenytoin (Dilantin)
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absorption
protein binding enzyme inhibition by cimetidine, INH, etc enzyme induction by phenobarb, rifampin, folic acid |
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Dosing of Phenytoin (Dilantin)
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5mg/kg/d
Dilantin Kapseal (daily) Dilantin suspension (shaken) IV (never faster > 50mg/min) IM (never- possibly with Fosphenytoin) |
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Therapeutic range of Phenytoin (Dilantin)
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total (10-20mcg/ml)
free (1-2mcg/ml) |
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Metabolism of Topiramate (Topamax)
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50% renal elimination, hepatic elimination
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Acute adverse effects of Topiramate (Topamax)
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Difficulty concentrating
Psychomotor slowing Speech or language problems Somnolence Fatigue Dizziness Headache |
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Chronic adverse effects of Topiramate (Topamax)
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kidney stones (1.5%)
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Dosing of Topiramate (Topamax)
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minimally 200mg/d
1000mg/d (monotherapy) |
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Types of Valproic Acid (Divalproate Na)
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Depakote, Depakene, Depacon
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Metabolism of Valproic Acid (Divalproate Na)
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liver
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Therapeutic range of Valproic Acid (Divalproate Na)
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50-150mcg/ml
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Adverse effects of Valproic Acid (Divalproate Na)
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GI upset (coated forms better-Depakote)
Sedation Unsteadiness Tremor Thrombocytopenia Polycystic ovary syndrome Alopecia Weight gain hyperammonemia |
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Drug interactions of Valproic Acid (Divalproate Na)
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increased by Topiramate (hepatotoxicity)
inhhibits phenobarb, carbamazepine, lamotrigine |
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Metabolism of Zonisamide (Zonegran)
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40% protein binding, 50% CPY3A4, 20% n-acetylation, 30% unchange urine excretion
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Therapeutic range of Zonisamide (Zonegran)
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10-40mcg/ml
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How is Zonisamide (Zonegran) different from other AEDs?
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contains sulfonamide but not an aromatic ring which doesn't normally have the hypersensitivity rxn
others: furosemide, glipizide, glyburide, sulfasalazine, thiazides |
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Adverse effects of Zonisamide (Zonegran)
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Somnolence
Dizziness Anorexia Headache Parathesias (mostly perioral) Nausea Agitation Irritability Hypersensitivity (0.02%) due to sulfonamide Kidney stones (2.6%) Modest weight loss Sweating/hyperthermia (children/Asian population) "A KISS on HAND for HIM" |
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Drug interactions of Zonisamide (Zonegran)
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increased by enzyme inducers and CPY3A4 inhibitors
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Dosing of Zonisamide (Zonegran)
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100-600mg/d (daily or bid)
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Similar AED to Gabapentin
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Pregabalin (Lyrica)
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Adverse effects of Pregabalin (Lyrica)
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weight gain, pedal edema, creatine kinase elevation
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Indication of Pregabalin (Lyrica)
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neuropathic pain and fibromyalgia
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When to monitor serum concentrations during/after pregnancy?
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Before, at the beginning of each trimester, last month, during first 8 weeks post partum
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If taking enzyme inducing med, how much and when do you give vit K to pregnant woman?
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Vitamin K 10 mg/day during last month
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Discontinuing criteria of AED
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Seizure free 2-5 years on medicine
Single type of seizure Normal neurological exam/normal IQ EEG normalized with treatment Withdraw slowly (3-6 months) |
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AEDs that increase risk for osteopenia/osteoporosis
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Phenytoin, phenobarbital, carbamazepine and possibly valproate
*limited data with newer agents |
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Status epilepticus
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A generalized seizure that lasts greater than 30 minutes whether or not consciousness is impaired OR recurrent seizures without an intervening period of consciousness between seizures
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Tx of status epilepticus
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lorazepam (DOC) and diazepam
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Why is lorazepam preferred over diazepam?
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Less lipophilic than diazepam
Longer duration of antiepileptic effect |
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Tx principles of status epilepticus
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ABCs
fast acting med to stop sz long acting med to prevent recurrence given parenterally only the muscular response to the brain’s electrical activity |
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Med for refactory status
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phenobarbital (hypotension and respiratory depression risk)
valproic acid (not FDA approved - hypotension risk) levetiracetam (not FDA approved) |
