Term
| main difference between 1st and 2nd generation AEDs with respect to tolerability and drug interactions |
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Definition
tolerability:
1st generation AEDs have more ADRs
drug interaction potential:
1st generation AEDs have higher potential for drug interactions |
|
|
Term
those seizures where initial onset arises from a localized area of the brain
most common type of seizure experienced by adults |
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Definition
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Term
| characteristics of simple partial seizures |
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Definition
no loss of consciousness
arise from disturbances in specific areas of cortex and abnormal discharges remain unilateral
symptoms are appropriate to function of discharging area of brain and may be motor, somatosensory, special sensory, or a combination
duration: 30 seconds or less
no postictal phse, although some patients may have temporary numbness or weakness of affected extremity |
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Term
| characteristics of complex partial seizures |
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Definition
IMPAIRED CONSCIOUSNESS:
refers to patients' ability to normally interact and respond to their environment
patients may appear to be conscious, but are unaware of their environment
fail to respond or respond inappropriately to questions
afterward, are unable to remember the episode
complex partial seizures involve portions of brain concerned with maintenance on consciousness and memory
ASSOCIATED WITH INITIAL AURA (i.e. simiple partial seizure which may then progress to a complex partial seizure)
most common forms of aura: fear, rising epigastric sensation, unilateral "funny feeling" or "numbness", visual disturbances
simple to complex automatisms (repetitive motor activity that is purposeless, undirected, and inappropriate) are frequently observed during complex partial seizures
repetitive chewing or swallowing, lip smacking, fumbling movements of fingers or hands, picking at clothing, mumbling, moving about aimlessly, purposeless behavior, and clumsy perseverance of a preceding motor act
duration: 1-3 minutes
postictal phase: confusion, lethargy, altered behavior, amnesic for event
most common seizure type seen in adult epilepsy |
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Term
| characteristics of partial seizures secondarily generalized |
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Definition
partial seizure may progress through several stages reflecting spread of discharge to different brain areas
ex) seizure may begin as simple partial (aura), progress to complex partial, and subsequently become secondarily generalized (tonic-clonic) |
|
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Term
seizures where first clinical changes indicate initial involvement of both hemispheres
the initial clinical event is loss of consciousness |
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Definition
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Term
| characteristics of generalized tonic-clonic seizures (grand mal) |
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Definition
loss of consciousness is quickly followed by a sudden fall to ground
tonic phase:
muscles become rigid and the simultaneous contractions of diaphragm and chest muscles may produce the characteristic "epileptic cry"
patient's eyes roll up or turn to the side and tongue may be bitten
clonic phase:
the rigidity is replaced shortly by series of synchronous clonic movements of head, face, legs and arms
autonomic changes also observed include: increased BP, HR, and bladder pressure, pupillary mydriasis, hypersecretion of skin and salivary glands, cyanosis of skin
duration: 2-5 minutes
postictally, patient is lethargic/sleepy lasting several minutes to hours |
|
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Term
| characteristics of absence seizures (petit mal) |
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Definition
onset between 5-12 years
brief episodes of transient loss of awareness without gross convulsive movements
in addition, most patients will have simple automatisms: blinking of eyes, drooping of head, chewing
less frequently seen are mild clonic, tonic, and/or atonic components to seizure
duration: short (10-45 seconds), patient usually unaware of occurrence
abrupt recovery without after effects
important in children to differentiate from complex partial seizures since treatment and prognosis vary
incontrast to absence, complex partial seizures usually have a longer duration, are often preceded by aura, and typically have a brief period of postictal confusion
the EEG pattern is markedly different |
|
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Term
| characteristics of atypical absence seizure |
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Definition
onset between 1-7 years
similar to typical absence except for loss of responsiveness during seizure is often less complete and more gradual in onset and cessation
also, clonic, tonic, and atonic components (increase or decrease in muscle tone) are more pronounced that in typical absence
commonly seen in patients with Lennox-Gastaut syndrome
this syndrome is also characterized by an encephalopathy with mental retardation or structural CNS damage |
|
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Term
| characteristics of atonic seizures |
|
Definition
onset usually between age of 2-5 years
sudden and total loss of muscle tone and posture control; patient drops to the ground; not necessarily associated with loss of consciousness
must wear helmet to protect from head injury
may or may not have postictal symptoms
druation: 10-60 seconds
brief, if any, postictal symptoms |
|
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Term
| characteristics of myoclonic seizures |
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Definition
sudden, brief shock-like contractions which may involve the entire body or be confined to face, trunk, or extremities
may be symptom of an organic CNS disorder (ischemia, trauma, progressive neurologic disorders)
duration 10-60 seconds
brief, if any, postictal symptoms |
|
|
Term
| characteristics of tonic seizures |
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Definition
sudden increase in muscle tone WITH LOSS OF CONSCIOUSNESS and autonomic signs (pupil dilation)
primarily seen in younger children; commonly associated with metabolic disorder or underlying neurological deficit
duration: 10-60 seconds
brief, if any, postictal symptoms |
|
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Term
| characteristics of infantile spasms |
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Definition
consist of sudden flexion of the head with abduction and extension of arms, accompanied by flexion of knees and often a little grunt or cry; spasms may also be extension rather than flexion
spasms commonly occur in series of 2 or more
onset commonly between 4-7 months
mortaility rate 11-23%; developmental retardation 80-90%
characterized by spasms, developmental retardation
unique among seizure types in responsiveness to ACTH/corticosteroids |
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Term
| characteristics of febrile seizures |
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Definition
convulsions that occur with fever (>38C) in children between 6 months and 6 years, not secondary to an infection of brain or meninges
strong genetic predisposition
primarily occur as generalized tonic-clonic seizures, but partial seizures can occur
increased risk: preexisting neurologic abnormaility, family history of afebrile seizures |
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Term
| drug entities and conditions associated with drug-induced seizures |
|
Definition
BUPROPION (>450 MG/DAY)
CIPROFLOXACIN (QUINOLONES) - have to be adjusted for renal insufficiency!
IMIPENEM (BETA-LACTAMS)
MEPERIDINE (RENAL INSUFFICIENCY)
THEOPHYLLINE
AED WITHDRAWAL - even if the patient isn't using it for seizures
clomipramine
clozapine
cyclosporine
lithium
loxapine
phenothiazines
TCAs
tramadol
alcohol (withdrawal)
amphetamines
cocaine
flumazenil - BZD antagonist
excitatory/inhibitory neurotransmitters
excitatory: glutamate, ACh, NE, histamine, corticotropin releasing factor
inhibitory: GABA, DA
OFTEN DOSE RELATED, MAY BE ADDITIVE |
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Term
| AEDs that are drugs of choice for absence seizures |
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Definition
ETHOSUXIMIDE is 1st line for absence seizures
valproate is indicated for absence seizures
rufinamide (efficacy shown) |
|
|
Term
| AEDs to avoid in absence seizures |
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Definition
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Term
| non-pharm and lifestyle modifications for a patient with epilepsy |
|
Definition
importance of adherence:
did medication fail or did adherence fail?
good habits
patient education
support system engagement
self-assessment methods: pill box, electronic bottle caps, mark date next refill due, journals
adjunctive non-pharm therapy:
sleep deprivation, stress, and a poor diet can increase incidence of seizures
counsel all patients to incorporate:
consistent sleep habits, adequate sleep
sound nutrition, regular meals
routine exercise
stress reduction
avoid recreational drugs
avoid excessive amounts of alcohol |
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|
Term
| how/when phenytoin serum concentrations can increase significantly with a small increase in dose |
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Definition
phenytoin has saturable hepatic metabolism (low dose = 1st order; high dose = 0 order)
at high plasma concentrations small increases in dose can result in very large increases in plasma concentrations (therapeutic plasma levels can quickly turn toxic) |
|
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Term
| the importance of albumin monitoring with respect to total phenytoin serum concentration |
|
Definition
REFERENCE RANGE:
5-20 mcg/mL TOTAL PHENYTOIN
0.5-2 mcg/mL FREE PHENYTOIN
free vs. total phenytoin levels:
total requires albumin monitoring |
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|
Term
| contrast phenytoin and fosphenytoin |
|
Definition
PHENYTOIN:
DOSE: 18-20 mg/kg IV
rate: (no IV push)
max 50 mg/min
decrease rate in those with underlying CV disease or hypotension; in elderly
poor water solubility and stability
FOSPHENYTOIN:
no anticonvulsant properties; desired activity due to phenytoin
DOSE: 18-20 mg PE/kg (same as phenytoin)
rate:
max 150 mg PE/min
decrease rate in those with underlying CV disease or hypotension; in elderly
ADRs:
most common - CNS (same as phenytoin)
decreased infusion related events (pain, burning, cording)
decreased hypotension during infusion; decreased HR and BP may be seen after infusion completed or stopped
transient pruritis or paresthesias; dose and rate related |
|
|
Term
| describe idiosyncratic and dose related ADRs of phenytoin |
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Definition
bioavailability differs with different formulations of phenytoin (all not directly interchangeable)
NON-DOSE DEPENDENT:
gingival hyperplasia
hirsuitism (hair growth)
osteoporosis
thickening of facial features
acne
cardiac arrhythmias
hypothyroidism
peripheral neuropathy
SJS
DOSE RELATED:
nystagmus
diplopia
ataxia
confusion/delirium
coma
IDIOSYNCRATIC:
blood dyscrasias
rash
immunologic reaction
MONITORING:
CBC with diff
baseline and annual LFT
phenytoin level every 2 weeks and with interacting drug addition
albumin prn
serum Ca |
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Term
| AEDs associated with significant hyponatremia |
|
Definition
carbamazepine
oxcarbazepine |
|
|
Term
| AEDs that are strong inducers of CYP450 isoenyzmes |
|
Definition
phenobarbital
phenytoin
primidone
carbamazepine: auto-induction (steady state at 28 days, need to titrate dose q 4-6 weeks)
oxcarbazepine: no auto-induction observed
topiramate: at doses above 200 mg/day; counsel patients about alternative birth control or raise estradiol dose |
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|
Term
|
Definition
somnolence
confusion
cognitive impairment
respiratory depression
hypotention
osteoporosis |
|
|
Term
|
Definition
NAUSEA
vomiting (although long half-life, split dose to BID to improve tolerability)
drowsiness
anorexia
GI upset
sleep disturbances
aggression |
|
|
Term
|
Definition
aplastic anemia
LEUKOPENIA
HYPONATREMIA
OSTEOPOROSIS
SJS |
|
|
Term
|
Definition
HYPONATREMIA
blood dyscrasias rare |
|
|
Term
|
Definition
WEIGHT GAIN
TREMOR
SOMNOLENCE
GI DISTRESS
thrombocytopenia (dose related)
pancreatitis
PCOS
hepatic failure (mostly youths < 10 years)
hyperammonemia
alopecia (temporary)
BBW for hepatic failures, especially in patients < 2 years |
|
|
Term
|
Definition
SOMNOLENCE
BEHAVIORAL ABNORMALITIES (MOOD CHANGES/IRRITABILITY)
WELL TOLERATED GENERALLY
MONITOR: RENAL FUNCTION
NO SIGNIFICANT DRUG INTERACTIONS |
|
|
Term
|
Definition
contraindicated in those with SULFONAMIDE ALLERGY
associated with significant baseline weight loss
PARAESTHESIAS
OLIGOHYDROSIS
HYPERTHERMIA
NEPHROLITHIASIS
ANGLE-CLOSURE GLAUCOMA
METABOLIC ACIDOSIS
PSYCHOMOTOR SLOWING
monitor: renal function, baseline and periodic Na bicarb
patients should drink copious amounts of water as it is a carbonic anhydrase inhibitor, it may predispose patients to renal stones |
|
|
Term
|
Definition
similar to zonisamide
weight loss
paresthesias
oligohydrosis
hyperthermia
nephroliathiasis
angle-closure glaucoma
metabolic acidosis
psychomotor slowing |
|
|
Term
|
Definition
benign rash (associated with dose and titration internal; more common in children)
SJS
hepatotixicity
MONITORING: DERMATOLOGIC ADRS
DRUG INTERACTIONS |
|
|
Term
|
Definition
saturable absorption in GI and BBB
FATIGUE
WEIGHT GAIN
ATAXIA
PERIPHERAL EDEMA
MONITORING: RENAL FUNCTION |
|
|
Term
|
Definition
CV controlled substance
renally eliminated, dosage adjustments
SIMILAR ADRS TO GABAPENTIN:
PERIPHERAL EDEMA (CAUTION WITH TZDS)
DIZZINESS AND SOMNOLENCE (may impair patient's ability to drive) |
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|
Term
|
Definition
diziness
tremor
somnolence
euphoria
monitoring: ECG, renal function
hypersensitivity reactions (rash, multi-organ), cardiac conduction disturbances
CV: "BZD-like" effects
primarily renally excreted
limited drug interactions (not affected by other AEDs or OCs) |
|
|
Term
|
Definition
somnolence
fever
rash
N/V
SJS
shortened QT interval
increased incidence of seizures?
monitoring: ECG, hypersensitivity reactions (rash, multi-organ)
cardiac conduction disturbances: DOSE RELATED QT SHORTENING |
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|
Term
|
Definition
OPHTHALMOLOGIC TOXICITIES
visual field defects
progressive and permanent peripheral vision loss
not regained after discontinuation of medication
somnolence
HA
irritability
dizziness
peripheral neuropathy
monitoring: renal function, ophthalmologic exam
RESTRICTED ASSESS PROGRAM |
|
|
Term
|
Definition
|
|
Term
|
Definition
weight loss
nausea
HE
APLASTIC ANEMIA
ACUTE HEPATIC FAILURE |
|
|
Term
|
Definition
somnolence
tremor
cognitive impairment
MAY INDUCE SEIZURES IN NON-EPILEPTICS: CONCERN ABOUT USING THIS DRUGS AS MONOTHERAPY
monitoring: renal function
potential long-term ophthalmologic effects |
|
|
Term
| 3 pairs of AEDs that are most similar to each other |
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Definition
zonisamide and topiramate
carbamazepine and oxcarbazepine
gabapentin and pregabalin |
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Term
| AEDs that are renally excreted |
|
Definition
levetiracetam
zonisamide
topiramate
gabapentin
pregabalin
lacosamide
viagabatrin
tiagabine |
|
|
Term
| rationale behind lamotrigine's titration schedule |
|
Definition
DOSE TITRATION OVER 5 WEEKS OR MORE
a rash can develop with lamotrigine, especially if it is titrated too rapidly |
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|
Term
| rationale behind medication order of administration for status epilepticus |
|
Definition
status epilepticus defined as:
> 30 minutes of continuous seizure activity
2 or more sequential seizures without full recovery of consciousness between seizures
goals in management of SE:
terminate electrical and clinical seizure activity within 30 minutes
prevent recurrence of seizures
insure adequate cardiorespiratory function and brain oxygenation
correct any precipitating factors such as hypoglycemia, electrolyte imbalance, fever
stabilize metabolic balance by prevention and correction of lactic acidosis, dehyration
PRIMARY GOAL = STOP SEIZURE ACTIIVTY
INITIATE THERAPY WITH IV BENZODIAZEPINE:
diazepam or lorazepam
help cease the seizure
INITIATE AED THERAPY WITH HYDANTOIN:
phenytoin sodium or fosphenytoin sodium
prevents recurrence of sizures
SLOWER ONSET OF ACTION THAN BZDS (10-30 MINUTES) |
|
|
Term
| how long should phenytoin be continued after a single seizure episode secondary to metabolic disturbance? |
|
Definition
| once seizure is controlled, patient should be tapered off phenytoin |
|
|
Term
| rationale for continuing AED therapy during pregnancy |
|
Definition
RISK VS. BENEFIT (SEIZURES CAN BE FATAL)
~90% OR MORE HAVE SATISFACTORY OUTCOMES
teratogenicity increased with polypharmacy, high doses
highest risk within first weeks of pregnancy
adverse pregnancy outcomes associated with maternal seizures (growth, psychomotor, and mental retardation) |
|
|
Term
| AEDs associated with major congenital malformations |
|
Definition
most AEDs are considered teratogenic
PREGNANCY CATEGORY D:
PHENYTOIN
VALPROATE
PHENOBARBITAL
CARBAMAZEPINE
TOPIRAMATE
rest Category C |
|
|
Term
| which has a much better prognosis for seizure freedom following treatment: generalized tonic clonic seizures, or complex partial seizures? |
|
Definition
| generalized tonic clonic seizures |
|
|
Term
| which has a much better prognosis for seizure freedom following treatment: generalized tonic clonic seizures, or complex partial seizures? |
|
Definition
| generalized tonic clonic seizures |
|
|
Term
| what is the treatment of choice for complex partial seizures? |
|
Definition
|
|
Term
| what is the treatment of choice for generalized tonic clonic seizures? |
|
Definition
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