Epilepsy Management
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- Created by: LBCW0502
- Created on: 24-11-18 14:35
What is epilepsy?
A neurological disorder marked by sudden recurrent episodes of sensory disturbance, loss of consciousness, or convulsions, associated with abnormal electrical activity in the brain - seizures
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What are the types of epilepsy?
Generalised (tonic-clonic or absence), partial and status epilepticus. Partial seizure can be simple or complex (can evolve into secondary generalised seizure)
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Give examples of differential diagnosis
Syncope, psychogenic episodes, transient ischaemic attacks, migraine, hypoglycaemia and REM sleep disorder
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What are the causes of epilepsy?
Idiopathic, trauma, vascular, infections, degenerative, alcohol and tumours
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What are the common factors which lower the seizure threshold?
Sleep deprivation, alcohol withdrawal, television flicker, epileptogenic drugs, systemic infection, head trauma, recreational drugs, anti-epileptic drug non-compliance and menstuation
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What are the occasional factors which lower the seizure threshold?
Dehydration, barbiturate withdrawal, benzodiazepine withdrawal, hyperventilation, flashing lights, diet and missed meals, specific reflex triggers, stress, intense exercise
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What are the ideal factors for an anti-epileptic drug?
Complete absorption, linear kinetics, low protein binding, low risk of interaction and long elimination half life
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What are the initial questions to about about epilepsy treatment?
Treat/not to treat? Chance or recurrence, potential negative consequences, potential adverse effects. What drug to use? Seizure type, age/lifestyle, concurrent/previously tried therapy
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Outline the strategy for newly diagnosed epilepsy
Newly diagnosed epilepsy - first drug (seizure free) - second drug (seizure free) - refractory - rational duotherapy, surgical assessment (prefer to use no more than 2 drug treatments)
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Give examples of established anti-epileptic drugs
Phenytoin, phenobarbitone, primidone, carbamazepine, ethosuximide, clonazepam, clobazam, sodium valproate
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Give examples of newer anti-epileptic drugs
Levetiracetam, zonisamide, lamotrigine, oxacarbazepine, topiramate, felbamate, retigabine, brivaracetam, gabapentin, pregabalin, tiagabine, rufinamide, lacosamide, eslicarbazepine, permapanel, vigabatrin
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What are the risks of anti-epileptic drugs?
Idiosyncratic reactions (Stevens-Johnsons, TENS), long term complications (hypertrophic changes, neuropsychiatric side effects, bone health). Teratogenicity (risk registers, avoid valproate)
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Summarise the risks with sodium valproate (MHRA)
High risk of serious developmental disorders and congenital malformations. Ensure female patients understand risk associated with valproate during pregnancy, use of effective contraception, review treatment, consult if pregnant or planning pregnancy
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Describe features of matching treatment to seizure type
Important to accurately classify seizure type before initiating treatment. Carbamazepine and phenytoin can worsen absence seizures. Ethosuximide has efficacy against absence seizures but not others. Evidence for efficacy of newer agents e.g. SANAD
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State features of NICE guidance
First line treatment of idiopathic epilepsy, first line treatment of focal seizures, first line treatment of newly diagnosed GTC seizures
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State factors considered for the choice of first line treatment
Seizure type, formulation available, frequency dosing, simplicity of dosage titration, co-medication, co-morbidities, cost, lifestyle, patient preference
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Describe features of therapeutic drug monitoring
Detection of non-adherence to prescribed medication. Suspected toxicity. When previous stable control deteriorates. Pregnancy. When doses are changed/other drugs initiated. Adjustment of phenytoin dose. Management of pharmacokinetics. Specifics
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Describe features of phenytoin kinetics
Zero order kinetics, small therapeutic window, highly protein bound. At low doses, drug metabolism is first order. At high doses drug metabolism is zero order (constant/independent of drug dose)
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Describe features of carbamazepine kinetics
Induces own metabolism at initiation. Repeated dosing reduces 1/2 life to around 1/3. Metabolism readily induced by drugs that induce hepatic microsomal enzymes. Use of slow release formulations can reduce peak concentrations/improve tolerance
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What are the possible types of interactions?
Drug-drug interactions (numerous, older anti-epileptics, valproate and lamotrigine). Drug-disease interactions (SSRIs and seizure threshold)
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What are the counselling points to consider?
Safety and lifestyle. SUDEP and suicidal ideation. Adverse effects and allergic reactions. Contraception and bone health. Driving implications, prescription exemptions
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What are the populations to consider?
Women (pregnancy, breastfeeding, contraception, menopause). Asian populations (increased risk of SJS when treated with phenytoin and carbamazepine). Older patients (rate/intensity of adverse effect tend to the greater)
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State features of status epilepticus
Neurological emergency. Mortality 10% (50% in elderly). Treatment protocols (0-5 min - BDZ IV, 10-30 min - phentoin/phenobarbitone, 30-60 min - general anaesthesia) - case studies
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Other cards in this set
Card 2
Front
What are the types of epilepsy?
Back
Generalised (tonic-clonic or absence), partial and status epilepticus. Partial seizure can be simple or complex (can evolve into secondary generalised seizure)
Card 3
Front
Give examples of differential diagnosis
Back
Card 4
Front
What are the causes of epilepsy?
Back
Card 5
Front
What are the common factors which lower the seizure threshold?
Back
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