Seizure/Epilepsy

Epilepsy is a

chronic seizure disorder

Tonic-clonic seizure

uncontrolled jerking movements

absence seizures

momentary loss of awareness

Seizures are caused by

excitatory neurons producing sudden surge of electrical activity in the brain

(fever, infection, alcohol withdrawal, hypoglycemia, electrolyte abnormalities)

First aid for seizures

1: prevent injury by clearing area of dangerous items

2: get person safely to floor, prop head up with something soft, get them on their side, this will clear the airway

3: remove glasses, loosen ties, anything to make breathing easier

4: Time the seizure, if lasts longer than 5 minutes without signs of slowing down, or odd recovery, call 911

5: Don't hold people down/try to stop their movement

6: don't put anything in someone's mouth

7: don't attempt artificial respiration unless the rare event they've stopped breathing after their seizure

T/F: A person having a seizure can swallow their tongue, and something should be placed in their mouth to protect them

FALSE. do not place anything in their mouth.

in first aid for someone having a seizure, someone should be laid down in what position

on their side: opens airways

if the seizure lasts longer than ____ call 911

5 minutes

Most common test to diagnose epilepsy

EEG (electroencephalogram)

T/F: An EEG can only show abnormal patterns while the patient is having a seizure

false- it can show abnormal patterns even when the patient is not having a seizure

drugs that lower the seizure threshold

bupropion

clozapine

theophylline

varenicline

carbapenems (especially imipenem)

lithium

lithium

meperidine

penicillin

quinolones

tramadol

Focal seizures

start on one side of the brain but can spread to the other

generalized seizures

start on both sides of the brain

Focal seizures are further classified into

focal aware seizures (simple partial seizures)

-no loss of consciousness

focal seizure with impaired awareness (complex partial)

-experiences lack of consciousness

tonic

rigid/tense muscles

rhythmic jerking movements

clonic

generalized seizures with non-motor symptoms

absence seizures

typically present as staring spells

absence seizure

Status epilepticus definition

seizure that lasts 5 minutes or more because the normal mechanisms that terminate seizures aren't working

-medical emergency

(long-term damage can occur at 30 minutes)

Initial treatment phase of status epilepticus (SE)

benzodiazepine injection

if not possible, IM midazolam

Diazepam rectal gel can also be utilized (Diastat AcuDial)

Phases of Status epilepticus treatment

Stabilization: 0-5 minutes

-time seizure

-start ECG, O2

-If BG is low, treat with D25-D50

Initial treatment: 5-20 minutes

-if seizure cont. give IV lorazepam or IM midazolam

-Alternatives: Diastat, intranasal/buccal midazolam

2nd Treatment Phase: 20-40 minutes

-if seizure cont. give AED

-phosphenytoin, valproic acid, levetiracetam

-phenobarb if others are not available

-if seizure lasts longer, there is no clear treatment

T/F: DiaStat AcuDial must be dialed to the right dose and locked before dispensing

true

On the Diatstat AcuDial, the band should be ____ in color and say "_____" and the syringe cannot be unlocked

green and say "ready"

When counseling on the Diastat Acudial, the patient should

check both syringes that they are dialed and locked before leaving the pharmacy

T/F: AEDs should NOT be stopped abruptly as this can lead to seizures

true

alternative options and non-drug options for seizures after AEDs fail

medical marijuana (cannabis), ketogenic diet, vagal nerve stimulation, surgical intervention

Embrace2 Smartwatch for 6+

T/F: Epidiolex contains THC

false: CBD epidiolex does not contain THC, but there are other CBD and medical marijuana products available that do.

A ketogenic diet may be helpful in those with

refractory seizures

a ketogenic diet utilizes a fats: Proteins + carbs ratio of

4:1 (fats: P+C)

T/F: The elevated ketone state ketosis may lead to a reduction in seizure frequency

true

Drug used for absense seizures

ethosuximide

Vigabatrin notable warning

vision loss

Calcium channel blocker drugs include:

Carbamazepine, lamotrigine, phenytoin/fosphenytoin, topiramate, oxcarb (Na AND Ca blocker)

Calcium channel blockers include

Oxcarbazepine (Na and Ca blocker), pregabalin, gabapentin, levetiracetam (Ca blocker and gaba increaser)

Drugs that increase GABA

benzodiazepines, valproic acid, levetiracetam, phenobarbital (enhances/potentiates GABA)

AED the blocks Na and Ca

oxcarbazepine

Phenytoin/Fosphenytoin drug class

Na channel blocker

Carbamazepine drug class

Na channel blocker

Ethosuximide drug class

T-Type Ca channel blocker

______ is the inhibitory neurotransmitter and ____ is the excitatory transmitter

GABA: inhibitory

Glutamate: excitatory

Carbamazepine, oxcarbazepine, eslicarbazepine side effects

hyponatremia, rash, enzyme induction

gabapentin and pregabalin side effects

weight gain, peripheral edema, mild euphoria, used for neuropathic pain primarily

phenobarbital and primidone (prodrug of phenobarb) side effects

sedation, dependence/tolerance/overdose risk, enzyme induction

topiramate and zonisamide

weight loss, metabolic acidosis, nephrolithiasis, oligohidrosis/hyperthermia (in children)

Vitamin supplement considerations with AEDS

All AED patients should take calcium and vitamin D

women of childbearing age should take folate

valproic acid: possibly need Carnitine

lamotrigine and valproic acid: if alopecia develops, supp w/ selenium and zinc

Lamictal generic

lamotrigine

boxed warning with lamictal

(lamotrigine)

serious skin reactions- SJS/TENS

Dosing of lamotrigine

initial: weeks 1 and 2: 25 mg daily (titrate)

Side effects of lamotrigine

alopecia (supp w/ selenium and zinc)

Valproic acid is a ______, so when using with lamotrigine, use the _____ (color) starter kit

Valproic acid is an inhibitor: it increases lamotrigine concentrations

must use lower dose starter kit: blue box

Colors of starter kits for Lamotrigine

Orange: standard - use if no interacting meds

Blue: lower - use if valproic acid - inhibitor

Green: higher - use if taking inducer (carbamazepine, phenytoin, phenobarbital, primidone, and NOT taking valproic acid)

Too much lamotrigine leads to ____, too little leads to _____

too much: rash

too little: seizure

A patient is taking carbamazepine and will be starting lamotrigine. Which started kit should they receive?

Green box: higher starting dose since carbamazepine is an inducer

Keppra generic

levetiracetam

warnings with keppra

psychiatric reactions, psychotic symptoms, somnolence, fatigue

notes with keppra

no significant drug reactions

IV: PO ratio with keppra

1:1

Monitor ____ with topiramate use

electrolytes (especially bicarbonate), intraocular pressure

Type of contraception recommended with topamax

non-hormonal (decrease oral contraceptive effectiveness especially doses 200+mg

Warnings with topamax

metabolic acidosis, oligohidrosis, reduced perspiration, nephrolithiasis, angle-closure glaucoma, hyperammonemia, visual problems, fetal harm

Topamax is also used for

migraine prophylaxis

Depakene generic

valproic acid

boxed warning for valproic acid and divalproex

hepatic failure

fetal harm (neural tube defects and lower IQ scores)

Therapeutic range of Divalproex (Depakote)

50-100 mcg/mL (total level)

Depakote is also used for:

used for bipolar disorder and migraine prophylaxis

Warnings with valproic acid and divalproex

hyperammonemia - treat with Carnitine in symptomatic pt

thrombocytopenia

side effects of valproic acid and depakote

alopecia (supplement selenium and zinc), weight gain

monitoring with valproic acid and divalproex

LFTs (baseline and in first 6 months), platelets (CBC)

Valproic acid is a:

CYP2C9 inhibitor and substrate of substrate of CYP2C19

valproic acid _____ levels of other AEDs

increases

Divalproex is a derivative of _____ with the same side effect profile and CYP enzyme/protein binding interactions

derivative of valproic acid

Estrogen and valproic acid interaction

estrogen lowers valproic acid

valproic acid and lamotrigine: must use caution due to risk of:

rash

Tegretol generic

carbamazepine

Therapeutic range of carbamazepine

4-12 mcg/mL

Boxed warning with carbamazepine

serious skin reactions - patients of asian descent should be tested for HLA-B*1502, aplastic anemia and agranulocytosis

contraindications to carbamazepine use

myelosuppression

warnings with carbamazepine use

hyponatremia (SIADH), fetal harm (monitor with CBC, platelets, eletrolyte tests- especially Na)

Monitoring for Carbapazepine

CBC- platelets

Electrolytes- Na

Drug that is an inducer as well as autoinducer

(reduces level of other drugs as well as itself)

carbamazepine

Carbamazepine is a strong inducer of many enzymes including _____

p-gp

Contraception recommended with Carbamazepine

non-hormonal contraceptive

Carbamazepine is a CYP_____

CYP3A4 substrate

Notes about carbamazepine suspension

don't take with other liquids - precipitate will form (especially w/ chlorpromazine)

Vimpat generic

Lacosamide

Lacosamide is a schedule ____ drug

C-V

Lacosamide warnings

prolongs PR interval, increased risk of arrx

Trileptal generic

oxcarbazepine

warnings with oxcarbazepine

screen patients of asian descent of HLA-B*1502

Hyponatremia

Monitoring for oxcarbazepine

sodium levels, espeiclally first 3 months of therapy

T/F: Oxcarbazepine is an autoinducer

false

T/F: Non hormonal contraception should be used with oxcarbazepine

true

phenobarbital is a schedule ___ drug

C-IV

Therapeutic range of phenobarbital

20-40 mcg/mL (adults)

warnings with phenobarbital

habit-forming, respiratory depression, fetal harm

side effects of phenobarbital

physiological dependence, tolerance, hangover effect

prodrug of phenobarbital

primidone

primidone is a prodrug of:

phenobarbital

phenobarbital is a CYP

INDUCER (strong) of most enzymes : 3A4, P-gp

Therapeutic range of Fosphenytoin

10-20mcg/mL (total level)

1-2.5 mcg/mL (free level)