Pharm -4- Anti Epileptics
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| Which occurs more often in children Grand Mal (generalized tonic clonic seizures) or Petit Mal (absence Seizures) | Petit Mal (absence Seizures)
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| What is a Lennox Gastaut seizure | severe serious seizure disorder in children marked by epilepsy progression and mental retardation w/ refractoriness to most anti-seizure meds
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| PT is suffering from continuous uninterrupted seizures what are they in | status epilepticus
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| What are the first line Anti Epileptic Drugs | Valproic Acid, Ethosuximide, Phenytoin, Carbamazepine, Oxcarbazepine; an Ox is THE SUCKI (ethosuximide) Valet (valproic acid) for Pheminin Toy (Phenytoin) Cars (Carbamazepine)
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| What drugs are considered secondary antiepileptic drugs | Barbiturates- phenobarbital, primidone and Benzodiazepines- Diazepam, Lorazepam, Clonazepam
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| Pt is suffering from absence seizures what is the first line drug therapy and alternatives | First line is Valproic Acid and Ethosuximide Alternatives are lamotrigine and levetiracetam; The Sucki Valet is Absent minded and Levt my Lamborghini.
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| What is the MOA of the antiepileptic drugs | reduce neuronal excitability and firing by enhancing or mimicking GABA, block voltage gated sodium channels, inhibit T-type calcium channels, block Glutamate receptors
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| Why do you need to check liver function and plasma levels of anti epileptic drugs every six months | they are metabolized extensively by the liver and excreted in urine are highly bound to plasma proteins and have long half lives. In addition they induce hepatic microsomal enzymes this makes them likely to mess with a lot of stuff
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| What are the common s/e of anti epileptic treatment as a whole | GI- N/V indigestion, lack of appetite, CNS- drowsiness, dizziness, depressed mood; Serious CNS- sedation, mental confusion, nystagmus, diplopia, ataxia, uncoordinated movements; Hepatotoxicity (elevated liver enzymes)
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| T/F antiepileptic have a positive s/e of weight loss | F
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| T/F antiepileptic have a positive s/e of reducing depression and suicidal behavior | F
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| What is a serious s/e that can occur from taking anti epileptics that starts as a rash | Steven Johnson's syndrome and toxic epidermal necrosis
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| Because anti epileptics increase suicidal behavior and depression what should you do when a patient is taking these drugs | monitor them carefully for the first six months for behavior changes.
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| T/F most anti epileptic drugs have been shown to cause birth defects and majority of mothers deliver severely deformed babies if taking anti epileptics while pregnant | F- They have been shown to cause birth defects but majority of mothers deliver normal healthy infants
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| If a women becomes pregnant while taking antiepileptic the drugs should be tapered and stopped because they cause birth defects | No- stopping the meds has a high risk for precipitating status epilepticus and causing hypoxia for mother and fetus. If possible reduce mother to a single anti epileptic if she is taking combos
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| What is the MOA of Valproic Acid (Depakote) | Blocks Voltage gated sodium channels and T-type calcium channels and Inhibits GABA transaminase (GABA-T)
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| What are the uses for Valproic Acid in epilepsy | Wide used for Absence, partial, generalized and is the drug of choice for pts with both Petit Mal and Grand Mal seizures. Good for infantile epilepsy as well
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| What other condition besides epilepsy can valproic acid be given to treat | Bipolar Depressive illness and Prophylactic for migraines
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| T/F valproic acid has low hepatotoxicity compared to other anti epileptics | F risk is greatest for pts under 2 or taking multiple meds and can be fatal in 4 months. Monitor liver function carefully and switch meds or D/C if abnormal
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| T/F Valproic Acid is more likely to cause hypersensitivity rxns than other antiepileptic | T Rash and Thrombocytopenia are more common
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| What are the birth defects caused by Valproic Acid | Spina Bifida, Cardiovascular defects, Malformation of digits
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| What is different about valproic acid and liver enzymes than all the other anti epileptic drugs | it INHIBITS hepatic microsomal enzymes and can cause an increase in the steady state of other drugs precipitating CNS depression, sedation and possibly COMA use care in combining with other drugs
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| What is the MOA of Ethosuximide (Zarontin) | Inhibits T-Type calcium Channels
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| What are the uses of Ethosuximide (Zarontin) | absence seizures, may exacerbate tonic clonic (don't give for Grand Mal), can't control psychomotor or major motor seizures
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| What are the s/e of Ethosuximide | GI distress N/V weight loss
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| T/F Ethosuximide is protein bound and can cause problems with other protein bound drugs increasing concentrations | F- Ethosuximide is not protein bound and actually causes fewer drug interactions
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| What is the MOA of Phenytoin (Dilantin) | Blocks Voltage gated sodium channels
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| When should can you use Phenytoin (Dilantin) | All types of partial seizures, tonic clonic seizures, but is not useful in absence seizures. Can be used for Reye's syndrome, After head trauma and seizures that occur during or after neurosurgery
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| Why do you want to go low and slow with Phenytoin | metabolism is saturable so you can quickly overwhelm it and reach toxic levels fast and it has a narrow therapeutic index
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| What s/e are seen with Phenytoin (they may be very concerning to a woman) | Gingival hyperplasia, Hirsutism, Coarsening of features, Rash, Hyperglycemia, Osteomalacia
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| What birth defects have been linked with Phenytoin | Cleft Palate, Heart Malformation, Hypothrombinemia and hemorrhage
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| What is the MOA of Carbamazepine (Tegretol) | Voltage Gated Sodium channel blocker
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| What are the indications for using Carbamazepine | All types of partial seizures, tonic clonic seizures, but is not useful in absence seizures. Can be used for Reye's syndrome, After head trauma and seizures that occur during or after neurosurgery
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| Carbamazepine can be used for things other than epilepsy what are they | Trigeminal and Glossopharyngeal neuralgia, adjunct to bipolar mania in pts resistant to lithium
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| What drug type should you avoid giving with carbamazepine or vice versa | MAOIs
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| What are the s/e of Carbamazepine | Fluid Retention and hyponatremia
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| What is the very serious and severe rxn that can occur with carbamazepine especially to pts with HLA-B1502 Allele (greatest in Asians) | Toxic Epidermal Necrolysis and Stevens-Johnson Syndrome
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| Oxcarbazepine is an analog of Carbamazepine what are its advantages and disadvantages over carbamazepine | Less auto metabolism is the advantage but fluid retention and hyponatremia are more pronounced
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| Zonisamide (Zonegran) is a newer antiepileptic agent what are its s/e | cross rxn with sulfa allergies, causes hyperthermia in children by decreasing sweating, can cause aplastic anemia by binding erythrocytes
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| What is the MOA of Phenobarbital in preventing seizures | Enhances the effects of GABA by binding at GABAa receptors keeping chloride channels open (this is an inhibitory signal)
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| When would you want to use phenobarbital | Febrile Seizures in kids, status epilepticus, long term management of all types of seizures difficult to control with other meds, (NOT FIRST CHOICE DRUG)
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| What are the s/e of phenobarbital | Sedation, Habit Forming, can cause behavioral problems in kids, Agitation and confusion in adults, Respiratory depression CNS depression, coma and death if overdosed
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| T/F phenobarbital can lower plasma concentration of other drugs reducing their efficacy | T it is a powerful inducer of CYP enzymes
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| What is the MOA of the benzodiazepines in tx of epilepsy | act at GABAa receptor to increase frequency of Cl- channels
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| When would you want to use Diazepam and Lorazepam to tx epilepsy | status epilepticus, and febrile seizures
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| When would you want to use Clonazepam and Clorazepate in epilepsy | long term tx when pt is resistant to other anti epileptic drugs especially absence seizures refractory to ethosuximide or valproic acid, can be used in lennox-gastaut syndrome and infantile spasms and restless leg syndrome
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| Why would you counsel your pt to not stop taking their clonazepam or clorazepate suddenly | can precipitate status epilepticus if stopped abruptly
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| Pt is in status epilepticus you have managed their ABCs what drugs should you start 1st | IV diazepam or Lorazepam
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| Pt is just come out of status epilepticus after you treated them with IV diazepam (or Lorazepam) what should you do next (step 2) | start a longer acting anti epileptic such a Phenytoin or even better Fosphenytoin (water soluble) and monitor cardiac function
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| You started Phenytoin/Fosphenytoin and pt is still in status epilepticus what should you do next You have already given IV diazepam and Lorazepam | Proceed to phenobarbital monitor for respiratory depression and hypotension have ventilatory support handy
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| What if the phenobarbital can't control the status epilepticus even after Phenytoin and diazepam | General Anesthesia w/ intubation and respiratory support
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| What drug can you give rectally to a child suffering from febrile seizures | Diazepam
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| What drug might you prescribe for a mother to have on hand with a child who has recurrent febrile seizures | Phenobarbital
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