What are the first generation anti-epileptic drugs?
What are the second generation anti-epileptic drugs?
Is the following drug a first or second generation anti-epileptic?
Carbamazepine
Is the following drug a first or second generation anti-epileptic?
Phenytoin
Is the following drug a first or second generation anti-epileptic?
Phenobarbital
Is the following drug a first or second generation anti-epileptic?
Ethosuximide
Is the following drug a first or second generation anti-epileptic?
Valproic acid
Is the following drug a first or second generation anti-epileptic?
Clonazepam
Is the following drug a first or second generation anti-epileptic?
Oxcarbazepine
Is the following drug a first or second generation anti-epileptic?
Gabapentin
Is the following drug a first or second generation anti-epileptic?
Pregabalin
Is the following drug a first or second generation anti-epileptic?
Lamotrigine
Is the following drug a first or second generation anti-epileptic?
Levetiracetam
Is the following drug a first or second generation anti-epileptic?
Topiramate
Is the following drug a first or second generation anti-epileptic?
Felbamate
Non-pharmacological therapy for epilepsy includes what?
True or False
Pharmacological treatment can control but not cure epilepsy.
True or False
Status epilepticus is a medical emergency.
True or False
Focal (partial) seizure initiates in a specific site.
What type of seizure is described below?
minimal spread within brain; often clonic jerking, no diminished awareness, 20-60 sec duration
What type of seizure is described below?
localized onset but discharge spreads; alteration of consciousness (but not unconscious), automatisms (integrated
motor behavior, e.g. lip smacking, button picking)
What type of seizure is described below?
focal seizure precedes a generalized
tonic-clonic seizure
What type of seizure is described below?
They start with a tingling in the right thumb. Then the thumb starts jerking. In a few seconds, the whole right hand is jerking. The jerking spreads up my arm. When it reaches the shoulder, I pass out and people tell me that my whole body starts to jerk.
What is a Secondarily Generalized focal seizure?
What is a focal seizure?
What is a Simple focal seizure?
What is a Complex focal seizure?
What is a generalized seizure?
What type of seizure is describe below?
tonic rigidity of all extremities, followed by relaxation, then by massive jerking of the body; patient is groggy/disoriented afterwards, urinary incontinence is common, 1-2 min duration
What type of seizure is describe below?
sudden onset, abrupt cessation; 10-45 sec duration; may occur >100 times per day; characterized by a spike and wave pattern on EEG; patient may simply stare (daydream) or show postural changes,
autonomic phenomena, automatisms
What type of seizure is describe below?
muscles spasm and limbs jerk; contractions and relaxations repeat rapidly
What type of seizure is describe below?
sudden loss of postural tone
What type of seizure is describe below?
increased tone of all muscles
What is a generalized Tonic seizure?
What is a generalized Atonic seizure?
What is a generalized Myoclonic seizure?
What is a generalized Absence seizure?
What is a generalized Tonic-clonic seizure?
What type of seizure is described below?
When it starts, she suddenly shrieks with this unnatural cry, then she falls, and every muscle in her body seems to be activated. Her teeth clench. Shortly after she falls, her arms and upper body start to jerk while her legs are more or less still stiff. This is the longest part of the seizure. Then it finally stops and she passes into a deep sleep.
What type of seizure is described below?He is a 7 year old boy. He often “blanks out” for a few seconds. His teacher calls his name, but he doesn’t seem to hear her. He usually blinks a few times, and his eyes may roll up a bit. Then he is right back where he left off. Some days he has more than 50 of these spells.
What are the goals of therapy for epilepsy?
What are the mechanisms of action of anti-epileptic drugs to inhibit excitability?
What are the mechanisms of action of anti-epileptic drugs to increase inhibitory neurotransmission?
What are the mechanisms of action of anti-epileptic drugs to Inhibit T-type Ca2+ channels?
What is/are the mechanism(s) of action of Carbamazepine?
What is/are the mechanism(s) of action of Phenytoin?
What is/are the mechanism(s) of action of Phenobarbital?
What is/are the mechanism(s) of action of Ethosuximide?
What is/are the mechanism(s) of action of Valproic acid?
What is/are the mechanism(s) of action of Clonazepam?
What is/are the mechanism(s) of action of Oxcarbazepine?
What is/are the mechanism(s) of action of Gabapentin?
What is/are the mechanism(s) of action of Pregabalin?
What is/are the mechanism(s) of action of Lamotrigine?
What is/are the mechanism(s) of action of Levetiracetam?
What is/are the mechanism(s) of action of Topiramate?
What is/are the mechanism(s) of action of Felbamate?
Neurons in thalamus are dependent on what for depolarization?
Depolarization of thalamic neurons activates what?
The following is a drug of choice for which type(s) of epileptic seizure?
Carbamazepine
The following is a drug of choice for which type(s) of epileptic seizure?
Lamotrigine
The following is a drug of choice for which type(s) of epileptic seizure?
Oxcarbazepine
The following is a drug of choice for which type(s) of epileptic seizure?
Levetiracetam
The following is a drug of choice for which type(s) of epileptic seizure?
Valproate
The following is a drug of choice for which type(s) of epileptic seizure?
Ethosuximide
What are the drugs of choice for Focal (Partial) seizures?
What are the drugs of choice for Primary GTC seizures?
What are the drugs of choice for Absence
seizures?
What are the alternative drugs for Absence
seizures?
What are the alternative drugs for Primary GTC seizures?
What are the alternative drugs for Focal (Partial) seizures?
The following is an alternative drug for which type(s) of epileptic seizure?
Valproate
The following is an alternative drug for which type(s) of epileptic seizure?
Phenytoin
The following is an alternative drug for which type(s) of epileptic seizure?
Topiramate
The following is an alternative drug for which type(s) of epileptic seizure?
Gabapentin
The following is an alternative drug for which type(s) of epileptic seizure?
Pregabalin
The following is an alternative drug for which type(s) of epileptic seizure?
Clonazepam
The following is an alternative drug for which type(s) of epileptic seizure?
Levetiracetam
For which type of epileptic seizures is the following a drug of choice for? Alternative drug for?
Carbamazepine
For which type of epileptic seizures is the following a drug of choice for? Alternative drug for?
Lamotrigine
For which type of epileptic seizures is the following a drug of choice for? Alternative drug for?
Oxcarbazepine
For which type of epileptic seizures is the following a drug of choice for? Alternative drug for?
Levetiracetam
For which type of epileptic seizures is the following a drug of choice for? Alternative drug for?
Valproate
For which type of epileptic seizures is the following a drug of choice for? Alternative drug for?
Ethosuximide
For which type of epileptic seizures is the following a drug of choice for? Alternative drug for?
Phenytoin
For which type of epileptic seizures is the following a drug of choice for? Alternative drug for?
Topiramate
For which type of epileptic seizures is the following a drug of choice for? Alternative drug for?
Gabapentin
For which type of epileptic seizures is the following a drug of choice for? Alternative drug for?
Pregabalin
For which type of epileptic seizures is the following a drug of choice for? Alternative drug for?
Clonazepam
Which type of anti-epileptic is described below?
Oldest non-sedating, anti-seizure drug
Effective but no longer drug of choice because of pharmacokinetics, adverse
effects and drug interactions
The following are the Pharmacokinetics for which drug?
Many PO formulations available – IR / ER formulations
90% _____ in vascular space is bound to albumin
At steady-state, 10% ______ in vascular space, 90% tissue
Takes up to 6 weeks to achieve steady state, depending ondose
What are the Pharmacokinetics of Phenytoin?
The following is true for what drug?
Metabolism: dose-dependent capacity-limited pharmacokinetics (zero order metabolism)
MUST MONITOR SERUM LEVELS
10-20 mg/L is common therapeutic range
Why are there dramatic increases in plasma phenytoin with small increases in dose?
What are the dose related adverse effects (seen in CNS) of Phenytoin?
The following are the dose related adverse effects (seen in CNS) of which drug?
Nystagmus – common at therapeutic levels
Dizziness, sedation – seen with IV loading
Diplopia, ataxia – require dose reduction
Involuntary movements – seen at high doses
May interfere with learning
What are the chronic therapy related adverse effects of Phenytoin?
The following are the chronic therapy related adverse effects of which drug?
Gingival hyperplasia (40%)
Acne / Hirsuitism / Coarsening of facial features
Folate and Vitamin D deficiencies (megaloblastic anemia, osteomalacia)
Vitamin D and Calcium supplementation appropriate
No routine supplementation with folate - can affect phenytoin levels
What is shown here? For what drug is it a chronic therapy related adverse effect?
The following describes what the drug-to-drug reactions of what anti-epileptic?
Significant enzyme induction
CYP2B6, CYP2C19, CYP2C8, CYP2C9, CYP3A4, P-glycoprotein
Warfarin: _____ can decrease anticoagulant effect
Can reduce blood levels of contraceptive hormones
Interactions due to plasma protein binding
e.g. valproate inhibits plasma protein binding and inhibits metabolism of _______F
What are the drug-drug interactions of Phenytoin?
The following are the contraindications / precautions of what anti-epileptic?
Contraindication: IV use for patients with sinus bradycardia, sinoatrial block,
second- and third-degree heart block
Precaution: black box warning on rate of IV administration (<50mg/min)
Teratogenic risk
What are the contraindications / precautions of Phenytoin?
The following are the Pharmacokinetics of which anti-epileptic?
Induces its own metabolism; t1/2 ~36 hr ~20 hr
Induces metabolism of phenytoin, ethosuximide, valproate, clonazepam
Drug level affected by CYP3A4 inducers (phenytoin, phenobarbital), inhibitors
Reduces blood levels of contraceptive hormones
What are the Pharmacokinetics of Carbamazepine?
The following are the Dose related adverse effects of which anti-epileptic?
CNS
• Transient diplopia; ataxia
• Dizziness, drowsiness, nausea, anorexia
- common upon initiation; tolerance develops
Hyponatremia, common but mild
What are the dose related adverse effects of Carbamazepine?
The following are idiosyncratic adverse reactions to which anti-epileptic?
• Rare serious blood dyscrasias
• Skin rash (5%)
• Stevens-Johnson syndrome (1:10,000)
- HLA-B*1502
What are the idiosyncratic adverse reactions to Carbamazepine?
The following are the contraindications/precautions of which anti-epileptic?
HLA-B*1502, common in Asians, linked to 10X increased incidence of Stevens-Johnson syndrome
Recommended to test Asians for this allele prior to initiating carbamazepine therapy
Teratogenic risk
What are the contraindications/precautions of Carbamazepine?
True or False
Valproate is a drug of choice for women of childbearing potential.
Which anti-epileptic is described below?
No longer a drug of 1st choice for women of childbearing potential
Effective and well tolerated so used for many seizure types
Also used for migraine prophylaxis and bipolar disorder
The following are the Pharmacokinetics
of which anti-epileptic?
90% protein bound – can be significant
Many enzymes responsible for valproate metabolism
- (2A6, 2B6, 2C9, UGT, etc.)
What are the Pharmacokinetics
of Valproate?
The following are the drug-drug interactions for which anti-epileptic?
Fewer drug interactions than phenytoin or carbamazepine
Enzyme inducers can increase valproate clearance
Can increase plasma levels of carbamazepine metabolite,
phenytoin, phenobarbital, ethosuximide, lamotrigine and tricyclic antidepressants
What are the drug-drug interactions of Valproate?
The following are the Dose related adverse effects of which anti-epileptic?
• GI discomfort (tolerance)
• CNS: dizziness /tremor
• Weight gain / alopecia
• Thrombocytopenia
• Monitor for liver function
• Hyperammonemia
VPA inhibits urea synthesis and can increase renal production of ammonia.
Hyperammonemia usually asymptomatic; but may alter mental status
What are the Dose related adverse effects of Valproate?
The following are idiosyncratic adverse reactions to which anti-epileptic?
• Fulminant hepatitis
• Acute pancreatitis
• Stevens-Johnson syndrome (rare)
• Menstrual abnormalities / polycystic
ovaries
What are the idiosyncratic adverse reactions to Valproate?
The following are adverse effects of which anti-epileptic?
Nausea, vomiting, hiccups, behavioral changes
What are the adverse effects of Ethosuximide?
What are the drug-drug interactions of Ethosuximide?
The following are the drug-drug interactions of what anti-epileptic?
Metabolism inhibited by valproate
Which type of anti-epileptic is described below?
Used in children more than adults
Febrile seizures
Infrequently used for seizures due to adverse effects, and risks
True or False
Phenobarbital is rarely used in children.
The following are the adverse reactions of what anti-epileptic?
Sedation, tolerance, dependence, respiratory depression
What are the adverse reactions of Phenobarbital?
The following are the drug-drug interactions of which anti-epileptic?
Significant enzyme induction
- CYP1A2, CYP2A6, CYP2B6, CYP2C8, CYP2C9, CYP3A4
Reduces blood levels of contraceptive hormones
What are the drug-drug interactions of Phenobarbital?
The following are the contraindications / precautions of which anti-epileptic?
Do not use in patients with history of sedative addiction
Risk of dependence is high
Teratogenic risk
What are the contraindications / precautions of Phenobarbital?
The following are the adverse effects of which anti-epileptic?
Sedation, tolerance, dependence
What are the adverse effects of Clonazepam?
The following are the contraindications / precautions of which anti-epileptic?
Caution in patients with history of sedative dependence
What are the contraindications / precautions of Clonazepam?
The following are the drug-drug interactions of which anti-epileptic?
Metabolized by CYP3A4
What are the drug-drug interactions of Clonazepam?
What anti-epileptic is described below?
Adjunctive therapy in children with focal seizures and generalized tonic clonic seizures
Monotherapy in >16 yr old for focal seizures
Also used in absence
Also used in bipolar disorder
What are the uses of Lamotrigine?
The following are the Pharmacokinetics for which anti-epileptic?
Does not induce or inhibit CYP enzymes
Metabolism induced by carbamazepine, phenobarbital, phenytoin
Oral contraceptives can reduce ______ levels
Metabolism inhibited by valproate
***Starting dosage and escalation schedule dependent upon concomitant therapy
What are the Pharmacokinetics for Lamotrigine?
The following are the adverse effects of which anti-epileptic?
Dizziness, headache, nausea, insomnia
Skin rash (including Stevens-Johnson)
More common with higher starting dose, rapid escalation and concomitant
valproate therapy;
Discontinue if rash occurs
Titration Schedule on new start (go slow)
What are the adverse effects of Lamotrigine?
To which anti-epileptic does the following statement apply?
Fewer cognitive adverse effects vs. other commonly-used antiepileptic
drugs (controversial)
Which anti-epileptic is described below?
Focal and generalized tonic clonic seizures
Also used for migraine prophylaxis, weight management
What are the uses of Topiramate?
The following are the adverse effects of which anti-epileptic?
Somnolence, nervousness, confusion, difficulty with speech, impaired concentration and memory
Mild parasthesias
Reduces blood levels of contraceptive hormones
What are the adverse effects of Topiramate?
For which anti-epileptic does the following statement apply?
Weight loss common (80% patients; 3-4% bodyweight loss)
Which anti-epileptic is described by the following?
Focal seizures in adults (not approved for
generalized tonic-clonic)
Off label use for bipolar disorder
What are the uses of Oxcarbazepine?
Which anti-epileptic is described below?
Chemically similar to carbamazepine; possibly useful in patients who fail other therapies due to poor seizure control
or adverse effects
Adverse effects similar to carbamazepine; higher incidence of
hyponatremia; do not use in patients with severe hypersensitivity to carbamazepine
Less enzyme-inducing activity than carbamazepine
Affected by CYP3A4 inducers
True or False
Oxcarbazepine is possibly useful in patients who fail other therapies due to poor seizure control or adverse effects.
True or False
Oxcarbazepine should be used for patients with severe hypersensitivity to carbamazepine
What are the uses of Gabapentin?
What are the uses of Pregabalin?
The following describes which anti-epileptic?
Adjunct for Focal Seizures in adults
Modest efficacy
Also used for neuropathic pain
The following describes which anti-epileptic?
Adjunct for Focal Seizures in adults and children
Modest efficacy
Also used for neuropathic pain
The following are the pharmacokinetics for which drug?
100% renal elimination
What are the pharmacokinetics for Gabapentin?
What are the pharmacokinetics for Pregabalin?
The following are the adverse effects for which anti-epileptic?
Mild
drowsiness, weight gain (modest), lower extremity edema
The following are the drug-drug interactions of which anti-epileptic?
No significant drug interactions
What are the uses of Levetiracetam?
What are the drug-drug interactions of Levetiracetam?
The following are the adverse effects of which anti-epileptic?
CNS disturbances (irritability, depression, aggression, hallucinations) more common than with other anti-epileptic drugs
What are the adverse effects of Levetiracetam?
The following are the Pharmacokinetics of which anti-epileptic?
Renal elimination (>70%)
What are the Pharmacokinetics of Levetiracetam?
The following describes which anti-epileptic?
Indication: Focal and generalized tonic-clonic seizures
Reserved for failure of alternate anti-epileptic drugs due to
severe idiosyncratic reactions
What are the uses of Felbamate?
The following are the adverse reactions of which anti-epileptic?
Aplastic anemia – 1:5,000 incidence; occurs within 1 year of
initiation; 30% mortality
Hepatic failure – 1:30,000 incidence; occurs within 1 year of
initiation; 50% mortality
What are the adverse reactions to Felbamate?
What is described below?
Significant interest in the epilepsy community
Anecdotal reports of efficacy; safety and efficacy data are limited
Small trials with oral _______ indicate short-term use is safe but study
design prevents conclusions on efficacy
Concerns with negative effects on brain development with long term
________
More studies are currently underway
What should be done if monotherapy fails?
What should be done if monotherapy fails with several drugs?
Which AEDs reduce blood levels of contraceptive hormone?
True or False
Status epilepticus is a medical emergency; IV lorazepam is used to stop the seizures. IV phenytoin is then initiated for longer
term control
What is done for status epilepticus?
True or False
Antiepileptics are gradually increased to therapeutic concentrations to minimize adverse effects and are withdrawn
gradually to reduce the risk of inducing seizures
True or False
Blood level monitoring is often required to maintain therapeutic levels.
