Anti-epileptics

Pregunta	Respuesta
What are the first generation anti-epileptic drugs?	Carbamazepine Phenytoin Phenobarbital Ethosuximide Valproic acid Clonazepam
What are the second generation anti-epileptic drugs?	Oxcarbazepine Gabapentin Pregabalin Lamotrigine Levetiracetam Topiramate Felbamate
Is the following drug a first or second generation anti-epileptic? Carbamazepine	Carbamazepine: First
Is the following drug a first or second generation anti-epileptic? Phenytoin	Phenytoin: First
Is the following drug a first or second generation anti-epileptic? Phenobarbital	Phenobarbital: First
Is the following drug a first or second generation anti-epileptic? Ethosuximide	Ethosuximide: First
Is the following drug a first or second generation anti-epileptic? Valproic acid	Valproic acid: First
Is the following drug a first or second generation anti-epileptic? Clonazepam	Clonazepam: First
Is the following drug a first or second generation anti-epileptic? Oxcarbazepine	Oxcarbazepine: Second
Is the following drug a first or second generation anti-epileptic? Gabapentin	Gabapentin: Second
Is the following drug a first or second generation anti-epileptic? Pregabalin	Pregabalin: Second
Is the following drug a first or second generation anti-epileptic? Lamotrigine	Lamotrigine: Second
Is the following drug a first or second generation anti-epileptic? Levetiracetam	Levetiracetam: Second
Is the following drug a first or second generation anti-epileptic? Topiramate	Topiramate: Second
Is the following drug a first or second generation anti-epileptic? Felbamate	Felbamate: Second
Non-pharmacological therapy for epilepsy includes what?	surgery, vagus nerve stimulation, deep brain stimulation, diets
True or False Pharmacological treatment can control but not cure epilepsy.	True
True or False Status epilepticus is a medical emergency.	True
True or False Focal (partial) seizure initiates in a specific site.	True
What type of seizure is described below? minimal spread within brain; often clonic jerking, no diminished awareness, 20-60 sec duration	Simple - Focal seizure
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)	Complex - Focal seizure
What type of seizure is described below? focal seizure precedes a generalized tonic-clonic seizure	Secondarily generalized - Focal 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.	Focal Seizure with Secondary Generalization
What is a Secondarily Generalized focal seizure?	Focal seizure precedes a generalized tonic-clonic seizure
What is a focal seizure?	When the seizure initiates in a specific site.
What is a Simple focal seizure?	minimal spread within brain; often clonic jerking, no diminished awareness, 20-60 sec duration
What is a Complex focal seizure?	localized onset but discharge spreads; alteration of consciousness (but not unconscious), automatisms (integrated motor behavior, e.g. lip smacking, button picking)
What is a generalized seizure?	There is no evidence of localized onset.
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	Tonic-clonic - Generalized
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	Absence - Generalized
What type of seizure is describe below? muscles spasm and limbs jerk; contractions and relaxations repeat rapidly	Myoclonic - Generalized
What type of seizure is describe below? sudden loss of postural tone	Atonic - Generalized
What type of seizure is describe below? increased tone of all muscles	Tonic - Generalized
What is a generalized Tonic seizure?	Increased tone of all muscles
What is a generalized Atonic seizure?	Sudden loss of postural tone
What is a generalized Myoclonic seizure?	Muscles spasm and limbs jerk; contractions and relaxations repeat rapidly
What is a generalized Absence seizure?	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 is a generalized Tonic-clonic seizure?	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 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.	Generalized tonic-clonic seizure
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.	Generalized absence seizure
What are the goals of therapy for epilepsy?	Improve quality of life by:  Controlling seizures Rarely are seizures eliminated; even occasional seizures are still a concern for patients  Minimizing adverse effects Usually lifelong treatment
What are the mechanisms of action of anti-epileptic drugs to inhibit excitability?	 Inhibit voltage dependent Na+ channels Reduce the rate of Na+ channel opening; use dependent blockade phenytoin, carbamazepine, oxcarbazepine, lamotrigine, topiramate, valproate Inhibit glutamate receptors NMDA – felbamate AMPA – topiramate Modulate glutamate release (putative) Gabapentin, pregabalin, levetiracetam
What are the mechanisms of action of anti-epileptic drugs to increase inhibitory neurotransmission?	 Enhance GABA-A activity (positive allosteric modulation) Phenobarbital, clonazepam, topiramate  Enhance GABA availability Several proposed
What are the mechanisms of action of anti-epileptic drugs to Inhibit T-type Ca2+ channels?	 Neurons in thalamus are dependent on calcium channel pacemaker currents for depolarization  Depolarization of thalamic neurons activates cortical neurons Ethosuximide, valproate
What is/are the mechanism(s) of action of Carbamazepine?	Inhibit excitability  Inhibit voltage dependent Na+ channels - Reduce the rate of Na+ channel opening; use dependent blockade - At therapeutic concentrations, prolongs inactivated state of Na+ channel
What is/are the mechanism(s) of action of Phenytoin?	Inhibit excitability  Inhibit voltage dependent Na+ channels - At therapeutic concentrations, prolongs inactivated state of Na+ channel
What is/are the mechanism(s) of action of Phenobarbital?	Increase inhibitory neurotransmission  Enhance GABA-A activity (positive allosteric modulation)
What is/are the mechanism(s) of action of Ethosuximide?	Inhibit T-type Ca2+ channels  Neurons in thalamus are dependent on calcium channel pacemaker currents for depolarization  Depolarization of thalamic neurons activates cortical neurons  Limits 3Hz spike-wave
What is/are the mechanism(s) of action of Valproic acid?	Inhibit excitability Inhibit voltage dependent Na+ channels Reduce the rate of Na+ channel opening; use dependent blockade Inhibit T-type Ca2+ channels  Neurons in thalamus are dependent on calcium channel pacemaker currents for depolarization  Depolarization of thalamic neurons activates cortical neurons
What is/are the mechanism(s) of action of Clonazepam?	Increase inhibitory neurotransmission  Enhance GABA-A activity (positive allosteric modulation)
What is/are the mechanism(s) of action of Oxcarbazepine?	Inhibit excitability Inhibit voltage dependent Na+ channels Reduce the rate of Na+ channel opening; use dependent blockade
What is/are the mechanism(s) of action of Gabapentin?	Inhibit excitability Modulate glutamate release (putative)
What is/are the mechanism(s) of action of Pregabalin?	Inhibit excitability Modulate glutamate release (putative)
What is/are the mechanism(s) of action of Lamotrigine?	Inhibit excitability Inhibit voltage dependent Na+ channels - Reduce the rate of Na+ channel opening; use dependent blockade - At therapeutic concentrations, prolongs inactivated state of Na+ channel
What is/are the mechanism(s) of action of Levetiracetam?	Mechanism of Action: Under investigation  Synaptic Vesicle Glycoprotein 2A (SV2A)  Likely modifies release of Glu / GABAA
What is/are the mechanism(s) of action of Topiramate?	Increase inhibitory neurotransmission  Enhance GABA-A activity (positive allosteric modulation) Inhibit excitability  Inhibit voltage dependent Na+ channels - Reduce the rate of Na+ channel opening; use dependent blockade Inhibit Excitability  Inhibit glutamate receptors - AMPA – topiramate
What is/are the mechanism(s) of action of Felbamate?	Inhibit Excitability  Inhibit glutamate receptors NMDA – felbamate Mechanism of Action: not fully characterized  Use-dependent block of postsynaptic NMDA
Neurons in thalamus are dependent on what for depolarization?	Neurons in thalamus are dependent on calcium channel pacemaker currents for depolarization
Depolarization of thalamic neurons activates what?	Cortical neurons
The following is a drug of choice for which type(s) of epileptic seizure? Carbamazepine	Focal (Partial)
The following is a drug of choice for which type(s) of epileptic seizure? Lamotrigine	Focal (Partial) and Primary GTC
The following is a drug of choice for which type(s) of epileptic seizure? Oxcarbazepine	Focal (Partial)
The following is a drug of choice for which type(s) of epileptic seizure? Levetiracetam	Focal (Partial) Approved as adjunctive therapy only and Primary GTC
The following is a drug of choice for which type(s) of epileptic seizure? Valproate	Primary GTC and Absence
The following is a drug of choice for which type(s) of epileptic seizure? Ethosuximide	Absence
What are the drugs of choice for Focal (Partial) seizures?	Carbamazepine Lamotrigine Oxcarbazepine Levetiracetam* * Approved as adjunctive therapy only
What are the drugs of choice for Primary GTC seizures?	Valproate Lamotrigine Levetiracetam
What are the drugs of choice for Absence seizures?	Ethosuximide Valproate
What are the alternative drugs for Absence seizures?	Clonazepam Levetiracetam
What are the alternative drugs for Primary GTC seizures?	Valproate Lamotrigine Levetiracetam
What are the alternative drugs for Focal (Partial) seizures?	Valproate Phenytoin Topiramate Gabapentin* Pregabalin*
The following is an alternative drug for which type(s) of epileptic seizure? Valproate	Focal (Partial)
The following is an alternative drug for which type(s) of epileptic seizure? Phenytoin	Focal (Partial) and Primary GTC
The following is an alternative drug for which type(s) of epileptic seizure? Topiramate	Focal (Partial) and Primary GTC
The following is an alternative drug for which type(s) of epileptic seizure? Gabapentin	Focal (Partial) Approved as adjunctive therapy only
The following is an alternative drug for which type(s) of epileptic seizure? Pregabalin	Focal (Partial) Approved as adjunctive therapy only
The following is an alternative drug for which type(s) of epileptic seizure? Clonazepam	Absence
The following is an alternative drug for which type(s) of epileptic seizure? Levetiracetam	Absence
For which type of epileptic seizures is the following a drug of choice for? Alternative drug for? Carbamazepine	Drug of Choice: Focal (Partial)
For which type of epileptic seizures is the following a drug of choice for? Alternative drug for? Lamotrigine	Drug of Choice: Focal (Partial) and Primary GTC
For which type of epileptic seizures is the following a drug of choice for? Alternative drug for? Oxcarbazepine	Drug of Choice: Focal (Partial)
For which type of epileptic seizures is the following a drug of choice for? Alternative drug for? Levetiracetam	Drug of Choice: Focal/Partial (Approved as adjunctive therapy only) and Primary GTC Alternative: Absence
For which type of epileptic seizures is the following a drug of choice for? Alternative drug for? Valproate	Drug of Choice: Primary GTC and Absence Alternative: Focal (Partial)
For which type of epileptic seizures is the following a drug of choice for? Alternative drug for? Ethosuximide	Drug of Choice: Absence
For which type of epileptic seizures is the following a drug of choice for? Alternative drug for? Phenytoin	Alternative: Focal (Partial) and Primary GTC
For which type of epileptic seizures is the following a drug of choice for? Alternative drug for? Topiramate	Alternative: Focal (Partial) and Primary GTC
For which type of epileptic seizures is the following a drug of choice for? Alternative drug for? Gabapentin	Alternative: Focal (Partial) Approved as adjunctive therapy only.
For which type of epileptic seizures is the following a drug of choice for? Alternative drug for? Pregabalin	Alternative: Focal (Partial) Approved as adjunctive therapy only.
For which type of epileptic seizures is the following a drug of choice for? Alternative drug for? Clonazepam	Alternative: Absence
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	Phenytoin
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	Phenytoin
What are the Pharmacokinetics of Phenytoin?	 Many PO formulations available – IR / ER formulations  90% of phenytoin in vascular space is bound to albumin  At steady-state, 10% phenytoin in vascular space, 90% tissue  Takes up to 6 weeks to achieve steady state, depending on dose  Metabolism: dose-dependent capacity-limited pharmacokinetics (zero order metabolism)  MUST MONITOR SERUM LEVELS  10-20 mg/L is common therapeutic range
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	Phenytoin
Why are there dramatic increases in plasma phenytoin with small increases in dose?	Caused by dose-dependent metabolism
What are the dose related adverse effects (seen in CNS) of Phenytoin?	List in order of Increasing serum concentration  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
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	Phenytoin
What are the chronic therapy related adverse effects of Phenytoin?	 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
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	Phenytoin
What is shown here? For what drug is it a chronic therapy related adverse effect? Image: 1ac5abe5-679a-4d36-b229-eeecca2e8973.JPG (image/JPG)	Gingival hyperplasia - chronic therapy related adverse effect of Phenytoin (40%)  Upper – after 2 yrs of unsupervised PHT therapy  Lower – 3 months after removal of PHT
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	Phenytoin
What are the drug-drug interactions of Phenytoin?	 Significant enzyme induction  CYP2B6, CYP2C19, CYP2C8, CYP2C9, CYP3A4, P-glycoprotein  Warfarin: Phenytoin 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 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	Phenytoin
What are the contraindications / precautions of Phenytoin?	 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
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	Carbamazepine
What are the Pharmacokinetics of Carbamazepine?	 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
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	Carbamazepine
What are the dose related adverse effects of Carbamazepine?	 CNS • Transient diplopia; ataxia • Dizziness, drowsiness, nausea, anorexia - common upon initiation; tolerance develops Hyponatremia, common but mild
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	Carbamazepine
What are the idiosyncratic adverse reactions to Carbamazepine?	• Rare serious blood dyscrasias • Skin rash (5%) • Stevens-Johnson syndrome (1:10,000) - HLA-B*1502
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	Carbamazepine
What are the contraindications/precautions of Carbamazepine?	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
True or False Valproate is a drug of choice for women of childbearing potential.	False Valproate is no longer a drug of 1st 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	Valproate
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.)	Valproate
What are the Pharmacokinetics of Valproate?	 90% protein bound – can be significant  Many enzymes responsible for valproate metabolism - (2A6, 2B6, 2C9, UGT, etc.)
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	Valproate
What are the drug-drug interactions of Valproate?	 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
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	Valproate
What are the Dose related adverse effects of Valproate?	• 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
The following are idiosyncratic adverse reactions to which anti-epileptic? • Fulminant hepatitis • Acute pancreatitis • Stevens-Johnson syndrome (rare) • Menstrual abnormalities / polycystic ovaries	Valproate
What are the idiosyncratic adverse reactions to Valproate?	• Fulminant hepatitis • Acute pancreatitis • Stevens-Johnson syndrome (rare) • Menstrual abnormalities / polycystic ovaries  Teratogenic risk  Lamotrigine often used instead  Not used in children <3 yrs because of risk of liver failure
The following are adverse effects of which anti-epileptic? Nausea, vomiting, hiccups, behavioral changes	Ethosuximide
What are the adverse effects of Ethosuximide?	Nausea, vomiting, hiccups, behavioral changes
What are the drug-drug interactions of Ethosuximide?	Metabolism inhibited by valproate
The following are the drug-drug interactions of what anti-epileptic? Metabolism inhibited by valproate	Ethosuximide
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	Phenobarbital
True or False Phenobarbital is rarely used in children.	False It is used in children more than adults.
The following are the adverse reactions of what anti-epileptic? Sedation, tolerance, dependence, respiratory depression	Phenobarbital
What are the adverse reactions of Phenobarbital?	Sedation, tolerance, dependence, respiratory depression
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	Phenobarbital
What are the drug-drug interactions of Phenobarbital?	 Significant enzyme induction - CYP1A2, CYP2A6, CYP2B6, CYP2C8, CYP2C9, CYP3A4  Reduces blood levels of contraceptive hormones
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	Phenobarbital
What are the contraindications / precautions of Phenobarbital?	 Do not use in patients with history of sedative addiction  Risk of dependence is high  Teratogenic risk
The following are the adverse effects of which anti-epileptic? Sedation, tolerance, dependence	Clonazepam
What are the adverse effects of Clonazepam?	Sedation, tolerance, dependence
The following are the contraindications / precautions of which anti-epileptic? Caution in patients with history of sedative dependence	Clonazepam
What are the contraindications / precautions of Clonazepam?	Caution in patients with history of sedative dependence
The following are the drug-drug interactions of which anti-epileptic? Metabolized by CYP3A4	Clonazepam
What are the drug-drug interactions of Clonazepam?	Metabolized by CYP3A4
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	Lamotrigine
What are the uses of Lamotrigine?	 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
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	Lamotrigine
What are the Pharmacokinetics for Lamotrigine?	 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
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)	Lamotrigine
What are the adverse effects of Lamotrigine?	 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)
To which anti-epileptic does the following statement apply?  Fewer cognitive adverse effects vs. other commonly-used antiepileptic drugs (controversial)	Lamotrigine
Which anti-epileptic is described below?  Focal and generalized tonic clonic seizures  Also used for migraine prophylaxis, weight management	Topiramate
What are the uses of Topiramate?	 Focal and generalized tonic clonic seizures  Also used for migraine prophylaxis, weight management
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	Topiramate
What are the adverse effects of Topiramate?	 Somnolence, nervousness, confusion, difficulty with speech, impaired concentration and memory  Mild parasthesias  Reduces blood levels of contraceptive hormones
For which anti-epileptic does the following statement apply? Weight loss common (80% patients; 3-4% bodyweight loss)	Topiramate
Which anti-epileptic is described by the following?  Focal seizures in adults (not approved for generalized tonic-clonic)  Off label use for bipolar disorder	Oxcarbazepine
What are the uses of Oxcarbazepine?	 Focal seizures in adults (not approved for generalized tonic-clonic)  Off label use for bipolar disorder
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	Oxcarbazepine
True or False Oxcarbazepine is possibly useful in patients who fail other therapies due to poor seizure control or adverse effects.	True
True or False Oxcarbazepine should be used for patients with severe hypersensitivity to carbamazepine	False  Adverse effects similar to carbamazepine; higher incidence of hyponatremia; do not use in patients with severe hypersensitivity to carbamazepine
What are the uses of Gabapentin?	 Adjunct for Focal Seizures in adults and children  Modest efficacy  Also used for neuropathic pain
What are the uses of Pregabalin?	 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  Modest efficacy  Also used for neuropathic pain	Pregabalin
The following describes which anti-epileptic?  Adjunct for Focal Seizures in adults and children  Modest efficacy  Also used for neuropathic pain	Gabapentin
The following are the pharmacokinetics for which drug? 100% renal elimination	Gabapentin and Pregabalin
What are the pharmacokinetics for Gabapentin?	100% renal elimination
What are the pharmacokinetics for Pregabalin?	100% renal elimination
The following are the adverse effects for which anti-epileptic? Mild drowsiness, weight gain (modest), lower extremity edema	Gabapentin, Pregabalin
The following are the drug-drug interactions of which anti-epileptic? No significant drug interactions	Gabapentin and Pregabalin
What are the uses of Levetiracetam?	 Adjunct for Focal and generalized tonic-clonic seizures  Commonly used in monotherapy as well
What are the drug-drug interactions of Levetiracetam?	No clinically significant drug interactions  Not an inhibitor or inducer of CYP enzymes
The following are the adverse effects of which anti-epileptic? CNS disturbances (irritability, depression, aggression, hallucinations) more common than with other anti-epileptic drugs	Levetiracetam
What are the adverse effects of Levetiracetam?	CNS disturbances (irritability, depression, aggression, hallucinations) more common than with other anti-epileptic drugs
The following are the Pharmacokinetics of which anti-epileptic? Renal elimination (>70%)	Levetiracetam
What are the Pharmacokinetics of Levetiracetam?	Renal elimination (>70%)
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	Felbamate
What are the uses of Felbamate?	 Indication: Focal and generalized tonic-clonic seizures  Reserved for failure of alternate anti-epileptic drugs due to severe idiosyncratic reactions
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	Felbamate
What are the adverse reactions to Felbamate?	 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 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	Cannabinoids – fyi (not testable)
What should be done if monotherapy fails?	Choose alternate monotherapy agent and repeat process
What should be done if monotherapy fails with several drugs?	Try adjuvant therapy  Concern is management of adverse effects of two drugs
Which AEDs reduce blood levels of contraceptive hormone?	Carbamazepine, phenobarbital, phenytoin, felbamate, lamotrigine, oxcarbazepine, topiramate
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	True
What is done for status epilepticus?	Status epilepticus is a medical emergency; IV lorazepam is used to stop the seizures. IV phenytoin is then initiated for longer term control
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
True or False Blood level monitoring is often required to maintain therapeutic levels.	True Especially for drugs that affect drug metabolizing enzymes

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