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EPILEPSY

MODE OF ACTION

INDICATION
1.

CARBAMAZEPINE

Prolongation of Na+
channel inactivation

PHENYTOIN

Prolongation of Na+
channel inactivation

SODIUM
VALPROATE

Block voltage-gated
inward positive
+
currentsNa or
++
Ca
Highly Pleiotrophic

2.
3.
4.
5.

Simple/Complex Partial
seizures
Tonic-clonic seizures
Trigeminal Neuralgia
MDP
Diabetic Neuropathy

Tonic/clonic & Partial seizures,


Status epilepticus, Trigeminal
Neuralgia(rare)

1.
2.

3.

First line myoclonus


All forms of Epilepsy
Tonic / Clonic, myoclonic,
Atonic, Absence seizures
Acute mania

1.
Lamotrigine

DIAZEPAM
LORAZEPAM

Prolongation of Na+
channel inactivation

Bind to GABA
inhibitory receptors
to reduce firing rate.

Primary / secondary
generalized Tonic-Clonic
2. Prevention of relapse in
BPD
3. Trigeminal Neuralgia
Given PR in initial status
epilepticus

Initial management in status


epilepticus. Given IV

CI/INTERACTION

Auto-inducer; i.e
increase their
own metabolism.
Interact w/
warfarin lamotrigine

Fetal hydantoin
syndrome
Auto-inducer

Causes liver
toxicity
Neural tube
defects
inhibits CYP450
enzymes

ADVERSE EFFECTS

Leucopenia
Diplopia, Blurring of vision
SIADH
Drowsiness
Ataxia
Generalized rash
Risk of Steven Johnson syndrome(HLA-B 1502 PM)
Ataxia and Nystagmus
Cognitive impairment
Hirsutism
Gingival hyperplasia
Coarsening of facial features
Dose-dependent zero order kinetics.
Apetite / Weight gain
Liver failure
Pancreatitis
Reversible hair loss
Oedema
Ataxia
Tremor / Thrombocytopenia
Encephalopathy
Steven Johnson syndrome - rash
Diplopia, Blurring of vision
Photosensitivity
Agitation
Tremor

Simple partial (focal) seizures

First line treatment for focal seizures:


o Carbamazepine or lamotrigine
First-line treatment if above contra-indicated:
o Levetiracetam, oxcarbazepine or sodium valproate
Second-line treatment
o Alternative from above

Adjunctive treatment (1)


o As above, also clobazam, topiramate, gabapentin

Adjunctive treatment (2)


o Eslicarbazepine, lacosamide, phenytoin, phenobarbital, pregabalin, tiagabine, zonisamide, vigabatrin

Generalised epileptic seizure

ABCDE
Oxygen
Safe environment
Keep patient supported during seizure protecting from injury. As soon as movements cease put into recovery
position and ensure she is watched until she has recovered consciousness

Counselling for people with epilepsy

Nature and causes of epilepsy

Pregnancy and teratogenicity

Precipitating factors

Interactions of AEDs esp with OCP

Need for regular medication

Adverse effects of medication

Employment/education

Driving

Free prescriptions

Dangerous situations

Psychological issues

(NB also emergency contraception)

Status epilepticus

More than 30 minutes of continuous seizure activity


Two or more sequential seizures spanning this period without full recovery between seizures
Medical emergency

Management

>5mins medical intervention advised


IV lorazepam, PR diazepam, Buccal midazolam
20 mins : Alert anaesthetist
30mins : Emergency investigations
ABG, glucose, U+E, LFTs, Ca, Mg, FBC, clotting screen, Anticonvulsant blood level
Blood + urine sample for future analysis (tox screen)
Glucose +- IV thiamine
60/90mins : ICU
Continuous ECG monitoring +- intracranial pressure monitoring if appropriate

Myoclonus

First-line treatment:
Sodium valproate
Consider levetiracetam or topiramate if sodium valproate unsuitable or not tolerated
Adjunctive treatment:
Sodium valproate, levetiracetam or topiramate
Clobazam, clonazepam, piracetam or zonisamide (after discussion with tertiary centre)

Alcohol withdrawal syndrome


Clinical features
1. Delirium tremens
a. hyperadrenergic state, disorientation, tremors, diaphoresis, impaired attention/consciousness
2. Hallucinations (auditory, visual, or olfactory)
3. Seizures
a. Generalised tonic-clonic seizures

Symptoms occur after 8 hours, peaking on day 2, recovering by day 5.

Treatment

ABC assessment

Treat any hypoglycaemia

Sedation with benzodiazepines

Barbiturates/ITU may also be necessary in those refractory to benzodiazepine

Screening for Wernicke's encephalopathy or Korsakoff , and treatment 2x 500 mg thiamine should be given IV three times daily for three days. Continued OD for 5 more days if
the patient is responsive to the treatment

Benzodiazepines
Fixed-dose regimens

e.g chlordiazepoxide (long acting)

20mg qds on day 1, then reduced by 10 mg a day

Symptom triggered regimen

50 mg chloridiazepoxide as required based on a symptom score scale e.g CIWA score

Note risks of respiratory depression and can precipitate hepatic encephalopathy in patients with ALD

EPILEPSY