3/27/2013. T/F Seizures are waves of abnormal electrical activity in the brain

Transcription

1 To understand the different types of seizure disorders To identify the basic pharmacological principles in management of seizure disorders To identify the common non-pharmacologic therapies for seizures disorders Cynthia Samantha Valle-Oseguera, PharmD PGY1-Pharmacy Resident BVAMC ISHP Spring Meeting 2013 T/F Seizures are waves of abnormal electrical activity in the brain 1

2 Seizure is a sudden change in behavior due to brain dysfunction Epilepsy is characterized by recurrent epileptic seizures due to an acquired brain disorder or genetically determined disorder <1% of the population has epilepsy Some seizures are provoked Drug or alcohol withdrawal Acute neurologic disorders Nonepileptic seizures (NES) are sudden changes in behavior that resemble epileptic seizures but are not associated with the typical neurophysiological changes of epileptic seizures Genetics Stroke Cerebral degeneration Head trauma Brain tumors Intracranial infection Congenital brain malformations History Signs/symptoms Medication history Analgesics: Fentanyl, tramadol, meperidine Antidepresssants: Amitriptyline, bupropion, nortriptyline Antipsychotics: Haloperidol, prochlorperazine, thioridazine Local anesthetics: Bupivacaine, lidocaine, procaine Others: Amphetamines, alcohol, antihistamines, insulin, atenolol, folic acid Past medical history Head injury, alcohol/drug abuse, stroke Family history Intense exercise Lack of sleep Strong emotions Stress Loud music Fever Flashing lights Menstrual period 2

3 1997 Pokémon cartoon aired in Japan 685 children sought medical attention for neurologic symptoms 80% were felt to be seizures ¾ children had not experienced seizures previously Hypoglycemia Falls in serum sodium concentrations Associated with a high risk of mortality and must be treated urgently Hypocalcemia Magnesium levels below 0.8 meq/l Renal failure Uremia Dialysis Hyperthyroidism Withdrawal states Drug toxicity/intoxication Psychological disorders Migraine Syncope Sleep disorders Other neurologic events Paroxysmal movement disorders 3

4 Partial Seizures Simple Partial Seizures (consciousness not impaired) Motor symptoms ie. Arrest of speech Somatosensory symptoms ie. Visual, auditory, gustatory Autonomic ie. Pallor, sweating Psychic ie. hallucinations Complex Partial (with impaired consciousness) Partial Seizures (simple/complex) evolving to secondarily generalized seizures Generalized Seizures Nonconvulsive (absence) Convulsive Myoclonic Clonic Tonic Tonic-clonic Atonic Unclassified T/F An antiepileptic drug is generally started in individuals after a single provoked seizure Goals Maintaining quality of life Controlling seizures Avoiding or minimizing treatment side effects AED treatment is started after 2 unprovoked seizures >50% chance for repeated seizures 4

5 No single AED is the most effective or best tolerated Seizure type Broad Spectrum: All seizure types Narrow Spectrum: Simple partial, complex partial, and secondarily generalized seizures Antiepileptic drug Lamotrigine, levetiracetam, topiramate, valproate, zonisamide Carbamazepine, gabapentin, lacosamide, oxcarbazepine, phenobarbital, phenytoin, pregabalin, primidone, tiagabine Patient-specific Dosing frequency Most prescribed are BID dosing More frequent dosing Pregabalin (t ½ = 6 hrs) Once daily dosing Phenobarbital (t ½ = hrs) Side effects Drug Interactions Absence Seizure Ethosuximide Table modified from UpToDate T/F Oral contraceptives may decrease valproic acid clearance and their use is associated with increased valproic acid blood levels Carbamazepine Drug Systemic side effects Neurotoxic side effects Nausea, n/v, hyponatremia, rash, Drowsiness, dizziness, blurred or double vision, lethargy, headache Ethosuximide Nausea, vomiting Sleep disturbance, drowsiness, hyperactivity Gabapentin Infrequent Somnolence, dizziness, ataxia Lamotrigine Rash, nausea Dizziness, tremor, diplopia Levetiracetam Infection Fatigue, somnolence, dizziness, agitation, anxiety, irritability, depression Phenytoin Gingival hypertrophy, rash Confusion, slurred speech, double vision, ataxia Pregabalin Weight gain Dizziness, somnolence, ataxia Phenobarbital Nausea, rash Alteration of sleep cycles, sedation, lethargy, behavioral changes, hyperactivity, ataxia, tolerance, dependence Topiramate Valproate Weight loss, paresthesias Weight gain, n/v, hair loss, easy bruising Fatigue, nervousness, difficulty concentrating, confusion, depression, anorexia, language problems, anxiety, mood problems, tremor Tremor, dizziness Table modified from UpToDate 5

6 Drug Carbamazepine Ethosuximide Lamotrigine Phenytoin Phenobarbital Rufinamide Topiramate Valproate Side effects Agranulocytosis, Stevens-Johnson syndrome, aplastic anemia, hepatic failure, dermatitis/rash, serum sickness, pancreatitis, lupus syndrome Agranulocytosis, Stevens-Johnson syndrome, aplastic anemia, hepatic failure, dermatitis/rash, serum sickness Stevens-Johnson syndrome, hypersensitivity, aseptic meningitis Agranulocytosis, Stevens-Johnson syndrome, hepatic failure, dermatitis/rash, neuropathy, lupus-syndrome, hirsuitism Agranulocytosis, Stevens-Johnson syndrome, hepatic failure, dermatitis/rash, serum sickness Stevens-Johnson syndrome, dermatitis/rash, shortened QT interval Acute myopia and glaucoma; kidney stones Agranulocytosis, Stevens-Johnson syndrome, aplastic anemia, hepatic failure, dermatitis/rash, serum sickness, pancreatitis, polycystic ovary syndrome Seizure Calendar Generic Substitution Alcohol Intake Non-compliance Table modified from UpToDate Melatonin and cannabis may have anticonvulsant effects Some herbal and dietary supplements may be proconvulsant Ephedra Gingko biloba Sage Star Fruit Medications supplements can affect the metabolism of AEDs and alter drug levels Ginkgo biloba reduces serum levels of phenytoin and valproate Chinese herb Bai Shao increases serum carbamazepine levels Insurance problems Decreased self-esteem Loss of independence Loss of employment 6

7 T/F All states in the United States require drivers with epilepsy to report their condition A person with uncontrolled epilepsy is at risk for a MVA For many adults, restrictions on driving significantly diminish independence and quality of life Clinicians neither suspend nor grant driving privileges Physicians should counsel patients regarding the risks associated with driving and epilepsy Clinicians are required to report patients with seizures to driving authorities in six states (California, Delaware, Nevada, New Jersey, Oregon, and Pennsylvania) Physicians not reporting when required are open to legal actions 7

8 Any person who in the opinion of the department, based upon recommendation of the person's physician, is afflicted with or subject to any condition which brings about momentary or prolonged lapses of consciousness or control, which is or may become chronic, shall have his or her license suspended, revoked, or denied [IDAHO CODE ANN (1)(c)(1) (2011)] Idaho Department of Transportation officials can request that a person submit to a medical examination for public safety reasons, based on observations or other evidence [IDAHO CODE ANN (2011)] State Seizure-Free Period Periodic Medical Updates Required After Licensing Doctors Required to Report Epilepsy DMV Appeal of License Denial Idaho No set seizure-free period At discretion of DMV No Within 20 days Table obtained from epilepsyfoundation.org Keep calm and gently reassure other people who may be in close proximity Don t physically hold the person down Time the duration of the seizure with your watch or cell phone Clear the area around the person of anything hard or sharp Loosen ties that may make breathing more difficult Put something flat and soft (such as a folded jacket) under their head Turn a seizing person onto their side Do not try to force the mouth open with any hard instrument or with fingers Don t attempt artificial respiration Stay with the person until the seizure ends naturally Be friendly and reassuring as consciousness returns Offer to call a relative to help the person get home Watch the person carefully and explain to others what is happening Speak quietly in a friendly way Guide the person away from any danger Don t grab them unless there is a danger of immediate threat to their safety Stay with the person until full consciousness returns Offer help in arranging their transport back to a residence Epilepsyidaho.org Epilepsyidaho.org 8

9 The person is pregnant, injured, or diabetic The seizure continues for more than five minutes The seizure takes place in water Another seizure begins shortly after the first has ended There s no medical I.D., and no way of knowing the nature of the seizure Consciousness does not start to return after the shaking has ended Epilepsyidaho.org Schachter, SC. Evaluation of the first seizure in adults. In: UpToDate, Pedley, TA (Ed), UpToDate, Waltham, MA, Krumholz, A. Driving restrictions for patients with seizures and epilepsy. In: UpToDate, Pedley, TA (Ed), UpToDate, Waltham, MA, Karceski, S. Initial treatment of epilepsy in adults. In: UpToDate, Pedley, TA (Ed), UpToDate, Waltham, MA, Schachter, SC. Pharmacology of antiepileptic drugs. In: UpToDate, Pedley, TA (Ed), UpToDate, Waltham, MA, Schachter, SC. Overview of the management of epilepsy in adults. In: UpToDate, Pedley, TA (Ed), UpToDate, Waltham, MA, Samuels, N. Herbal medicine and epilepsy: Proconvulsive effects and interactions with antiepileptic drugs. Epilepsia, 2008, 49, 3,