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PHARMACY PREP

SEIZURES AND EPILEPSY

1. TL, a 70-year old patient is currently taking phenytoin (Dilantin) 100 mg three
capsules daily at bedtime. TL can no longer swallow these capsules so the doctor
requests an equivalent dose of Dilantin suspension 125 mg/5 mL.
In order to maintain similar blood levels, you would give:
A. 5.5 mL in the morning and at bedtime
B. 6 mL in the morning and at bedtime
C. 7.5 mL in the morning and at bedtime
D. 11 mL daily at bedtime
E. 12 mL daily at bedtime
Ans:

2. A patient receiving phenytoin begins to exhibit hematologic disorders and mild
confusion. What vitamin deficiencies are associated with these symptoms in patients that
take anticonvulsants?
a) Vitamin A
b) Vitamin E
c) Vitamin D and folic acid
d) Vitamin C and Calcium supplements
e) Folic acid
Ans-E

3-How long will it take for phenytoin to achieve optimum anticonvulsant effects if a
loading dose is not given?
a) 1-3 weeks
b) 3-5 days
c) 4-5 weeks
d) 1-2 months
e) 5-6 weeks
Ans-C

4-What percent of phenytoin is present in phenytoin chewable tablets?
a) 10%
b) 25%
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c) 50%
d) 75%
e) 100%
Ans-E

5-What are the monitoring parameters for phenytoin?
I. Plasma phenytoin levels
II. Liver function tests and CBC
III. Blood pressure and vital signs (with IV use).
a) I only
b) III only
c) I and II only
d) II and III only
e) All of the above
Ans-E

6-Name the dosage forms available for phenytoin.
I. Capsule
II. Injection and suspension
III. Tablet
A. I only
B. III only
C. I and II only
D. II and III only
E. All of the above
Ans-E

Next 2 Questions refer to the antipsychotics
ZM is a 20-year-old woman receiving 300 mg phenytoin for treatment of a generalized
disorder secondary to a motor vehicle accident 1 year ago. Although seizure free for the
past 6 months, she now reports being increasingly confused and lethargic. Nystagmus is
detected at physical examination. She is taking no other medications, but has been
dieting to lose weight before her upcoming wedding. A total phenytoin concentration is
obtained and is reported to be 14 mg/L (desired range, 10 to 20 mg/L). Other laboratory
results are as follows:

Na: 138 mEq/L (135-145 mEq/L) K: 3.5 mEq/L (3.5-3 mEq/L)
BUN: 10 mg/dL (8-20 mg/dL) Cl: 98 mEq/L (96-106 mEq/L)
Cr: 1.0 mg/dL (0.7 1.5 mg/dL) ALT: 8 IU/L (0-35 IU/L)
Albumin 2.5 g/dL (3.5-5 g/dL) AST: 10 IU/L (0-40 IU/L)

1. What is the patients primary drug-related problem?
A. Phenytoin toxicity secondary to impaired hepatic function
B. Phenytoin toxicity secondary to impaired renal function
C. Phenytoin toxicity secondary to a decrease protein binding
D. Phenytoin toxicity secondary to a decrease in free phenytoin concentration
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E. Phenytoin toxicity secondary to serum electrolyte abnormalities
Answer: C Phenytoin is highly protein bound, particularly to albumin. A decrease
in serum albumin can increase the concentration of free phenytoin, which is the
pharmacologically active component. Patients with low albumin concentrations or
impaired protein binding may have drug toxicity despite normal serum phenytoin
concentrations.

2. Which of the following side effects of phenytoin therapy is not related to
increased serum concentrations?
I-Ataxia
II-Sedation
III-Hirsutism
A-I only
B-III only
C-I and II only
D-II and III only
E-All of the above
Answer: C Hirsutism is a common side effect of phenytoin and is not correlated with
serum phenytoin concentration. Ataxia and sedation are concentration-dependent side
effects.

3. After her phenytoin therapy has been optimized, ZM returns to the clinic just before
her wedding and requests an oral contraceptive. Which of the following statements
regarding oral contraceptives and phenytoin is most correct?
A. There is no potential drug-drug interaction
B. Phenytoin inhibits the metabolism of phenytoin and may increase their side effects.
C. Oral contraceptives inhibit the metabolism of phenytoin and may increase its side
effects.
D. Phenytoin induces the metabolism of oral contraceptives and may decrease their
efficacy.
E. Oral contraceptives induce the metabolism of phenytoin and may decrease its
efficacy.
Answer: D Phenytoin is an enzyme inducer. It may increase the metabolism of oral
contraceptives and reduce their efficacy. Patients should be advised to consider
alternative methods of contraception to avoid unplanned pregnancy.

4. ZM returns for a routine follow-up visit in 1 year after the wedding. She is relatively
seizure free, and she and her husband are considering starting a family. Which of the
following vitamin supplements is recommended for women taking anticonvulsants to
reduce the potential for teratogenic effects?
A. Thiamine
B. Ascorbic Acid
C. Vitamin K
D. Folic Acid
E. Vitamin B12
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Answer: D Although folic acid may not reliably reduce the risk of birth defects in
women receiving antiepileptic drugs, adequate folate supplementation is still
recommended.

5. During the follow-up visit ZM exhibits moderate gingival hyperplasia and asks about
an alternative medication to phenytoin. Which of the following would be the least
appropriate alternative for treatment of her type of seizure disorder?
A. Phenobarbital
B. Carbamazepine
C. Valproic acid
D. Ethosuximide
E. All of the above
Answer: D Ethosuximide is considered the drug of choice for absence seizures, but it is
little value in the management of generalized seizures.


Next 3 Questions refer to the partial seizures
1-A 28-year old woman, patient CC, is being treated for generalized seizures (simple
partial). Presents with prescription of carbamazepine.
Her medical history includes: No allergies and no other medical conditions
1-Which medication causes tolerance?
a) Carbamazepine
b) Valproic acid
c) Phenytoin
d) Clobazam (Frisium)
Ans: D
Comments: Phenobarbital and primidone also have tolerance.

2- Patient has come into the pharmacy and falls down; he had a seizure. What is to be
done?
A-Call 911 and see if his wife has coverage
B-Try to keep his mouth open to prevent chalk up.
C-give chewable tablets of phenytoin
D-call doctor to get prescription of carbamazepine
E-call his family to inform his condition
Ans-B

3-All of the following side effects of carbamazepine are NOT dose dependent EXCEPT:
A-Allergic rash
B-thrombocytopenia
C-Leukopenia
D-Neutropenia
E-Headache
Ans-A

4-In the above side effects, what side effects require discontinuation of drug immediately:
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A-Allergic rash
B-thrombocytopenia
C-Leukopenia
D-Neutropenia
E-Headache
Ans-E

5-What would you use in the treatment (s) of partial seizures?
a. Phenobarbitone
b. Carbamazepine and Lamotrigine
c. Phenytoin
d. Gabapentin
e. Wait for another seizure before initiating treatment
Ans-B

6-Which drug does not react with oral contraceptive
a. phenytoin
b. phenobarbitone
c. primidone
d. gabapentin
E-carbamazepine
Ans-D
Comment: CPS p1214 anti-convulsants that affects the OC includes phenytoin,
Carbamazepine, Primidone, ethosuximide, Phenobarbital. Must use higher dose of OC.
Because of rapid metabolism of estrogen and increased binding of progestin & ethyl
estradiol.
The OC should contain >35 microgram estradiol

Next 4 Question refer to the following case
MD, a 17 year old, presents with a purpuric skin rash. She wonders if she is having
another flare-up of her eczema, but this rash looks different. Her patient record is as
follows:
Allergies: penicillin

History: eczema x 2.5 years
epilepsy x 1 month

Current medications: betamethasone (Betnovate) Cr 0.05% bid prn x 2.5 years
ethinyl estradiol/ levonorgestrel (Min-Ovral) x 10 months
phenytoin (Dilantin) 200mg qhs x 1 month

1-What is the most probable cause of her skin rash?
A. An acute flare-up of her eczema
B. A reaction to phenytoin
C. A reaction to oral contraceptives
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D. An interaction between ethinyl estradiol/ levonorgestrel (Min-Ovral) and phenytoin
(Dilantin)
Ans.: B

2-What plasma phenytoin levels are considered to be therapeutic?
a) 100-200 mcg/mL
b) 20-40 mcg/mL
c) 40-60 mcg/mL
d) 10-20 mcg/mL.
e) 80-100 mcg/mL
Ans-D

3. Phenytoin side effects are all of the following EXCEPT
a) Hirsutism
b) Gingival hyperplasia
c) Increase liver enzyme
d) Pulmonary fibrosis
e) Osteomyelitis
Ans: D
For osteomyelitis give vitamin D and Calcium

Next 5 Questions refer to the Phenobarbital

1-How does vitamin C affect Phenobarbital effects in seizure?
I-Does not effect
II-Displaces Phenobarbital from binding sites resulting in increased urinary excretion of
the drug
III-Increases the risk for seizures.
a) I only
b) III only
c) I and II only
d) II and III only
e) All of the above
Ans-D

Next 6 Questions refer to the Carbamazepine
1. Which of the following drugs may INCREASE warfarin levels
I. carbamazepine
II. clarithromycin
III. co-trimoxazole
a) I only
b) III only
c) I and II only
d) II and III only
e) All of the above
Ans: D
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Carbamazepine is an enzyme inducer. IT will decrease warfarin blood levels.
Clarithromycin (and, to a lesser extent, azithromycin) and co-trimoxazole may increase
warfarin blood levels.
Clarithromycin may also increase levels of carbamazepine, digoxin, statins and
theophyllines.
Other antibiotics that may increase warfarin and digoxin levels include fluoroquinolones.

2-What laboratory values should be periodically monitored on a patient that has just been
prescribed carbamazepine?
A. Complete blood counts
B. LFT
C. Renal function
D. Blood pressure
E. All of the above

3. A patient with renal failure and we want to give him carbamazepine:
a) Give loading dose
b) Give low dose & increase dose gradually
c) Give SR dose to give controlled scrum of carbamazepine in the blood stream
d) Discontinue carbamazepine
e) Switch to phenytoin
Ans: B
Comments: Thiazides, spironolactone, acetazolamide, laxatives, Milk of magnesia are
contraindicated in renal failure.

4. Comparing carbamazepine and phenytoin, why carbamazepine is preferable:
a. Phenytoin has unpredictable kinetics
b. Dose adjustment not need in renal impairment (CBZ)
c. Carbamazepine, it is easy to adjust the dose
d. Carbamazepine have no idiosyncratic reactions
Ans: A

Next 7 Questions refer to the Gabapentin
1-What is true for Gabapentin?
A. Dose can be increased daily without titrating dose due to any severe side effects
B. It has few drug interactions
C. It decrease efficacy of oral contraceptives
D. Its chemical structure is not similar to GABA neurotransmitter
E. None of the above
Ans-B

2-Which of the antipsychotic drug has weight loss side effects.
A-Lamotrigine
B-Carbamazepine
C-Phenytoin
D-Valproic acid
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E-Gabapentin
Ans-A

Next 8 Questions refer to the gingival hyperplasia
1. Gingival hyperplasia caused by:
I. Cyclosporine
II. Phenytoin
III. Valproic acid
a) I only
b) III only
c) I and II only
d) II and III only
e) All of the above
Ans: C

2-All of the following antiepileptic drugs have tolerance, EXCEPT?
A-Clobazam
B-Diazepam
C-Valproic acid
D-Phenobarbital
E-Primedone

3-All the following antiepileptic drugs lower efficacy of oral contraceptives, EXCEPT
A-Carbamazepine
B-oxacarbazepine
C-Phenytoin
D-Gabapentin

4-Antiepileptic drugs that have no effect on generalized seizures?
A-Ethosuccimide
B-Gabapentin
C-Phenytoin
D-Carbamazepine
E-Valproic acid

5-A patient using phenytoin for the six months, reports had swollen gum, which of the
following is the appropriate recommendation.
A-Mouth hygiene
B-Refer to dentist
C-Chlorhexidine mouth rinse
D-Recommend toothpaste
E-Refer to doctor
Ans-A

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6. A 44-year old patient with epilepsy, he is using Valproic acid 500mg TID, however he
is experiencing some side effect like stomach upset. The pharmacist should advise the
patient:
I Talk to doctor to reduce the dose
II Talk to doctor to switch him to liquid form
III Talk to doctor to give him another medication in the same class (divalproex)
(A) I only
(B) III only
(C) I and II
(D) II and III
(E) All of the above
Answer:
TIPS: Changing the dosage form will not reduce the side effect. However usually, if
there is a good response to any medication with side effect, it is better to keep within the
same class.