Ch 39 Seizures

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1. AEDs That Are - Carbamazepine/Oxcarbazepine 13. Carbamazepine - myelosuppression

Inducers - Phenytoin/Fosphenytoin contraindications - hypersensitivity reaction to
- Topiramate tricyclic antidepressants (b/c similar)
- Phenobarbital/Primidone - taken MAOI in the past 14 days
- Perampanel
14. Carbamazepine Side - Hepatotoxicity
2. Antiepileptic - Suppress Neuronal Discharge Effects - Aplastic Anemia
Pharmacotherapy - Suppress Propagation - Hyponatremia
MOA - Stabilize Seizure Threshold - Rash (SJS)
- Visual Disturbances
3. Aplastic Anemia - Carbamazepine
- Agranulocytosis
- Felbamate
- Valproate 15. Carbamazepine - Na+ channel modulator
(Tegretol, Tegretol- - Causes release of anti-diuretic
4. Barbiturates - Phenobarbital (Luminal)
XR) MOA hormone
- Pentobarbital (Nembutal)
- PO mainly
5. Brivaracetam - Modulate synaptic vesicle
16. Cardiac - Lacosamide
(Briviact ) MOA - No renal adjustment needed
- Phenytoin
6. Brivaracetam Drug - Undergoes hepatic metabolism so - Pentobarbital
interactions (ugly undergoes drug interactions - Rufinamide
stepsisters) - Rifampin will decrease
17. Clobazam MOA - Enhance GABA
concentrations of brivaracetam
- Used for Lennox Gastaut
- Lowers concertation of oral
syndrome
concentrations
- Class 3 drug
- Carbamazepine or Phenytoin can
- NO alcohol b/c it will increase
increase levels of these epileptic
blood levels by 50%
drugs
18. Clobazam side - Steven Johnsons syndrome
7. Brivaracetam side - Somnolence
effects - drowsiness
effects - Gait disturbances
- lethargy
- Fatigue
- drooling
- Psychiatric
- aggressive/irritable
8. Cannabidiol Clinical - Approved for pt 2+ years - upper respiratory tract infections
Pearls - Given with high fat meal will - D/c gradually to avoid withdrawal
increase concentration by 5x symptoms
- Class 5 drug (controlled substance)
19. Clonazepam Black - No benzos b/c of profound
9. Cannabidiol - Unknown (Enhance GABA Box Warning sedation respiratory depression,
(Epidiolex) MOA according to lecture) coma, death
10. Cannabidiol labs to - ALT, AST, bilirubin 20. Clonazepam - narrow angled glaucoma
check before starting contraindication
11. Cannabidiol side - Hepatocellular Injury 21. Clonazepam - Enhance GABA
effects - Somnolence (Klonopin) MOA - Class 4 drug (controlled
- Hypersensitivity substance)
- Weight loss
22. Clonazepam side - Hepatotoxicity
- Diarrhea
effects - Sedation
12. Carbamazepine - Bipolar & Trigeminal Neuralgia - Tolerance
Clinical Pearls - Enzyme Inducer
23. Corrected phenytoin Total Phenytoin Level ÷ ((Albumin x
- Autoinducation (self induces its
level equation 0.2) + 0.1)
own metabolism) - IV:PO 70% of
TDD ÷ q 6 hours
24. Elderly tx - Phenytoin 34. Lamotrigine side - rash (2-8 weeks after initiation, Rapid
• Most common used effects titration, Valproic acid)
• Drug-drug interactions - hepatic failure
• PK changes (low albumin levels = - N/V
high phenytoin levels) - suicidal ideation
- Carbamazepine
35. Levetiracetam - Modulate synaptic vesicle
• Drug-drug interactions
(Keppra) MOA - Inhibits Ca2+ release
• PK changes
• St Johns Wart can decrease levels = 36. Levetiracetam side NO significant drug interactions!! Very
increase seizures effects (unicorn) few side effects!!
- Valproate - Behavioral "Keprage"
• Associated with tremor - Euphoria
• Drug-drug interactions 37. Life Threatening - Carbamazepine
• Do NOT take Aspirin Rash - Clobazam
- New generation AEDs - Lamotrigine*
• Favorable alternative - Oxcarbazepine
• Levetiracetam - Phenytoin
25. Fosphenytoin - Compatible with NS or D5W or LR - Phenobarbital
- Max infusion rate = 150 mg/min 38. Medications That - Lamotrigine
- Same onset time as Phenytoin Need Titration - Topiramate
26. Fosphenytoin - Prodrug - Clobazam
(Cerebyx) MOA - Takes time to become 39. Mood - Brivaracetam
active form (15min) - Levetiracetam
- IV only *not ordinarily given IM - Lacosamide
27. Fosphenytoin Side - better tolerated than Phenytoin - Perampanel
Effects 40. Oxcarbazepine - Prodrug (less autoinduction and
28. Hepatotoxicity - Carbamazepine (Trileptal, Oxtellar) agranulocytosis)
- Felbamate Clinical Pearls - more hyponatremia
- Phenytoin 41. Pediatrics tx - Carbamazepine better cognitive and
- Phenobarbital behavioral profiles
- Valproate - Lamotrigine and Oxcarbazepine
29. Lacosamide side - prolonged PR interval improve concentration and attention
effects - Euphoria - Phenobarbital and Phenytoin have
- headache negative impact on memory and
- Dizziness cognition so should not be 1st line

30. Lacosamide (Vimpat ) - Na+ channels modulator 42. Pentobarbital - IV only

MOA - Class 5 dug (controlled substance) Clinical Pearls - refractory status
r/t euphoria epilepticus/uncontrolled ICP
- Renally cleared
31. Lamotrigine Black Steven Johnsons Syndrome
- Propylene glycol
Box Warning
43. Pentobarbital - Enhance GABA
32. Lamotrigine Drug - - Birth control pills will decrease
MOA
Drug Interactions Lamotrigine concentration by 50%
- Valproic Acid ↑ T1/2 to 48 hours 44. Pentobarbital side - Rash
- Phenytoin & Carbamazepine ↓ T1/2 effects - Bradycardia & Hypotension
to 12 hours - Sedation & Hypnosis

33. Lamotrigine - Inhibits glutamate release 45. Phenobarbital - Class 4 drug (controlled substance)
(Lamictal) MOA - Na+ channel modulator Clinical Pearls - Primidone pro-drug
- PO only - IV or PO
- long half life
- Not often started now
46. Phenobarbital - Enhance GABA (inhibitory
MOA neurotransmitter)
47. Phenobarbital side - Hypnosis 56. Teratogenicity - Carbamazepine
effects - Respiratory depression - Phenobarbital
- Hepatotoxicity - Phenytoin
- Steven Johnsons syndrome at high - Topirimate
dose - Valproate
48. Phenytoin - Compatible with NS only 57. Topiramate side effects - Cognitive Impairment (Ditzy)
- Max infusion rate = 50 mg/min (barbie) - Weight Loss
- Must give with 0.22 micron filter - Taste Disturbances
- Enteral feed interaction with PO: - Metabolic acidosis
hold 2hr before and after phenytoin - Kidney Stones
dose - *Suicidal ideation
49. Phenytoin (Dilantin) - Na+ channel modulator 58. Topiramate (Topamax, - Na+ channel blocker
MOA - Prolongs refractory period Trokendi XR) MOA - Enhances GABA
- PO or IV - Blocks glutamate receptors
- PO only
50. Phenytoin & - Hypotension
- Discontinuation: taper
Fosphenytoin IV - Bradycardia
- Renally adjusted medication
reactions - Arrhythmia
Cr/Cl cut of is 70
51. Phenytoin Level Side > 20 mg/L: Nystagmus
59. Valproate/Valproic - Bipolar & Migraine tx
Effects (drunken > 30 mg/L: Nystagmus, ataxia,
Acid/Divalproex Sodium - Highly protein bound so if
monkey) slurred speech, N/V
Clinical Pearls albumin is low need to
> 40 mg/L: Decreased mentation,
correct that level
lethargy, seizures
> 100 mg/L: Lethal 60. Valproate/Valproic - Na+ channel modulator
Acid/Divalproex Sodium - Increases GABA
52. Phenytoin - Highly protein bound (90%)
(Depacon, Depakene, - Monitor LFT frequently at
Pharmacokinetics
Depakote) MOA first then every 6 months
53. Phenytoin Side Effects - Aplastic anemia
61. Valproate/Valproic - Valproic acids stop
- Steven Johnsons Syndrome
Acid/Divalproex Sodium metabolism of Phenytoin,
(Asians)
Drug - Drug Interactions Phenytoin starts metabolism
- Static epilepticus (loading dose)
of Valproic acid
- Gingival hyperplasia
- ↑ Free Phenytoin b/c
- Thrombocytopenia
valproic acid will kick
- Hepatotoxicity
phenytoin off albumin
- Birth defects
- ↓ Meropenem (will decrease
54. Phenytoin Therapeutic Total level + Albumin correction = valproic acid level by 66%)
Drug Monitoring (TDM) 10-20 mg/L -↓
55. Pregnancy tx - Avoid valproate & phenytoin Carbamazepine/lamotrigine
- Monotherapy & low doses (increase risk of rash and
recommended decrease valproic acid)
- Increased clearance/volume of - ↓ Salicylates (displace
distribution valproic acid from albumin
- Monitor monthly and increase valproic acid
- Keppra and Lamotrigine safest in levels)
pregnancy 62. Valproate/Valproic - Hepatotoxicity
- NO Carbamazepine if there is hx Acid/Divalproex Sodium - Severe Pancreatitis
of neural tube defects side effects (grandpa) - Congenital Malformations
- Don't change regimen if already - Inc. ammonia
taking teratogenic drugs - Thrombocytopenia
- Cerebral Atrophy