CNS PART 3.docx

[CNS PART 3] SEIZURES +-------------+-------------+-------------+-------------+-------------+ | Seizure | FOCAL | GENERALIZED | ABSENCE | ATYPICAL, | | type | | | | MYOCLINIC, | | | | | | AN...

[CNS PART 3] SEIZURES +-------------+-------------+-------------+-------------+-------------+ | Seizure | FOCAL | GENERALIZED | ABSENCE | ATYPICAL, | | type | | | | MYOCLINIC, | | | | | | AND ATONIC | +=============+=============+=============+=============+=============+ | 1^st^ line | Carbamazepi | Carbamazepi | Valproic | Valproic | | | ne | ne | acid | acid | | | | | | | | | Phenytoin | Phenytoin | Lamotrigine | | | | | | | | | | Fosphenytoi | Fosphenytoi | Ethosuximid | | | | n | n | e | | | | | | | | | | Valproic | Valproic | | | | | acid | acid | | | | | | | | | | | Lamotrigine | | | | | | | | | | | | Lacosamide | | | | | | | | | | | | Topiramate | | | | | | | | | | | | Oxcarbazepi | | | | | | ne | | | | +-------------+-------------+-------------+-------------+-------------+ | 2^nd^ line | Eslicarbaze | Felbamate | Clonazepam | Clonazepam | | | pine | | | | | | | Gabapentin | Paramethadi | levetiracet | | | Felbamate | | one | am | | | | Levetiracet | | | | | Gabapentin | am | Trimethadio | | | | | | ne | | | | Levetiracet | Phenobarbit | | | | | am | al | Methsuximid | | | | | | e | | | | Perampanel | Primidone | | | | | | | Phensuximid | | | | Phenobarbit | Ethotoin | e | | | | al | | | | | | | Mephobarbit | | | | | Pregabalin | al | | | | | | | | | | | Primidone | Mephenytoin | | | | | | | | | | | Tiagabine | Vigabatrin | | | | | | | | | | | Vigabatrin | | | | +-------------+-------------+-------------+-------------+-------------+ +-----------------------------------+-----------------------------------+ | Phenytoin- focal and tonic clonic | \- therapeutic levels are 10-20 | | | | | Inhibition of sodium channels | \- AE: nystagmus, sedation, | | | ataxia, diplopia, gingival | | | hyperplasia, skin rash, toxic to | | | fetus, and CV | | | | | | \- gingival hyperplasia: treated | | | w/gingivectomy or folic acid 0.5 | | | mg daily. Good oral hygiene! | | | | | | \- decreases effects or oral | | | contraceptives, warfarin and | | | glucocorticoids. Increases levels | | | of diazepam, isoniazid, | | | cimetidine, alcohol and valproic | | | acid. | | | | | | \- administer w/food | +===================================+===================================+ | Carbamazepine- focal and tonic | -BBW: people of Asian descent | | clonic | should have HLA-B1502 genetic | | | testing done due to risks of | | | dermatologic reactions, aplastic | | | anemia and agranulocytosis CBC | | | | | | \- AE: pruritus, rash, c/n/v, | | | ataxia, dizzy, somnolence, | | | blurred vision, retention, | | | xerostomia, hyponatremia, blood | | | dyscrasias, SIADH | +-----------------------------------+-----------------------------------+ | Oxcarbazepine- CYP inducer, | \- AE: hyponatremia, necolysis, | | partial in adults and kids | SJS, and toxic epidermal | | | necolysis | | | | | | \- lower birth control and raises | | | phenytoin | | | | | | \- monitor if being given | | | w/diuretics due to low Na | +-----------------------------------+-----------------------------------+ | Eslicarbazepine- focal in adults | | | and kids \>4 | | +-----------------------------------+-----------------------------------+ | Valproic acid | \- uses for seizure, bipolar, and | | | migraines | | | | | | \- AE: hepatotoxicity, | | | pancreatitis, teratogenic, | | | hyperammonemia | | | | | | \- BBW: liver failure | +-----------------------------------+-----------------------------------+ | Ethosuximide- drug of choice for | \- associated with blood | | absence seizures. | dyscrasias, CNS depression, SLE, | | | and cutaneous reactions | | Major substrate= serum | | | concentrations are affected by | | | CYP inducers/inhibitors | | +-----------------------------------+-----------------------------------+ | Phenobarbital- anticonvulsant | \- works w/out causing sedation | | barbiturate | | | | \- monitor serum concentration | | | 10-40 | | | | | | \- AE: dependency, exacerbation | | | of porphyria, rickets | | | osteomalasia, nystagmus, and | | | ataxia | | | | | | \- do not give in pregnancy | | | malformations/bleeding | | | | | | \- drug should be stopped | | | gradually to avoid w/draw | +-----------------------------------+-----------------------------------+ | Primidone- active against all | Similar to phenobarbital | | seizures except absence | | +-----------------------------------+-----------------------------------+ | Gabapentin- partial | \- off label for neuropathic | | | pain, prophylaxis of migraines, | | | fibromyalgia, post-menopausal hot | | | flashes | | | | | | \- hypersensitivity: angioedema, | | | rhabdo | +-----------------------------------+-----------------------------------+ | Pregabalin | \- may enhance sedative effects | | | of other CNS depressants and may | | | enhance fluid retaining of | | | thiazolidinediones | | | | | | -AE: weight gain | | | | | | \- high risk for dependency/abuse | | | | | | \- interactions: alcohol, | | | opioids, benzos | +-----------------------------------+-----------------------------------+ | Lamotrigine | \- seizure, bipolar | | | | | | \- AE: meningitis, risk for | | | suicide | +-----------------------------------+-----------------------------------+ | Levetiracetam- focal, myoclonic, | \- monotherapy for focal and | | tonic clonic | general | +-----------------------------------+-----------------------------------+ | Lacosamide | \- add on therapy for partial | | | onset in pts 17yrs or older | | | | | | \- AE: prolonged PR, euphoria | +-----------------------------------+-----------------------------------+ | Tigabine- partial \>12 | | +-----------------------------------+-----------------------------------+ | Perampanel- focal \>4 and | \- BBW: psych reactions | | adjunctive for general tonic | | | clonic \>12 | | +-----------------------------------+-----------------------------------+ | Topiramate- adjunctive therapy w/ | \- AE: weigh loss, thinking | | Lennox-Gastaut syndrome | issues, kidney stones | +-----------------------------------+-----------------------------------+ | Zonisamide | | +-----------------------------------+-----------------------------------+ | Felbamate- can be used w/ | \- life threatening, informed | | Lennox-Gastaut | consent needed | | | | | | \- aplastic anemia and liver | | | failure | | | | | | \- restricted to pts that all | | | other tx have failed | +-----------------------------------+-----------------------------------+ | Vigabatrin- infantile spasms and | \- only distributed through REM | | complex partial \>10 not | program | | controlled w/ usual tx | | | | \- BBW: permanent loss of vision, | | | test q3mo | +-----------------------------------+-----------------------------------+ | Rufinamide- lennox \>1yr | | +-----------------------------------+-----------------------------------+ | Ezogabine- K channel opener | \- urinary hesitancy or | | | retention, red/orange urine | +-----------------------------------+-----------------------------------+ | Brivaracetam | \- partial \>4 and injectable | | | \>16 | | | | | | \- neutrophil to decrease | | | | | | \- cautious w/ renal or liver. | | | Strong CYP substrate | +-----------------------------------+-----------------------------------+ Status epilepticus - Maintain ventilation, hypoglycemia - Drug of choice: benzo lorazepam or diazepam if lorazepam is not available In children Lennox-Gastaut syndrome - Respond to valproic acid, benzo, and lamotrigine