1
Q
Anticonvulsants:
A
- epilepsy
- drug therapy of patients with epilepsy
- dental treatment of the patient with epilepsy
- Nonseizure uses of anticonvulsants
2
Q
Epilepsy:
A
- generalized seizures
- Partial (focal) seizures
3
Q
Nonseizure uses of anticonvulsants:
A
- Neurological pain
- Psychiatric pain
4
Q
Define Epilepsy:
A
A group of disorders involving a chronic stereotype recurrent attack of involuntary behavior or experience or changes in neurological function caused by electrical activity in the brain that can be recorded via an electroencephalogram (EEG)
5
Q
International Classification of Epileptic Seizures:
A
- Generalized Seizures
- Partial Seizures
- Miscellaneous
6
Q
Generalized Seizures:
A
- Tonic Clonic
- Abscence
7
Q
Partial Seizures:
A
- Simple
- Complex
8
Q
Miscellaneous Seizures:
A
-Status epilepticus
9
Q
Tonic Clonic Seizures:
A
- Loss of consciousness for longer period of time
- Major movement of large muscle groups
- Aura and postictal state
- Slow recovery
10
Q
Drugs of choice for Tonic Clonic Seizures:
A
- Valproate
- Lamotrigine
- levetiracetam
11
Q
Absence Seizures:
A
- Brief loss of consciousness
- Little movement
- Body tone is not lost
- No aura or postical state
- Quick recovery
12
Q
Drug of choice for absence seizures:
A
Ethosuxumide
13
Q
Status epilepticus:
A
- Continuous Tonic-Clonic Seizures that last longer than 30 minutes OR
- Recur before the end of the postical period of the previous seizure
- Emergency situation
- Parenteral benzodiazepines
- Diazepam (Valium)
14
Q
Partial (Focal) Seizures:
A
- Involve activation of only part of the brain and the location of the activity determines the clinical manifestations
- Simple partial attack-Consciousness is not impaired
- Complex partial attack- consciousness is impaired; may have aura and slow recovery
15
Q
Drug of choice for partial (focal) Seizures:
A
- Iamogotrigine
- Carbamazepine
- Levetiracetam
- oxcarbazepine
16
Q
Drug therapy of patients with epilepsy: General Adverse Reactions
A
- Central nervous system depression:
- tolerance to sedative effects
- impaired learning and cognitive abilities
- hyperactivity and sedation
- Exacerbation of different seizure type
- Gastrointestinal distress-anorexia, nausea, or vomiting
- Drug interactions:
- Stimulation of hepatic microtonal enzymes
- More interactions with older drugs including phenytoin due to narrow TI
17
Q
Drug therapy of patients with epilepsy: general adverse reactions, drug interactions, idiosyncratic reactions
A
- Dermatoligic side effects:
- Rash
- Stevens-Johnson’s syndrome
- Exfoliative dermatitis
- erythema mutliforme
- Drug-induced systemic lupus erythematosus
- Hematologic effects
- Teratogenicity/growth
- Withdrawal-abrupt withdrawal can precipitate a seizure
18
Q
Valproate: Mechanism of Action
A
- Effect on Sodium and potassium channels
- Reduction in aspirate levels
- Increase in the inhibitory neurotransmitter gamma aminobutyric (GABA)
19
Q
Adverse reactions of Valporate GI Effects:
A
- Indigestion, Nausea, Vomiting
- Hypersalivation
- Anorexia
- Increased appetite
- Cramping
- Diarrhea
- Constipation
20
Q
Adverse reactions of Valproate CNS effects:
A
- Sedation and drowsiness
- Rarely: Ataxia, headache, nystagmus
- Hyperactivity, aggression, behavioral disturbances
- Weight gain
- Increased appetite
21
Q
Adverse reactions of Valproate:
A
- Hepatotoxicity; liver function tests should be performed. Black box warning
- Prolonged bleeding time
- Teratogenicity
22
Q
Drug interactions of Valproate:
A
- additive CNS depressant effect
- Inhibits the metabolism of phenobarbital > Excessive sedation
- Drug interactions with phenytoin > decrease Valproate action and Increased PHENYTOIN action
- Bleeding; prolongs bleeding time
23
Q
Lamotrigine (Lamictal): uses
A
- Elderly Patients, newly diagnosed with partial or generalized seizures
- Children with absence seizures
- Bipolar disorder maintenance therapy
- Improved depression in patients with epilepsy
24
Q
Lamotrigine (lactimal) Adverse Reactions:
A
- Dizziness
- ataxia
- somnolence
- headache
- dislopia
- nausea
- vomiting
- rash
- insomnia
- in coordination
- Steven-Johnson’s syndrome
25
Lamotrigine (lactimal): Drug interactions
-Carbamazepine reduces Lamotrigine levels
| Valproate increases Lamotrigine levels
26
Levetiracetam (Keppra): uses
- Monotherapy for Partial- onset and generalized Tonic-Clonic Seizures
- Children with absence seizures
27
Levetiracetam (Keppra): Adverse Reactions
- dizziness
- somnolence
- weakness
- suicide ideation
- Agressive behavior
- Irritability
- Hostility
- Psychosis
- Steven-Johnson’s Syndrome
28
Carbamazepine (Tegretol)
- Related to tricyclic antidepressants
- Uses:
- Trigeminal neuralgia
- Bipolar depression
- Pharmilogical effects:
- Blocking sodium channels
- Inhibition of High-frequency repetitive firing in neurons
- Decrease in synaptic transmission
29
Carbamazepine (tegretol): Adverse Reactions, CNS effects
- Dizziness
- Vertigo
- Drowsiness
- Fatigue
- ataxia
- Confusion
- Headache
- Nystagmus
- Visual (diplopia) and speech disturbances
- Latent psychosis
- abnormal involuntary movements
- depression
- peripheral neuritis
30
Carbamazepine (tegretol): Adverse Reactions
- GI effects:
- Nausea, vomiting, gastric distress
- abdominal pain
- Diarrhea, constipation
- anorexia
- Hematologic effect:
- Fatal Blood dyscrasias such as aplastic anemia have been reported in the first 4 months of treatment of the elderly
31
Carbamazepine (tegretol): Adverse Reactions (Cont.)
- Dermatologic Effects:
- Rashes
- Urticaria
- Photosensitivity Reactions
- Altered skin pigmentation
- erythema multiforme
- erythema nodosum
- Aggrevation of systemic lupus erythematous
- Alopecia
32
Carbamazepine (tegretol): Adverse Reactions (cont.)
- Oral Effects:
- Dry mouth
- Glossitis
- Stomatitis
- Chewable Carbamazepine-63% sugar
33
Carbamazepine (tegretol): Drug interactions
- Carbamazepine can induce liver microsomal enzymes
- Decreases the effect of doxycycline, warfarin, theophylline, and oral contraceptives
- Effects may be increased by erythromycin, isoniazid, and calcium channel blockers
34
Phenytoin (Dilantin)
- Used to treat Tonic-Clonic and partial seizures
- GI Effects
- CNS Effects:
- Mental confusion, nystagmus,ataxia, slurred speech, blurred vision, diplopia, amblyopia, Dizziness, and insomnia
- Dermatologic Effects:
- Skin Reactions range from rash to exfoliate dermatitis, lupus erythematous, or Steven-Johnson’s syndrome
- Hypertrichosis on the trunk and face
35
Phenytoin (Dilantin): Adverse Reactions
```
Vitamin Deficiency:
-Vitamin D and folate
-Osteomalacia May result
Teratogenicity/growth:
-Fetal hydantion syndrome
-craniofacial anomalies, microcephaly,nail or digit hypoplasia, limb defects, growth deficiency, and mental retardation
-Thickening of facial structures
```
36
Phenytoin: Adverse Reactions
Gingival enlargement symptoms
- Often painless enlargement of the gingival margin
- interproximal papillae involvement
- Coalesce to cover occlusal surfaces of the teeth
- Occurs in approx. 50% of patients using the medication long term
- More common in anterior than posterior
- More common on buccal than lingual/palatial
- Rarely involves edentulous areas
- gingival does not bleed easily
37
Gingival enlargement:
-Drug induced gingival overgrowth is a side effect associated principally with 3 types of drugs: anticonvulsants (phenytoin), immunosuppressant (cyclosporine A), and various calcium channel blockers (nifedipine, verapamil, diltiazem)
38
Phenytoin: Adverse Reactions Gingival enlargement
- Unknown etiology
- Management:
- Choose another anti epileptic drug
- Discontinue phenytoin
- Improve oral hygiene
- Consider gingivectomy
- Consider other drugs
39
Miscellaneous Anticonvulsant Agents: Ethosuxumide (Zarontin)
- Mechanism of action: Inhibiting the T-type calcium channels
- GI Adverse Effects: Drowsiness, hyperactivity, headache, and hiccups
- Blood dycrasias, systemic lupus erythematous, Steven Johnson’s syndrome, hirsutism, gingival enlargement, and swelling of the tongue
40
Miscellaneous Anticonvulsant Agents: Benzodiazepines
- Clonezepam (Klonopin) uses:
- Absence Seizures not responsive to ethosuximide
- Mental Illnesses
41
Anti epileptic Agents:
Gabapentin (Neurontin)
- Mechanism of Action: GABA analog but does not interact with GABE receptor
- Use: adjunct treatment of partial seizures, with and without generalized in adults and children 3 years of age and older
- Adverse Reactions: Somnolence, Dizziness, fatigue, ataxia, nystagmus, blurred vision, and confusion. Edema weight gain and movement disorders have been reported.
42
Nonseizure Uses of Anti-epileptics:
- Chronic Pain Management (Neurontin)
- Trigeminal Neuralgia (Carbamazepine
- Migraine Headache Prophylaxis (Valproice Acid)
43
Dental treatment of the patient with Epilepsy:
```
Preventive measures:
-Detailed Seizures history
-Thoughtful treatment planning
-Education of entire staff
Management:
-Move patient to the floor if possible
-Tilt Patients head to one side
-Remove objects from the Patients mouth
```
Pharmocology
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