Treatment pathway of Epilepsy
Focal seizures
1. Lamotrigine or Levetiracetam
2. Carbamazipene
Generalised seizures
1. Sodium Valproate
2. Lamotrigine or Levetiracetam
Absent seizures
1. Ethosuximide
2. Sodium Valproate
Management of Status Epilepticus
Seizures that last longer than 5 minutes
- IV Lorazepam
(Buccal midazolam/ rectal diazepam if in community) - Can give a second dose if no response after 5 minutes
- If seizure doesn’t stop after 2x benzo doses:
Levetiracetam, Phenytoin or Sodium Valproate - Phenobarbital/ general anesthesia as a last resort
Side effects of Sodium Valproate
- Skin disorders
- Hepatotoxicity
- Anaemia (blood dyscrasias)
- Vitamin D deficiency- impaired bone health
- Depression/suicide
- Pancreatitis
- TETAROGENIC!
Side effects of Phenytoin
- Skin disorders
- Hepatotoxicity
- Anaemia (blood dyscrasias)
- Vitamin D deficiency- impaired bone health
- Depression/ suicide
- Facial hair
Side effects of Carbamazepine
- Skin disorders
- Hepatotoxicity
- Anaemia (blood dyscrasias)
- Vitamin D deficiency- impaired bone health
- Depression/ suicide
- Hyponatraemia
- Oedema
Which two anti-epileptics have a narrow therapeutic range?
- Carbamazipene: 4-12mg/L
- Phenytoin: 10-20mg/L
What does Phenytoin interact with?
- Anti-folates (e.g., Methotrexate, Trimethroprim)
- CYP inducer (so warfarin, statins, etc. )
What does Carbamazipene interact with?
It’s hyponatraemic, so need to be careful with:
1. SSRIs
2. Diuretics
Pregnancy Prevention Programme- what is suitable contraception?
Pregnancy Prevention Programme- what anti-epileptics require it?
- Sodium Valproate
- Topiratmate
Side effects of Lithium
- Lowers seizure threshold
- Insides (gastrointestinal)
- Thyroid disorders
- Heart- QT prolongation
- Insipidus diabetes - patients should avoid
- Urine increased. Nephrotoxic.
- Metallic taste
HAS TO BE PRESCRIBED BY BRAND!
Lithium monitoring
Therapeutic index (first time): 0.6-0.8 mmol/L
Therapeutic index (relapse): 0.8-1 mmol/L
- Weekly until stable
- Then 3 monthly for the first year
- 6 monthly after that
Side effects of Levodopa
- Impulse disorders
- Red urine
Side effects of non-ergot derived dopamine agonists
Pramipexole, Ropinirole, Rotigotine
- Hallucinations
- Hypotension
- Impulse disorders (much higher risk than in Levodopa)
What drugs are contraindicated in Parkinson’s?
- Haloperidol
- Prochlorperazine
- Metoclopramide
- Chlorpromazine
(“Harry Potter Makes Chaos”)
Treatment of Dementia
Mild to moderate
* Donepezil- causes diziness, take at bedtime
* Galantamine
* Rivastigmine
Moderate to severe
* Memantine
Sedation- What antipsychotics pose the highest risk of causing this side effect, and what antipsychotics pose the lowest risk of causing this side effect?
- Highest risk:
Clozapine
Chlopromazine - Lowest risk:
Aripiprazole
Extra-pyramidal side effects- What antipsychotics pose the highest risk of causing this side effect, and what antipsychotics pose the lowest risk of causing this side effect?
- Highest risk:
Haloperidol - Lowest risk:
Aripiprazole
Anticholinergic- What antipsychotics pose the highest risk of causing this side effect, and what antipsychotics pose the lowest risk of causing this side effect?
- Highest risk:
Clozapine - Lowest risk:
Aripiprazole
QT prolongation- What antipsychotics pose the highest risk of causing this side effect, and what antipsychotics pose the lowest risk of causing this side effect?
- Highest risk:
Haloperidol - Lowest risk:
Aripiprazole
Which SSRI is best to use in unstable angina or recent MI?
Sertraline
Which SSRIs have the highest risk of QT prolongation?
- Citalopram
- Escitalopram
What antipsychotics interact with smoking? And what’s the interaction?
- Clozapine
- Olanzapine
Smoking decreases concentration of Clozapine and Olanzapine
So adverse effects can occur if patient quits smoking.
(N.b., same applies to Theophylline)
