METODOS DE LABORATORIO PARA DETECCIÓN DE ANTICUERPOS

-Epilepsy = documented h/o at least 2 seizures not related to a metabolic or febrile cause -Risk factors: head trauma, CNS infections, cerebrovascular disease, alcohol, drug overdose or withdrawal, metabolic disorders, genetics, malignancy

-Common provoking factors: sleep deprivation, excessive stimulants, withdrawal from sedatives or alcohol, substance abuse, high fever, hypoxia, hypoglycemia, electrolyte disturbance, estrogen (= more seizures during ovulation and menses)

Differential -Hyperventilation -Migraine -Panic attack -Pseudoseizure -Syncope -Transient global ischemia -TIA -Sleepwalking -Meningitis Workup

-EEG to determine seizure type

-Electrolytes, glucose, anticonvulsant levels, alcohol and tox screen, ABG -LP to r/o meningitis -Head CT or MRI

Management

-When to treat after a single seizure: patients with structural lesion, abnormal EEG, focal seizure

-When NOT to treat after a single seizure: EtOH, drug abuse, provoked seizure, head injury with no structural abnormality

-Drugs are selected based on type of seizure, AEs, toxicity, cost, and childbearing potential

-Begin with monotherapy

-Consider 2nd agent if inadequate trial of 2 different single agents Prognosis

-Most epileptics who go into remission do so within 3 years after their first seizure -Poor prognostic factors for remission: FH of epilepsy, psychiatric comorbidity, h/o febrile seizures, > 20 seizure history, adult age, failed monotherapy

Partial Seizures

Simple Partial Seizures Complex Partial Seizures Management

-No LOC

-Alternation contraction and relaxation of muscle groups -Eye movements and turning of head to the same side -Speech arrest or vocalization

-May see flashes of light or color or have hallucinations -May hear humming, buzzing, or hissing

-May experience unpleasant tastes or odors -Dizziness

-Autonomic symptoms: flushing, incontinence, nausea, vomiting, goose bumps, pupillary dilation, sweating, tachycardia

-Psychiatric symptoms: detachment, memory distortion, time distortion, unprovoked emotion -Can turn into a complex partial seizure or manifest in a continuous form (epilepsia partialis continue)

-The most common kind of seizure

-Can occur after head trauma and many of these pts will have abnormal tissue or lesions in their temporal lobe

-Involves alteration of consciousness

-Automatisms such as lip smacking, picking, patting, chewing, or swallowing

-Inability to carry out simple commands or execute willful movement

-Lack of awareness of surrounding and events -Can become generalized tonic-clonic seizure

-1st _{line: carbamazepine,} phenytoin, lamotrigine, valproate, or oxcarbazepine -2nd line: gabapentin, topiramate, levetiracetam, zonisamide, tiagabine, phenobarbital, felbamate Generalized Seizures

Absence (Petit Mal) Seizures Tonic-Clonic (Grand Mal) Seizures Myoclonic Seizures Other Seizures -5-10 recurrent episodes of staring

-May have minor motor automatisms

-Pts have no memory of incident but are completely normal afterwards

-Can be triggered by hyperventilation Workup

-EEG abnormality will be present even when not seizing

Management

-1st-line: valproate, ethosuximide -2nd line: lamotrigine, levetiracetam Prognosis

-Most cases resolve spontaneously

-Tonic phase begins with LOC, tensing of muscles, and often a loud yell or moan -Clonic phase commences with

convulsions, eyes rolling back, strong jaw contractions

-May have aura -Lasts 5-20 minutes -May have incontinence

-May have unconsciousness after seizure followed by post-ictal state

Management

-1st line: phenytoin, carbamazepine, valproate

-2nd line: lamotrigine, levetiracetam, topiramate, phenobarbital, primidone, oxcarbazepine

-Caused by metabolic abnormalities such as hepatic or renal failure

-Brief major motor seizure with quick, lightning-like jerking movements of the trunk or extremities

-May occur throughout body or limited to certain muscle groups

-Onset may be so sudden that pt falls to the ground but can also be so brief that consciousness is not lost

Management

-1st line: clonazepam, valproate -2nd: lamotrigine, levetiracetam, topiramate, felbamate, zonisamide

Tonic seizures

-Relatively rare to occur alone

-Involve stiffening of the body, upward deviation of the eyes, dilation of the pupils, and altered

respiratory patterns Atonic seizures

-Sudden loss of muscle tone that may cause a fall -Last 1-4 secondes but without LOC

-May affect one part of body to all body tone Management

-1st line: valproate

51

Agent & MOA Info Risks & AEs

Carbamazepine: inhibits voltage-gated Na channels

-Also for treating bipolar disorder, trigeminal neuralgia, and glossopharyngeal neuralgia

-AEs: diplopia, dizziness, drowsiness, nausea, Stevens-Johnson (don’t use in Asians), hypoCa, hypoNa, SIADH, hematologic, hepatitis  monitor CBC, LFTs, mental status, bone density, levels

-Decreases effectiveness of OCPs and warfarin -Pregnancy D

Oxcarbazepine: blocks voltage- gated Na channels, modulates Ca

channels, increases K conductance

-For partial seizures -AEs: sedation, dizziness, ataxia, nausea, Stevens-Johnson, hypoNa  monitor Na -Decreases effectiveness of OCPs and phenytoin

-Pregnancy C Clonazepam: modulates GABA

transmission in the brain

-Not a first-line choice

-Frequently added as a 2nd agent with levetiracetam Ethosuximide: increases seizure

threshold, depresses nerve transmission in the motor cortex

-For absence seizure -AEs: ataxia, drowsiness, GI, unsteadiness, hiccups, Stevens-Johnson, hematologic, SLE -Interactions with carbamazepine and valoproate

-Pregnancy C

Felbamate: glycine-R agonist -For partial and generalized seizures -AEs: anorexia, n.v, insomnia, HA, Stevens-Johnson, aplastic anemia, hepatic failure = weekly LFTs & last resort drug!

-Must sign informed consent

-Interacts with many other seizure meds -Pregnancy C

Gabapentin or pregabalin: modulate Ca channels

-Add-on therapy for seizures -Also for neuropathic pain

-Renal dosing needed

-AEs: dizziness, fatigue, ataxia, nystagmus, tremor, HA, peripheral edema, Stevens-Johnson -Pregnancy C

Lamotrigine: blocks voltage- gated Na channels and inhibits

glutamate release

-Also for bipolar disorder -AEs: nausea, diplopia, dizziness, unsteadiness, HA, rash, Stevens-Johnson, hematologic, liver failure -Interaction with valproate

-Pregnancy C Levetiracetam: inhibits Ca

channels, facilitates GABA, reduces K currents, modulates

NT release

-For partial, tonic-clonic, and myoclonic seizure -AEs: sedation, suicidal ideation, pancytopenia, liver failure -Pregnancy C

Phenobarbital: decreases post- synaptic excitation

-Indicated for seizure and sedation -AEs: ataxia, hyperactivity, HA, unsteadiness, sedation, nausea, cognitive impairment, blood dyscrasia, S- J, hepatic injury, osteopenia

-Many drug interactions -Pregnancy D Phenytoin: stabilizes neuronal

membranes by altering Na efflux

-May be given as fosphenytoin for faster effect -For generalized and complex partial seizures

-AEs: ataxia, nystagmus, behavior, dizziness, HA, sedation, lethargy, incoordination, blood dyscrasias, rash, hirsutism, peripheral neuropathy

Tiagabine: inhibits GABA reuptake

-Adjunct therapy for partial seizures -Pregnancy C Topiramate: modulates Na

channels, enhances GABA, antagonizes glutamate-R

-For partial or generalized seizures -Also indicated for migraine prevention

-AEs: difficulty concentrating, psychomotor retardation (“dopamax”), speech or language problems, fatigue, HA, metabolic acidosis, kidney stones  monitor BMP

-Interacts with OCPs -Pregnancy C Valproate: increases GABA -For absence, complex partial, or mixed-type seizures

-Also for bipolar disorder or migraine prophylaxis

-AEs: GI upset, sedation, unsteadiness, tremor, thrombocytopenia, palpitations, immune hypersensitivity, ototoxicity  monitor CBC and LFTs

-Many drug interactions -Pregnancy D Vigabatrin: irreversibly inhibits

GABA transaminase

-For refractory complex partial seizures or complex generalized seizures -AEs: permanent visual loss, psychiatric disturbances = in a restricted dist program

Zonisamide: MOA unknown -Adjunct for partial seizure -AEs: sedation, dizziness, cognitive impairment, nausea, kidney stones, S-J, schizophreniform disorder -Pregnancy C

52