RxPrep: Ch. 53 - Epilepsy

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kerioppi
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158335
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RxPrep: Ch. 53 - Epilepsy
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2012-06-12 22:02:16
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RxPrep NAPLEX pharmacy pharmacist epilepsy
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Chapter 53 in RxPrep
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  1. Which AEDs decrease effectiveness of oral contraceptives?
    • Carbamazepine
    • Oxcarbazepine
    • Phenytoin
    • Phenobarbital
    • Topiramate (Notes)? or Felbamate (RXP)?
  2. Which AEDs are pregnancy category D?
    • Carbamazepine
    • Clonazepam
    • Phenobarbital
    • Phenytoin
    • Topiramate
    • Valproic acid
    • *CC and Peter Pan like watching TV*
  3. Which AEDs are pregnancy category C?
    Others like lamotrigine (prob safer than others)
  4. What AEDs give modest weight loss?
    • Topiramate (Topamax)
    • Levetiracetam (Keppra)
    • Lamotrigine (Lamictal)
    • Zonisamide (Zonegran)
  5. In general, what is the most common side effect of AEDs?
    CNS side effects, like dizziness, ataxia, somnolence, blurry vision, diplopia
  6. Partial
    • 1st Line:
    • Carbamazepine
    • Oxcarbazepine
    • Lamotrigine
    • Levetiracetam
    • Alternatives: ezogabine, gabapentin, phenytoin, pregabalin, topiramate, valproate, zonisamide
  7. Absence
    • 1st Line:
    • Ethosuximide
    • Valproate
    • Alternative: clonazepam, levetiracetam, zonisamide
  8. Atypical absence, myoclonic, atonic
    • 1st Line:
    • Lamotrigine
    • Levetiracetam
    • Valproate
    • Alternative: clonazepam, felbamate, topiramate, zonisamide
  9. Generalized, tonic-clonic
    • 1st Line:
    • Lamotrigine
    • Levetiracetam
    • Valproate
    • Alternative: carbamazepine, oxcarbazepine, phenytoin, topiramate, zonisamide
  10. What can you mix phenytoin IV in? Max rate of infusion? What happens when you exceed this rate?
    • NS
    • 50 mg/min
    • Severe bradycardia, hypotension
  11. Phenytoin (and Fosphenytoin)
    • Dilantin (and Cerebyx - pro-drug, IV/IM)
    • 100 mg TID, up to 600 mg TID
    • Range: 10-20 mcg/mL
  12. What kind of kinetics does phenytoin have?
    Michaelis-Menten kinetics (small increase in dose, big increase in serum level)
  13. What happens if the albumin is low? How do you correct phenytoin levels?
    • If alb is <3.5, true phenytoin level may be higher than it appears
    • PHTcorr = PHT meas/[(0.2xalb) + 0.1]
  14. How do tube feedings interact with phenytoin?
    Decrease PHT absorption; must separate - hold tube feedings 2 hrs before or 2 hrs after
  15. What is the IV-to-PO ratio of phenytoin? Also compare ER caps to susp/chewable.
    • 1:1
    • ER caps have 8% less drug
  16. What can you mix Cerebyx in? What is the max rate of infusion? What is the ratio between Cerebyx (PE)-to-Phenytoin?
    • NS or D5W
    • 150 mg/min - can push drug in faster
    • 1 mg PE = 1 mg PHT
  17. Is PHT an inducer or inhibitor?
    Inducer
  18. PHENYTOIN
    • Potent inducer, purple glove
    • Hirsutism
    • Enlarged gums (brush and floss!), SLE
    • Nystagmus
    • Yukky blood dyscrasias, yukky purple skin color/damage if drug extravasates
    • Teratogenicity
    • Osteomalacia, osteoporosis
    • Interference w/folic acid absorption (anemia)
    • Neuropathies
  19. What are the major side effects of PHT?
    • Sedation, cognitive impairment
    • Toxicity Sxts:
    • Blurred vision, diplopia
    • Lethargy, drowsiness, HA
    • Ataxia, slurred speech
    • Nystagmus (wobbly eyes)
    • *These sxts are BLANd
    • Chronic Sxts:
    • *SLuG HOPpin', defnitely
    • Skin thickening of face
    • Lupus-like syndrome
    • Gingival hyperplasia
    • Hirsutism
    • Osteomalacia, osteoporosis
    • Peripheral neuropathies
    • VitD, Ca2+ deficiency
  20. What are some serious AEs of PHT?
    SJS, TEN
  21. What should you supplement with PHT?
    Folic acid, vitD, Ca2+
  22. Carbamazepine
    • Tegretol, Tegretol XR, Carbatrol, Epitol
    • Initial: 100-200 mg BID, or daily if XR; Maintenance: 400-1600 mg/d
    • Range: 4-12 mcg/mL
  23. What are the major side effects of carbamazepine (Tegretol)?
    • Nausea, dizziness, drowsiness
    • Rare: hepatotoxicity, SIADH/low Na+
  24. What are Tegretol's BBW?
    • SJS and TEN, esp. if Asian
    • If Asian, need HLA-B*1502 test done
    • Others: aplastic anemia, agranulocytosis
  25. What is another indication of Tegretol? Is it an inducer or inhibitor?
    • Trigeminal neuralgia
    • Inducer and autoinducer
  26. Oxcarbazepine
    • Trileptal
    • 300-600 mg BID
    • If CrCl<30, start at 300 mg daily
  27. What are Trileptal's major side effects?
    • Similar to Tegretol's:
    • GI upset, sedation, ataxia, diplopia
    • SJS and TEN: 20-30% cross rxtivity with Tegretol
    • HypoNa+
  28. Valproate, valproic acid
    Divalproex DR
    • Depakene, Stavzor: soln, liq-filled caps
    • Depakote (ER): ext-rel, sprinkle-filled caps
    • Initial: 125-250 mg BID; Maintenance: 15-45 mg/kg/d
    • Range: 50-100 mcg/mL
  29. Is valproic acid an inducer or inhibitor?
    Inhibitor
  30. Can you substitute Depakote ER for Depakote DR tabs?
    No; must increase ER by 8-20%
  31. What are the major side effects of valproate?
    • Wt gain
    • Alopecia (tx w/selenium, Zn)
    • Thrombocytopenia
    • GI upset, sedation, tremor
  32. What are the 3 BBWs of valproate?
    • Teratogenicity
    • Hepatotoxicty
    • Pancreatitis
  33. Lamotrigine
    • Lamictal, Lamictal ODT, Lamictal CD (chewable), Lamictal XR
    • Titration Schedule:
    • Wk 1-2: 50 mg/d
    • Wk 3-4: 100 mg/d
    • Wk 5: 200 mg/d
    • Wk 6: may increase 100 mg/d every 1-2 wks, max: 400 mg/d
    • Divide BID, daily if XR
  34. What are the side effects of Lamictal?
    N/V, HA, sedation, ataxia, diplopia
  35. What is Lamictal's BBW?
    • SJS, TEN - that's why we have titration schedule
    • FDA 2010: increased risk of aseptic meningitis
  36. Topiramate
    • Topamax
    • Titration Schedule:
    • Wk 1: 25 mg BID
    • Wk 2: 50 mg BID
    • Wk 3: 75 mg BID
    • Wk 4: 100 mg BID
    • Wk 5: 150 mg BID
    • Wk 6: 200 mg BID
    • Sprinkle caps 15 and 25 mg
  37. What are the major side effects of topiramate?
    • Memory problems, concentration diff., paresthesias
    • Nephrolithiasis (keep hydrated!)
    • Oligohydrosis, hyperthermia (limit sun expo., drink H2O!)
    • *I like my MON (man) on top!
  38. What is the intxt b/t valproate and Topamax?
    HyperNH3-emia
  39. What schedule is clonazepam (Klonopin) in?
    CIV
  40. What are the side effects of Klonopin?
    • Sedation, dizziness, ataxia, depression, mood changes, psychological dependence, tolerance
    • Do not d/c abruptly! --> seizures
  41. Levetiracetam
    • Keppra, Keppra XR
    • 500-1500 mg BID
  42. What are the side effects if Keppra?
    Nothing major - sedation, dizziness
  43. If you have a sulfa allergy, which AED must you avoid?
    Zonisamide (Zonegran)
  44. What are the major side effects of Zonegran?
    • SJS and TEN
    • Oligohydrosis/hyperthermia (in kids) (limit sun! Drink H2O!)
    • Nephrolithiasis (drink H2O!)
    • *SON*
  45. What schedule is phenobarb in?
    CIV
  46. What is Primidone (Mysoline)?
    Pro-drug of phenobarbital (Luminal, Barbital)
  47. Is phenobarb an inducer or inhibitor?
    Inducer
  48. What is the t1/2 of phenobarb?
    ~100 hrs
  49. What are the major side effects of phenobarb?
    Somnolence (major!), cognitive impairment, dependence, tolerance, SJS and TEN
  50. What is the schedule of lacosamide (Vimpat) and pregabalin (Lyrica)?
    CV
  51. What is another indication of Lyrica?
    Neuropathic pain
  52. Pregabalin
    • Lyrica
    • 75 mg BID, up to 300 mg/d
    • Decrease dose if CrCl<60
  53. What are the side effects of Lyrica?
    • Slight euphoria (why it's CV)
    • Peripheral edema/wt gain, dizziness, somnolence, blurred vision
  54. Vigabatrin (Sabril) is only available through what program?
    SHARE (Support, Help, and Resources for Epilepsy)
  55. What is the major side effect of vigabatrin (Sabril)?
    Vision loss (thus, vision testing at BL and every 3 mon)
  56. What is the AED used for Lennox-Gastaut seizures?
    Rufinamide (Banzel)
  57. What is status epilepticus?
    Seizure lasting more than 5 minutes or 2+ seizures with incomplete recovery of consciousness between
  58. What are favorable factors for withdrawal of AEDs?
    • Seizure-free for 2-4 yrs
    • Complete seizure control within 1 yr of onset
    • An onset of seizures after age of 2 and before age 35
    • Normal EEG
  59. Why should you be cautious with the combo valproate-lamotrigine?
    May cause rash (valproate is inhibitor --> increase levels of Lamictal --> rash)
  60. Can you take Tegretol with grapefruit?
    No
  61. Which AEDs are inducers?
    • Carbamazepine
    • Phenobarbital/primidone
    • Phenytoin
  62. Which AED is an inhibitor?
    Valproic acid
  63. Which AED does not have any significant drug intxts?
    Keppra
  64. What program should women enroll to if they become pregnant while taking a teratogenic AED?
    NAAED - North American Antiepileptic Drug Pregnancy Registry
  65. Which AEDs have the FDA BBW for hepatotoxicity?
    • Valproic acid
    • Felbamate
  66. Which AEDs require caution in hepatic dysfunction?
    • Vaproic acid
    • Carbamazepine
    • Phenytoin
    • Phenobarbital
    • Tiagabine
  67. Which AEDs require caution in renal failure?
    • Topiramate
    • Gabapentin
    • Pregabalin
  68. Which AEDs are associated with significant cognitive impairment?
    • Phenobarbital/primidone
    • Phenytoin
    • Clonazepam
  69. Which AED has the FDA BBW of pancreatitis?
    Valproate
  70. Which AEDs have the FDA BBW of aplastic anemia?
    • Carbamazepine
    • Felbamate
  71. Which AEDs are known for causing SJS?
    • Carbamazepine
    • Oxcarbazepine
    • Lamotrigine
    • Valproic acid
    • Phenytoin
    • Phenobarbital
    • Zonisamide
    • *PLZ Visit a COP named Steven*
  72. What AEDs causes oligohydrosis (inability to sweat) in kids and nephrolithiasis?
    • Topiramate
    • Zonisamide
  73. Which AED causes wt gain?
    Valproate
  74. Which AEDs cause weight loss?
    • Topiramate
    • Lamotrigine
    • Levetiracetam
    • Zonisamide
  75. What AED increases the risk of aseptic meningitis?
    Lamotrigine
  76. What is one risk that all anticonvulsants have that we must counsel?
    Suicidal ideation/behavior
  77. Can we abruptly d/c AEDs?
    No - must taper
  78. Can we take AEDs with CNS depressants?
    No - avoid if possible
  79. What are 2 OTCs we must avoid with AEDs?
    • St. John's Wort
    • Evening primrose oil
  80. What drugs can decrease the seizure threshold?
    • Bupropion
    • Meperidine (w/poor renal function)
    • Beta lactams (w/poor renal function)
    • Ultram
  81. Which AEDs are FDA approved for migraine prophylaxis?
    • Valproate
    • Topiramate

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