Anti- epileptic Drugs
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-Management of various of forms of epilepsies including treatment of status epilepticus -Status of newer anti-epileptic drugs in treatment of epilepsies
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Anti- epileptic Drugs
- 1. ANTI-EPILEPTIC DRUGS •Management of various of forms of epilepsies including treatment of status epilepticus •Status of newer anti-epileptic drugs in treatment of epilepsies CHOYTOO Shiksha Roll No 12
- 2. CONTENTS • Introduction • Types of seizures • Brief description of each type of seizures and their management • Status of newer anti-epileptic drugs
- 3. INTRODUCTION • Aim : control and totally prevent all types of seizures at an acceptable level of S/E • Treatment should be started early with single low dose • Simple therapy • Drug withdrawal should be gradual • Pregnancy : treatment not stopped dose is reduced folic acid is supplemented in 1st and 2nd trimester along with vit k in last trimester
- 4. TYPES OF SEIZURES GENERALISED SEIZURES PARTIAL SEIZURES Generalized Tonic Clonic Seizures Simple partial seizure Absence seizures Complex partial seizures Atonic seizures Simple or complex partial seizures secondary to generalised seizures Myoclonic seizures Infantile spasms
- 5. GTC SEIZURE • Sudden loss of consciousness • Tonic phase - 1min - sustained muscle contraction • Clonic phase - 2-4 min - muscle relaxation • CNS depression follows and patient goes into sleep
- 6. PARTIAL SEIZURES Simple Partial Seizures (Jacksonian) Involves one side of the brain at onset. motor, sensory or speech disturbances. Confined to a single limb or muscle group. Last for 20-60 s No alteration of consciousness.
- 7. MANAGEMENT OF PS AND GTCS • Carbamazepine - preferred drug in PS Preferred in young girls – cosmetic effects • Valproate - used in GTCS cautious with children-hepatotoxicity • Alternative s- Lamotrigine, gabapentin & topiramate are good alternatives (either add on or as monotherapy) • Complete control in 90% patients with generalised seizures but, only 50% in patients with partial seizures.
- 8. Type First choice Second choice Add on General tonic- clonic Simle Partial seizures Carbamazepine, phenytoin Valproate, phenobarbitone Lamotrigine, gabapentin, topiramate, primidone, levetiracetam
- 9. PARTIAL SEIZURE Complex Partial Seizures • Produces confusion and inappropriate or dazed behavior. • Motor activity appears as non-reflex actions. • Automatisms (repetitive coordinated movements). • Purposeless movements like lips smacking or hand wringing • Last for 30 s to 2 min, preceded by aura • Consciousness is impaired or lost.
- 10. MANAGEMENT OF CPS • It is usually difficult to control • Carbamazepine + phenytoin or valproate is given • Refractory cases: levetiracetam, lamotrigine, gabapentin, topiramate or zonisamide. Type First choice Second choice Add on Complez partial seizure Carbamazepine Valproate Phenytoin Gabapentin Lamotrigine Levetiracetam Clobazam Zonicamide Topiramate
- 11. ABSENCE SEIZURE • Sudden onset of impaired conciousness • With staring • Last less than 30 min • attack may be associated with mild clonic jerking of the eyelids or extremities • postural tone changes • autonomic phenomena
- 12. MANAGEMENT OF ABSENCE SEIZURE • Both valproate and Ethosuximide can be use • Valproate : most commonly used - prevent kindling & emergence of GTCS • Lamotrigine is a good alternative • Clonazepam limited by sedative effects, and development of tolerance • clobazam- more sustained response
- 13. Type First choice Second choice Add on absence valproate Ethosuximide , lamotrigine Clobazam, clonazepam
- 14. ATONIC SEIZURES • Akinetic epilepsy • Unconsciousness , Relaxation of all muscles • Sudden loss of postural tone • Due to excessive inhibitory discharges • Patient may fall MYOCLONIC SEIZURES • Sudden , brief, shock like contraction of muscles • It may be limited to one part of the body or whole body
- 15. MANAGEMENT OF ATONIC & MYOCLONIC SEIZURES • Valproate is preferred • Lamotrigine preferred alternative • Topiramate & levetiracetam may be added in unresponsive or poor response Type First choice Second choice Add on myoclonic valproate Lamotrigine, topiramate Levetiracetam, clonazepam atonic valproate Clonazepam, clobazam lamotrigine
- 16. MANAGEMENT OF FEBRILE CONVULSIONS AND INFANTILE SPASMS • Rectal diazepam 0.5mg/kg • Anti epileptics ineffective in infantile spasms • corticosteroids provide symptomatic relief. • Valproate, clonazepam or Vigabatrin has some efficacy Type First choice Second choice Add on febrile Diazepam-rectal
- 17. STATUS EPILEPTICUS • continuous seizure lasting more than 30 min, • or two or more seizures without full recovery of consciousness between any of them. • medical emergency associated with significant morbidity and mortality Type First choice Second choice Add on Status epilepticus Lorazepam & diazepam IV Fosphenytoin, phenobarbitone GA
- 18. MANAGEMENT OF STATUS EPILEPTICUS • Lorazepam 0.1 mg/kg IV inj at 2mg/min (effective and longer acting anticonvulsant) If lorazepam is unavailable, • Diazepam 5-10 mg every 10-15 min (max. 30 mg) • Phenytoin 500 – 1000 mg (max 1000 in 24 hr) IV • Nowadays fosphenytoin is prefered max 1000 phenytoin equivalent
- 19. • No respond to phenytoin, phenobarbitone is used , 100 -200 mg • Seizure continues GA with propofol or thiopental in the last resort. • This is guided by EEG. • General measures ▫ Maintenance of airways , oxygenation, fluid and electrolyte balance, BP, Pulse rate
- 21. LAMOTRIGINE • Dose 50mg/day initially, increase upto 300mg/day as needed • not to be used in children • MOA: same as carbamazepine • Broad spectrum anti-epileptic • Abs orally, half life 24 hours • Better tolerated than carbamazepine or phenytoin, no negative effect on cognitive function
- 22. GABAPENTINE • Modifies maximal electro shock and inh. PTZ induced clonic seizure • Add on to first line of drug • Can even be used as monotherapy • Reduces seizure frequency in refractory partial seizures • No change in primary antiepileptic drug is required when gabapentine is added • Dose: start with 300 mg OD, inc up to 300- 600mg TDS as required
- 23. TOPIRAMATE • Weak carbonic anhydrase inhibitor • broad spectrum anti convulsant activity in partial tonic seizures & kindling model • Monotherapy & adjuvant drug • Great results in myoclonic epilepsy • Dose: initially 25mg OD increase weekly upto 100- 200mg BD as required
- 24. ZONISAMIDE • Weak carbonic anhydrase inhibitor • Add on drug in refractory partial seizures • Dose : 25-100mg BD
- 25. LEVETIRACETAM • Unique- suppresses kindled seizures but ineffective against PTZ or maximal electroshock. • Free of drug interactions. Good tolerability hence, use increasing in complex partial seizures, grand mal epilepsy & myoclonic epilepsy. • Dose : 0.5mg BD, increase upto 1.0g BD
- 26. TIAGABINE & VIGABATRIN • Tiagabine : Potentiates GABA • Add on therapy of partial seizures • Vigabatrin : (-) of GABA transaminase • effective in refractory epilepsy • only adjuvant medication.
- 27. REFERENCES • padmaja udaykumar – med. pharmacology
- 28. •THANK YOU