of seizure disordersmark kotlarewsky md 癫痫发作disordersmark kotlarewsky管理课件

ManagementofSeizureDisordersMarkKotlarewsky MDFACPDepartmentofMedicineMedstarWashingtonHospitalCenter Learningobjectives Understandthedefinitionofseizure epilepsyUnderstandthetypesoftreatment bothmedicalandsurgicalUnderstandnotablesideeffectsofcommonantiepilepticdrugsUnderstandtreatmentandmanagementofepilepsy relatedcomorbiditiesManagementofantiepilepticdrugsinwomenManagementofstatusepilepticus Conflictsofinterest None Definitions seizure abnormal excessive orsynchronousneuronalactivityinthecerebralcortex1 2min alteredconsciousnessiscommon confusion fatigueafteranepisode increasedHR tonic clonicmovement paresthesias aphasiaepilepsy twoormoreunprovokedseizures Seizuretypes Partialsimple doesnotimpairawareness eg epilepticauras jacksonianmarch complex impairsawarenessbytypicallyspreadingtooneorbothtemporallobessecondarilygeneralized whensimpletypespreadstoinvolvebothhemispheresdiffuselyGeneralizedprimary tonic clonicabsence impairmentofconsciousnessmyoclonic musclecontractionsinrapidsuccessionwithoutconsciousnessimpairment Epilepsytypes partialtemporallobe mesialtemporalsclerosisgeneralizedjuvenilemyoclonic morningmyoclonus absence Mesialtemporalsclerosis Epilepsy relatedcomorbidities psychiatricdisorders depression suicide anxietycognitiveproblems visual verbalmemory attentionosteoporosis heartdisease hypertension stroke obesity obstructivesleepapneasuddendeath Choosinganantiepilepticdrug AED effectivenessforseizuretypesideeffectsdrug druginteractionscomorbidconditionsagegenderlifestyle patientpreferencescost ChoosinganAEDbyepilepsytype partial nearlyall particularlylamotrigine carbamazepine oxcarbazepine levetiracetamgeneralized lamotrigine levetiracetam topiramate zonisamide NOTcarbamazepine gabapentin pregabalinastheycansometimesexacerbatethistypeabsence ethosuximide valproateatypicalabsence myoclonic atonic valproate lamotrigine levetiracetam Initiating addingtreatment usuallyonedrug ratherthantwoormore2nddrugshouldhavedifferentmechanism differentsideeffectprofilepublishedtherapeuticserumrangesshouldnotbeusedifpatientisdoingwellclinically unclearwhethergenericsubstitutionsleadtopoorercontrol Mechanisms inhibitorytransmission benzodiazepines clobazam phenobarbital tiagabine vigabatrin sodiumchannels carbamazepine lacosamide lamotrigine oxcarbazepine phenytoin rufinamide calciumchannels ethosuximide potassiumchannels ezogabine excitatorytransmission perampanel multiplemechanisms felbamate valproate gabapentin levetiracetam topiramate AEDsideeffects sedation ataxiafolatedeficiencyrenalmetabolism gabapentin levetiracetam pregabalin topiramate zonisamidehepaticmetabolism carbamazepine phenytoin valproateelderly YES gabapentin lamotrigine levetiracetamNO oxcarbazepine phenytoin carbamazepine AEDsideeffects suicide levetiracetam topiramate vigabatrinStevensJohnsonSynrome toxicepidermalnecrolysis drugrash phenytoin carbamazepine allelescreeninghlab1502inasians oxacarbazepine primidone phenobarbital zonisamide lamotrigineosteoporosis especiallywith phenytoin carbamazepine phenobarbital primidoneandvalproate considercheckingbonemineraldensityafterfiveyearsusewithcautioninpatientswithcardiacconductionpathology lacosamide phenytoin ezogabine AEDsideeffects weightloss zonisamide felbamate topiramateweightgain pregabalin gabapentin valproateinsomnia felbamate lamotriginenephrolithiasis topiramate zonisamidevalproicacid exacerbatessxofpolcysticovariandiseasecarbamazepine inducesownmetabolism Oralcontraceptives carbamazepine phenytoin phenobarbital primidonetendtodecreasecontraceptiveserumlevels alsofelbamate topiramate oxcarbazepine rufinamide clobazam perampanel nointeractionwithlevetiracetam valproatereducedlamotrigineconcentrations whichthengoupduringtheweekofinactivetablets Pregnancy 4 6 rateofteratogenicity 2 3xgeneralpopulationseizurecontrolmoreimportantthanteratogenicityaim monotherapyatlowestdoseforcontrolavoidolderAED s phenytoin phenobarbital valproate lattertwoassociatedwithoralcleft cardiac urinarytract andneuraltubedefects lowerIQtopiramate oralcleft hypospadiasbetter lamotrigine carbamazepine levetiracetam oxcarbazepine gabapentin butmonitorlevelsclosely Pregnancy inducesAEDmetabolism esp lamotriginephenytoin carbamazepine primidone phenobarbital hemorrhageinnewbornduetovitaminKdeficiencyfolate give4mgstarting1 3monthspriortoconceptionifoncarbamazepine valproicacid standarddoseforothers Drug druginteractions phenytoin carbamazepine primidone phenobarb oxcarbazepine topiramate warfarin OCP s anti infectives anti cancerbetweenAED s eg carbamazepinereduceslamotriginelevels valproateincreasesthem alcohol 1 2drinksinwell controlledpatientOK highestriskofseizure7 48hrsaftercessationofalcohol Alternativetx vagalnervestimulation deepbrainstimulationofanteriornucleusofthalamus responsiveneurostimulatorepilepsysurgery highrateofcureinpatientswithknownlesions eg tumor vascularmalformation mesialtemporalsclerosis ketogenic modifiedAtkinsdiet hifat lowcarb STATUS convulsivecontinuedseizureactivity 30min practically initiatetreatmentwithin5minlorazepamfosphenytoinintubate sedate additionalAED STATUS nonconvulsive20 treatedforconvulsivestatusepilepticus developEEGseizurestartmanagementifalteredmentalstatusmorethan20minpostcessationofconvulsiveepisodesensitivityofEEGincreaseslongeritisdone 95 at48hrs paradoxicalimprovementwithlowdosebenzodiazepines Case 1 35yomwh osimplepartialseizure failedlevetiracetamduetosideeffects recentlyswitchedtocarbamazepine presentsc orecurrentseizure Whattodo switchtolamotrigineaddlamotrigineswitchtoethosuximideswitchbacktolevetiracetamcheckcarbamazepinelevel Case 2 70yofwh oosteoarthritis 1stdegreeAVblock hepaticdisease deepvenousthrombosisonwarfarinwasdiagnosedwithpartialseizuredisorderandstartedonprimidone patientwaslosttofollowupbutshowedupintheEDwithanotherDVTandasubtherapeuticINR Whattodo switchtovalproicacidswitchtogabapentincontinueprimidone lowINRisduetowarfarinnon