Neuro L43 Epilepsy Treatment

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Treatment modalities for Epilepsy

Pharm
Surgery (resection, transection, vagal nerve stimulation)
Dietary (ketogenic diet)
Alternative (biofeedback, stress reduction, yoga, complementary meds/herbs, acupunture, seizure dogs

Mechanisms of Pharm drugs for epilepsy

1) block repetitive sodium APs by decreasing activity of Na channel (fast and slow inactivation) or increasing activity of K channels
2) block Ca spike
3) block glutamate
4) target GABA
-increase feed forward inhibition at GABA-A receptor
-reduce GABA reuptake, catabolism
-increase GABA-B activity

Phenytoin

mech: Na channel blockade, Ca channel blockade (secondary)

For: First thing you use in status epilepticus

Do not use chronically because many long term effects (Gingival hyperplasia, cosmetic issues, bone loss, risk of toxicity, teratogenicity)
Induces cytochrome P 450

Carbamazepine

mech: Fast Na channel blockade, Ca channel blockade (secondary)

for: partial seizures
may worsen idiopathic generalized epilepsy
Must be given slowly
Strong hepatic enzyme inducer results in multiple drug-drug interactions

Valproate

mech: Na channel blockade, Ca channel blockade (Secondary)

for: idiopathic generalized epilepsy

AE: weight gain, tremor, hair loss; bone loss, teratogenicity, Polycystic ovarian syndrome
hepatic enzyme inhibitor

Ethosuximide

mech: T type Ca channel blockade

for: absence seizures only, can exacerbate other seizure types (generalized tonic clonic seizures)

Gabapentin

mech: potentiate GABA, by increasing total GABA pools with the brains of epileptic patients, and it modifies an auxiliary subunit of a voltage-sensitive calcium channel, Ca Channel blockade

for: very little use in epilepsy, often used for pain management in elderly since no drug interactions

Oxcarbazepine

mech: Fast Na channel blockade, Ca channel blockade (secondary)

for: partial epilepsy

No need for bone marrow or liver function monitoring, unlike CBZ
Adverse effects similar to CBZ; Hyponatremia
Mild hepatic enzyme inducer, does have some drug-drug interactions, adjustment required with phenytoin

Topiramate

mech: Na channel blockade, Ca channel blockade (broadest mech profile of the pharm drugs)

Levetiracetam

mech: Ca channel blockade (secondary)

for: first line use for partial epilepsy, but also juvenile myoclonic epilepsy (JME), primary generalized epilepsy

Behavioral disturbance reported in up to 10% (significant psychiatric side effects)

Zonisamide

mech: Na channel blockade

Lacosamide

mech: Slow Na channel blockade

Benzodiazepines

mech: increase GABA-A

Don't use for chronic management of epilepsy, only in the acute emergent setting

The effect of 2nd generation epilepsy drugs and why there are so many

Not more effective, but safer with fewer side effects
Antiepileptic drugs can be used for pain, psychiatric illnesses, etc which sig increases the pt population

Old AEDs vs New AEDs (AE, spectrum

Old: narrower spectrum
more safety concerns
more are inducers/inhibitors of liver enzymes
bone loss, neuropathy
teratogenicity (but better than New)

New: broader spectrum of epilepsy
less safety concerns
less are inducers/inhibitors of liver enzymes
don't know about bone loss/neuropathy yet
worse profile in teratogenicity

Surgical treatment for epilepsy: what happens, prognosis

Remove the epileptogenic zone
Area whose removal is necessary to abolish seizures
Lesional vs. nonlesional resection--lesional like mesial temporal sclerosis is easier to get out, better prognosis
Temporal vs extratemporal resection--temporal has better prognosis than extratemporal

Mech of Vagal Nerve stimulating treatment of epilepsy

Magnet described as aborting or shortening seizure
Magnet provides a "measure of control" over seizures

AE: related to increased vagus nerve stimulation
Implantation: hoarseness, cough, pain, paresthesia
Stimulation: hoarseness and dyspnea

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