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Management of seizures
This document discusses the management of seizures. It covers the approach to evaluating a patient with seizures, including common diagnostic tests. It then classifies traditional and newer antiepileptic drugs, describing their mechanisms of action and uses in treating different seizure disorders. The document discusses in detail several commonly used antiepileptic drugs, including phenytoin, carbamazepine, phenobarbital, vigabatrin, lamotrigine, felbamate, gabapentin, pregabalin, topiramate, and valproic acid. It also addresses status epilepticus, drug interactions, teratogenic effects, surgical treatment options, and newer drugs in development.
In this document
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Introduction to seizure management framework and key components such as classification and treatment approaches.
Approach to seizure cases involving investigations like EEG, CT, and MRI; four main treatment parts.
Discussion on traditional AEDs such as phenytoin and carbamazepine, and new AEDs like lamotrigine.
Details on excitatory and inhibitory neurotransmission mechanisms alongside specific AEDs.
Guidance on AED selection based on seizure type and combination therapy for refractory seizures.
Key features of Phenytoin’s action, metabolism, half-life, interactions, and potential toxic effects.
Carbamazepine's mechanisms, uses in various seizure types, metabolism, and dosage details.
Descriptions of multiple AEDs, including their mechanisms of action, side effects, and specific indications.
Discusses interactions between AEDs and other medications, alongside teratogenic effects of some drugs.
Overview of surgical treatments for epilepsy, status epilepticus classification, and recommendations for AEDs in pregnancy.
Discussion on newer drugs in the development pipeline targeting seizure disorders.
Q&A session, references for further reading, and concluding remarks for the presentation.
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Management of seizures
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- 2. 1.APPROACH TO ACASE OF A SEIZURE2.ANTIEPILEPTIC DRUG CLASSIFICATION3.MECHANISM OF ACTION AT RECEPTORS4.DRUGS IN EACH SEIZURE DISORDER5.INDIVIDUAL DRUG DESCRIPTION 6.STATUS EPILEPTICUS7.SPECIFIC SCENARIOS8.CONCLUSION
- 3. Approach to acase of seizure
- 4. Investigations1.EEG2.CT scan3.MRI 4.ROUTINEINVESTIGATIONS- serum electrolytes,blood glucose levels,ABG.5.LUMBAR PUCTURE
- 5. FOUR PARTS1.Use ofanti epileptic drugs2.Surgical excision of epileptic foci3.Removal of causative and precipitating factors4.Regulation of physical and mental activity
- 7. Course of acase of EPILEPSY
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- 12. INHIBITORY GABA ergicSYNAPSEGABA-TVIGABATRINGAT -1 TIAGABINEGABA A BENZODIAZEPINES
- 13. Choice of AEDsby type of adult seizure disorder
- 14. COMBINATION of AEDsfor REFRACTORY seizures
- 15. PHENYTOINOldest non sedativeantiseizure drugMore soluble parenteral drug is fosphenytoinM.O.A- blocks sustained high frequency repetitive firing of action potentials –Na channels – at therapuetic concentrations Inhibits release of serotonin,NEPromotes uptake of dopamineInhibits MAO activityStabilization of membraneReduces calcium permeability
- 16. Accumulates in liver,brain,muslcefat.Elimination is dose dependent.T1/2 -24 hoursWhen oral therapy is started -300mg/day regardless of the body weight.Increased the dose by 25-30 mg in adultsDrug interactions – sulfonamides displace phenytoinHigh affinity for Thyroid binding globulinConc. is with use of phenobarbitone,carbamazepine concentration of phenytoin –isoniazidToxicity – nystagmus,diplopia,ataxia,sedationGingival hyperplasia,hirusitismCoarsening of facial featuresMild peripheral neuropathy OsteomalcaiaCausal relation to hodgkin’ s lymphoma agranulocytosis
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- 18. CARBAMAZEPINEClosely related toIMIPRAMINEM.O.A –similar to phenytoin – blocks Na channelsPotentiates post synaptic action of GABAInhibits uptake ,release of NEUses – focal seizures,GTCS,trigeminalneuralgia,BPDNot sedativeINDUCES MICROSOMAL enzymesValproic acid its levels, Phenytoin ,phenobarbitone – levelsOnly oral form.15-25mg/kg/d – children 1gm/day -adults
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- 20. PhenobarbitalOldest of theavailable antiseizure drugs –sedativeDOC in seizures of infantsM.O.A –exact is unknownEnhancement of inhibitory processes,dimintion of excitatory transmissionNa channel blocking at high dosesGABAa receptor actionMay worsen absence ,atonic ,infantile spasmsIn febrile seizures <15ug/ml -ineffective
- 21. VIGABATRINIrreversible inhibitor ofGABA T (degrades GABA)Increases GABA at synaptic sitesInhibits GABA transporterFOCAL seizures,WEST syndromeT1/2 -6-8 hrs 500mg bid2-3 g/dayToxicity -drowsiness,dizziness,weight gain
- 22. LamotrigineSimilar to phenytoinin action Absence attacks in children –voltage gated Ca channelsAdd on treatmentLinear kineticsT1/2 -24 hrs
- 23. FelbamateM.O.A –not knownThirdline drug because of aplasticanemia,hepatitisNMDA receptor blockade via glycine binding siteIncreases phenytoinlevels,valproateDecreases carbamazepineLennox gestaut syndrome
- 24. Gabapentin,PregabalinGABAPENTIN –analog ofGABASpasmolytic,antiseizure drugDoes not act on GABA receptorsAdjunctive drugsNot metabolisedNot bound to plasma proteinsExcreted via renal
- 25. TopiramateSubstituted monosaccharideM.O.A –phenytoinPotentiates GABA action200- 600 mg/ daTIAGABINE –inhibitor of GABA uptakeLEVETIRACETAM – analog of piracetam ,M.O.A unknown,notmetabolised by cytochrome P450Linear kinetcis
- 26. EthosuximidePure petit maldrugReduces T TYPE CALCIUM CURRENTS in thalamusInhibits na k ATPaseDepresses cerebral metabolic rateInhibits GABAaminotransferaseNot protein boundDecrease the dose with valproic acid
- 27. Valproic acidSodium salt,orfree acidFatty carboxylic acidBranching,unsaturation – increases lipophilictyEffective agianst absence seizuresEffective in myoclonic seizuresHepatotoxicity90% bound to plasmaproteinsSedation with phenobarbital useBipolar disorders,migraine prophylaxis
- 28. Benzodiazepines6 Lorazepam –longacting than dioazepamDiazpeam –short acitng,GTCS,respiratory depressionClobazam – 1.,5 benzodiazepineNitrazepamClobazateAcetazomaide –mild acidosis in brain,rapidtolernace
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- 33. Classification of STATUSEPILEPTICUS
- 34. AEDs InPregnancy
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- 37. NEWER drugs inpipeline
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- 42. REFERENCES1.KATZUNG’S 11 thEd PHARMACOLOGY2.LIPPINCOTT ‘S PHARMACOLOGY3.MEDICINE UPDATE 20094.HARRISON’S PRINCIPLES OF INTERNAL MEDICINE 17 th Ed5.ADAM and VICTOR’S NEUROLOGY,9 th Ed6.www.medscape.com7.www.ilae.org8.www.netterimages.com
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