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Anticonvulsants
Roach Ch 30
85
Pharmacology
Undergraduate 1
11/07/2012

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Cards

Term
Convulsion
Definition
  • sudden and involuntary contraction of muscles, often with loss of consciousness
Term
Seizure
Definition
disturbance in brain’s electrical activity, often causing convulsion, though not necessarily.
Term
Idiopathic Seizures
Definition
No known cause
Term
Acquired seizures
Definition
  • from known causes, eg high fevers, elec imbalances, hypoglycemia, brain tumors, etc; best to treat underlying condition
Term
Partial seizures 
Definition
  • = most common, from local brain area with specific symptoms; can cause a simple seizure (consciousness impaired/changed), motor seizure, or somatosensory seizure, etc. Depends on area of brain.  There is not a loss of consciousness.
Term
Generalized seizures
Definition
  • loss of consciousness with or without convulsions. 
  • tonic-clonic or myoclonic
Term
Tonic Clonic and Myoclonic Genrealized Seizures
Definition

§         Tonic-clonic = alternating bt tonic (contraction) and clonic (relaxation) and abnormal behavior

§         Myoclonic = sudden forceful contractions

Term

1.        ethotoin

2.        fosphenytoin

3.        phenytoin (Dilantin)

Definition
hydantoin anticonvulsants
Term

1.        valproic acid (Depakote)

Definition
carboxylic acid derivitive anticonvulsant
Term
carboxylic acid derivitive anticonvulsant
Definition
valpoic acid (Depakote)
Term

1.        ethosuximide

2.        methsuximide

Definition
succinimides
Term

1.        clonazepam (Klonipin)

2.        clorazepate

3.        diazepam (Valium, Diastat)

4.        lorazepam (Ativan)

Definition
BENZODIAZEPINES
Term

1.        acetazolamide

2.        carbamazepine (Tegretol)

3.        felbamate

4.        gabapentin (Neurontin)

5.        lamotrigine (Lamictal)

6.        levetiracetam

7.        magnesium

8.        oxcarbazepine

9.        pregabalin (Lyrica)

10.     primidone

11.     tiagabine

12.     topiramate (Topamax)

13.     zonisamide

Definition
Miscellaneous anticonvulsants
Term
General action of ALL anticonvulsants
Definition
depresses abnormal nerve impulses in CNS
Term
Action of hydantoins
Definition

stabilize hyperexcitability postsynaptically in motor cortex

Term
carboxylic acid derivitive action
Definition
increase GABA to stabilize sell membranes
Term
actions of succinimides
Definition

depress motor cortex, making higher threshold for nerve reaction to convulsive stimuli

Term
Action of oxazolidinediones
Definition
decrease repetitive synaptic transmissions
Term
Actions of benzodiazepines and barbituates
Definition

elevate seizure threshold by decreasing post synaptic excitability

Term
Uses of anticonvulsants
Definition

a.        Prevention of seizures after trauma, neurosurgery, or brain tumors

b.       seizure disorders

c.        neuropathic pain

d.       bipolar

e.        anxiety disorder

f.         lorazepam is drug of choice for status epilepticus – though lasts only about an hour, so must give with longer lasting anticonvulsant like phenytoin

Term
CNS Adverse reactions of anticonvulsants
Definition

                                                               i.      drowsiness, somnolence

                                                              ii.      weakness

                                                            iii.      dizziness

                                                            iv.      headache

                                                             v.      nystagmus

                                                            vi.      ataxia

                                                          vii.      slurred speech

Term
GI adverse reactions of anticonvulsants
Definition

                                                               i.      N/V

                                                              ii.      anorexia

                                                            iii.      C/D

                                                            iv.      gingival hyperplasia (overgrowth of gums)

Term
Other adverse reactions to anticonvulsants (besides CNS and GI)
Definition

                                                               i.      rash, pruritus, urticaria

                                                              ii.      urinary frequency

                                                            iii.      serious skin reactions like Steven-Johnsons syndrome assoc with lamogrigine (Lamictal)

                                                            iv.      Some assoc with hematologic changes like pancytopenia, leucopenia, aplastic anemia, thrombocytopenia (carbamezepine, felbamate, trimethadione)

Term
Contraindications of phenytoin (Dilantin)
Definition

                                                               i.      sinus bradycardia

                                                              ii.      sinoatrial block

                                                            iii.      Adams-Stokes syndrome

                                                            iv.      2nd and 3rd degree AV block

                                                             v.      pregnancy and lactation (cat D)

Term

Contraindications of ethoin (Peganone)

What type of drug is ethoin?

Definition

                                                               i.      hepatic abnormalities

                                                  


A HYDANTOIN

Term
Contraindications of oxazolidineediones
Definition

                                                               i.      associated with serious adverse reactions and fetal malformations

                                                              ii.      Only used when less toxic drugs are not effective

Term
contraindicatinos of succinimides
Definition

                                                               i.      bone marrow depression

                                                              ii.      hepatic or renal impairment

                                                            iii.      associated with higher rate of lupus

Term
contraindications of carbamazepine
Definition

                                                               i.      do not give within 14 days of MAOI

                                                              ii.      bone marrow depression

                                                            iii.      hepatic or renal impairment

                                                            iv.      pregnancy (cat D)

Term
contraindications of valproic acid (Depakote)
Definition

                                                               i.      renal impairment

                                                              ii.      pregnancy (cat D) – increased risk for birth defects

Term
contraindication of oxcarbazepine (Trileptal)
Definition
can exacerbate demntia
Term
Use of anticonvulsants in pregnancy
Definition
anticonvulsants in pregnancy associated with birth defects; sometimes anticonvulsants NOT DCed in pregnancy bc possible status epilepticus.  If no serious threat to pregnant women, will DC during pregnancy.
Term
Precautions barbituates
Definition

                                                               i.      kidney disease

                                                              ii.      neuro disorders

                                                            iii.      pulmonary disease

                                                            iv.      hyperactive children

Term
precautions benzodiazepines
Definition

                                                               i.      kidney disease

                                                              ii.      neuro disorders

                                                            iii.      pregnancy (cat D)

                                                            iv.      psychoses

                                                             v.      acute narrow glaucoma

                                                            vi.      elderly

                                                          vii.      debilitated

Term
Precautions phenytoin
Definition

                                                               i.      kidney disease

                                                              ii.      neuro disorders

                                                            iii.      hypotension

                                                            iv.      severe myocardial insufficiency

                                                             v.      hepatic impaiment


phenytoin can also cuase hemo changes, leading to increased risk of infetions, increased bleeding, etc; signs of infection and bleeding, etc must be reported immediately

Term
Precautions trimethadione
Definition

                                                               i.      kidney disease

                                                              ii.      neuro disorders

                                                            iii.      eye disorders like retinal or optic nerve disease (can cause vidual disturbances)

Term
Precautions of miscellaneous anticonvulsant drugs
Definition

                                                               i.      kidney disease

                                                              ii.      neuro disorders

                                                            iii.      glaucoma or increased IOP

                                                            iv.      Hx of cardiac, renal, or liver dysfunction

                                                             v.      psychiatric disorders

Term
precautions of valproic acid
Definition

                                                               i.      kidney disease - increased risk for failure

                                                              ii.      neuro disorders

                                                            iv.      increased risk for pancreatitis

Term
anticonvulsant + antibiotics/antifungals
Definition
increased effect of anticonvulsant
Term
anticonvulsant and tricyclics
Definition
increased effect of anticonvulsnat
Term
anticonvulsants and cimetidine
Definition
à increased effect of anticonvulsant
Term
anticonvulsant and theophyline
Definition
decreased serum levels of anticonvulsant
Term
anticonvulsant with antiseizure meds
Definition

à may increase seizures

Term
carbamezapine (Tegratol) + protease inhibitors
Definition
à increase carbamezapine to toxic levels
Term
anticonvulsants with oral contraceptives
Definition
à decreased effect of BC
Term
anticonvulsants with CNS depressants like alcohol, analgesics
Definition

a.        increases depressant effect

Term
anticonvulsants with antidiabetic meds
Definition

 increased blood glucose levels

Term
Preassessment for anticonvulsant admin
Definition

a.        Thorough history, including hx of head trauma

b.       Observations of friends/family – description, frequency, length, LOC, triggers and presence of aura (feeling that precedes a seizure)

c.        Family history of seizures

d.       recent drug tx

e.        Vitals for baseline

f.         Review lab orders e.g. EECG, MRI, CBC, hep/renal fnx etc

Term
Ongoing assessment for anticonvulsant admin
Definition

a.        Dosage/drug type may frequently changes initially based on therapeutic response and adverse reactions

b.       Blood tested for toxicity

c.        If hospitalized, watch seizures closely and document descriptions as much as possible to help PCP dx type of seizures and tx effect

Term
STATUS EPILEPTICUS
Definition
  • constant seizure activity lasting longer than 5 minutes
  • can be caused by missing a dose, even pt on a small dose
Term

Implementation

Admin of hydantoins

Definition

                                                               i.      Phenytoin is most common (Dilantin) bc relatively less toxic

                                                              ii.      However, some can’t metab phenytoin, so pts must be monitored for toxicity

                                                            iii.      Signs of phenytoin toxicity are slurred speech, ataxia (uncoordinated muscle movements), lethargy, dizziness, N/V

                                                            iv.      When oral, give with food to avoid GI upset

                                                             v.      When parenteral, IV preferred over IM bc can harm/hurt muscle

                                                            vi.      NURSING ALERT – when admin phenytoin, closely monitor for signs of toxicity (slurred speech, ataxia, lethargy, dizziness, N/V, nystagmus, mental changes).  Phenytoin bt 10-20 mcg/mL is optimal, greater than 20 associated with toxicity.

Term
Admin of Barbituate (phenobarbitol) for epilepsy to an elderly person
Definition

                                                               i.      causes CNS depression

                                                              ii.      in ELDERLY, can cause marked excitement, depression and confusion.  Monitor elderly closely for unusual reactions

Term
Implementation/Admin of benzodiazepines for epilepsy
Definition

                                                               i.      dose individualized

                                                              ii.      IV lorazepam can quickly control seizures, but effect is short

                                                            iii.      diazepam can precipitate when mixed with other drugs, don’t do this

                                                            iv.      LIFESPAN ALERT – apnea and cardiac arrest can occur when diazepam given to older adults, very ill and those with limited pulm capacity.  Watch these pts closely for oversedation.  May need lower dose.

Term

“Risk for Injury rt seizure disorder, drowsiness and ataxia”

Definition

a.        drowsiness common adverse reactions, esp. early in tx

b.       Assis pt until stable

c.        Careful with oral admin, bc drowsi pt could choke; assess swallowing first with water; if unable to swallow, notify PCP ASAP for different route    

Term

“Risk for Impaired Skin Integrity rt adverse reaction to drug”

Definition

a.        phenytoin, lamotrigine and the barbiturates can produce a severe and potentially fatal hypersensitivity rash

b.       notify PCP immediately

c.        Closely examine areas and describe

d.       If itchy, keep nails short and give antiseptic cream (may open skin); avoid use of soap (drying)

e.        NURSING ALERT – tell PCP immediately; Certain types of rashes necessitate permanent DC. 

Term

“Risk for Infection rt immunosupression secondary to drug therapy”

Definition

a.        Be alert for pancytopenia signs: sore throat, fever, malaise, bleeding from mucos membranes, epistaxis (nose bleeding) and easy bruising

b.       carbamazepine can cause aplastic anemia and agranulocytosis

c.        succinimides also toxic

d.       Should be routine labs taken like CBC and differentials

e.        Looking for bone marrow suppression (resulting in pancytopenia); if apparent, probably DCed

f.         Protect pt from injury and trauma (bleeding) bc of low platelets.

g.       Also protect from infection

h.       NURSING ALERT – phyenytoin can cause hemo changes like aplastic anemia, leucopenia, thrombocytopenia; immediately report to PCP signs of thrombocytopenia (low platelets) which means more bleeding or leucopenia (signs of infection)

Term

“Impaired Oral Mucous Membranes rt gum overgrowth secondary to hydantoins”

Definition

a.        long-term hydantoins can cause gingivitis and gingival hyperplasia

b.       periodically inspect mouth, teeth, gums and report changes to PCP

c.        Oral care very important

Term

“Disturbed Sensory Perception: Visual rt adverse drug reactions”

Definition

a.        Assist pt with ambulation

b.       ensure safe environment

c.        May want dimmer light if sensitive to light

d.       May be photosensitive, so wear protection until know

Term
General education for ALL anticonvulsants
Definition

a.        Some pts, when under contoll, may start missing doses; explain that pt must never miss dose

b.       Blood levels of anticonvulsant will be monitored

c.        Don’t put anything into mouth of person having a seizure

d.       Do not do anything hazardous while drowsy

e.        Driving privileges can be reinstated once controlled

f.         Avoid alcohol unless approved

g.       Med ID

h.       Do not use OTC without approval

i.         Keep record of seizures and take with to appointments

Term
Education specific to hydantoins
Definition

                                                               i.      inform dentist and other PCPs

                                                              ii.      good oral care necessary

                                                            iii.      Take with food to lessen GI upset

                                                            iv.      Thoroughly shake suspension form just before use

                                                             v.      Do not take discolored capsules

                                                            vi.      Notify if:

1.        rash

2.        bleeding

3.        swollen or tender gums

4.        yellow skin or eyes

5.        fever

6.        sore throat

7.        unusual bleeding/bruising

8.        persistant headache

9.        malaise

10.     pregnancy

Term
Education specific to succinimides
Definition

                                                               i.      Take with food or milk if GI upset

                                                              ii.      Notify PCP if:

1.        rash

2.        joint pain

3.        fever

4.        sore throat

5.        unusual bleeding/bruising

6.        drowsiness

7.        dizziness

8.        blurred vision

9.        pregnancy


  • "You can take with food/milk, but you might die with a full stomach"
Term
Education specific to oxazolidinediones
Definition
  • can cause photosensitivity.  Protective measures needed until tolerance determined
  • Do not become pregnant with trimethadione bc or risk of serious birth defects
  • Notify PCP if:

1.        visual disturbances

2.        excesss drowsiness or dizziness

3.        sore throat

4.        fever

5.        rash

6.        malaise

7.        easy bruising

8.        epitaxis or bleeding tendencies

9.        pregnancy

10.     trimethadione can cause serious birth defects

Term
what kind of drug is trimethadione?
Definition
an oxazolidinedione anticonvulsant 
Term
what is carbamezapine?
Definition
Tegertol, an anticonvulsant
Term
What are signs of phenytoin toxicity?  What serum levels are associated with toxicity of phenytoin? What are therepeutic levels
Definition

slurred speech, ataxia, lethargy, dizziness, N/V

 

20 mcg/mL

 

Tx levels are 10-20 although below 10 can be effective

Term
Which barbituate is commonly used to treat convulsive disorders?
Definition
Phenobarbitol
Term
Diazepam and elderly, very ill and those with limited pulmonary capacity
Definition
Apneea and cardiac arrest can occur when diazepam given to older adults, very ill and those with limited pulm capacity.  Watch these pts closely for oversedation.  May need lower dose.
Term
Types of anticonvulsants
Definition

hydantoins

carboxylic acid derivative

oxazolidinediones

succinimides

bezodiazepines

miscellaneous

barbituate

 

Having convulsions or seizures breaks my brain

Term
phenytoin toxicity
Definition

                                                               i.      Phenytoin is most common (Dilantin) bc relatively less toxic

                                                              ii.      However, some can’t metab phenytoin, so pts must be monitored for toxicity

                                                            iii.      Signs of phenytoin toxicity are slurred speech, ataxia (uncoordinated muscle movements), lethargy, dizziness, N/V

Term
General assessments of seizures
Definition

Describe

Frequency

Length

Aura?

LOC

Triggers

Term
trimethadione and pregnancy
Definition
Do not become pregnant with trimethadione bc or risk of serious birth defects
Term
Drug of choice for status epilepticus w/ one caveat
Definition

lorazepam

short term control, so must be given with another longer lasting anti-convulsant

Term
a precaution of carbamazepine (Tegratol)
Definition
Can cause aplastic anemia and agranulocytosis
Term
Major precautions/contraindication of the succinimides
Definition
  • They are particularly toxic 
  • Are contraindicated in those with bone marrow depression (and hepatic/renal impoairment)
  • Associated with greater risk of lupus erythematosis
Term
Which general category of drugs can cause bone marrow suppression?
Definition
Anticonvulsants can suppress blod cell production, resulting in pancytopenia, which means lower platelets, lower WBCs and lower RBCs, leading to increased risk of infection, bleeding, etc
Term
phenytoin induced hemologic changes
Definition

phyenytoin can hemo changes like aplastic anemia, leucopenia, thrombocytopenia

Must be reported immediatey: signs of infection (leucopenia) and excess bleeding (thrombocytopenia)

Term
What kind of drug is trimethadione and what is it's most serious reaction?
Definition

An oxazolidinedione

Can cuase serious birth defects

Term
Which class of drugs can cause photosensitivity?
Definition
oxazolidinediones
Term
Adverse reactions to oxazolidinediones that must be reported:
Definition

visual disturbances

excess drowsiness/dizziness/malaise

 

Signs indicating hemotologic changes

 

Signs of infection

sore throat

fever

skin rash

 

Signs of bleeding

easy bruising

epistaxis

bleeding tendencies

Term
Which anticonvulsants can cause a severe and potentially fatal hypersensitivity rash?
Definition

phenytoin (Dilantin)

lamotrigine (Lamictal)

barbituate (Phenobarbitol)

Term
Which hydantoin can cause hemotologic changes resulting in icreased infection and bleeding?
Definition
phenytoin (Dilantin)
Term
Which anticonvulsants cause visual disturbances?
Definition

valproic acid - diplopia

oxcarbazepine (Trileptal) - diplopia

benzodiazepines

Diamox (a misc = acetazolamide)

trimethodione

 

Term
What conditions require precautious use of all types of anticonvulsants?
Definition

Kidney disease

Neurological disorders

Term
When phenytoin given parenterally, which form is preferred and why?
Definition

IV

IM hurts muscle

Term
which anticonvulsnats have potential to cause severe potentially fatal rash?
Definition

phenytoin

lamotringine (Lamictal) also used for bipolar?

phenobarbitol

Term
diazepam admin in older adult, very ill and those with limited pulmonary capacity
Definition

can cause apnea and cardiac arrest

monitor for over sedation and report

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