Epilepsy_Patho3

Phenobarbital/primidone has ___________ pharmacokinetics.

Vigabatrin has a REMS program for which treatment related AE due to higher total dose and duration?

Jack Daniels is a pre-term infant, born earlier today at 4 lbs. 10 oz.

Although he is doing well despite his prematurity and low weight, he has had 3 seizures in the past two hours, and the medical resident has came to you for advice on which medication might be best to give baby Jack. What is your recommendation?

Maureen McCormick presents to your clinic today, having just had a seizure that lasted 35 minutes. The physician classifies it as status epilepticus.

If her seizure had lasted only 8 minutes, but required therapy, would this have still probably qualified clinically as status epilepticus?

Han Solo is coming into your pharmacy for his first fill of phenytoin.

His medication list is as follows:
Tagamet 200mg PRN for heartburn
Simethicone 180mg PRN for flatulence related to Wookie cuisine
Cardizem CD 120mg qD for angina
Warfarin 2mg qD for DVT prophylaxis
Furosemide 20mg qD for heart failure and related edema

Which changes to therapy would be acceptable AND useful in this patient?

Kesha Sebert presents to your clinic today, for recent follow up after having a seizure while rolling around in glitter before her most recent concert. Her glitter-thrower Miguel describes her as "looking looking spaced out...like the first time you hear a dirty beat on Molly" and he notes that her eyes rolled back a little. He says her "trippin" only lasted less than 10 seconds.

The medical team comes to you for advice on which medication to give her.

What is her diagnosis, and which medication is the MOST appropriate to treat Ke$ha?

Which AED is NOT indicated to treat absence seizures?

Which of the following AEDs is a CYP enzyme INHIBITOR?

Miley Cyrus was in a tragic wrecking ball accident while filming her latest music video. Her father, Billy Ray, notes that she has been drinking often for several months, and her actions have damaged his heart, which was already achey and breakey.

She is being fed by enteral nutrition, and her medications are as follows.

Crack cocaine, 2 puffs PRN boredom
ParaGard IUD
IBU 400mg PRN for hangovers
Azithromycin 2GM last week for gonoccocal infection
Plan B One Step for "extra protection from becoming preggerz"
Adderall XR 30mg qD for weight loss and "all nighters"
Dilantin Infatabs 200mg QHS for generalized tonic-clonic seizure disorder

Urine hCG: 1.0 mIU/mL

Total phenytoin: 13 mcg/mL

Her expected inpatient stay is 6 days.

Besides the obvious other concerns related to her therapy, which of the following conclusions and modifications are appropriate regarding her medication and nutrition? (select ALL that apply)

Which of these is NOT a CONCENTRATION DEPENDENT adverse effect of valproic acid?

Sandra Bullock presents to your pharmacy, having recently returned to earth after a brush with death while working on the Hubble Telescope in IMAX 3D.

She has had some breakthrough seizures, despite many other concomitant AED therapies, related to the emotional stress of the ordeal, and her doctor has prescribed her some medications to treat the seizures.

She is given phenobarbital, and titrated upward appropriately.

Ms. Bullock returns in 3 weeks and her phenobarbital level is 30 mcg/mL. Her current dose is 200mg, divided twice daily. Is this acceptable?

Kim Jong-un, the Supreme leader of DPR North Korea comes into your pharmacy, complaining of weird uncontrollable twitching in his right arm, and major "deja vu," after a recent intense game of NBA Jam with Dennis Rodman.

He says that he wants to take carbamazepine, because he owns a factory (and the workers in it) that makes carbamazepine.

Is this acceptable therapy for his likely seizure type? Would you do anything else before starting Tegretol?

Dilantin inhibits CYP450.

If Jake from State Farm, who is 45, and Lizzy from that cute AT&T commercial, who is 8, both take 20mg of tiagabine at 1PM on a Tuesday, what can you say about their drug levels at 6PM?

Which one of the following is NOT a mechanism contributing to synchronous hyperexcitability in seizure disorders?

Which of these is NOT an IDIOSYNCRATIC (unrelated to concentration) adverse effect related to phenytoin?

Jane Doe, a 19 year old college sophomore comes into your clinic today for recent therapeutic issues with her AEDs. The decision is made to add on a new therapy for seizure control. Jane reports that she is very sexually active, with multiple partners every month. She indicates that she practices safe sex, and she has had the Gardasil vaccine.

Knowing the various adverse effects of AEDs, which medication is most likely to potentially have adverse effects, given Jane's sexual history?

(Idiosyncratic---Slide 24/96)

Ender Wiggin, a 6-year old, comes into your clinic after an episode of status epilepticus. Which of these are probable etiologies of his SE episode?

I. Recent discontinuation of his Dilantin, while staying with his stepfater.
II. Influenza
III. Undiagnosed Atrial Septal Defect (ASD)
IV. Hypothermia

Walter White comes in to your pharmacy one day to buy his usual 600 pseudoephedrine 30mg tablets (he reports that he gets "REALLY congested this time of year") and to pick up a new prescription for Zonegran for an unspecified seizure disorder (not important for the question).

PMH:
Stage IIIa NSCLC, with L858R EGFR mutation (Dx & FISH in 7/2011)
Mild OA
Dyslipidemia

Allergies: Sulfa (anaphylaxis)

Current Medications:
PSE (OTC), unknown quantity per day, PRN
Livalo 2mg QHS
IBU 200 PRN
Tarceva 150mg qD

Does Mr. White have any major contraindications or precautions to therapy with Zonegran?

Mary presents to your clinic today for a routine check of her valproic acid levels.

Her ranges for the past 6 months are as follows:
4/28/2013: 68 mcg/mL
5/28/2013: 79 mcg/mL
6/28/2013: 85 mcg/mL
7/28/2013: 83 mcg/mL
8/28/2013: 84 mcg/mL
9/28/2013: 87 mcg/mL
10/28/2013 (Today): 84 mcg/mL

She has had no seizures in 11 months and reports no intolerable side effects.

During your visit, Mary indicates that she recently received a new prescription for Ortho Tri-Cyclen from her doctor, and she wishes to fill it today. This is Mary's first time on oral contraceptives.

Is it likely that her dose of valproic acid will need adjustment to maintain therapeutic levels and/or avoid toxicity?

(Slide 23/96 - Epilepsy Part 2)

Which of these are NOT CONCENTRATION-DEPENDENT adverse effects related to phenytoin?

Joshua Hodge, a first-year pharmacy student, comes to your pharmacy today after recently having his first seizure, where he reports losing control of his bowels, crying out not unlike a little girl, and turning blue. His friends Brandon and Brandon report sharp contraction of muscles with rigidity and synchronous jerking of his arms and legs as well.

Despite the severity of presentation, his seizure cleared quickly and he did not require emergent treatment.

Today he presents to you for a recommendation. Considering he is on no other therapies, and has no known contraindications to any therapies, which medication would be a good choice for Joshua, and why?

(Epilepsy 2 -- 29/96)

SIADH is an adverse effect of carbamazepine, but is prevented by oxcarbazepine's improved pharmacokinetics.

Oxcarbazepine is a prodrug. (It is a structural derivative of carbamazepine.)

Which one of these likely would NOT be a factor involved in the etiology of a single seizure episode?

Generalized convulsive status epilepticus (GCSE) is largely caused by:

Which one of these likely would NOT be a factor involved in the etiology of a single seizure episode?

Felbamate blocks ______ and promotes ________. It has a black-box warning for _________________.

Sandra Bullock presents to your pharmacy, having recently returned to earth after a brush with death while working on the Hubble Telescope in IMAX 3D.

She has had some breakthrough seizures, despite many other concomitant AED therapies, related to the emotional stress of the ordeal, and her doctor has prescribed her some medications to treat the seizures.

Her prescriptions are as follows:

phenobarbital 100mg #30
tk 1 t PO qD for 30 days, then return to the physician for phenobarbital monitoring

primidone 50mg #60
tk 2 ts qHS for 30 days

Should you fill these prescriptions? Why or why not?

Which of the following are the primary mechanisms by which anti-epileptic drugs (AEDs) work to reduce or prevent seizures?

Han Solo is coming into your pharmacy for his first fill of phenytoin.

His medication list is as follows:
Tagamet 200mg PRN for heartburn
Simethicone 180mg PRN for flatulence related to Wookie cuisine
Cardizem CD 120mg qD for angina
Warfarin 2mg qD for DVT prophylaxis
Furosemide 20mg qD for heart failure and related edema

Would switching his Cardizem CD to Calan SR prevent any issues related to phenytoin/Cardizem drug-drug interactions?

Mary Jane Watson comes in to your pharmacy today for a new AED. Her physician, Dr. Otto Octavius, has diagnosed her with partial complex seizures, and would like to start her on an AED.

Mary Jane's PMH is non-remarkable. She indicates that she is sexually active, but has been in a monogamous relationship with her boyfriend Peter for 2 years. She is nulliparous, and wishes to keep it that way.

Which of the available options is the BEST choice to treat MJ's seizures?

HINT: You might have to adjust the dose, but it will not affect OCs.

Ep2 - 23/96

Which of the following is NOT a concentration dependent side effect of phenobarbital/primidone?

Phenytoin (Dilantin) follows ____________ pharmacokinetics, is ____________, and is ____________, requiring adjustments based on ______________.

Which of the following is not an idiosyncratic adverse effect of carbamazepine?

Which of these medications does likely NOT lower the seizure threshold?

(Slide 11/62 - Epilepsy Part 1)

Fycompa works on _________ receptors and is a _____________ ____________.

Tom Selleck, a medical resident, sends an inpatient prescription to your pharmacy that reads as follows:

Patient Name: John Doe
DOB: 12/15/1999
Fosphenytoin 300mg
give 300mg SQ over 1 minute for partial seizures

[The note on the medication order states that John was on a home dose of 300mg of phenytoin once daily.]

What of the following are the MOST correct choices regarding John's prescription?

I. Fosphenytoin is not administered SQ. It is only IM or IV.
II. The maximum daily dose of fosphenytoin is 250mg, due to its increased absorption and bioavailability
III. The fosphenytoin dose should be 450mg, due to differences in phenytoin's and fosphenytoin's ADME.
IV. Fosphenytoin cannot be infused at >150 mg/min meaning the infusion should last at least 3 minutes if given IV
V. The prescription is acceptable as written

You have a patient that has just been diagnosed with seizures, with a BMI of 29.2 kg/m^2.

Assuming, for this example, that all seizure medications would be equally effective, which one of these are you most likely to prescribe?

Kesha Sebert presents to your clinic today, for recent follow up after having a seizure while rolling around in glitter before her most recent concert. Her glitter-thrower Miguel describes her as "looking looking spaced out...like the first time you hear a dirty beat on Molly" and he notes that her eyes rolled back a little. He says her "trippin" only lasted less than 10 seconds.

The medical team comes to you for advice on which medication to give her.

Ethosuximide is currently on backorder. What is your recommendation for therapy?

Slide 25/96 vs. Slide 39/96

_______________ is a metabolic cause of SE.

Molly Ringwald, a 16YO ginger, presents to your clinic today to pick up her newly upped dose of Vimpat. After failing treatment with several AEDs, her doctor has been titrating her for a few weeks. She seems unusually stressed after being assigned to detention with her friend, hockey coach Emilio Estevez, for spraying a rival teams locker room with liquid nitrogen, and reports that she has been feeling dehydrated lately.

Her prescription is as follows:

lacosamide 400mg #30
tk i t PO qD

Her vitals are as follows:
BP 116/74
Weight: 59.3kg
Height: 5'6"
BG: 92
SCr: 3.0

Should you fill this prescription?

(Ep2 -- 51/96)

B Knowles presents to your clinic this week complaining of new seizures this week. She has been taking lamotrigine (Lamictal XR 300mg qD) for 2 years now with no major problems, but due to a breakthrough seizure a few weeks ago, her doctor started her on primidone in addition to lamotrigine.

What is the probable etiology and best reconciliation for Mrs. Knowles problem, of the available choices?

Epilepsy is the occurrence of at least 2 unprovoked seizures, separated by 12 hours.

Cheryl H comes into your clinic today, complaining of new seizure activity over the past few months. Her PMH is non-significant, but her SH indicates recent anxiety following the cancellation of her husband Larry's TV show.

In addition to her anxiety potentially lowering her seizure threshold, what other findings might support an increased incidence of seizures in Cheryl?

Tegretol blocks ____ channels and a major concern related to Tegretol's ADME is ____________________.

Han Solo is coming into your pharmacy for his first fill of phenytoin.

His medication list is as follows:
Tagamet 200mg PRN for heartburn
Simethicone 180mg PRN for flatulence related to Wookie cuisine
Cardizem CD 120mg qD for angina
Warfarin 2mg qD for DVT prophylaxis
Furosemide 20mg qD for heart failure and related edema

Which of his medications are likely to be affected by phenytoin (based on CYP450 related actions of phenytoin)?

Which of the following best represents the mechanism of action of valproic acid?

Aura is:

The mechanism of action of levetiracetam is _________________________.