understanding and managing epilepsy handout - free ce

Understanding and Managing Epilepsy Event Type Live Online ACPE Expiration Date 2/4/2016 Credits 1 Contact Hour Target Audience Nurses, Pharmacists, Pharmacy Technicians

Program Overview

Epilepsy is a brain disorder that leads to repeated seizures, which are episodes of disturbed

brain activity that alter perception or behavior. Approximately 50 million people worldwide

have epilepsy, although nearly 90% of it occurs in developing countries such as the United

States. Onset of new cases occurs most often in infants and the elderly. Epilepsy becomes more

common as people age. Epilepsy is usually controlled, but not cured, with some preventative

strategies and medication. However, over 30% of epileptics cannot control their seizures even

with medication, so surgery is sometimes explored. Not all epilepsy disorders are permanent, as

some forms are confined to certain stages of childhood.

Nurse Educational Objectives

Describe the cause, frequency, and health implications of epilepsy

Outline the non-pharmacological methods used to manage epilepsy and prevent seizures

Compare and contrast the most common pharmaceuticals used to manage epilepsy and

prevent seizures, including mechanisms of action and potential side effects

Pharmacist Educational Objectives

Describe the cause, frequency, and health implications of epilepsy

Outline the non-pharmacological methods used to manage epilepsy and prevent seizures

Compare and contrast the most common pharmaceuticals used to manage epilepsy and

prevent seizures, including mechanisms of action and potential side effects

Pharmacy Technician Educational Objectives

List symptoms of epilepsy List common medications used to manage epilepsy

Activity Type

Knowledge

Accreditation

Nurse Pharmacist Pharmacy Technician

N-809 0798-0000-12-097-L01-P 0798-0000-12-097-L01-T

PharmCon, Inc. is accredited by the Accreditation Council for Pharmacy Education as a provider of continuing pharmacy education.

PharmCon, Inc. has been approved as a provider of continuing education for nurses by the Maryland Nurses Association which is accredited as an approver of continuing education in nursing by the American Nurses Credentialing Center’s Commission on Accreditation.

Faculty

J Dufton, MD Medical Writer, Wellness Partners

Financial Support Received From

Pharmaceutical Education Consultants, Inc.

Disclaimer

PharmCon, Inc. does not view the existence of relationships as an implication of bias or that the

value of the material is decreased. The content of the activity was planned to be balanced and

objective. Occasionally, authors may express opinions that represent their own viewpoint.

Participants have an implied responsibility to use the newly acquired information to enhance

patient outcomes and their own professional development. The information presented in this

activity is not meant to serve as a guideline for patient or pharmacy management. Conclusions

drawn by participants should be derived from objective analysis of scientific data presented

from this activity and other unrelated sources.

Understanding and Managing Epilepsy

© 2013 Pharmaceutical Education Consultants, Inc. unless otherwise noted. All rights reserved.

Reproduction in whole or in part without permission is prohibited.

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1/24/2013 1 1/24/2013 2 This activity is supported by an educational grant from Merck & Co.


Accreditation Pharmacists: 0798-0000-12-097-L01-P Pharmacy Technicians: 0798-0000-12-097-L01-T Nurses: N-809

Faculty

Johnathon Dufton MD Wellness Partners

CE Credit(s) 1.0 contact hour(s)

Faculty Disclosure Dr. Dufton has no actual or potential conflicts of interest in relation to this program.

Learning Objectives • Describe the cause, frequency, and health implications of epilepsy • Outline the non-pharmacological methods used to manage epilepsy and prevent seizures • Compare and contrast the most common pharmaceuticals used to manage epilepsy and prevent seizures, including

mechanisms of action and potential side effects

Legal Disclaimer The material presented here does not necessarily reflect the views of Pharmaceutical Education Consultants (PharmCon) or the companies that support educational programming. A qualified healthcare professional should always be consulted before using any therapeutic product discussed. Participants should verify all information and data before treating patients or employing any therapies described in this educational activity.

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• Describe the cause, prevalence and risks of epilepsy.

• Outline the non-pharmacological methods used to manage epilepsy and prevent seizures.

• Compare and contrast the most common medications used to manage epilepsy and prevent seizures, including modes of action and potential side effects.

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• A brain disorder characterized by disruption of normal electrochemical activity of the brain

• Not just seizures, but the

tendency to have recurrent

seizures




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• Recurrent seizures recorded as a medical condition for thousands of years

• Derived from Ancient Greek

• Historically, “falling sickness,” or “sacred disease”

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• Difficult to identify and labeled “unknown”

• Factors associated with epilepsy: • brain trauma

• CNS infections

• strokes from clots or aneurysms

• brain cancer / benign tumors

• drug / alcohol abuse or withdrawal

• metabolic disorders / genetics

• food / chemical allergy?

• electromagnetic pollution?

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• Reflex Epilepsy

• Other triggers include: • hyperventilation and/or emotional stress • sleep deprivation • over heating and/or fever from febrile

illness • menstruation - termed catamenial epilepsy • excessive reading • loud music / noises

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• Classified in numerous ways depending on the cause, related physical manifestations, region of the brain affected, connection to disease syndromes and triggers

• Older medical terms: • Gran mal seizure (now known as a tonic-clonic seizure) involves loss of

consciousness and violent muscle contractions

• Petit mal seizure, (now known as an absence seizure) involves brief disturbance of brain function (often less than 15 seconds) with related staring spell or black out – occurs most commonly in children and can include myoclonus (muscle twitches and jerks) and loss of muscle strength




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1) whether the source of the seizure is

localized (focal onset) or generalized within the brain

2) the extent to which awareness is affected: unaffected = simple, whereas affected = complex

3) the extent to which the body is affected: absence of effect (Petit mal), myoclonic, clonic, tonic, tonic-clonic (Gran mal), and atonic seizures

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• About 60% of people with epilepsy have focal seizures

• Focal seizures are often subtle and may go unnoticed or be mistaken for anything from intoxication to daydreaming

• If a person is aware they are having a seizure, then it’s termed a simple focal, simple partial or awareness retained seizure

• If a person is unaware they are experiencing a seizure, then it’s termed complex focal, complex partial or awareness altered seizure

• Seizure activity can start in one focal area of the brain and spread to other regions and become a generalized seizure with convulsions

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• Symptoms depend on where the electrical disturbance takes place in the brain

• No lose of consciousness

• Typical symptoms include: staring spells, repetitive movements, facial tics, numbness, tingling , hallucinations, abdominal pain, nausea, sweating, flushed face, dilated pupils, increased heart rate, visual disturbance, déjà vu sensations and mood changes (fear)

• Sometimes abnormal muscle contraction is involved

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• Abnormal activity in both brain hemispheres

• Often begin with a sudden cry and cause the person to fall

• Generalized seizures don’t always lead to muscle involvement (absence seizure), but more often they do

• Vision, taste, smell or sensory changes called auras

• The seizures last about 2 minutes and usually involve muscle rigidity (tonic), followed by violent muscle contractions (clonic)

• Other symptoms may include: shallow breathing, frothy saliva, blood from bitten tongue, loss of bladder control, extreme fatigue, headache

• Myotonic = muscle twitching, whereas atonic = muscle weakness




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Tonic

Clonic

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• The best initial response to a generalized tonic-clonic seizure

is to roll the person on their side (“recovery position”) to

prevent choking on saliva, vomit, blood or swallowing tongue

• The person should be prevented from self-injury by moving

them away from sharp edges and placing something soft

beneath the head

• Speak calmly and reassuringly

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• Gene mutations

• Dysfunction of voltage

• Defective sodium channels stay open for too long, making neurons hyper-excitable

• Glutamate (excitatory neurotransmitter) is released from neurons in large amounts which triggers excessive calcium in post-synaptic cells -> spread of excitation

• Another mechanism involves mutations leading to ineffective GABA action (inhibitory neurotransmitter)

• Chemical excitotoxicity hotly debated

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• Evaluating patients aimed at determining cause and type of seizures

• Diagnosis based on patient's medical history (including meds), family history of seizures, neurological exam and various tests:

• electroencephalogram (EEG) test - measures electrical impulses in the brain

• magnetic resonance imaging (MRI) and spectroscopy (MRS) of the brain

• positron emission tomography (PET) scan

• single photon emission computed tomography (SPECT) scan

• blood tests to measure blood cell counts, glucose, calcium, electrolytes

PET scan




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PET scan of focal seizure SPECT scan of focal seizure

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• Epilepsy affects about 3 million people in the

U.S. and almost 60 million people worldwide

• Over 80% of epilepsy occurs in developing

regions

• Most new cases occur in infants and elderly

• More common with age

• Not always permanent

• Prevalence between 5–10 people per 1000

• ADHD affects 3-5 times more children with epilepsy

• Epileptics experience more depression, anxiety disorders, autism, migraines, infertility

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Death most significant risk:

symptoms from underlying diseases that cause certain epilepsies

status epilepticus - continuing seizure attacks without intervals

leading to brain damage and death - most often associated with

changing medications

suicide associated with depression

trauma and serious injury from seizures

sudden unexpected death in epilepsy (SUDEP) – cardiac arrest

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• Photosensitive epilepsy - seizures are triggered by flashing / flickering lights or certain geometric shapes / patterns

• A type of reflex epilepsy affecting about 5% of epileptics

• Diagnosed by undergoing an EEG with strobe light or pattern stimulation

• Triggers • Watching TV and playing video games (between 8-30Hz or flashes per second)

• Other triggers include faulty fluorescent lights, strobe lights, driving at dawn / dusk, sun flickering on water, geometric patterns featuring contrasting stripes or checkerboard




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• Common sense and logical

• Avenues of investigation / research include:

• food allergies, or perhaps more importantly, preservatives (MSG), dyes and artificial sweeteners (aspartame)

• cleaning products

• cell phone, wi-fi, EM sensitivity in general

• vaccination contamination / toxicity (mercury-based thimerosal)

• aluminum or heavy metal accumulation in brain

• vitamin (B6) / mineral (copper) / fatty acid deficiencies?

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• Avoiding known triggers such as flashing lights, loud music or sleep deprivation

• Environmental investigation may reveal triggers (food allergy, chemical sensitivity)

• Avoidance of sports with relatively high risk of head injury

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• Uses relaxing imagery to change body functions such as breathing, heart rate and blood pressure

• A biofeedback practitioner describes a stressful situation and then teaches the patient various relaxation techniques

• Biofeedback only seems to be effective if patient has reflex epilepsy triggered by emotional stress or anxiety

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• Vitamin / mineral supplements may be helpful, especially folate (vitamin B9), vitamin B6, vitamin D and magnesium

• Nutrient deficiencies known to induce seizures include: • vitamins: B1 and B6

• minerals: magnesium (70% deficiency rate), zinc, copper

• Omega-3 fatty acids have beneficial effects on the nervous system – some research indicates that supplements (fish oils, flaxseed) might help reduce frequency of seizures




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• Some remedies may reduce seizure frequency or various related symptoms

• Some animal-based research indicates that bacopa leaf, an herb native to India and used in Ayurvedic medicine, may be helpful – possible brain protecting properties

• Bacopa has no known interactions with any of the anti-convulsant meds used to treat epilepsy

• Bacopa dose is typically 200-400 mg per

day in 2-3 divided doses of an extract

standardized to 20% bacosides

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• Valerian root extract is a very popular antispasmodic herbal remedy used in Russia and parts of Europe

• In the U.S., it’s mostly known for its sedation, but its anticonvulsant properties may benefit epileptics

• Skullcap and Indian tobacco (lobelia) are traditional natural remedies used to control convulsions, seizures and tremors - Skullcap is calming (sedative), whereas Indian tobacco relaxes muscles

• Not all herbs are either benign or beneficial

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• Anticonvulsants • conventional treatment of epilepsy is via meds that control seizures

(70-80% effective) .

• usually lifelong – not a cure

• major effects on quality of life

• Early Anticonvulsants • Potassium bromide was he first anticonvulsant

• Phenobarbital (1912) used for both its sedative and antiepileptic properties

• Phenytoin - 1930s

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More than 20 different anticonvulsant meds on the market –older ones still in use include:

• Phenobarbital (Luminal) • strong sedative and hypnotic properties

• WHO recommends first-line use for all seizures in developing countries, but second-line choice for most seizure types in more affluent countries

• main side effects include dizziness, nystagmus, ataxia and confusion

• Phenytoin (Dilantin) • common first-line anti-seizure drug, however, it’s a known teratogen and shouldn’t be

taken during pregnancy

• ironically, brain atrophy and seizures are reported side effects

• long-term use = bone thinning / osteopenia




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• Carbamazepine (Tegretol, Carbatrol)

• stabilizes the inactivated state of voltage-gated sodium channels, making fewer of these channels available to open and leaving the affected cells less excitable

• longer half-life means more drowsiness

• migraines, rash and motor control impairment common side effects

• greatly decreases alcohol tolerance

• Primidone (Mysoline) - once a mainstay anticonvulsant for treating partial and generalized seizures (especially of temporal lobes), but surpassed by carbamazepine in the early 1980s due to less sedation

• now used primarily in developing countries

• not as toxic as phenobarbital

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• Topiramate (Topamax) • exact mechanism of action is unknown, but blockage of voltage-gated sodium

channels is involved

• common side effects include paresthesia, upper respiratory tract infection, diarrhea and short-term memory problems

• carbamazepine increases elimination of topiramate so shouldn’t combine

• Felbamate (Felbatol) – treats partial and some generalized seizures in adults and children (Lennox-Gastaut syndrome)

• works mainly as a positive modulator of GABA receptors

• increased risk of potentially fatal aplastic anemia and/or liver failure limit usage to severe refractory epilepsy – “last option” drug

• patients must have blood cell counts and liver tests regularly w/ therapy

• interacts w/ many other anticonvulsants

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• Ethosuximide (Zarontin) • thought to be a T-type calcium channel blocker

• Zarontin capsules discontinued by Pfizer in 2007, leaving only syrups

• main adverse effects include nausea, vomiting, anorexia and weight loss

• Gabapentin (Neurontin) • FDA approved for treatment of focal seizures, but insufficient evidence for

generalized seizures

• more of a second-line / adjunctive epilepsy drug

• synthesized to mimic the chemical structure of the neurotransmitter GABA, but some of its activity may involve voltage-gated calcium channels

• few lasting side effects other than tiredness and dizziness

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• Lacosamide (Vimpat) – treats partial-onset seizures and neuropathy

• works by enhancing slow activation at voltage-gated sodium channels

• fairly new drug - FDA approved in 2008

• more of a second-line / adjunctive drug given w/ other anticonvulsants

• well-tolerated w/ dizziness the main side effect

• Ezogabine / Retigabine (Potiga) – a new anticonvulsant approved in 2011 as treatment for partial epilepsies

• works primarily as a potassium channel opener, which is unique among antiepileptic drugs

• widely studied, quickly absorbed and appears to be free of drug interactions

• sometimes requires thrice-daily dosing due to its very short half-life




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• Diazepam (Valium, Diastat)

• benzodiazepines enhance the effects of GABA, resulting in sedative, hypnotic, anticonvulsant, muscle relaxant properties

• tolerance develops within weeks, so doses need to be increased

• advantages are rapid onset of action and high efficacy rates

• adverse effects include amnesia, depression, dependence and paradoxical effects such as worsening of seizures in epileptics

• Lorazepam (Ativan)

• used for short-term treatment (2-4 weeks) of acute seizures

• more effective than diazepam in the treatment of status epilepticus

• relatively high addiction potential

• benzodiazepines not usually first-line drugs for epilepsy mainly because of tolerance development

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• The optimum result • no seizures with minimal side-effects

• Achieved with monotherapy - use of single anticonvulsant

• Some patients require two or more anticonvulsants / hypnotics for seizure control, although side effects significantly increase

• Others cannot be brought under control after adequate trials of two or three different drugs - “medically refractory”

• Studies of patients with previously untreated epilepsy reveal: • 47% achieve control of seizures with the use of their first single drug

• 14% become seizure-free during treatment with second or third drug

• additional 3% become seizure-free with use of two drugs simultaneously

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• Brain surgery an option for the roughly 25% of epileptics who gain no control over their seizures from meds

• Only if the area of the brain where the seizures start (seizure focus) can be clearly identified and if the area to be removed is not responsible for critical functions

• Two main categories of epilepsy surgery: • to remove the area of the brain generating seizures

• to interrupt the nerve pathways through which the electrical impulses spread within the brain

• Post surgery, meds may still be needed to control seizures

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• Lobe resection/temporal lobe resection: removal of an entire lobe where the seizure focus is

• Lesionectomy: removal of isolated brain lesions – tumors, malformed blood vessels or areas of injury

• Corpus callosotomy: cutting of the corpus callosum, which is the band of nerve fibers connecting the two brain hemispheres

• Functional hemispherectomy: radical procedure in which an entire hemisphere is disconnected, but only a limited area of brain tissue is removed, generally is limited to children younger than 13 years old who have one hemisphere not functioning normally




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• Multiple subpial transection (MST): • involves a series of shallow cuts into the cerebral cortex in efforts to interrupt

spread of nerve impulses

• does not typically cause long-lasting impairment in the critical brain areas

• Vagus Nerve Stimulation: consists of an electrical device similar to a pacemaker connecting to the vagus nerve within the neck • stimulates vagus nerve at preset intervals and intensities w/ current

• 50% of patients experience a 50% improvement in seizure rate

• Responsive Neurostimulator: • device contains seizure-detection software and sends current to epileptic

focus to disrupt seizure

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• Memory / speaking problems from removing temporal lobe

• Motor skills / language problems from removing frontal lobe

• Double vision from temporal or occipital lobe surgery

• Increased number of seizures from disconnecting corpus callosum

• Reduced visual field from hemispherectomy

• Partial, one-sided paralysis

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• Epilepsy occurs in a number of other animals including cats and dogs

• Epilepsy is the most common brain disorder in dogs

• Dogs can be trained as seizure detection animals

• Dogs can also be trained to summon help or ensure personal safety when a seizure occurs

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Thank you for listening to this webinar on epilepsy and please feel free to ask any

questions for further clarification.




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understanding and managing epilepsy handout - free ce

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