Epilepsy Final

8/14/2019 Epilepsy Final

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EPILEPSYEPILEPSYPresented By Amol.B.Lavate

(M.Pharm)1st year Pharmacy Practice,

KLES University Belgaum.


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CONTENT

INTRODUCTION

FACTS

CAUSES OF SEIZURES

POSSIBLE SEIZURE TRIGGERS

PATHOPHYSIOLOGY

TYPES OF EPILEPSY

CLASSIFICATION OF SEIZURES

PREVALENCE

SYMPTOMS OF EPILEPSY

SCREENING & DIAGNOSIS

TREATMENT

ACTIONS OF ANTISEIZURE DRUGS

USE OF ANTISEIZURE DRUGS


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INTRODUCTION

Epilepsy: Periodic and unpredictable seizurescaused by the rhythmic firing of large groups ofneurons may range from mild twitching to loss ofconsciousness and uncontrollable convulsion

Seizures-:A seizure is a paroxysmal behavioral spell

generally caused by an excessive disorderlydischarge of cortical or sub cortical nerve cells

Seizures usually occurs without warning andwithout the person's awareness of what ishappening. Some people with epilepsy will haveonly an occasional seizure, while others will havemany on a daily basis.


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Facts about Epilepsy

Epilepsy affects 2.7 million Americans, more Americans than cerebralpalsy, multiple sclerosis and Parkinsons Disease combined.

Approximately 200,000 new cases of epilepsy occur each year.

Everyone's brain has the ability to produce a seizure under the rightconditions.

Epilepsy can develop at any age. However, it is diagnosed most oftenbefore the age of 20 and after the age of 60.

With the appropriate treatment, up to 70% of people with epilepsy couldbe seizure free.

Only a few percent of people with epilepsy are affected by flashinglights this is called photosensitivity.

The Greek philosopher Hippocrates (460-377 BC) was the first person torecognize that epilepsy starts in the brain.

Ten percent of the American population will experience a seizure atleast once in their lifetime. 1 person in 20 will have a seizure at sometime in their life


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Causes of seizures

-eredity th e risk o f g e ttin g e p ile p sy.is 2 5 times greater with a family

history of seizures than when no familymember has had the disorder

-ead trauma the more severe the,injury the greater the risk of

developing epilepsy Brain tumor and stroke

-oisoning .such as lead poisoning,More than 5 000 people annually suffer

.seizures caused by alcoholism

-nfections ,such as meningitis viral, ,encephalitis mumps measles and

diphtheria

-aternal injury such as infectionor systemic illness affecting the

fetus' developing brain duringpregnancy

Unknown,

65%Infection,

3%

Degene-

rative, 4%

Tumor, 4%

Trauma,6%

Congenital,

8%

Vascular,

10%


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Possible seizure triggers

S tre ss

U n h e a lth y n u tritio n

,Lack of sleep exhaustion

Alcohol

Flickering lights

Skipping meals

Irregular medication Illness and allergies


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PATHOPHYSIOLOGY (I)

Normal brain function involves "communication"between millions of nerve cells (neurons)

A nerve cell is made up of a cell body and branches

called axons and dendrites which join otherneurons at junctions called synapses

At any one time, there are nerve cells which areresting, exciting or inhibiting other nerve cells

Electrical signals are sent from the cell body alongthe axon to the synapse, these electrical signalsbeing the result of ion (Na+, K+ , Ca2+) currentsacross channels in the nerve cell membrane

Chemical signals (neurotransmitters) pass acrosssynapses between neurons

( )


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PATHOPHYSIOLOGY (II)

Neurotransmitters cross the synaptic gap between neurons

and fix to receptor points of the adjoining neuron

Some neurotransmitters function to excite the joining

neuron (eg. glutamate) to send a further electrical signal.

Other neurotransmitters function to inhibit the joining

neuron (eg. GABA) and inhibit electrical signals passing

down that neuron

It is by these electrical and chemical pathways that the

millions of neurons within the brain communicate and

function normally

seizures occur when there is an imbalance within these

excitatory and inhibitory circuits in the brain, either

throughout the brain (generalized epilepsy) or in a

localized part of the brain (focal epilepsy), such that

neurons fire off in an abnormal fashion

Mechanism of AEDs to prevent

Altering electrical transmission along neurons

by affecting ion (Na+, K+ , Ca2+) channels in

the cell membrane.

Altering chemical transmission between

neurons by affecting neurotransmitters

(GABA,glutamate) in the synapse


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CLASSIFICATION OF SEIZURES

onic Clonic - rand mal orconvulsionoss of ,onsciousnesst iff en ing o f bo dyhen jerking oflimbs

Absence etit mal ortarting fit orrance like state

onic orAtonic r op a tta ck,brupt fall eitherith stiffening( )onic or with lossf muscle tone( tonic or astatic)ttacks

Myoclonicud den m usc le jer ks

Seizure Classification

Partialeizure activity starts in onerea of the brain

Generalized&e iz ure i nvo lv es w hole b rai nonsciousness is affected

Simpleetains awarenessComplex

ltered awareness andbehaviorecondarygeneralization ( preading from one area to)he whole brain


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SEIZURE CLASSIFICATIONS:SEIZURE CLASSIFICATIONS:

Generalized Jacksonian FocalGeneralized Jacksonian Focal


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PARTIAL SEIZURES

Simple partial seizures. These seizures don't result in loss of consciousness.

They may alter emotions or change the way thingslook, smell, feel, taste or sound.

Complex partial seizures. These seizures alter consciousness, causing you to

lose awareness for a period of time. Complex partialseizures often result in staring and non purposefulmovements such as hand rubbing, lip smacking,arm positioning, vocalization or swallowing.


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Generalized Seizures

Absence seizures (petit mal) These seizures are characterized by staring, subtle body movement and

brief lapses of awareness.

Myoclonic seizures These seizures usually appear as sudden jerks of your arms and legs.

Atonic seizures Also known as drop attacks, these seizures cause you to suddenly

collapse or fall down.

Tonic- clonic seizures (grand mal) Themost intense of all types of seizures, usual sequence is aura-cry-

unconsciousness -tonic spasm of all body muscles clonic jerkfollowed by prolong sleep & depression of all CNS functions.


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Prevalence of seizure types

Generalized

tonic clonic,

23%

Complex

Partial, 36%

Simple Partial,

14%

Other

generalized,8%

Partial

unknown, 7

Absence, 6%

Myoclonic, 3%

Unclassified,3%


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Symptoms of Epilepsy

sion with or without a fever Sudden stiffeningBlackout or confused memory,Sudden fear anger for no reasonBlank staring

Conditions that may be mistaken for epilepsy Seizures associated with high fever Fainting

: , ,Sleep disorders nightmares narcolepsy cataplexy : , ,Psychiatric disorders panic attacks fugue states psychogenicseizures

Migraine headaches -Childhood breath holding episodes

,Muscle jerks of arms legs


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Screening & DiagnosisElectroencephalogram (EEG)Computerized tomography (CT)

Magnetic resonance imaging (MRI)Positron emission tomography (PET)

Single-photon emission computerized tomography


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MAGNETIC RESONANCE IMAGINGMAGNETIC RESONANCE IMAGING(MRI)(MRI)[ ]Magnetic Resonance Imaging MRI was first introduced in the USA in the

early 1980s revolutionizing the practice of neurology and neurosurgery .because of the excellent detail resemblance of the brain s structure

,This is extremely helpful because it identifies brain scar tissue areas, ,of abnormal brain development or dysplasia small brain tumors blood

, .vessel abnormalities and changes in the brain s white matter


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Positron emission tomography PET scans use injected radioactive material to help visualize

active areas of the brain. The radioactive material istagged in a way that makes it attracted to glucose.Because the brain uses glucose for energy, the parts thatare working harder will be brighter on a PET image.

After the radioactive material is injected, it will take between30 and 90 minutes for the substance to accumulate in yourbrain tissue. During this waiting period, you will be asked torest quietly and not talk or move around much. The actualscan takes 30 to 45 minutes. The amount of radioactive

material used in the test is very small, and its glucosebinding activity in the brain lasts only a short period oftime.

Si l h t i i t i d


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Single-photon emission computerizedtomography(SPECT)

This type of test is used primarily in peoplebeing evaluated for epilepsy surgerywhen the area of seizure onset is unclearon MRIs or EEGs. SPECT imaging

requires two scans one during aseizure and one 24 hours later.Radioactive material is injected for bothscans and then the two results arecompared. The area of the brain with thegreatest activity during the seizure canbe superimposed onto the person's MRI,to show surgeons exactly what portion ofthe brain should be removed


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Treatment Algorithm


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Treatment Options

There are four main categories of epilepsytreatmentsMedications

Surgery

Ketogenic DietVagus Nerve Stimulation

Other treatments for epilepsy


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Medications

Each medication has benefits and side effects and differentmedications are appropriate for different types ofepilepsy.

No one medication is proven to be the best treatment for

epilepsy. Only a complete evaluation can determinewhich medication will work best for each patient.

Approximately

50% of seizures are eliminated by medication 30% of seizures are reduced in intensity and frequency by

medication


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Seizure type and Drug selectionSeizure type First line drugs Second line drugs

Partial ,simple, complex,with or without secondarygeneralization

LacosimideLeveiiracetamCarbamazepineSodium valproate

ClobazamClonazepamGabapentinLamotriginePhenytoinTiagabineTopiramateVigabatrin

PregabalinZonisamide

Generalized absence Sodium valproateEthosuximide

ClobazamClonazepamLamotrigine

Generalized tonic-clonic LevetiracetamSodium valproate

CarbamazepineClobazamGabapentinLamotriginePhenytoinTopiramateVigabatrin

Myoclonic LeveitiracetamSodium valproate

Phenobarbital


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Actions of antiseizure drugs

Antiseizure Drugs act by distinctmechanisms:

increasing effect of GABA , inhibitory

neurotransmitterdelaying the influx of sodium and calcium

ions into neuronsMajor Chemical categories of

antiseizure meds:1. Barbiturates2. Benzodiazepines


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Barbiturates

( ) - /henobarbital Luminal 60 180mg day - /rimidone750 1000mg day:OA potentiate the effects of GABA:ndication- ,tonic clonic seizures status epilepticus

adjuncts to anesthesia:E drowsiness dizziness hypotension respiratory depression drug tolerance &physical drug dependency withdrawal syndrome


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Benzodiazepines

( ) - /iazepam Valium 4 40mg day ( ) - /clonazepam Klonopin 1 12mg day ( ) - /lorazepam Ativan 2 6mg day ( ) . - . /clorazepate Tranxene 7 5 22 5mg day:OA intensify GABA action:ndication - ,short term severe convulsions status epilepticus , &relieve tension anxiety skeletal muscle spasms:E ataxia cardiac depression drug tolerance physical drug dependency with withdrawal syndrome


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Hydantoin

( ) - /henytoin Dilantin 300 400mg day:OA delay influx of sodium ions into neurons:ndicationall types of seizure except for absence seizures:ide Effects gingival hyperplasia

slurred speech , &confusion headache depression blood dyscrasias severe liver toxicity alopecia hirsutism

Stevens Johnson syndrome


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Succinimides

( ) - /Ethosuximide Zarontin 750 1250mg day:OA delay calcium influx into neurons:ndication DOC for absence seizures;E &anorexia vomiting blood dyscrasia -Stevens johnson syndrome


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Other antiseizure drugs

Valproates750-2000mg/day valporic acid ( Depakene) divalproex Na (Depakote) Indication:

absence seizures

mania migraine headache SE: GI upset Hepatotoxic

Iminostilbenes carbamazepine

(Tegretol)600-1800mg/day gabapentin (Neurontin)900-

2400mg/day lamotrigine150-500mg/day topiramate200-400mg/day Indication:

seizure DO that have notresponded to other convulsants

trigeminal neuralgia

DOC for partial seizures SE;

Blood dyscrasia CNS depression GI upset

Stevens- johnson syndrome


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STATISTICS SHOW THATSTATISTICS SHOW THAT


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70% of patients managetheir epileptic attacks withthe use of drugs

But the other 30% aretreated with surgery.

STATISTICS SHOW THATSTATISTICS SHOW THAT


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LESIONECTOMLESIONECTOMYY

LOBELOBERESECTIONRESECTIONt common procedure among adults and adolescents, is the removal of the lobe where the

in lesions, such as areas of injury, tumors, or malformed blood vessels.


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In a FUNCTIONALHEMISPHERECTOMY, one

hemisphere is disconnectedfrom the rest of the brain, butonly a specific area of braintissue is removed. This surgeryis typically done on children

younger than 13 years old whohave one hemisphere that isnot functioning normally.

FUNCTIONALFUNCTIONALHEMISPHERECTOMYHEMISPHERECTOMY


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MULTIPLE SUBPIALTRANSECTION (MST) isused to help control

seizures that begin inareas of the brain thatcannot be safelyremoved. The surgeonmakes a series of

shallow cuts ortransections in the braintissue to interrupt thecourse of seizureimpulses but do not

disturb normal brainactivity, leaving theperson's abilities intact.

MULTIPLEMULTIPLE

SUBPIALSUBPIALTRANSECTIONTRANSECTION


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Ketogenic Diet

The ketogenic diet is primarily used in childhoodepilepsy.

The mechanism of ketogenic diet is unknown. The

high-fat, low-protein, no-carbohydrate dietmimics some effects of starvation that seem toinhibit seizures.

The diet is very rigid and carefully controlled andmust be supervised by a physician -- sometimesin a hospital setting.

Ketogenic diets have been used for children with

epilepsy for many years with a success rate ofa roximatel 50 ercent.


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Vagus Nerve Stimulation (VNS)

Vagus nerve stimulation (VNS) is approved

to treat partial seizures in patients 12years of age or older

Approximately 30 to 50 percent of patientscan be expected to have less seizureactivity with VNS

The vagus nerve stimulator is surgicallyimplanted under the skin in the chest. Thedevice is attached to a wire that istunneled under the skin and attached tothe vagus nerve, which is located in theleft side of the neck

The vagus nerve stimulator is adjusted to

automatically stimulate the vagus nervefrom every few seconds to every fewminutes.

The device does not detect seizure activity.It can be adjusted easily in a physician'soffice using a laptop computer


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OTHER TREATMENTS FOR

EPILEPSY

NATUROPATHYYOGA THERAPY

ACUPUNCTURE

HYPNOTISM COLLOIDAL SILVER


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Naturopathy

NATUROPATHY is the belief that avoidingcertain drugs such as caffeine and alcohol;chemicals; and maintaining a well-balanceddiet high in vitamins D and B6, as well aszinc, calcium, and magnesium, which haveanticonvulsant properties, and the aminoacid taurine, would help control seizures.


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HypnotismHypnotism has been proven to be a mean ofrelief that is normally safe and beneficial for

patients with partial seizures. Commonly, tobe in a hypnotic state it takes an effort ofintense concentration and some studiesfound a degree of high arousal in the EEGsof people being hypnotized, which meansthat this could, in certain cases induce a

seizure.


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Prognosis

Certain types of childhood epilepsy resolve or improve withage.

A seizure-free period of 4 years may indicate thatreduction or elimination of medications is possible.

Death or permanent brain damage from seizures is rare,but can occur if the seizure is prolonged.

Death or brain damage are most often caused byprolonged lack of breathing and resultant death of braintissue from lack of oxygen.

Infrequent seizures may not severely restrict the person'slifestyle.)


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References

1.Joseph T.Dipiro,Barbera G.Wells,Terry LSchwinghamar,CindyW.Hamlilton-Pharmacotherapyhandbook,5th edition2003; 505-22

2. Roger Walkar,Clive Edwards-Clinical pharmacay andTherapeutics 3rd edition 2003;465-81

3. Eric T. Herfindal,Dick R. Gourley-Textbook of Therapeutics drugand disease management,7th edition 2002;1107-11

4. www.unisanet.unisa.edu.au/12163/undlecs2002

5. www.sfn.org/.../epilepsy_illus_large.gif

6. thebrain.mcgill.ca

7. www.aesnet.org/go/professionaldevelopement/educational-opport

8. www.wellsphere.com/wellpage/epilepsy

9. www.med.uc.edu/neurology/epilepsyinfo.htm

10.

11.
http://www.unisanet.unisa.edu.au/12163/undlecs2002http://www.aesnet.org/go/professionaldevelopement/educational-opportunities/epilepsyeducation.../basic-mechanisams-of-epilepsyhttp://www.wellsphere.com/wellpage/epilepsyhttp://www.med.uc.edu/neurology/epilepsyinfo.htmhttp://www.med.uc.edu/neurology/epilepsyinfo.htmhttp://www.wellsphere.com/wellpage/epilepsyhttp://www.aesnet.org/go/professionaldevelopement/educational-opportunities/epilepsyeducation.../basic-mechanisams-of-epilepsyhttp://www.unisanet.unisa.edu.au/12163/undlecs2002


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Epilepsy Final