Known as Anticonvulsants Goal of tx: control or prevent seizures while maintaining a reasonable quality of life Many patients must

take for life Abrupt discontinuation can cause withdrawal seizures If 1st agent not effective, must be tapered slowly while 2nd is introduced Depending on agent, therapeutic drug monitoring of serum levels must be done to assess effectiveness of therapy and avoid toxicities or under treatment

Classified into
Traditional AED Newer AED

Classes
Barbiturates Hydantoins Iminostilbenes plus valproic acid

Phenobarbital [generic] oldest Sch IV- B Carbamazepine [Tegretol]- I Phenytoin [Dilantin]-H Pimidone [Mysoline]-B Valproic acid [Depakene, Depakote, Depakote ER]-unspecified Exthosuximide [Zarontin]-Succinimide

Gabapentin [Neurontin]-used to treat neuropathic pain also Lamotrigene [Lamictal] Levetiracetam [Keppra]-**sleepiness Pregabalin [Lyrica]-Schedule V; also for neuropathic pain & postherpetic pain Tiagabine [Gabitril] Topiramate [Topamax] Zonisamide [Zonegram] Lacosamide [Vimpat] Banzel [rufinamide] Onfi [Clobazam] 2011 U.S.

Oxacarbazepine-Trileptal Gabapentin-Neurontin Lamotrigine-Lamictal Levetiracetam-Keppra Topamax Gabitril, Zonegram, pregbalin-Lyrica

1. increase threshold activity in area of brain called motor cortex 2. limit spread of seizure discharge from its origin 3. decrease speed of nerve impulse conduction within a given neuron

Pheno: sedation/drowsiness [most common], lethargy, depression, learning impairment, physical dependence, poryphyria Valporic acid-hepatoxicity, pancreatitis Phenytoin-gingival hyperplasia, sedation/drowsiness,nystagmus, diplopia, ataxia, cognitive impairment, skin rash, dyrsrhythmias [IV]

Topiramate [Topamax]-met. Acidosis, hypohidrosis [reduced sweating], close-angle glaucoma Zonisamide [Zonegram]- nephrolithiasis, psych effects Pregabalin [Lyrica]-blurred vision, somnolence, rhabdomyolysis [rare], dependence Lamotrigine [Lamictal]-life threatening rashesSJS, toxic epidermal necrolysis Oxcarbazepine [Trileptal]- hyponatremia [less 125 mEq/L], fatal skin rashes, mult-iorgan hypersensitivities

Pregnancy:

AEDS: teratogenic BUT Benefits must outweigh the risks Common malformations Valproic acid-spina bifida & other neural tube defects Uncontrolled seizures
Safety concern Induce labor Injury to baby during last month

Carbamazepine [Tegretol]Traditional/first generation Uses: partial and general tonic-clonic; trigeminal neuralgia DO NOT GIVE w/GRAPEFRUIT-increased toxicity of antiepileptic medication Instruct patient to report visual abnormalities. Instruct patient that abrupt withdrawal after long-term use may precipitate seizures Must monitor drug levels: 4-12 mcg/mL A/E: bone marrow suppression, fatal aplastic anemia

1st line drug-Protypical-HYDANTOIN Used: tonic-clonic/partial seizures Most common adverse effects are lethargy, abnormal movements, mental confusion, and cognitive changes. Gingival hyperplasia is a well-known adverse effect of longterm oral phenytoin therapy. Scrupulous dental care can help prevent gingival hypertrophy. Long-term=gingival hyperplasia, acne, hirsutism, and hypertrophy of subcutaneous facial tissue resulting in an appearance known as Dilantin facies. Another long-term consequence of phenytoin therapy is osteoporosis.

Need Vitamin D supplements

Therapeutic drug levels are usually 10 to 20 mcg/mL. Above 20 mcg/mL: Toxic levels: nystagmus, ataxia, dysarthria, and encephalopathy. Phenytoin can interact with other medications for two main reasons.
First, it is highly bound to plasma proteins and

competes with other highly protein-bound medications for binding sites. Second, it induces hepatic microsomal enzymes, mainly cytochrome P-450

Route: PO, IV Should be given slow IVP [not to exceed 50 mg/min in adults] Must be diluted in NORMAL SALINE for IV infusion & a filter must be used. Follow each dose by saline flush to avoid local venous irritation Loading dose: 1 gram IV: pt needs to be on a CARDIAC monitor.

Gingival inflammation

injectable prodrug of phenytoin [Dilantin] Route: intramuscularly or intravenouslyby IV push or continuous infusionwithout causing burning on injection Fosphenytoin is dosed in phenytoin equivalents (PE) Fosphenytoin is given at a rate of 150 mg PE/min or less to avoid hypotension or cardiorespiratory depression. If dysrhythmias or hypotension occur, discontinue the infusion. Implement fall prevention measures after infusion of either phenytoin or fosphenytoin because of possible ataxia and dizziness. Take vital signs up to 2 hours after infusion.

two of the most commonly used antiepileptic drugs were the barbiturates phenobarbital and primidone (Mysoline) Phenobarbital-Schedule IV
used for the management of status epilepticus and

is an effective prophylactic drug for the control of febrile seizures Most common effect: sedation Therapeutic serum drug levels: 10-40 mcg/mL. Long half-life-50-120 hours Route: PO, Injectible

Benzodiazepines-Status epilepticus
Lorazepam [Ativan]-preferred

Phenytoin [Dilantin] loading 1 gram IV

Diazepam [Valium]
Phenobarbital [rarely used]

SAFETY ALERT
During a seizure, you should do the following:

Maintain a patent airway.

Protect the patient's head, turn the patient to the side,

loosen constrictive clothing, ease patient to the floor, if seated.

Do not restrain the patient. Do not place any objects in the mouth.

When a seizure occurs, you should carefully observe and record details of the event because the diagnosis and subsequent treatment often rest solely on the seizure description. All aspects of the seizure should be noted. What events preceded the seizure? When did the seizure occur? How long did each phase (aural [if any], ictal, postictal) last? What occurred during each phase?

Monitor serum drug levels Baseline and periodic lab studies as ordered O2 as ordered IV access essential Maintain seizure precautions Through neuro/respiratory assessment Instruct patient not to abruptly stop Instruct patient regarding worsening effects Instruct to administer same time each day

IV pump for IV infusions Follow agency protocol for dilantin Cardiac monitoring as indicated esp. w/dilantin loading [1 gram IV] Instruct to check whether driving is allowedmost states driving is not allowed for a specific period of time All safety precautions