1. Drugs Used for Seizure Disorders
Chapter 19
Drugs Used for Seizure Disorders
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2. Chapter 19
Lesson 19.1
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3. Objectives Discuss the basic classification systems used for epilepsy
Develop a teaching plan for patient education for people diagnosed with a seizure disorder
Discuss non-drug treatment of seizures
Explain the rationale for proper dental care for people receiving hydantoin therapy
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4. Objectives (cont’d)
Prepare a chart to be used as a study guide that includes the following information:
Name of seizure type
Description of seizure
Medications used to treat each type of seizure
Nursing interventions and monitoring parameters for seizures
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5. Seizure Disorders
Symptoms of an abnormality in the nerve centers of the brain
Chronic and recurrent seizures point to epilepsy
Two broad categories
Generalized seizures – affect both brain hemispheres
Partial seizures – begin in one hemisphere
Epilepsy is the most common of all neurologic disorders.
Causes include fever, head injury, brain tumor, meningitis, hypoglycemia, drug overdose or withdrawal, poisoning.
Patients may report an aura prior to having a seizure.
Sodium and calcium are ions that affect seizure activity within the brain.
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6. Classification of Seizures
Generalized convulsive seizures
Tonic-clonic (grand mal)
Atonic or akinetic
Myoclonic
Generalized nonconvulsive seizures
Absence (petit mal)
Partial (localized)
Status epilepticus is a medical emergency
Tonic-clonic seizures - have a tonic phase, during which sudden intense muscular contractions occur, and a clonic phase, during which bilateral symmetric jerks occur and usually end in a postictal state – or recovery phase of flaccid paralysis and sleep.
Atonic seizures - sudden loss of muscle tone and dropping of a limb or slumping to the ground; results in dramatic falls.
Myoclonic seizures - lightning-like repetitive contractions of the face, trunk, and extremities.
Absence seizures - occur primarily in children and disappear at puberty; involve staring off into space, rhythmic movements of eyes, head, mumbling, chewing, lip smacking.
Partial seizures - localized convulsions of single body parts such as a finger or extremity; involves jerking.
Status epilepticus - rapidly recurring generalized seizures that do not allow normal functioning between seizures; may result in death.
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7. Teaching Plan for Seizure Disorders
Take histories, describe seizures, record postictal behavior
Identify a care plan, have proper supplies, discuss with patient and family
Assist patient during seizures, observe and record, discuss lifestyle and feelings with patient
Encourage patients to maintain medication regimen unless otherwise directed by health care provider
Long-term goals for patients are to reduce the frequency of—and injury from—seizures while still having minimal adverse effects from therapy.
Perform premedication and ongoing assessments, patient education regarding expectations of therapy, and adverse effects. Monitor serum electrolytes, get a baseline of speech patterns, and determine changes in the degree of orientation and level of alertness.
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8. Patient Education and Health Promotion
Exercise and activity
Nutrition
Safety
Stress
Oral hygiene
Medical considerations
Expectations of therapy
Fostering health maintenance
Written record
Difficulty in comprehension
Maintain regular activity.
Avoid stimulants such as caffeine and limit alcohol. Seizures are known to follow significant intake of alcoholic beverages.
Avoid driving or operating power equipment. State laws may prohibit patients with seizures disorders from driving.
Gingival hyperplasia (gum overgrowth) has been associated with hydantoins. Maintain daily oral hygiene with frequent gum massage and regular brushing as well as regular dental exams.
Carry an identification card or bracelet.
Do not discontinue medications unless told to do so by health care provider; inform provider of suspected pregnancy.
Discuss expectations of therapy which will involve all aspects of daily life.
Explore underlying problems in acceptance of disease.
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9. Non-Drug Therapy for Seizures
Surgical intervention can treat refractory seizures
Implantable vagus nerve stimulator
Ketogenic diet (restricts carbohydrates and protein)
Implantable vagus nerve stimulators are approved for children age 12 and older.
Ketogenic diet uses fat as the primary fuel of the body; it has been shown to reduce refractory seizures in children who have not experienced effective control with drug therapy. Adverse effects include high lipid levels.
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10. Study Guide Chart Prepare a chart for study with: Seizure type
Generalized convulsive
Generalized nonconvulsive
Describe each category carefully and include all subdivisions
Medications used for each type of seizure
Benzodiazepines
Hydantoins
Nursing interventions and monitoring parameters
Make chart with:
Name of seizure type
Description of seizure
Medications used to treat each type of seizure
Nursing interventions and monitoring parameters for seizures
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11. Chapter 19
Lesson 19.2
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12. Objectives
Identify the mechanisms of action thought to control seizure activity when anticonvulsants are administered
Cite the desired therapeutic outcomes for seizure disorders
Cite precautions needed when administering phenytoin or diazepam intravenously
Describe the effects of the hydantoins on patients with diabetes and on people receiving oral contraceptives, theophylline, folic acid, or antacids
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13. Anticonvulsant Therapy
Goals:
Reduce frequency of seizure activity
Minimize adverse effects of the medicine
Selection of drug depends on type of seizure, age and gender of patient, potential adverse effects
Anticonvulsants increase seizure threshold
Agents either inhibit excitatory processes or enhance inhibitory processes
Broad spectrum agents: levetiracetam (Keppra), topiramate (Topamax), valproic acid (Depakene), and lamotrigine (Lamictal).
Narrow spectrum agents: phenytoin (Dilantin), carbamazepine (Tegretol), oxcarbazepine (Trileptal), tiagabine (Gabatril), gabapentin (Neurontin), and pregabalin (Lyrica).
Before therapy is started, contributing factors of the underlying cause must be identified: head injury, fever, hypoglycemia, drug overdose, etc.
Anticonvulsant drugs and antiepileptic therapy are used interchangeably.
Prevents seizures from spreading to adjacent neurons.
Can be either broad-spectrum or narrow-spectrum agents in relation to their efficacy against different types of seizures.
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14. Drug Class: Benzodiazepines
Actions
Thought to enhance inhibitory effects of GABA in postsynaptic clefts between nerve cells
Uses
Anticonvulsant
Common adverse effects
Sedation, drowsiness, dizziness, fatigue, lethargy; blurred vision
Drugs: clonazepam (Klonopin), clorazepate (Tranxene), diazepam (Valium), lorazepam (Ativan)
CAUTION: When giving diazepam IV, it must be administered slowly and not mixed with other medications in the same syringe; heart rate must be closely monitored.
Therapeutic outcomes: reduced frequency of seizures, reduced injuries, minimal adverse effects from therapy.
Serious adverse effects: behavioral disturbances; blood dyscrasias; hepatotoxicity
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15. Drug Class: Hydantoins
Actions
Mechanism of action unknown
Uses
Anticonvulsants to control tonic-clonic seizures
Common adverse effects
Nausea, vomiting, indigestion; sedation, drowsiness, dizziness, fatigue, lethargy; blurred vision; gingival hyperplasia
Serious adverse effects
Hyperglycemia; blood dyscrasias; hepatotoxicity; dermatologic reactions
Drugs: ethotoin (Peganone), fosphenytoin (Cerebyx), phenytoin (Dilantin)
CAUTION: When given IV, phenytoin must be administered slowly and not mixed with other medications in the same syringe.
CAUTION: Toxicity may cause nystagmus - involuntary movement of the eyes; often noted as a shaky or wiggly movement.
Phenytoin (Dilantin) is the most common hydantoin.
Therapeutic drug serum levels must be monitored when taking this drug.
Therapeutic outcomes: Reduced frequency of seizures, reduced injuries; minimal adverse effects from therapy.
This drug class is particularly effective with grand mal seizures.
For patients taking oral contraceptives, spotting and bleeding may indicate reduced contraceptive effects; using alternative forms of birth control is recommended. Theophylline levels may be effected by phenytoin and increased doses may be needed to maintain therapeutic response.
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16. Drug Class: Succinimides
Drugs
Ethosuximide (Zarontin)
Methsuximide (Celontin)
Actions
Mechanism of action unknown
Uses
Control absence (petit mal) seizures
Common adverse effects
Nausea, vomiting, indigestion; sedation, drowsiness, dizziness, fatigue, lethargy
Toxic effects of succinimides can be enhanced by antihistamines, alcohol, analgesics, anesthetics, tranquilizers, other anticonvulsants, and sedative-hypnotics.
Measures to alleviate common GI adverse effects: gradually increase the dose and give with food or milk to reduce gastric irritation.
Therapeutic outcomes: Reduced frequency of seizures, reduced injuries; minimal adverse effects from therapy.
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17. Miscellaneous Anticonvulsants
Drug: carbamazepine (Tegretol)
Actions
Block reuptake of norepinephrine
Decrease release of norepinephrine and rate of dopamine and GABA turnover
Uses
In combination with other anticonvulsants to control tonic-clonic seizures, treat trigeminal neuralgia, treat manic-depressive disorders when lithium not optimal
Common adverse effects
Nausea, vomiting; drowsiness, dizziness
Not effective for myoclonic or absence seizures.
Therapeutic outcomes: Reduced frequency of seizures, reduced injuries; minimal adverse effects from therapy.
Serious adverse effects: orthostatic hypotension, hypertension; dyspnea, edema; neurologic changes; nephrotoxicity; hepatotoxicity; blood dyscrasias; dermatologic reactions.
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18. Miscellaneous Anticonvulsants (cont’d)
Drug: gabapentin (Neurontin)
Actions
Mechanism of action unknown; does not appear to enhance GABA
Uses
In combination with other anticonvulsants to control partial seizures, treat postherpetic neuralgia
Common adverse effects
Sedation, drowsiness, dizziness; blurred vision
Serious adverse effects
Neurologic changes
Drugs enhancing its sedative effect include sleep aids, analgesics, tranquilizers, alcohol.
Therapeutic outcomes: Reduced frequency of seizures, reduced injuries; symptomatic relief from postherpetic neuralgia; minimal adverse effects from therapy.
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19. Miscellaneous Anticonvulsants (cont’d)
Drug: lamotrigine (Lamictal)
Actions
Thought to block voltage-sensitive sodium and calcium channels in neuronal membranes
Uses
In combination with other anticonvulsants to control partial seizures
Common adverse effects
Nausea, vomiting, indigestion; sedation, drowsiness, dizziness; blurred vision
Serious adverse effects
Most patients develop skin rash and urticaria
Used to treat generalized seizures of Lennox-Gastaut syndrome in pediatric and adult patients.
Therapeutic outcomes: Reduced frequency of seizures and injuries; minimal adverse effects from therapy.
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20. Miscellaneous Anticonvulsants (cont’d)
Drug: levetiracetam (Keppra)
Actions
Classified as pyrrolidine derivative; unrelated to other antiepileptic drugs
Mechanism of action unknown
Uses
In combination with other anticonvulsants to treat adult partial-onset seizures
Common adverse effects
Weakness, drowsiness, dizziness
Serious adverse effects
Neurologic changes
Patients should not operate vehicles or heavy machinery until effects are known.
Therapeutic outcomes: reduced frequency of seizures and injuries; minimal adverse effects from therapy.
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21. Miscellaneous Anticonvulsants (cont’d)
Drug: oxcarbazepine (Trileptal)
Actions
Metabolizes into active metabolites of carbamazepine; interacts with sodium, potassium, and calcium ion channels, stabilizing neurons, preventing repetitive firing
Uses
Monotherapy or combination therapy to treat partial seizures
Common adverse effects
Confusion, poor coordination, drowsiness, dizziness
Therapeutic outcomes: Reduced frequency of seizures and injuries; minimal adverse effects from therapy.
Used only as combination therapy in treating partial seizures in children 4 to 16 years of age.
Serious adverse effects: nausea, headache, lethargy, confusion, obtundation, malaise; blood dyscrasias.
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22. Miscellaneous Anticonvulsants (cont’d)
Drug: phenobarbital (Luminal)
Actions
Long-acting barbiturate; elevates the seizure threshold, prevents spread of seizure
Uses
Primarily as alternative when single anticonvulsants are unsuccessful
Treat partial and generalized tonic-clonic seizures and generalized myoclonic seizures
In combination with other anticonvulsants
See Chapter 14 for further discussion
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23. Miscellaneous Anticonvulsants (cont’d)
Drug: pregabalin (Lyrica)
Actions
Chemically related to gabapentin
Does not appear to enhance GABA
Uses
In combination with other anticonvulsants to control partial seizures
Treat pain from fibromyalgia, diabetic neuropathy, and postherpetic neuralgia
Common adverse effects
Sedation, drowsiness, dizziness; blurred vision
Therapeutic outcomes: Reduced frequency of seizures and injuries; symptomatic relief of pain from fibromyalgia, diabetic neuropathy, and postherpetic neuralgia; minimal adverse effects from therapy.
Serious adverse effects: neurologic changes; excessive use or abuse
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24. Miscellaneous Anticonvulsants (cont’d)
Drug: primidone (Mysoline)
Actions
Metabolized into phenobarbital and PEMA, both active anticonvulsants
Exact mechanism of action unknown
Uses
In combination with other anticonvulsants to treat tonic-clonic seizures
Common adverse effects
Sedation, drowsiness, dizziness; blurred vision
Serious adverse effects
Blood dyscrasias, paradoxical excitability
Structurally related to barbiturates.
Therapeutic outcomes: Reduced frequency of seizures and injuries; minimal adverse effects from therapy.
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25. Miscellaneous Anticonvulsants (cont’d)
Drug: tiagabine (Gabitril)
Actions
Mechanism of action unknown; appear to prevent reuptake of GABA into presynaptic neurons, making more GABA available
Uses
In combination with other anticonvulsants to control partial seizures
Common adverse effects
Sedation, drowsiness, dizziness
Serious adverse effects
Neurologic changes, memory loss
Therapeutic outcomes: Reduced frequency of seizures and injuries; minimal adverse effects from therapy.
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26. Miscellaneous Anticonvulsants (cont’d)
Drug: topiramate (Topamax)
Actions
Mechanism of action unknown; appears to prolong blockade of sodium channels, enhance activity of GABA, antagonize certain receptors for the neurotransmitter
Uses
In combination with other anticonvulsants to control tonic-clonic seizures
Prevention of migraine headaches
Common adverse effects
Sedation, drowsiness, dizziness
Phenobarbital enhances the metabolism of topiramate.
Therapeutic outcomes: Reduced frequency of seizures and injuries; minimal adverse effects from therapy.
For patients taking oral contraceptives, spotting or bleeding may be an indication of reduced contraceptive activity. Recommend alternative methods of birth control.
Serious adverse effects: neurologic changes, hydration status; decreased sweating and overheating have been reported.
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27. Miscellaneous Anticonvulsants (cont’d)
Drug: valproic acid (Depakene)
Actions
Appear to support GABA activity as an inhibitory neurotransmitter
Uses
Control tonic-clonic seizures
Only single-drug therapy to treat combination of generalized tonic-clonic, absence, or myoclonic seizures
Treat acute mania of bipolar disorder
Common adverse effects
Nausea, vomiting, indigestion; sedation, drowsiness, dizziness; blurred vision
One metabolite of valproic acid is a ketone, which may cause a false-positive on urine tests for ketones.
Liver function and serum therapeutic drug levels should be monitored when taking this drug.
Therapeutic outcomes: Reduced frequency of seizures and injuries; minimal adverse effects from therapy.
Serious adverse effects: blood dyscrasias; hepatotoxicity; pancreatitis.
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28. Miscellaneous Anticonvulsants (cont’d)
Drug: zonisamide (Zonegran)
Actions
Block sodium and calcium channels to stabilize neuronal membranes
Uses
In conjunction with other anticonvulsants to control adult partial seizures
Common adverse effects
Drowsiness, dizziness
Serious adverse effects
Neurologic changes, nephrotoxicity, blood dyscrasias, dermatologic reactions
Classified as a sulfonamide.
Phenobarbital enhances the metabolism of zonisamide.
Therapeutic outcomes: Reduced frequency of seizures and injuries; minimal adverse effects from therapy.
Determine if patient has allergies to sulfonamides or a history of skin rashes.
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