Seizure Disorder

Seizure Disorder

Definition• A seizure is a paroxysmal event due to abnormal, excessive,

hypersynchronous discharges from an aggregate of CNS neurons. • Epilepsy describes a condition in which a person has recurrent

seizures due to a chronic, underlying process.

Partial seizures

Simple partial seizures

Complex partial seizures

Partial seizures with secondary generalization

Primarily generalized seizures

Absence seizures

Tonic clonic seizures

Tonic Seizureso When a tonic seizure occurs, the muscles in the body contract and

the entire body stiffenso And it often causes the person to fall down

Atonic seizureso Characterised by loss of postural tone lasting 1-2 secso Consciousness is briefly impairedo No post ictal confusion

Myoclonic seizureso Characterised by sudden and brief contraction of one part of the

body or entire body

Unclassified Seizureso Seizures that occur in neonates and infants

Status epilepticus

Vineetha Bharathan Menon

VI Pharm.D

JSSCP

SEIZURE DISORDER

Patient details:

IP no: 279411 Age: 15 years Sex: Male Weight: 53 kg Unit: Neurology I

DOA: 17/1/14

Reason for admission:

Recurrence of seizures since 2 days (5 episodes in 2 days lasting 10-20 secs).

PMx:

K/C/O: seizure disorder since 8 years (since 2010) and on regular medications (T. Phenytoin 50 mg- 0 - 50 mg, T. Clobazam 5 mg 1-0-1, recently started on T. Valproic acid 250 mg 0-0-1).

GTCS type of seizures a/w LOC for 2-3 mins

Post ictal headache (+)

No post ictal confusion

Post ictal myalgia (+)

h/o cough/ headache (+)

No h/o fever in the last week

No h/o vomiting

Developmental history:

Normal hospital vaginal delivery- normal developmental milestones achieved.

Provisional diagnosis:

Seizure disorder for evaluation

Day 1:

BP: 130/80 mmHg Pulse: 86 bpm

C/O 6 episodes of GTCS in the morning

O/E: skin lesions (+)

CNS: conscious oriented, clinically no FND

Motor System: Power 5/5, Reflexes (N)

CVS: S1S2 (+)

R/S: B/L NVBS (+), no added sounds.

ADV: Hb, TC, DC, ESR, LFT, Calcium

Treatment Chart:Drugs Dose Route Frequenc

yD1 D2 D3 D4 D5 D6

Valproic acid 250 mg PO 0-0-1 +

Phenytoin Sodium

100 mg PO 1-0-1 + + + + + +

Clobazam 10 mg PO 1-0-1 + + + + + +

Magaldrate + simethicone gel

400 mg + 20 mg in

5 ml

PO BD + + + + + +

Multivitamin 5 ml PO BD + + + + + +

Protein powder 1 tsp PO BD + + + + +

Pantoprazole + Domperidone

40 mg + 10 mg

PO 1-0-0 + + + + +

Fosphenytoin 50 mg IV 1-1-1 + + +

Lamotrigine 25 mg PO 1-0-1 + + 1-0-2

+ +

Laboratory Data:

Hb 14.2 gm/dl (13.5 ± 2 gm/dl)

WBC 6,900 cells/cu.mm (4000-11,000 cells/cu.mm)

PLT 2.75 lakhs/cu.mm (1.5-5 lakhs/cu.mm

ESR 5 mm/hr (0-10 mm/hr)

Hematology: Biochemistry:

Electrolytes:

Bilirubin T

0.60 mg/dl (0.1-1.0 mg/dl)

D

0.20 mg/dl (0.0-0.2 mg/dl)

Total proteins

6.5 gm/dl (6-8 gm/dl)

Albumin 3.6 gm/dl (3.4-5.0 gm/dl)

A/G ratio 1.2 (1.2-2.5)AST 35 U/L (0-40 U/L)ALT 34 U/L (0-40 U/L)ALP 277 U/L (37-306 U/L)

Ca 9.6 mg/dl (8.8-10.8 mg/dl)

Day 2:

BP: 130/80 mmHg

Case reviewed, no fresh complaints

H/o movement of hands at 4:00 am today

O/E no FND, vital stable

Rx: as per chart

Referred to dermatologist for features suggestive of adenoma sebaceum on face with ash leaf macule on chest.

Derma opinion: H/O burning sensation, lesion on nose and malar area, photosensitivity, hypopigmented patches since 7 yrs of age

Imp: Xeroderma pigmentosum

Start Suntop 30 cream (octinoxate and micronized zinc oxide lotion) and Desowen cream (desonide lotion)

Treatment Chart:

Drugs Dose Route Frequency

D1 D2 D3 D4 D5 D6

Valproic acid 250 mg PO 0-0-1 +

Phenytoin Sodium

100 mg PO 1-0-1 + + + + + +

Clobazam 10 mg PO 1-0-1 + + + + + +

Magaldrate + simethicone gel

400 mg + 20 mg in 5

ml

PO BD + + + + + +

Multivitamin 5 ml PO BD + + + + + +

Protein powder 1 tsp PO BD + + + + +

Pantoprazole + Domperidone

40 mg + 10 mg

PO 1-0-0 + + + + +

Fosphenytoin 50 mg IV 1-1-1 + + +

Lamotrigine 25 mg PO 1-0-1 + + 1-0-2

+ +

Day 3:

BP: 110/80 mmHg

Case reviewed, no fresh complaints

O/E no FND, vital stable

Rx: as per chart, Optho opinion

Treatment Chart:

Drugs Dose Route Frequency

D1 D2 D3 D4 D5 D6

Valproic acid 250 mg PO 0-0-1 +

Phenytoin Sodium

100 mg PO 1-0-1 + + + + + +

Clobazam 10 mg PO 1-0-1 + + + + + +

Magaldrate + Simethicone gel

400 mg+ 20 mg in

5 ml

PO BD + + + + + +

Multivitamin 5 ml PO BD + + + + + +

Protein powder 1 tsp PO BD + + + + +

Pantoprazole + domperidone

40 mg+ 10 mg

PO 1-0-0 + + + + +

Fosphenytoin 50 mg IV 1-1-1 + + +

Lamotrigine 25 mg PO 1-0-1 + + 1-0-2

+ +

Day 4:

BP: 110/80 mmHg

C/O 7-8 episodes of myoclonic jerks at night

CNS: no FND

CVS: NAD

Rx: as per chart

Optho opinion: c/o burning sensation and redness of eyes

Imp: NAD

Treatment Chart:

Drugs Dose Route Frequency

D1 D2 D3 D4 D5 D6

Valproic acid 250 mg PO 0-0-1 +

Phenytoin Sodium

100 mg PO 1-0-1 + + + + + +

Clobazam 10 mg PO 1-0-1 + + + + + +

Magaldrate + simethicone gel

400 mg+ 20 mg in

5 ml

PO BD + + + + + +

Multivitamin 5ml PO BD + + + + + +

Protein powder 1 tsp PO BD + + + + +

Pantoprazole + Domperidone

40 mg + 10 mg

PO 1-0-0 + + + + +

Fosphenytoin 50 mg IV 1-1-1 + + +

Lamotrigine 25 mg PO 1-0-1 + + 1-0-2

+ +

Day 5:

BP: 126/74 mmHg

Case reviewed, no fresh complaints

CNS, CVS: NAD

Rx: as per chart

Treatment Chart:

Drugs Dose Route Frequency

D1 D2 D3 D4 D5 D6

Valproic acid 250 mg PO 0-0-1 +

Phenytoin Sodium

100 mg PO 1-0-1 + + + + + +

Clobazam 10 mg PO 1-0-1 + + + + + +

Magaldrate + simethicone gel

400 mg + 20 mg in

5ml

PO BD + + + + + +

Multivitamin 5 ml PO BD + + + + + +

Protein powder 1 tsp PO BD + + + + +

Pantoprazole + Domperidone

40 mg + 10 mg

PO 1-0-0 + + + + +

Fosphenytoin 50 mg IV 1-1-1 + + +

Lamotrigine 25 mg PO 1-0-1 + + 1-0-2

+ +

Day 6:

BP: 140/80mmHg

Case reviewed, no fresh complaints

Rx: as per chart

Treatment Chart:

Drugs Dose Route Frequency

D1 D2 D3 D4 D5 D6

Valproic acid 250 mg PO 0-0-1 +

Phenytoin Sodium

100 mg PO 1-0-1 + + + + + +

Clobazam 10 mg PO 1-0-1 + + + + + +

Magaldrate + simethicone gel

400 mg+ 20 mg in

5 ml

PO BD + + + + + +

Multivitamin 5 ml PO BD + + + + + +

Protein powder 1 tsp PO BD + + + + +

Pantoprazole + Domperidone

40 mg + 10 mg

PO 1-0-0 + + + + +

Fosphenytoin 50 mg IV 1-1-1 + + +

Lamotrigine 25 mg PO 1-0-1 + + 1-0-2

+ +

Day 7:

BP: 120/80 mmHg

Case reviewed, no fresh complaints

CNS, CVS: NAD

Rx: as per chart

Adv: discharge, review after 1 week in OPD

Dishcarge medications:

Drugs Dose Route Frequency

Phenytoin Sodium 100 mg PO 1-0-1

Clobazam 10 mg PO 1-0-1

Magaldrate + simethicone gel 400 mg + 20 mg in 5 ml

PO BD

Multivitamin 5 ml PO BD

Protein powder 1 tsp PO BD

Pantoprazole + Domperidone 40 mg + 10 mg

PO 1-0-0

Lamotrigine 25 mg PO 1-0-2

Pharmaceutical Care Plan:

For seizures• Seizures since 2 days• PmHx: K/c/o seizure disorder

since 8 years

For xeroderma pigmentosum• Photosensitivity• Burning sensation and

lesion on nose and malar area

• Hypopigmentation • Irritation and redness of

eyes

For seizures• Nil

For xeroderma pigmentosum• Nil

Subjective Evidence Objective Evidence

Goals of therapy:

For seizures• To accurately diagnose the patient's seizure type and epilepsy

syndrome and determine the etiology. • To identify and eliminate patient-specific seizure precipitants. • To select optimal anticonvulsant therapy based on seizure

type, epilepsy syndrome, patient age, sex, and concomitant medical conditions. • To minimize the use of poly-drug therapy and sedating

antiepileptic drugs whenever possible.• To monitor for clinical and laboratory evidence of adverse

effects of drug therapy. • To identify and address patient concerns regarding the effect

of epilepsy and its management on daily activities, employment, and social interactions.

For XP• To protect patient from sunlight and to reduce

damaging effect of UV rays on skin

Goals achieved:

• Seizure was controlled by day 5

General treatment options

Seizure type First line agents Second line agents

Partial seizures Carbamazepine, phenytoin, lamotrigine, oxcarbazepine, valproic acid

Levetiracetam, topiramate, gabapentin, phenobarbital, primidone, felbamate

Tonic clonic seizures

Valproic acid, lamotrigine, topiramate

Zonisamide, penytoin, carbamazepine, oxcarbazepine, phenobarbital, primidone, felbamate

Absence seizures Valproic acid, ethosuxcimide

Lamotrigine, clonazepam

Atypical seizuresAtonic siezuresMyoclonic seizures

Valproic acid, lamotrigine, topiramate

Clonazepam, felbamate

For seizures

For XP: sunscreen, vit D supplements, emollients, retinoid preparations, T4N5 lotion

Specific treatment optionsFor seizures:

GTCS: Valproic acid, lamotrigine, topiramate

Multivitamins: vit B complex, vit D & calcium supplementation

For XP: avoid exposure to sunlight, sunscreen, emollients, vit D preparations

Monitoring parameters:

• EEG• Electrolytes: Ca, Mg DISEASE SPECIFIC• Serum glucose• Neurological status

• LFTs• CBC DRUG SPECIFIC• Patients adherence to the medications

Problems identified:

• Drug interactions: valproic acid and phenytoin ( level of phenytoin)

phenytoin and lamotrigine ( level of lamotrigine)

pantoprazole and clobazam ( effect of clobazam)

• Concomitant use of magaldrate and pantoprazole• Phenytoin and clobazam not the apppropriate treatment options

for GTCS, moreover phenytoin should not be used in young patients who require long term therapy with phenytoin

• Use of protein powder• Concomitant use of phenytoin and fosphenytoin together for 3

days

Patient counseling about seizure:

Patient counseling about the common signs:

Lifestyle modifications• Care takers were informed to give stress free environment• They were advised to monitor him during sleep hours to identify seizure activity• They were asked to visit their doctor regularly• They were informed the benefits of relaxation techniques like deep breathing and meditation• They were told to provide him with healthy diet, including plenty of whole grains, fresh vegetables, and fruits• They were explained the benefit of high fat, no sugar, low protein diet• They were informed to make him wear protective clothes and avoid sun exposure as far as possible

Thank you