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Annual Fundamentals Symposium - Epilepsy On The Consult Service
Annual Fundamentals Symposium - Epilepsy On The Consult Service
Symposium Chair:
Fred Lado, MD
and
Aradia Fu, MD
Statement of Need
The need for this activity has been determined based on
identifying professional practice gaps, previous course
evaluations, and AES self-assessments. The educational content
of this activity was based upon current issues and topics provided
by the Annual Meeting Committee and membership.
Accreditation
Target Audience This activity has been planned and implemented in accordance with
Neurologists, epileptologists, pediatric neurologists, nurses, the Essential Areas and policies of the Accreditation Council for
psychologists, neuropsychologists, nurse practitioners, physician Continuing Medical Education. The American Epilepsy Society (AES)
assistants, pharmacists, researchers, and scientists. is accredited by the Accreditation Council for Continuing Medical
Education to provide continuing medical education for physicians.
3. Consider the public health implications of epilepsy and the impact Physician Assistants
of the disease on patients, communities, and health systems. AAPA accepts certificates of participation for educational
activities certified for AMA PRA Category 1 Credits™ from
NOTE: Each session has its own specific learning objectives, which organizations accredited by ACCME or a recognized state
are included within the program book. medical society. Physician assistants may receive a maximum of
29.75 hours of Category 1 credit for completing this program.
Mission Statement
The American Epilepsy Society (AES) promotes research and
education for physicians and other healthcare professionals
dedicated to the prevention, treatment and cure of epilepsy.
Its continuing professional education (CPE) offers an array of
activities to assist the learner in assessing their educational needs
and expanding their knowledge, competence and performance Continuing Education for Nurses and Pharmacists
in the field of epilepsy, which leads to an improvement in the Jointly provided by AKH, Inc., Advancing Knowledge in
outcomes of care. Healthcare, and the American Epilepsy Society.
The CPE program always reinforces the fundamental components
of epilepsy care in accordance with an Epilepsy Core Curriculum,
Nurses
including quality improvement and patient safety. In addition, its
Advancing Knowledge in Healthcare is accredited as a provider
educational interventions also provide an opportunity to advance
of continuing nursing education by the American Nurses
professional practice in new and emerging areas of the specialty.
Credentialing Center’s Commission on Accreditation. This activity
In recognition of the importance of the added qualification in
is awarded 29.00 contact hours
epilepsy by the American Board of Psychiatry and Neurology as
well as the Maintenance of Certification requirements, AES is
committed to the provision of educational opportunities and
tools that aid in the certification and MOC requirements.
The expected results of AES’s program of continuing professional
development are as follows:
• The AES CPE Program fosters a culture of interprofessional Pharmacists
collaboration amongst the cadre of professionals that care for Advancing Knowledge in Healthcare is accredited by the Accreditation
persons with epilepsy. Council for Pharmacy Education as a provider of continuing pharmacy
education. Select portions of the Annual Meeting are approved
• The AES CPE Program enhances the professional practice of for pharmacy CE credit. Specific hours of credit for approved
healthcare professionals who care for persons with epilepsy. presentations and the Universal Activity Numbers assigned to select
• The AES CPE Program provides education in epilepsy therapy to presentations are found in the program materials. Criteria for success:
increase the competence of clinicians in the use of these complex credit is based on documented program attendance and online
and multi-layered options to manage epilepsy in patients. completion of a program evaluation/assessment. NOTE: Questions
regarding CE activity and reporting relative to nursing and/or
• The AES CPE Program uses educational interventions as a tool to
pharmacy please contact AKH, Inc. at service@akhcme.com.
improve the quality of care and patient safety of persons with epilepsy.
NURSING
AKH Inc., Advancing Knowledge in Healthcare is accredited as a provider of continuing nursing education by the
American Nurses Credentialing Center’s Commission on Accreditation.
PHARMACY
AKH Inc., Advancing Knowledge in Healthcare is accredited by the Accreditation
Council for Pharmacy Education as a provider of continuing pharmacy education.
TO CLAIM CREDITS:
Nursing and Pharmacy credit (per session) is based on attendance as well as completion of an
online evaluation form available at:
akhcme.com/akhcme/pages/AES
THIS MUST BE DONE BY JANUARY 15, 2019 TO RECEIVE YOUR CE/CPE CREDIT.
We CANNOT submit credit to NABP after this date.
If you have any questions, please contact AKH at jgoldman@akhcme.com.
Description
The purpose of this activity is to explore issues at the intersection of epilepsy and medical
conditions. Epileptologists must often confront diagnostic dilemmas or weigh the risk of a
seizures against the potential side effects of medications. "Epilepsy and the heart" will discuss
the effects of anticonvulsants on cardiovascular risk and of seizures on cardiac arrhythmias.
"Seizure mimickers" will discuss the differentiation of epileptic seizures from syncope.
"Medications that lower seizure threshold" will focus on consideration of the effect that
psychiatric and other medications can have on susceptibility to seizures. "Seizure management
during pregnancy" addresses the risks that seizures and seizure medications pose to pregnancy
and the risks that pregnancy may destabilize seizure control. Finally, "Epilepsy and the skin"
examines the risk factors and pathophysiology of hypersensitivity reactions causing rash and
more serious consequences related to anticonvulsant use.
Learning Objectives
Following participation in this activity, learners will be able to:
1. Comprehend and manage the cardiovascular risks of anticonvulsants
2. Identify and manage the selection of antibiotics and psychiatric medications to minimize
risk of seizures
3. Examine and differentiate seizures from syncope and distinguish different more serious
from less serious forms of syncope
4. Employ and manage anticonvulsants during pregnancy to optimize seizure control and
pregnancy outcomes
5. Evaluate and comprehend pathogenesis of skin reactions from seizures medications and
minimize the risk
Target Audience
Adult Neurologists/Clinician (MD/DO), Allied Health Professionals/Advance Practice
Providers, Clinical Trainee Student/Fellow, Pediatric Neurologists/Clinician (MD/DO)
Program
Co-chairs: Fred Lado, MD, and Aradia Fu, MD
Epilepsy and the Heart: AEDs and Cardiovascular Risk, AEDs and Arrhythmias, and Discussion
of Ictal Arrhythmia: Scott Mintzer, MD
Seizure Mimickers: Distinguishing Seizures from Syncope and Other Mimickers: Steven Pacia,
MD
Medications that Lower Seizure Threshold: How Much do Psychiatric Medications and
Antibiotics Increase Seizure?: Andreas Kanner, MD
Seizure Medications and the Skin Hypersensitivity: Arturo Saavedra, MD, PhD
Disclosures
Detailed disclosure information is available via:
• AES Annual Meeting app;
• Annual Meeting Online Final Program (https://meeting.aesnet.org/program)
Faculty Bios
Fred Lado, M.D., Ph.D.
Northwell Health
Dr. Lado is the Director of the Epilepsy Division for the Central and Eastern Regions of Northwell
Health. He chairs the AES Council on Education and serves on the AES board. Dr. Lado also
serves as the chair of the accreditation task force of National Association of Epilepsy Centers. He
obtained his MD PhD from New York University, completed residency training in neurology at
New York Presbyterian-Cornell, and clinical neurophysiology fellowship at Albert Einstein
College of Medicine - Montefiore Medical Center. He is interested in the treatment of medically
refractory epilepsy and in the use of non-invasive testing to localize the brain regions triggering
seizures.
Steven Pacia, MD
Northwell
Steven V. Pacia, MD, is Vice Chair, Neurology, North Shore University Hospital and Director,
Neurology, Northwell Health Eastern Region since 2017. Dr Pacia was previously with NYU
Comprehensive Epilepsy Center and prior to this was Director of Neurology at Lenox Hill
Hospital for 12 years. Dr Pacia has been awarded a number of grants to support his research
and was the principal site investigator for the first multi center NIH fundedstudy of epilepsy
surgery. He has authored many peer reviewed articles on the diagnosis and treatment of
epilepsy and co authored the book Alternative Therapies for Epilepsy which provides an
evidence based review of complementaryand alternative therapies for care of the epilepsy
patient. He earned his Medical Degree from Medical College of Wisconsin and completed both
Residency (Neurology) and Fellowship (EEG/ Epilepsy) from Yale University School of Medicine.
Dr Pacia is board certified in both Neurology and Clinical Neurophysiology.
Jeanne Young, MD
Aradia Fu, MD
Northwell Health
Aradia Fu is an assistant professor of neurology in the Zucker School of Medicine at
Hofstra/Northwell and attending physician at Northwell Health Comprehensive Epilepsy Center.
She earned her BS in neuroscience & BA in psychology from UCLA and her MD from University of
California Irvine School of Medicine. She completed neurology residency training at Barrow
Neurological Institute and then went to Yale New Haven Hospital for 2-year fellowship training
in clinical neurophysiology and epilepsy.
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Disclosure
I (and my co‐authors) have something to disclose.
Fundamentals of Epilepsy Symposium
Detailed disclosure information is available via:
“Epilepsy on the Consult Service” • AES Annual Meeting app;
and
• Annual Meeting Online Final Program (https://meeting.aesnet.org/program)
• Explore the effects of AEDs on lipids, interactions between AEDs and Larry Hirsch, MD Professor of Neurology, Yale University; Chief, Division of Epilepsy and EEG; Co‐
Director, Yale Comprehensive Epilepsy Center
cardiac medication. Andres Kanner, MD Professor of Clinical Neurology, University of Miami, Miller School of Medicine;
• Review key features that distinguish seizures from syncope and other Director, Comprehensive Epilepsy Center and Head, Section of Epilepsy
mimickers. Fred Lado, MD PhD Director, Epilepsy Division, Northwell Health Eastern and Central Regions
Scott Mintzer, MD Professor of Neurology, Jefferson Comprehensive Epilepsy Center, Thomas Jefferson
• Review psychiatric medications that potentially lower seizure threshold. University
• Learn about management of seizure during pregnancy. Steven Pacia, MD Director, Neurology, Northwell Health Eastern Region; Vice Chairman, North Shore
University Hospital
• Discuss AEDs and risk of skin hypersensitivity, evaluate cross reactivity
Page Pennell, MD Professor of Neurology, Harvard Medical School; Director of Research, Division of
among different AEDs. Epilepsy, Brigham and Women’s Hospital
Jeanne Young, MD Asst. Professor of Dermatology, University of Virginia
Program
12:30‐12:40 Introduction of Program and Speakers Impact on Clinical Care and Practice
12:40‐1:05 Epilepsy and the heart
AEDs and cardiovascular risk, AEDs and cardiac drugs
Conclusions
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Disclosure
Epilepsy & Heart Disease:
Tips for the Consultant I have disclosures.
Detailed disclosure information is available via:
S M E , MD
PROFESSOR OF NEUROLOGY • AES Annual Meeting app;
THOMAS JEFFERSON UNIVERSITY and
PHILADELPHIA, PA • Annual Meeting Online Final Program (https://meeting.aesnet.org/program)
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“Switch” study:
Inducing drugs and lipids Measure
(mg/dL)
Pt group (N) On CBZ/PHT On LEV/LTG p -value
(2-tailed)
patients on
• Many cross‐sectional studies show higher chol levels in Total cholesterol All (n =38) 217 ± 43 191 ± 38 p<0.0001 CB or PHT
patients taking inducers (LoPinto‐Khoury & Mintzer 2010) crossing over to
Non-HDL chol. All (n =38) 155 ± 42 135 ± 36 p<0.0001 LTG or LEV
• Giving CB to young healthy men produced substantial
increase in total cholesterol and Lp(a) (Br mswig et al. 2003) HDL cholesterol All (n =38) 62 ± 21 56 ± 16 p=0.002
Mean±SD values; All changes p<0.05 relative to changes in normal subjects (not shown)
Baseline
weeks post‐switch Switch to LEV/LTG Measure Pt group (N) On inducer On non-inducer p -value
➙
months post‐switch (2-tailed)
(Mintzer et al Ann Neurol 200 )
CRP (mg/L) All (n =37) 4.2 ± 5.2 2.4 ± 4.1 p=0.003
Long‐term “switch” study:
Switch to TPM Lp(a) (mg/dL) CBZ only (n=20) 33 ± 25 23 ± 18 p=0.004
(Mintzer et al Epilepsy Behav 2012) Homocysteine
Pts on CB or PHT crossing PHT only (n=13) 13.5 ± 6.4 10.5 ± 3.9 p=0.02
➘ (μmol/L)
over to LEV, LTG, or NS
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Inducers and statins: functional impact Inducers’ interactions with other CV drugs
• Ca2 ‐channel blockers
• amlodipine, verapamil, ditiazem, nifedipine, nicardipine, nimodipene, others
• Antiarrythmics
• mexiletine, amiodarone, procainamide, uinidine, disopyramide
• 𝛃‐blockers
• propranolol, metoprolol
• Others
• losartan, digoxin, warfarin, rivaroxaban
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• When problem is interdisciplinary, somebody needs to take • Especially dangerous for those w/ vascular dz or risk factors
ownership • Healthy people eventually wind up taking medications
• Problem with the “specialty silos” of medical practice • Even if you can remember all those interactions will others??
• Other docs will not change anticonvulsant • If already on one consider switching to non‐inducing drug
☞ If you don’t fix it, nobody will ☜
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Disclosure
Syncope and Other Seizure Mimics
Pathophysiology
Migraine
• Migraine headache is a complex, recurrent headache disorder Images not available due to copyright
that is one of the most common complaints in medicine.
1
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Images not available due to copyright Images not available due to copyright
• Diagnosis of exclusion
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Consciousness TLOC
• Epilepsy
• Cardiac
Syncope vs Seizure
Video
3
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4
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Syncope Incidence
Images not available due to copyright Images not available due to copyright
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Epilepsy
Atonic Seizure
Tonic Seizure
Video Video
Cardiac Syncope
Non‐Epileptic Seizure
• Any posture, common in bed, exertion/emotion
Tussive Syncope
Video
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Tussive Syncope
• Event‐ loss of tone, fall, clonic jerks, rare incontinence and tongue
bite, rapid recovery without confusion
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Images not available due to copyright • Jardine, et al. Heart Rhythm 2018
• Teenagers and young adults‐vasodilatation or falling cardiac
output.
• The fall in cardiac output due to decrease in stroke volume as
blood is pooled in the splanchnic veins.
• Older adults‐ reduced cardiac output is the dominant
hypotensive mechanism as systemic vascular resistance
remains above baseline levels.
Myoclonic Jerks
Video
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Video Video
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Images not available due to copyright Images not available due to copyright
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Learning Objectives
Case 1
35 year‐old woman with a 2 year history of a mixed
depressive disorder and anxiety disorder. sychotropic sychiatric
ru isorder
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roconvulsant effect n
o effect n 21
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5‐HT perfusions protected the rats from limbic seizures as long as extracellular
5‐HT concentrations ranged 80–350 increments relative to baseline levels.
Antipsychotic drugs
High extracellular 5‐HT ( 00 increases) concentrations worsened seizure
outcome.
The latter proconvulsant effects were associated with significant increases in
extracellular glutamate.
lson, earney et al 99
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CNS Stimulants
Exacerbation of seizures reported in 0 ‐18 of study populations on
methylphenidate, but most are mild and transient, with no more than 5
stopping medication.
Studies were not placebo‐controlled. Therefore, it is not possible to
determine if the changes are related to baseline fluctuations.
Seizure exacerbation rates for atomoxetine were ‐ , but again the
numbers were too small to draw conclusions, and there are no data for
amphetamines.
Seven studies, which included patients with refractory epilepsy, indicated
that methylphenidate is probably safe.
Data collected by the pharmaceutical manufacturer of atomoxetine found
that seizures were no more prevalent in children with ADHD treated with
this drug than in children with ADHD without psychostimulant
intervention.
Methylphenidate in children with ADHD and Epilepsy Anticonvulsant action of hippocampal dopamine and
Ravi Ic owit , Can Acad Child and Adolesc sychiatry 20 5 serotonin is independently mediated y D and H
receptors
Clinc ers et al, eurochem 200
Co‐perfusion with the selective D(2) blocker remoxipride abolished o psychiatric disorders increase
all anticonvulsant effects.
the ris of developing epilepsy
High extracellular DA ( 1000 increases) concentrations worsened
seizure outcome.
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rends in the incidence rate ratio for epilepsy versus controls ith confidence intervals for depression in the years efore
Epilepsy, Suicidality, and Psychiatric and years after epilepsy diagnosis
esdorffer et al , Ann eurol, 20 2
Disorders: A Bidirectional Association
esdorffer et al , Ann eurol, 20 2
b ective: to determine whether psychiatric disorders associated with suicide are more
common in incident epilepsy than in matched controls without epilepsy, before and after
epilepsy diagnosis.
ethods: A matched, longitudinal cohort study was conducted in the UK General Practice
Research Database.
A total of 3, 3 cases diagnosed with epilepsy between the ages of 10 and 0 years were
compared to 14,025 controls matched by year of birth, sex, general practice, and years of
medical records before the index date.
rends in the incidence rate ratio for epilepsy versus controls ith confidence intervals for an iety in the rends in the incidence rate ratio for epilepsy versus controls ith confidence intervals for suicidality in the
years efore and years after epilepsy diagnosis years efore and years after epilepsy diagnosis
rends in the incidence rate ratio for epilepsy versus controls ith confidence intervals for
Bidirectional Relationship Between Epilepsy and
psychosis in the
years efore and years after epilepsy diagnosis ADHD
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Seizures
Seizures as ad erse e ents of anti iotics idence for anti iotic-related symptomatic seizures
ru s systematic re iew
is low to ery low
Penicillins
Anti iotic Fre uency AA lass of ype of seizure ontri uting
evidence factors
Penicillin Up to 5 IV GTC Renal failure
acillin Myoclonic Brain lesions
Cephalosporins Carbapenems
Anti iotic Fre uency AA lass of ype of seizure ontri uting Anti iotic Fre uency AA lass of ype of ontri uting
evidence factors evidence seizure factors
mipenem Up to 5 III ‐ IV GTC Renal failure
efazolin 80 with renal IV GTC Renal failure Brain lesions
(1st generation) failure NCSE Intrathecal Epilepsy
CSE infusion Rx with
theophyline
efotiam IV GTC (one case) Mental
(2nd Generation) disorders Meropenem 1 III‐ IV GTC Renal failure
Brain lesions
eftazidime IV NCSE Renal failure; Epilepsy
(3rd generation) brain lesion treated ith
PA
efepime Up to 11 III – IV GTC Renal failure; Doripenem 1.2 III GTC Epilepsy
(4th generation) Myoclonic Brain lesion
seizures Ertapenem IV GTC Renal failure
NCSE Brain lesions
Epilepsy
ith PA
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Conclusions (2)
Conclusions (1)
1) The evidence that antibiotics can cause
seizures is low.
1) With a few exceptions, antidepressant do not cause 2) Seizures can occur in the setting of high doses,
seizures when used at therapeutic doses. renal failure and CNS disease with the use of
2) With two exceptions, second generation antipsychotic certain penicillins, cephalosporins and
drugs do not cause seizures when used at therapeutic carbipenems.
doses. 3) The main pathogenic mechanism responsible
3) CNS stimulants do not appear to cause seizures when for seizures consists of interference with
used at therapeutic doses. GABAergic transmission.
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Disclosure
Seizure Management during Pregnancy
PAGE B. PENNELL, MD I have nothing to disclose.
PROFESSOR OF NEUROLOGY, HARVARD MEDICAL SCHOOL
DIRECTOR OF RESEARCH, DIVISION OF EPILEPSY
BRIGHAM AND WOMEN’S HOSPITAL
a nitude
Learning Objectives
Avoid concomitant use ith the lo est dose oral contraceptive pills Contraceptive implant
D Medical Eligi ility riteria ategory ris s out eigh the enefits Davis A, Pennell PB, 2014. (etonogestrel), not w/ EIAEDs
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•
•
• type amount
• R n international re istry of s
and pre nancy
Spina Bifida
• North merican re nancy Re istry
reatment of omen
Major Congenital Malformation Rates in EURAP: Number of offspring with MCMs for the four monotherapies
at different doses at conception (mg per day), (rate, 95% CI)
NAAPR and EURAP and other registries
323
of M M
125
2 4
1 5
1
verall ates
35
152
442 145
2
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•
•
•
•
•
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Carbamazepine Lamotrigine
Phenytoin Valproate
Meador KJ, et al. Lancet Neurol 2013;12:244-52. Christensen J, et al. JAMA 2013.
No olate
• VPA’s pregnancy category for migraine use will be changed from "D"
(the potential benefit of the drug in pregnant women may be
acceptable despite its potential risks) to "X" (the risk of use in pregnant
women clearly outweighs any possible benefit of the drug).
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• AOR = 5.9 (CI 2.2-15.8) at 18 mos and AOR = 7.9 (CI 2.5-24.9) at 36
mos for the AED-no folate group compared to AED-folate group.
• Folate benefit still present but to lower degree in the WWoE
• Degree of autistic traits inversely associated with folate
concentrations (17-19 weeks GA) and folic acid doses.
• 60.4% were on folic acid >0.4 mg per day
•
•
Antiepileptic Drugs
•
•
•
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Clearance
aily dose (m / )
concentration (m / )
S eizure F requency
0.25
0.2
Proportion ofpatient
)/(m / )
0.15
N 3 5 samples 0.1
53 re nancies
0.05
(m /
0
1 2 3 4 5 6 7 8 9 10 PP1 PP2 PP3
M onth
•
•
Pennell PB, et al. Neurology, 2008. Funded by NIH P50 MH68036.
Pennell PB, et al. Neurology 2008. Supported by NIH P50 MH68036.
op.
219%
op
21%
2
Relative Clearance
1.5
Relative Clearance
1.5
1
1
O C
LEV Research Values
TPM
LEV Clinical Values
0.5 0.5
Baseline TM1 TM2 TM3 baseline TM1 TM2 TM3
Neurology .
Neurology .
•
•
•
Ohman, Epilepsia 2004; De Haan, Neurology 2004; Pennell PB, Neurology 2008.;
Neurology . Annals Clin & Trans Ngy 2014
Multiple-PIs:
Kimford Meador, MD (Stanford)
• Page B. Pennell, MD (BWH)
Obstetrics Core:
My Suggested Strategy T. McElrath (BWH), M. Druzin (Stanford)
modelin
Neonatal Core: L. Van Marter (BWH)
Semiology Core: J. French (NYU)
• Mood Core: Z. Stowe (U Arkansas)
in utero
Mea or, et al. JAMA Pediatrics, 201 .
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Prescribing Patterns in
Pregnant Women with
Epilepsy at MONEAD sites ercenta e of omen remainin Seizure- ree
1 %
% 88.6%
85. % 86. %
84. %
8 %
Generalized seizures ocal seizures nclassified
7 %
6 %
5 %
Su ects
4 %
3 %
No. of
2 %
1 %
%
Seizure-free durin pre nancy/ months Seizure-free months postpartum/ next months
G G ther C NS C C ther N
olyRx onoRx
Com os
Meador KJ, Pennell PB, May RC, et al. Epilepsy & Behavior, 2018.
P E n
ncreasin Ris
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Learning Objectives
• Recognize some common and some less common but more serious
hypersensitivity reactions associated with anticonvulsant medications
• Distinguish between hypersensitivity reactions based on
pathophysiologic mechanisms and clinical presentation
• Identify clinical features of drug hypersensitivity reactions that could
indicate a severe cutaneous adverse reaction
Bolognia, J. L., Jorizzo, J. L., & Schaffer, J. V. (2012). Dermatology, 3e (Bolognia, Dermatology).
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ommon culprits
DRESS
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PATHOMECHANISMS
• Eosinophil activation induced by IL5 which is generated from drug‐
specific CD4 and CD8 T cells
MANAGEMENT TO IC ERYTHEMAS
• Immediate cessation of offending drug
FI ED DRUG REACTION
‐First exposure: 1‐2 weeks Photo not available Photos not available
‐Re‐exposure 48 hrs
‐sulfonamides, tetracycline,
barbiturates, carbamazepine
‐Erythematous to dusky pla ue
with central bulla/erosion
‐Heals with post‐inflammatory
hyperpigmentation
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PATHOMECHANISM
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PATHOMECHANISM
PATHOGENESIS
• HLA‐B12
• HLA‐B 5801 for allopurinol
• HLA‐B 1502 for carbamazepine
• HLA‐DQB1 0 01 ocular involvement
• Infections (HSV, HIV, Mycoplasma)
• Immunizations
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SCORTEN Prognosis
• Supportive care • Most drug reactions are fairly benign and “treating through”
• Immediate cessation of medication
is a potential option
• Signs/symptoms of more concerning reaction include fever,
• Treatment of culprit infections facial swelling, lymphocyte activation, blisters or pustules,
• Cyclosporine (3‐4 mg/kg/day), cyclophosphamide (100‐300 mucosal involvement, signs of systemic organ involvement
mg/day), plasmapheresis, N‐acetylcysteine (2g/ hr) • Severe cutaneous adverse reactions re uire immediate
• Steroids (?) cessation of offending medication and often hospitalization
• Thalidomide (?) • Immune and idiosyncratic mechanisms play a role in most
SCARs
• IVIG (1 g/kg/day)
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