Anticonvulsants
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Outline
Overview
I. Overview
A. Management
1. Epilepsy
2. Convulsions
II. Mechanism of Action
A. Alter movement of Na, K, Ca & Mg ions
B. Stabilized & cell membranes & make cells less responsive
C. Decrease excitability & responsiveness of brain neurons
III. Types
A. Status epileptics
1. Diazepam
2. Fosphenytoin
3. Lorazepam
4. Phenobarbital
5. Phenytoin
B. Antiepileptics
1. Carbamazepine
2. Valproic acid
3. Clonazepam
4. Levetiracetam
5. Pregabalin
6. Oxcarbazepine
7. Lamotrigine
IV. Indications
A. Prevention or control of seizure activity
B. Maintenance therapy for chronic recurring seizures
C. Acute treatment of convulsions
D. Status epilepticus
E. Epilepsy
V. Contraindications
A. Drug allergy
B. Pregnancy
VI. Interactions
A. Carbamazepine
1. Grapefruit juice
a. Increase levels
2. Warfarin
a. Decrease in half-life
B. Valproic acid
1. Barbiturates
a. Increase CNS depression
C. Gabapentin
1. Antacids
a. Decrease levels
VII. Side Effects
A. Carbamazepine
1. Agranulocytosis
a. Bone marrow suppression
i. Aplastic anemia
ii. Agranulocytosis
iii. Thrombocytopenia
2. Stevens-Johnson syndrome
3. Dysrhythmias
4. Thrombophlebitis
B. Valproic acid
1. Pancreatitis
2. Weight gain
3. Thrombocytopenia
C. Levetiracetam / Oxcarbazepine / Lamotrigine
1. Somnolence
2. Headache
3. Dizziness
D. Gabapentin / Pregabalin
1. Peripheral edema
2. N/V/D
3. Visual changes
Nursing Points
Therapeutic Management
Successful control of a seizure disorder hinges on selecting the appropriate drug class and drug dosage, the patient complying with the treatment regimen, and limiting toxicity.
Patient Education
Serum drug concentrations are useful guidelines in assessing the effectiveness of therapy. Maintaining serum drug levels within therapeutic ranges helps not only to control seizures but also to reduce adverse effects.
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Transcript
Welcome back and today we are going to discuss anticonvulsants.
Anticonvulsants are used to treat or manage convulsions (seizures) and epilepsy. They accomplish this by altering the movement of sodium, potassium, calcium, and magnesium. This adjustment of electrolytes stabilizes cell membranes in the brain and decrease excitability in the neurons. When you think of seizures or epilepsy, think of over-excitement in the brain – too much going on at once. Anticonvulsants calm things down. Think if anticonvulsants as melatonin when you can’t turn your brain off to go to bed.
There are various types of anticonvulsants. During a seizure, there can be a lack of oxygen to the brain. The longer the seizure, the longer the damage caused by the lack of oxygen. Status epilepticus is a term for seizures greater than 5 mins and are considered medical emergencies – these require the one types of medications shown here (with your top two being benzodiazepines – diazepam and lorazepam). Now, once the emergency has passed the focus is then using maintenance medications (the list to your right). These meds cover many drug classes with the overall goal of altering the brain’s electrolytes therefore calming excitability. Neurologists are commonly consulted to manage anticonvulsants as there are many drugs with many serious side effects. I’ve had many patients on carbamazepine and valproic acid with a goal of control or limiting their seizure activity so they can function in life. As mentioned earlier, the goal is acute treatment and control of convulsions (seizures) and epilepsy. We again are trying to decrease the excitability in the brain which is causing things to go haywire (things are too exciting). Have you seen someone during a seizure episode? It’s all excitement – violent movements and jerking, it can be quite scary. As a caregiver, they goal to support safety and airway, with a goal of termination of the episodes as fast as possible. The longer the episodes, the longer the damage. Contraindications include allergies and pregnancy (as some drugs have serious side effects that could harm the baby). Although risks and benefits must of evaluated – as multiple seizures will ultimately cause hypoxia and cause fetal harm as well. Typically a neurologist or fetal medicine provider will determine the safest course of action with a pregnant patient’s anticonvulsant options. Interactions are individualized and vary. Carbamazepine with taken with grapefruit juice will cause increases in anticonvulsant medication levels due to its rapid metabolism. This drug also interacts with warfarin, with it decreasing in the drug’s half-life (the drug leaves the body faster than expected). Now valproic acid with used with barbiturates will increase CNS depression – remember we are slowing things down, barbituates also slow things down. Lastly, we have gabapentin. Which when used with antacids will decrease medication levels. Now the level of seizure control is based on therapeutic levels so if those are altered, more seizures will occur – which is a bad thing!
There are various types of anticonvulsants. During a seizure, there can be a lack of oxygen to the brain. The longer the seizure, the longer the damage caused by the lack of oxygen. Status epilepticus is a term for seizures greater than 5 mins and are considered medical emergencies – these require the one types of medications shown here (with your top two being benzodiazepines – diazepam and lorazepam). Now, once the emergency has passed the focus is then using maintenance medications (the list to your right). These meds cover many drug classes with the overall goal of altering the brain’s electrolytes therefore calming excitability. Neurologists are commonly consulted to manage anticonvulsants as there are many drugs with many serious side effects. I’ve had many patients on carbamazepine and valproic acid with a goal of control or limiting their seizure activity so they can function in life. As mentioned earlier, the goal is acute treatment and control of convulsions (seizures) and epilepsy. We again are trying to decrease the excitability in the brain which is causing things to go haywire (things are too exciting). Have you seen someone during a seizure episode? It’s all excitement – violent movements and jerking, it can be quite scary. As a caregiver, they goal to support safety and airway, with a goal of termination of the episodes as fast as possible. The longer the episodes, the longer the damage. Contraindications include allergies and pregnancy (as some drugs have serious side effects that could harm the baby). Although risks and benefits must of evaluated – as multiple seizures will ultimately cause hypoxia and cause fetal harm as well. Typically a neurologist or fetal medicine provider will determine the safest course of action with a pregnant patient’s anticonvulsant options. Interactions are individualized and vary. Carbamazepine with taken with grapefruit juice will cause increases in anticonvulsant medication levels due to its rapid metabolism. This drug also interacts with warfarin, with it decreasing in the drug’s half-life (the drug leaves the body faster than expected). Now valproic acid with used with barbiturates will increase CNS depression – remember we are slowing things down, barbituates also slow things down. Lastly, we have gabapentin. Which when used with antacids will decrease medication levels. Now the level of seizure control is based on therapeutic levels so if those are altered, more seizures will occur – which is a bad thing!
Carbamazepine side effects are plentiful and include agranulocytosis (which is a reduction in WBCs), bone marrow suppression, anemia, and thrombocytopenia. It also includes Steven-Johnson syndrome (flu-like symptoms followed by blisters), dysrhythmia (sinus tachycardia), and thrombophlebitis.
Side effects for valproic acid include pancreatitis, weight gain, and thrombocytopenia. If your patient has a baseline pancreatic disease or dysfunction, this drug clearly wouldn’t be the first choice. Now I had a patient with a history of chronic pancreatitis who was on this drug. I week later his amylase and lipase were sky-high. Of course, his neurologist changed his anticonvulsant medication. The goal is indeed seizure control but we don’t want other organs failing either.
Now levetiracetam, oxcarbazepine, and lamotrigine all have the same side effects: somnolence, headache, and dizziness – all neurological based. While gabapentin and pregabalin have side effects such as edema, N/V/D and visual changes.
Priority Nursing Concepts for a patient receiving anticonvulsant medications include cellular regulation and pharmacology.
Alright, let’s recap. Anticonvulsants will alter electrolytes in the brains in order to decrease excitability in neurons. Types of drugs are based on whether the provider is treating status epilepticus or general seizure control – they cover many drug classes. Indications are to treat and control seizure activity, status epilepticus and epilepsy. Contraindications are allergy and pregnancy based, as some medication can cause fetal harm. Interactions are drug-specific and include grapefruit juice, warfarin, antacids, and barbituates (depending on the drug). Always remember – the longer the seizures, the longer the damage. The goal is to control here. Now you know all there is to know about anticonvulsants. Now go out and be your best self and happy nursing!
Priority Nursing Concepts for a patient receiving anticonvulsant medications include cellular regulation and pharmacology.
Alright, let’s recap. Anticonvulsants will alter electrolytes in the brains in order to decrease excitability in neurons. Types of drugs are based on whether the provider is treating status epilepticus or general seizure control – they cover many drug classes. Indications are to treat and control seizure activity, status epilepticus and epilepsy. Contraindications are allergy and pregnancy based, as some medication can cause fetal harm. Interactions are drug-specific and include grapefruit juice, warfarin, antacids, and barbituates (depending on the drug). Always remember – the longer the seizures, the longer the damage. The goal is to control here. Now you know all there is to know about anticonvulsants. Now go out and be your best self and happy nursing!
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Pharmacology
Concepts Covered:
- Concepts of Pharmacology
- Test Taking Strategies
- Prefixes
- Suffixes
- Bipolar Disorders
- Immunological Disorders
- Medication Administration
- Learning Pharmacology
- Dosage Calculations
- Noninfectious Respiratory Disorder
- Anxiety Disorders
- Substance Abuse Disorders
- Adult
- Cardiac Disorders
- Cardiovascular Disorders
- Hematologic Disorders
- Central Nervous System Disorders – Brain
- Depressive Disorders
- Disorders of Pancreas
- Liver & Gallbladder Disorders
- Upper GI Disorders
- Urinary System
- Pregnancy Risks
- Microbiology
- Infectious Respiratory Disorder
- Respiratory Disorders
- Shock
- Male Reproductive Disorders
- Sexually Transmitted Infections
- Personality Disorders
- Psychotic Disorders
- Nervous System
- Labor Complications
- Postpartum Complications
- Prenatal Concepts
- Newborn Care
- Musculoskeletal Trauma
- Intraoperative Nursing
- Vascular Disorders
- Disorders of the Posterior Pituitary Gland
- Oncology Disorders
- EENT Disorders
- Emergency Care of the Cardiac Patient
- Female Reproductive Disorders
- Gastrointestinal Disorders
- Lower GI Disorders
- Neurologic and Cognitive Disorders
- Acute & Chronic Renal Disorders
- Urinary Disorders
- Disorders of the Adrenal Gland
- Integumentary Disorders
- Neurological
- Postoperative Nursing
- Peripheral Nervous System Disorders
- Disorders of the Thyroid & Parathyroid Glands
- Cardiovascular
Study Plan Lessons
Pharmacology Course Introduction
12 Points to Answering Pharmacology Questions
54 Common Medication Prefixes and Suffixes
Therapeutic Drug Levels (Digoxin, Lithium, Theophylline, Phenytoin)
Essential NCLEX Meds by Class
6 Rights of Medication Administration
Pharmacodynamics
Pharmacokinetics
The SOCK Method – Overview
The SOCK Method – S
The SOCK Method – O
The SOCK Method – C
The SOCK Method – K
Basics of Calculations
Oral Medications
Injectable Medications
IV Infusions (Solutions)
Complex Calculations (Dosage Calculations/Med Math)
Interactive Pharmacology Practice
Interactive Practice Drip Calculations
Pediatric Dosage Calculations
Disease Specific Medications
Antianxiety Meds
Benzodiazepines
ACLS (Advanced cardiac life support) Drugs
Anti-Platelet Aggregate
NG Tube Medication Administration
Coumarins
Thrombin Inhibitors
Thrombolytics
Anticonvulsants
Antidepressants
MAOIs
SSRIs
TCAs
Antidiabetic Agents
Insulin
Insulin – Mixtures (70/30)
Histamine 1 Receptor Blockers
Histamine 2 Receptor Blockers
Renin Angiotensin Aldosterone System
Sympatholytics (Alpha & Beta Blockers)
ACE (angiotensin-converting enzyme) Inhibitors
Angiotensin Receptor Blockers
Calcium Channel Blockers
Cardiac Glycosides
Anti-Infective – Aminoglycosides
Anti-Infective – Antifungals
Anti-Infective – Antitubercular
Anti-Infective – Antivirals
Anti-Infective – Carbapenems
Anti-Infective – Fluoroquinolones
Anti-Infective – Glycopeptide
Anti-Infective – Lincosamide
Anti-Infective – Macrolides
Anti-Infective – Penicillins and Cephalosporins
Anti-Infective – Sulfonamides
Anti-Infective – Tetracyclines
Atypical Antipsychotics
Antipsychotics
Autonomic Nervous System (ANS)
Sympathomimetics (Alpha (Clonodine) & Beta (Albuterol) Agonists)
Bronchodilators
Diuretics (Loop, Potassium Sparing, Thiazide, Furosemide/Lasix)
Proton Pump Inhibitors
Epoetin Alfa
HMG-CoA Reductase Inhibitors (Statins)
Magnesium Sulfate
Mood Stabilizers
NSAIDs
Tocolytics
Meds for Postpartum Hemorrhage (PPH)
Prostaglandins in Pregnancy
Rh Immune Globulin in Pregnancy
Lung Surfactant for Newborns
Eye Prophylaxis for Newborn
Phytonadione (Vitamin K) for Newborn
Opioids
Opioid Analgesics in Pregnancy
Sedatives-Hypnotics
Barbiturates
Anesthetic Agents
Corticosteroids
Betamethasone and Dexamethasone in Pregnancy
Hydralazine
Nitro Compounds
Vasopressin
ACLS (Advanced cardiac life support) Drugs
Anti-Infective – Aminoglycosides
Anti-Infective – Carbapenems
Anti-Infective – Macrolides
Anti-Infective – Fluoroquinolones
Anti-Infective – Sulfonamides
Anti-Infective – Tetracyclines
Anti-Infective – Antifungals
Anti-Infective – Antivirals
Anti-Infective – Lincosamide
Thrombolytics
Anticonvulsants
Antidiabetic Agents
Sympatholytics (Alpha & Beta Blockers)
Anti-Infective – Antitubercular
Anti-Infective – Glycopeptide
Bronchodilators
Opioids
Barbiturates
Anesthetic Agents
Antineoplastics
Alkylating Agents
Antimetabolites
Anti Tumor Antibiotics
Plant Alkaloids Topoisomerase and Mitotic Inhibitors
Patient Controlled Analgesia (PCA)
Epidural
Insulin Drips
Acetaminophen (Tylenol) Nursing Considerations
Acyclovir (Zovirax) Nursing Considerations
Adenosine (Adenocard) Nursing Considerations
Albuterol (Ventolin) Nursing Considerations
Alendronate (Fosamax) Nursing Considerations
Alprazolam (Xanax) Nursing Considerations
Alteplase (tPA, Activase) Nursing Considerations
Amiodarone (Pacerone) Nursing Considerations
Amitriptyline (Elavil) Nursing Considerations
Amlodipine (Norvasc) Nursing Considerations
Amoxicillin (Amoxil) Nursing Considerations
Ampicillin (Omnipen) Nursing Considerations
ASA (Aspirin) Nursing Considerations
Atenolol (Tenormin) Nursing Considerations
Atorvastatin (Lipitor) Nursing Considerations
Atropine (Atropen) Nursing Considerations
Azithromycin (Zithromax) Nursing Considerations
Benztropine (Cogentin) Nursing Considerations
Bisacodyl (Dulcolax) Nursing Considerations
Bismuth Subsalicylate (Pepto-Bismol) Nursing Considerations
Bupropion (Wellbutrin) Nursing Considerations
Buspirone (Buspar) Nursing Considerations
Butorphanol (Stadol) Nursing Considerations
Calcium Acetate (PhosLo) Nursing Considerations
Calcium Carbonate (Tums) Nursing Considerations
Captopril (Capoten) Nursing Considerations
Carbamazepine (Tegretol) Nursing Considerations
Carbidopa-Levodopa (Sinemet) Nursing Considerations
Cefaclor (Ceclor) Nursing Considerations
Cefdinir (Omnicef) Nursing Considerations
Celecoxib (Celebrex) Nursing Considerations
Cephalexin (Keflex) Nursing Considerations
Chlorpromazine (Thorazine) Nursing Considerations
Cimetidine (Tagamet) Nursing Considerations
Ciprofloxacin (Cipro) Nursing Considerations
Clindamycin (Cleocin) Nursing Considerations
Clopidogrel (Plavix) Nursing Considerations
Codeine (Paveral) Nursing Considerations
Cortisone (Cortone) Nursing Considerations
Cyclosporine (Sandimmune) Nursing Considerations
Dexamethasone (Decadron) Nursing Considerations
Diazepam (Valium) Nursing Considerations
Digoxin (Lanoxin) Nursing Considerations
Diltiazem (Cardizem) Nursing Considerations
Dimensional Analysis Nursing (Dosage Calculations/Med Math)
Diphenhydramine (Benadryl) Nursing Considerations
Diphenoxylate-Atropine (Lomotil) Nursing Considerations
Divalproex (Depakote) Nursing Considerations
Dobutamine (Dobutrex) Nursing Considerations
Dopamine (Inotropin) Nursing Considerations
Enalapril (Vasotec) Nursing Considerations
Enoxaparin (Lovenox) Nursing Considerations
Epinephrine (EpiPen) Nursing Considerations
Epoetin (Epogen) Nursing Considerations
Erythromycin (Erythrocin) Nursing Considerations
Escitalopram (Lexapro) Nursing Considerations
Famotidine (Pepcid) Nursing Considerations
Fentanyl (Duragesic) Nursing Considerations
Ferrous Sulfate (Iron) Nursing Considerations
Fluoxetine (Prozac) Nursing Considerations
Fluticasone (Flonase) Nursing Considerations
Furosemide (Lasix) Nursing Considerations
Gabapentin (Neurontin) Nursing Considerations
Gentamicin (Garamycin) Nursing Considerations
Glipizide (Glucotrol) Nursing Considerations
Glucagon (GlucaGen) Nursing Considerations
Guaifenesin (Mucinex) Nursing Considerations
Haloperidol (Haldol) Nursing Considerations
Heparin (Hep-Lock) Nursing Considerations
Hepatitis B Vaccine for Newborns
Hydralazine (Apresoline) Nursing Considerations
Hydrochlorothiazide (Hydrodiuril) Nursing Considerations
Hydrocodone-Acetaminophen (Vicodin, Lortab) Nursing Considerations
Hydromorphone (Dilaudid) Nursing Considerations
Ibuprofen (Motrin) Nursing Considerations
Indomethacin (Indocin) Nursing Considerations
Insulin – Intermediate Acting (NPH) Nursing Considerations
Insulin – Long Acting (Lantus) Nursing Considerations
Insulin – Rapid Acting (Novolog, Humalog) Nursing Considerations
Insulin – Short Acting (Regular) Nursing Considerations
Iodine Nursing Considerations
Isoniazid (Niazid) Nursing Considerations
Ketorolac (Toradol) Nursing Considerations
Lactulose (Generlac) Nursing Considerations
Lamotrigine (Lamictal) Nursing Considerations
Levetiracetam (Keppra) Nursing Considerations
Levofloxacin (Levaquin) Nursing Considerations
Lidocaine (Xylocaine) Nursing Considerations
Lisinopril (Prinivil) Nursing Considerations
Lithium (Lithonate) Nursing Considerations
Loperamide (Imodium) Nursing Considerations
Lorazepam (Ativan) Nursing Considerations
Losartan (Cozaar) Nursing Considerations
Magnesium Sulfate (MgSO4) Nursing Considerations
Mannitol (Osmitrol) Nursing Considerations
Meperidine (Demerol) Nursing Considerations
Meropenem (Merrem) Nursing Considerations
Metformin (Glucophage) Nursing Considerations
Methadone (Methadose) Nursing Considerations
Methylergonovine (Methergine) Nursing Considerations
Methylphenidate (Concerta) Nursing Considerations
Methylprednisolone (Solu-Medrol) Nursing Considerations
Metoclopramide (Reglan) Nursing Considerations
Metoprolol (Toprol XL) Nursing Considerations
Metronidazole (Flagyl) Nursing Considerations
Midazolam (Versed) Nursing Considerations
Montelukast (Singulair) Nursing Considerations
Morphine (MS Contin) Nursing Considerations
Nalbuphine (Nubain) Nursing Considerations
Naproxen (Aleve) Nursing Considerations
Neostigmine (Prostigmin) Nursing Considerations
Nifedipine (Procardia) Nursing Considerations
Nitroglycerin (Nitrostat) Nursing Considerations
Nitroprusside (Nitropress) Nursing Considerations
Norepinephrine (Levophed) Nursing Considerations
Nystatin (Mycostatin) Nursing Considerations
Olanzapine (Zyprexa) Nursing Considerations
Omeprazole (Prilosec) Nursing Considerations
Ondansetron (Zofran) Nursing Considerations
Oxycodone (OxyContin) Nursing Considerations
Oxytocin (Pitocin) Nursing Considerations
Pancrelipase (Pancreaze) Nursing Considerations
Pantoprazole (Protonix) Nursing Considerations
Parasympatholytics (Anticholinergics) Nursing Considerations
Parasympathomimetics (Cholinergics) Nursing Considerations
Paroxetine (Paxil) Nursing Considerations
Pentobarbital (Nembutal) Nursing Considerations
Phenazopyridine (Pyridium) Nursing Considerations
Phenobarbital (Luminal) Nursing Considerations
Phenytoin (Dilantin) Nursing Considerations
Procainamide (Pronestyl) Nursing Considerations
Promethazine (Phenergan) Nursing Considerations
Propofol (Diprivan) Nursing Considerations
Propranolol (Inderal) Nursing Considerations
Propylthiouracil (PTU) Nursing Considerations
Quetiapine (Seroquel) Nursing Considerations
Ranitidine (Zantac) Nursing Considerations
Rifampin (Rifadin) Nursing Considerations
Salmeterol (Serevent) Nursing Considerations
Selegiline (Eldepyrl) Nursing Considerations
Sertraline (Zoloft) Nursing Considerations
Spironolactone (Aldactone) Nursing Considerations
Streptokinase (Streptase) Nursing Considerations
Sucralfate (Carafate) Nursing Considerations
Terbutaline (Brethine) Nursing Considerations
Tetracycline (Panmycin) Nursing Considerations
Trimethoprim-Sulfamethoxazole (Bactrim) Nursing Considerations
Uterine Stimulants (Oxytocin, Pitocin) Nursing Considerations
Vancomycin (Vancocin) Nursing Considerations
Vasopressin (Pitressin) Nursing Considerations
Verapamil (Calan) Nursing Considerations
Warfarin (Coumadin) Nursing Considerations
02.01 Hypertensive Crisis for CCRN Review