Pediatric Neurology Quick Talks Common AEDs Michael Babcock

Pediatric Neurology Quick Talks Common AEDs Michael Babcock

Pediatric Neurology Quick Talks Common AEDs Michael Babcock Summer 2013 Daisy Dilantin (Phenytoin the ugly duckling) (1938) Indications: Broad- focal, GTC, neonatal, status (she's a swan this) Other uses: Dosing: Status- 15-20mg/kg IV Daily- 5-10mg/kg/d div BID/TID Levels: 10-20mg/l ADR: dose-dependent nystagmus, ataxia, encephalopathy; chronic

use- gingival hyperplasia, hirsutism, coarse face (not a pretty woman), tremor, peripheral neuropathy, hepatotoxicity, hematologic effects. *hypotension/arrythmia with IV load. Monitor: CBC, LFTs, ekg for IV. Pharmaco: high PB, liver met, non-linear, enzyme inducer. Preg: Cat. D-bad. (Daisy doesn't have children) +interact with contraception. Eddie Ethosuximide (Zarontin) (1950s) Indications: absence monotherapy (Eddie just does disco and does it well); can be adjuntive in other generalized. Other uses none Dosing

Daily dose start 5-10mg/kg/d, increase to 20-35 mg/kg/d div BID. Levels 40-100 mcg/ml ADRs GI symptoms (anorexia, abdominal pain, nausea), headache, behavior changes, pyschosis, withdrawal seizures; severe/idiosyncratic aplastic anemia, SJS, SLE, liver impairment Monitor CBC, LFTs, drug level Pharmaco: narrow therapeutic window (disco's cool window was narrow), high oral bioavailable, ~85% PB, hepatic metabolism, half-life 30-60 hrs. Preg cat C, contraception- no interaction Vinny Valproate (the Depakote Don) (1963) Indications: Broad general, focal (not as good), absence, status (call the Don for status) Other uses: bipolar, mood stabilization, migraine-acute and chronic

Dosing: status: 15-20mg/kg IV Daily: 20-30mg/kg/d div BID Levels: 50-100 mg/l. ADRs: acute liver necrosis/pancreatitis especially <2yo (1/600), neural tube defects, PCOS, hormonal changes (Don hangs around poker hall, no women and children). Tremor (no longer carries his gun). Calming affect (the Don doesn't lose his temper), thrombocytopenia, weight gain (Don likes pizza), coagulation abnl, encephalopathy-hyperammonemia Monitor: LFT, plt, coag at baseline. Pharamco: highly PB, hepatic metabolism, lots of interactions with other meds (Don is tough to get along with especially with Larry Lamictal) Preg: cat. D-bad, fetal valproate syndrome. Professor Larry Lamictal (1991)

Indications: Broad spectrum, not for status. Other uses: bipolar, mood stabalization Dosing: start low and go slow, differs for monotherapy, cotherapy with valproate/enzyme inducers Professor is very meticulous and has many different titration schedules. ADRs: lower cognitive effect/less sedating compared to other AEDs Professor can continue to teach. Bad skin rash- SJS or AED hypersensitivity syndrome usually within 2 months of starting imagine Professor in sun with bad sunburn rash. Some hematologic abnormalities and elevated LFTs. Monitor Cr baseline Pharmaco: good oral bioavailable, 50% protein bound, liver metabolized. Preg: Cat. C. Large changes in plasma levels breakthrough sz's 1st trimester, toxicity after delivery. Monitor baby LFT's.

Tommy Topamax (1995) Indications: Broad general, focal, spasms Other uses: headaches migraine, psuedotumor Dosing: Status not really, ?for refractory Daily- 5-9mg/kg/d div BID, start low, increase slow to try to avoid ADRs ADRs: abnormal thinking/word finding difficulties (Can't come up with right words around girls), Weight loss (skinny middle-schooler), parathesias, abdominal pain, kidney stones (always going to nurses station with new complaints), metabolic acidosis, glaucoma (wears glasses)

Monitor Cr baseline, bicarb Pharmaco: 15-40% PB, excreted unchanged in urine Preg: Cat C, no breastfeeding. Zed Zonegran (Tommy Topamax's Dad)(1989) Indications: Broad general, focal, spasms Other uses: Dosing: Daily- start 1-2mg/kg/d, titrate every 2 weeks to goal 4-8 mg/kg/d div BID. ADRs (like Tommy Topamax): abnormal thinking/word finding difficulties, weight loss, anorexia, kidney stones, oligohydrosis, hyperthermia; also depression, psychosis, treatment emergent status; also SJS, aplastic anemia

(sulfonimide) Monitor Cr baseline, bicarb, cbc Pharmaco: chemically a sulfonimide; 100% bioavailable, ~50% PB, hepatic metabolism with renal elimination; halflife 60 hrs (can take 2 weeks for steady state) Preg: Cat C, high breast milk transfer, no interaction contraception. Keppra Ken aka Superman (1999) Indications: Broad spectrum generalized, focal, neonatal, status Superman good against anything. Other uses consider for other uses-low side effects. Dosing

Status load 20mg/kg IV Daily dose 20-60 mg/kg/d div BID Dose-dependent ADRs usual somnolence, dizziness, anorexia. Additional ADR behavior changes, agitation Don't make Superman angry, caution with psych hx. can use vit. B6 to help Monitor Cr baseline Pharmaco: good oral availability, PO/IV equivalent. Renal excretion (decreased dose in renal impairment). Preg cat. C. breast milk- high transfer but very low infant levels, contraception no interaction. References C Panayiotopoulos. 2007. A clinical guide to epileptic syndromes and their treatment. 2nd ed. Springer. Ch. 18-Pharmacopia Simpsons. Fox Network.

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