Antiseizure medicines: selection, adverse effects and monitoring — formative SAQs

SAQ 1 (10)

A ten-year-old boy with newly diagnosed focal epilepsy is started on levetiracetam. Two weeks later his parents report that he has become increasingly irritable and aggressive, with two episodes of hitting a classmate, which is unlike his baseline. His seizures are controlled. [5] [1]

a) Name the adverse effect, estimate its approximate frequency in children on this drug, and explain why this drug has a favourable interaction profile despite this behavioural effect. (3 marks) [5]

b) Outline three management options for this adverse effect, and state the principle that governs the choice between them. (3 marks) [5]

c) The family asks whether carbamazepine, used by an uncle with epilepsy, might be a better choice. State the spectrum classification of carbamazepine and explain why it is or is not appropriate for this child. (2 marks) [1]

d) Describe the baseline and follow-up monitoring you would arrange for a child on this drug, and explain why routine therapeutic drug monitoring is not required. (2 marks) [5]

SAQ 2 (10)

A fourteen-year-old girl with juvenile myoclonic epilepsy has morning myoclonic jerks and occasional generalised tonic-clonic seizures. Her neurologist has recommended valproate as the most effective single drug. She is sexually active and uses no contraception. [7] [5]

a) State the valproate pregnancy prevention programme, naming the conditions that must be met before valproate is prescribed in a girl of childbearing potential. (3 marks) [7]

b) Name two broad-spectrum alternatives to valproate for this patient and state the principle that governs the choice. (3 marks) [5] [7]

c) If lamotrigine is chosen, state the titration rule and explain why concurrent valproate would require an even slower titration. Name the severe cutaneous adverse effect the slow titration prevents. (2 marks) [11]

d) Describe the transition planning required as she moves to adult care, addressing the medicine review, contraception and pregnancy planning. (2 marks) [7]