hmm - if you look at the previous suggestions, this was discussed at length and agreed that phenytoin is incorrect for treatment of acute seizure (that is, a patient seizing in front of you, or status epilepticus) as per tintinalli, https://i.imgur.com/Szta5XX.png - we settled on this being a card for primary seizure prevention. However, I see what you mean looking at the extra, as that certainly implies the former. The question remains of whether: a. we have cards testing both primary prevention & acute management; b. whether these cards are accurate, and match current guidelines. If this needs to be reverted to acute management of a fitting patient, I would suggest a rewrite, which I’m perfectly happy to do myself, but will await some guidance from those who’ve covered the topic as to whether Anking currently covers both adequately.
deferring to andy
The AAN supports the use of valproic acid (Depakote) as the first-line therapy for tonic-clonic seizures. (see https://n.neurology.org/content/91/2/74.long). Either levetiracetam (Keppra) or lamotrigine are suitable alternatives (see https://pubmed.ncbi.nlm.nih.gov/29243813/). However, many east-coast institutions actually use levetiracetam as first-line agents as a broad-spectrum anti-seizure medication (ASM) despite evidence showing ~technically~ valproic acid is superior. This is due to levetiracetam’s better side effect profile (patients usually just need to worry about the “Keppra rage”, i.e. irritability and mood changes). Phenytoin could be a reasonable alternative as a third-line agent, but in practice, epileptologists generally reach for levetiracetam and valproic acid for generalized seizures (and carbamazepine for focal seizures). Now the real question is, however, what is the answer on the Step exams? Well, the approach to answering “which seizure medication should I choose” in both testing scenarios and real life is this – First, you select your typical first-line agents depending on the seizure semiology (levetiracetam and valproic acid for generalized, and carbamazepine for focal seizures). Second, you will need to read the question stem or take a good history to look for any contraindications. Are they pregnant or of child-bearing age? Do they have liver or kidney problems? Have they had SJS before? Do they have mood swings or bipolar disorder? You basically look at the question stem to see which medications you ~can’t~ give and that should lead you to the right answer. Valproic acid, levetiracetam, and phenytoin are technically all correct if you see them all, but that would be a really, really mean question, and I guess I would select valproic acid since that’s the official AAN guidelines. But I would suspect the question stem would have more to it than that (if it says they are a young F, then you can’t give valproic acid or phenytoin, so the answer would be levetiracetam).
Thus, the current suggestion and original card are technically wrong. I am changing it to Valproic acid and levetiracetam (Valproic acid being the ~technical~ guidelines and levetiracetam being the practical guidelines what epielptologist actually do). It is important that you focus on the side effect profiles of each medications to get you to the right answer. Note, many ASMs are also PY450 inducers, so be aware of other medications they are on.