MCQ Quiz: Epilepsy

The management of epilepsy is a complex and crucial area of pharmacotherapy, representing a core module in the Patient Care VII: Brain and Behavior course. This quiz is designed to test your knowledge on the full spectrum of epilepsy care, from the introduction to epilepsy through the Pharmacists’ Patient Care Process (PPCP) to the medicinal chemistry, pharmacology, and management of anti-seizure medications. Questions will also cover transcending concepts like the pharmacokinetics of specific agents management in special populations and the legal and ethical issues patients face.

1. A seizure characterized by a loss of consciousness and violent muscle contractions involving the entire body is best classified as what type of seizure?

• A. Focal aware seizure
• B. Absence seizure
• C. Generalized tonic-clonic seizure
• D. Myoclonic seizure

Answer: C. Generalized tonic-clonic seizure

2. Many anti-seizure medications (ASMs) work by blocking which type of ion channel to reduce neuronal hyperexcitability?

• A. Voltage-gated sodium channels
• B. Ligand-gated potassium channels
• C. Chloride channels
• D. T-type potassium channels

Answer: A. Voltage-gated sodium channels

3. Which medication is considered a first-line agent specifically for the treatment of absence seizures?

• A. Carbamazepine
• B. Phenytoin
• C. Ethosuximide
• D. Levetiracetam

Answer: C. Ethosuximide

4. The management of status epilepticus, a neurologic emergency, typically begins with the rapid administration of which class of medication?

• A. A long-acting oral anti-seizure medication
• B. An intravenous benzodiazepine like lorazepam or diazepam
• C. An intravenous barbiturate like phenobarbital
• D. An intravenous anesthetic

Answer: B. An intravenous benzodiazepine like lorazepam or diazepam

5. Phenytoin exhibits non-linear, or Michaelis-Menten, pharmacokinetics. What is the clinical implication of this property?

• A. The dose can be increased by any amount without risk of toxicity.
• B. The drug’s half-life remains constant regardless of the dose.
• C. Small increases in the dose can lead to disproportionately large increases in serum concentration, raising the risk of toxicity.
• D. Therapeutic drug monitoring is not necessary.

Answer: C. Small increases in the dose can lead to disproportionately large increases in serum concentration, raising the risk of toxicity.

6. Before initiating carbamazepine, patients of Asian descent should be screened for which genetic marker to assess the risk of developing Stevens-Johnson Syndrome (SJS)?

• A. CYP2C9*3
• B. HLA-B*1502
• C. MTHFR C677T
• D. SLCO1B1

Answer: B. HLA-B*1502

7. A common counseling point for patients with epilepsy, as discussed in the transcending concepts lecture, involves state-specific laws regarding what activity?

• A. Traveling by airplane
• B. Purchasing alcohol
• C. Driving a motor vehicle
• D. Owning a pet

Answer: C. Driving a motor vehicle

8. Valproic acid has a broad spectrum of activity due to multiple mechanisms of action, including sodium channel blockade and:

• A. Increasing levels of the inhibitory neurotransmitter GABA.
• B. Antagonizing glutamate receptors.
• C. Increasing dopamine release.
• D. Inhibiting monoamine oxidase.

Answer: A. Increasing levels of the inhibitory neurotransmitter GABA.

9. A patient taking phenytoin presents with nystagmus, ataxia, and confusion. These are classic signs of:

• A. An allergic reaction.
• B. A subtherapeutic drug level.
• C. Phenytoin toxicity.
• D. A common, transient side effect.

Answer: C. Phenytoin toxicity.

10. What is a key advantage of many newer anti-seizure medications, such as levetiracetam, compared to older agents like phenytoin and carbamazepine?

• A. They are significantly more effective for all seizure types.
• B. They have fewer clinically significant drug-drug interactions.
• C. They do not require daily dosing.
• D. They are all available over-the-counter.

Answer: B. They have fewer clinically significant drug-drug interactions.

11. The mechanism of action for ethosuximide involves the blockade of which type of channel in thalamic neurons?

• A. High-voltage-activated N-type calcium channels
• B. Voltage-gated sodium channels
• C. Low-voltage-activated T-type calcium channels
• D. Inward-rectifier potassium channels

Answer: C. Low-voltage-activated T-type calcium channels

12. The concept of “auto-induction” is a key pharmacokinetic feature of which anti-seizure medication?

• A. Lamotrigine
• B. Levetiracetam
• C. Valproic acid
• D. Carbamazepine

Answer: D. Carbamazepine

13. A patient stabilized on phenytoin is started on a medication that is a potent inhibitor of CYP2C9. What is the expected effect on the phenytoin level?

• A. The phenytoin level will decrease.
• B. The phenytoin level will increase, risking toxicity.
• C. There will be no change in the phenytoin level.
• D. The phenytoin level will fluctuate unpredictably.

Answer: B. The phenytoin level will increase, risking toxicity.

14. Which anti-seizure medication has a black box warning for teratogenicity, including an increased risk of neural tube defects?

• A. Levetiracetam
• B. Valproic acid
• C. Lamotrigine
• D. Gabapentin

Answer: B. Valproic acid

15. A slow titration is required when initiating lamotrigine to reduce the risk of:

• A. Severe hepatotoxicity.
• B. Agranulocytosis.
• A serious dermatological reaction, such as SJS/TEN.
• D. Nephrotoxicity.

Answer: C. A serious dermatological reaction, such as SJS/TEN.

16. The “Management of Epilepsy through the PPCP” is a specific lecture in the curriculum. What is the first step of the PPCP for an epilepsy patient?

• A. Implement
• B. Plan
• C. Collect
• D. Assess

Answer: C. Collect

17. Fosphenytoin is a prodrug that is converted to phenytoin in the body. What is the primary advantage of using IV fosphenytoin over IV phenytoin?

• A. It is less expensive.
• B. It can be administered more rapidly with a lower risk of infusion-site reactions and hypotension.
• C. It has a longer half-life.
• D. It does not require therapeutic drug monitoring.

Answer: B. It can be administered more rapidly with a lower risk of infusion-site reactions and hypotension.

18. Which of the following is an important counseling point for a female patient of childbearing age taking an enzyme-inducing anti-seizure medication like carbamazepine?

• A. The anti-seizure medication will increase the effectiveness of oral contraceptives.
• B. The anti-seizure medication can decrease the effectiveness of hormonal contraceptives, and a backup method should be considered.
• C. There is no interaction between the two medications.
• D. She should stop taking the anti-seizure medication if she becomes sexually active.

Answer: B. The anti-seizure medication can decrease the effectiveness of hormonal contraceptives, and a backup method should be considered.

19. Topiramate is an anti-seizure medication known for which common cognitive and metabolic side effects?

• A. Weight gain and sedation.
• B. Word-finding difficulties and weight loss.
• C. Increased appetite and euphoria.
• D. Hair loss and tremor.

Answer: B. Word-finding difficulties and weight loss.

20. A patient reports gingival hyperplasia. This is a well-known, classic side effect of which anti-seizure medication?

• A. Valproic acid
• B. Lamotrigine
• C. Phenytoin
• D. Levetiracetam

Answer: C. Phenytoin

21. The term “broad-spectrum” when referring to an anti-seizure medication means:

• A. It is effective against a wide range of bacterial infections.
• B. It is effective for multiple seizure types, including both focal and generalized seizures.
• C. It has a very broad therapeutic index.
• D. It is metabolized by all CYP450 enzymes.

Answer: B. It is effective for multiple seizure types, including both focal and generalized seizures.

22. Which of the following is an example of a broad-spectrum anti-seizure medication?

• A. Ethosuximide
• B. Pregabalin
• C. Levetiracetam
• D. Lacosamide

Answer: C. Levetiracetam

23. The mechanism of action for barbiturates like phenobarbital involves:

• A. Increasing the frequency of GABA-A chloride channel opening.
• B. Increasing the duration of GABA-A chloride channel opening.
• C. Blocking T-type calcium channels.
• D. Inhibiting the reuptake of GABA.

Answer: B. Increasing the duration of GABA-A chloride channel opening.

24. Which anti-seizure medication is associated with a risk of hyponatremia?

• A. Phenytoin
• B. Valproic acid
• C. Oxcarbazepine
• D. Levetiracetam

Answer: C. Oxcarbazepine

25. A patient should be counseled to immediately report any signs of a serious rash when taking which medication?

• A. Gabapentin
• B. Pregabalin
• C. Lamotrigine
• D. Levetiracetam

Answer: C. Lamotrigine

26. The “Plan” step of the PPCP for an epilepsy patient involves:

• A. Collecting their medication history.
• B. Developing individualized, patient-centered goals and a care plan.
• C. Documenting the encounter.
• D. Assessing their vital signs.

Answer: B. Developing individualized, patient-centered goals and a care plan.

27. What is the primary goal of epilepsy management?

• A. To cure the patient of epilepsy.
• B. To achieve a seizure-free state with minimal side effects.
• C. To only use the oldest available medications.
• D. To ensure the patient sleeps for at least 12 hours a day.

Answer: B. To achieve a seizure-free state with minimal side effects.

28. The medicinal chemistry of many anti-seizure drugs, like phenytoin and carbamazepine, is based on a core ureide structure that resembles:

• A. Benzodiazepines
• B. Barbiturates
• C. Penicillins
• D. Statins

Answer: B. Barbiturates

29. Abrupt discontinuation of any anti-seizure medication can lead to:

• A. A rapid cure of the epilepsy.
• B. An increased risk of seizures or status epilepticus.
• C. A significant improvement in mood.
• D. A decrease in medication side effects with no other risks.

Answer: B. An increased risk of seizures or status epilepticus.

30. Which of the following is a critical counseling point for all patients starting a new anti-seizure medication?

• A. The medication will work immediately to stop all seizures.
• B. They should avoid driving or operating heavy machinery until they know how the drug affects them.
• C. It is safe to drink alcohol with all anti-seizure medications.
• D. They should stop the medication if they experience any side effects.

Answer: B. They should avoid driving or operating heavy machinery until they know how the drug affects them.

31. The pharmacokinetic concept of therapeutic drug monitoring (TDM) is most important for which group of drugs, as covered in PHA5132 and PHA5789C?

• A. Newer agents like levetiracetam and lacosamide.
• B. Older agents with narrow therapeutic indices and variable pharmacokinetics, like phenytoin and phenobarbital.
• C. All anti-seizure medications equally.
• D. Only drugs used for pediatric epilepsy.

Answer: B. Older agents with narrow therapeutic indices and variable pharmacokinetics, like phenytoin and phenobarbital.

32. A patient with focal seizures is well-controlled on their current medication but complains of behavioral side effects like irritability and aggression. Which ASM is most commonly associated with these effects?

• A. Lamotrigine
• B. Levetiracetam
• C. Lacosamide
• D. Pregabalin

Answer: B. Levetiracetam

33. What is the difference between a focal aware and a focal impaired awareness seizure?

• A. A focal aware seizure involves the entire brain.
• B. In a focal aware seizure, the patient’s consciousness is preserved, while in a focal impaired awareness seizure, it is not.
• C. Focal aware seizures do not have motor symptoms.
• D. Focal impaired awareness seizures are another name for absence seizures.

Answer: B. In a focal aware seizure, the patient’s consciousness is preserved, while in a focal impaired awareness seizure, it is not.

34. The “honeymoon effect” in epilepsy treatment refers to:

• A. The initial period after starting a new ASM when seizure control is excellent but may wane over time.
• B. A specific type of seizure that occurs only at night.
• C. The development of tolerance to side effects.
• D. The first seizure a person ever has.

Answer: A. The initial period after starting a new ASM when seizure control is excellent but may wane over time.

35. Gabapentin and pregabalin exert their effects by:

• A. Directly agonizing the GABA receptor.
• B. Binding to the alpha-2-delta subunit of voltage-gated calcium channels.
• C. Blocking sodium channels.
• D. Inhibiting GABA transaminase.

Answer: B. Binding to the alpha-2-delta subunit of voltage-gated calcium channels.

36. A key part of the “Assess” step in the PPCP for an epilepsy patient is to evaluate:

• A. The brand name of the medication only.
• B. The seizure type, frequency, and medication adherence and tolerability.
• C. The cost of the prescription.
• D. The pharmacy’s workflow.

Answer: B. The seizure type, frequency, and medication adherence and tolerability.

37. Which anti-seizure medication can cause metabolic acidosis and has a risk of kidney stones?

• A. Phenytoin
• B. Topiramate
• C. Levetiracetam
• D. Valproic acid

Answer: B. Topiramate

38. The “Follow-up: Monitor and Evaluate” step of the PPCP is crucial in epilepsy management to:

• A. Ensure the patient never returns to the pharmacy.
• B. Track seizure frequency, assess for adverse effects, and check drug levels if indicated.
• C. Only check if the prescription has been refilled.
• D. Document the initial seizure diagnosis.

Answer: B. Track seizure frequency, assess for adverse effects, and check drug levels if indicated.

39. Carbamazepine is contraindicated in a patient with a history of which adverse reaction to a tricyclic antidepressant?

• A. Sedation
• B. Weight gain
• C. Hypersensitivity
• D. Dry mouth

Answer: C. Hypersensitivity

40. Why is adherence to anti-seizure medication critically important?

• A. The medications are very expensive.
• B. Missing even a single dose can lower the seizure threshold and precipitate a breakthrough seizure.
• C. The medications have a high potential for abuse.
• D. Pharmacists are legally required to ensure 100% adherence.

Answer: B. Missing even a single dose can lower the seizure threshold and precipitate a breakthrough seizure.

41. Which formulation of valproic acid can be sprinkled on soft food?

• A. The delayed-release tablet.
• B. The extended-release tablet.
• C. The sprinkle capsule (Depakote Sprinkles).
• D. The intravenous solution.

Answer: C. The sprinkle capsule (Depakote Sprinkles).

42. The term “idiopathic” when used to describe epilepsy means:

• A. The epilepsy is caused by a traumatic brain injury.
• B. The epilepsy has a known genetic cause.
• C. The cause of the epilepsy is unknown.
• D. The epilepsy is caused by a brain tumor.

Answer: C. The cause of the epilepsy is unknown.

43. A common side effect of many traditional anti-seizure medications is CNS depression. This can manifest as:

• A. Insomnia and agitation.
• B. Drowsiness, dizziness, and cognitive slowing.
• C. Increased alertness and focus.
• D. Hypertension and tachycardia.

Answer: B. Drowsiness, dizziness, and cognitive slowing.

44. What is a primary consideration in managing pediatric epilepsy, as covered in the curriculum?

• A. Children metabolize all drugs slower than adults.
• B. The impact of the ASM on cognitive development and behavior is a key concern.
• C. Children cannot swallow tablets, so only liquid formulations can be used.
• D. Pharmacogenomic testing is required for all pediatric patients.

Answer: B. The impact of the ASM on cognitive development and behavior is a key concern.

45. Phenytoin’s high degree of plasma protein binding means its free (active) concentration can be affected by:

• A. The patient’s diet.
• B. The time of day the drug is taken.
• C. Low serum albumin levels or co-administration of other highly protein-bound drugs.
• D. The patient’s blood type.

Answer: C. Low serum albumin levels or co-administration of other highly protein-bound drugs.

46. Which of the following is an appropriate brand-to-generic substitution?

• A. Substituting Keppra XR for levetiracetam immediate-release.
• B. Substituting Tegretol XR for carbamazepine immediate-release.
• C. Substituting Depakote ER for divalproex delayed-release without physician approval.
• D. None of the above are automatically interchangeable.

Answer: D. None of the above are automatically interchangeable.

47. The management of epilepsy involves balancing seizure control with:

• A. Medication cost.
• B. The prescriber’s preferences.
• C. The patient’s quality of life and medication tolerability.
• D. The pharmacy’s inventory.

Answer: C. The patient’s quality of life and medication tolerability.

48. Why might a ketogenic diet be considered in the management of epilepsy?

• A. It is a first-line treatment for all adults with new-onset seizures.
• B. It is an evidence-based dietary therapy for some patients with refractory epilepsy, particularly children.
• C. It has no side effects.
• D. It is easy for all patients to adhere to.

Answer: B. It is an evidence-based dietary therapy for some patients with refractory epilepsy, particularly children.

49. A patient taking oxcarbazepine develops a rash. The pharmacist should be aware that there is a risk of cross-reactivity if the patient is switched to:

• A. Levetiracetam
• B. Valproic acid
• C. Carbamazepine
• D. Gabapentin

Answer: C. Carbamazepine

50. An important part of the “Implement” step of the PPCP for a new epilepsy prescription is to:

• A. Document the seizure classification.
• B. Assess the patient for side effects.
• C. Counsel the patient on the importance of adherence and what to do if they miss a dose.
• D. Develop the care plan.

Answer: C. Counsel the patient on the importance of adherence and what to do if they miss a dose.