MCQ Quiz: Management of Epilepsy in Special Populations

The management of epilepsy requires a nuanced, patient-centered approach that becomes even more complex when caring for special populations. The PharmD curriculum dedicates specific learning to the management of epilepsy in groups such as pediatric and geriatric patients, as well as in women of childbearing potential, acknowledging the unique pharmacokinetic and pharmacodynamic considerations in each. This quiz will test your knowledge on applying principles of drug therapy individualization to these vulnerable populations, a key competency for ensuring safe and effective care.

1. Which of the following is a primary consideration in the management of epilepsy in a pediatric patient?

• A. The impact of anti-seizure medications (ASMs) on cognitive development and behavior.
• B. The preference for using only intravenous medications.
• C. The fact that children are less sensitive to side effects than adults.
• D. The goal of using at least three ASMs simultaneously.

Answer: A. The impact of anti-seizure medications (ASMs) on cognitive development and behavior.

2. Due to physiological changes like decreased renal clearance and lower serum albumin, what is the key dosing principle for initiating an ASM in a geriatric patient?

• A. Start with a high loading dose.
• B. Use the standard adult dose.
• C. “Start low and go slow”.
• D. Titrate the dose as quickly as possible.

Answer: C. “Start low and go slow”.

3. Which anti-seizure medication is associated with the highest risk of major congenital malformations, particularly neural tube defects, when used during pregnancy?

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

Answer: C. Valproic acid.

4. A woman of childbearing potential who must take an enzyme-inducing ASM like carbamazepine should be counseled that:

• A. Her hormonal contraceptive will become more effective.
• B. The ASM can decrease the efficacy of hormonal contraceptives, and alternative or backup methods should be considered.
• C. There is no interaction between ASMs and hormonal contraceptives.
• D. She should only use a low-dose oral contraceptive.

Answer: B. The ASM can decrease the efficacy of hormonal contraceptives, and alternative or backup methods should be considered.

5. The management of pediatric epilepsy is a specific topic covered in which Patient Care course?

• A. Patient Care VII: Brain and Behavior.
• B. Patient Care VI: Skin and Musculoskeletal Disorders.
• C. Patient Care V: Endocrinology and Women’s and Men’s Health.
• D. Patient Care IV: Gastrointestinal and Renal Disorders.

Answer: A. Patient Care VII: Brain and Behavior.

6. Geriatric patients are more susceptible to which dose-related side effect of ASMs, increasing their risk of falls?

• A. Hypertension
• B. Agitation
• C. Dizziness and ataxia.
• D. Weight loss

Answer: C. Dizziness and ataxia.

7. Why is folic acid supplementation recommended for all women of childbearing potential on ASMs?

• A. To prevent common side effects like dizziness.
• B. To reduce the risk of major congenital malformations, particularly neural tube defects.
• C. To enhance the efficacy of the anti-seizure medication.
• D. To prevent weight gain.

Answer: B. To reduce the risk of major congenital malformations, particularly neural tube defects.

8. Pharmacokinetic changes during pregnancy can significantly affect ASM concentrations. The clearance of which ASM is known to increase substantially during pregnancy, often requiring dose adjustments?

• A. Phenytoin
• B. Phenobarbital
• C. Lamotrigine
• D. Topiramate

Answer: C. Lamotrigine

9. When selecting an ASM for an elderly patient, which of the following is most preferred?

• A. An agent with a high potential for drug-drug interactions.
• B. A highly sedating medication.
• C. An agent with a favorable side effect profile and low potential for drug interactions, like levetiracetam.
• D. A drug with non-linear pharmacokinetics like phenytoin.

Answer: C. An agent with a favorable side effect profile and low potential for drug interactions, like levetiracetam.

10. What is a key challenge in managing epilepsy in adolescents?

• A. They are immune to side effects.
• B. Issues surrounding medication adherence and risk-taking behaviors.
• C. They metabolize all drugs very slowly.
• D. There are no effective liquid formulations for them.

Answer: B. Issues surrounding medication adherence and risk-taking behaviors.

11. The “Principles of Drug Use in Pregnancy” is a foundational topic that helps guide the management of all chronic conditions, including epilepsy, in this special population.

• A. True
• B. False

Answer: A. True

12. For a pediatric patient who cannot swallow tablets, which of the following dosage forms would be an appropriate management strategy?

• A. Crushing an extended-release tablet.
• B. Using an available oral solution, chewable tablet, or sprinkle capsule formulation.
• C. Administering a regular tablet rectally.
• D. Dissolving an enteric-coated tablet in juice.

Answer: B. Using an available oral solution, chewable tablet, or sprinkle capsule formulation.

13. A corrected phenytoin level should be calculated in a geriatric patient with low serum albumin because:

• A. The total level may be in the “therapeutic” range while the active, free fraction is actually elevated.
• B. Low albumin increases the metabolism of phenytoin.
• C. Geriatric patients clear phenytoin more rapidly.
• D. The total level will be falsely low.

Answer: A. The total level may be in the “therapeutic” range while the active, free fraction is actually elevated.

14. When considering ASM use in a breastfeeding mother, the pharmacist should assess:

• A. The color of the medication.
• B. The potential for the drug to pass into breast milk and cause adverse effects in the infant.
• C. Only the mother’s preference.
• D. The cost of the medication only.

Answer: B. The potential for the drug to pass into breast milk and cause adverse effects in the infant.

15. The “Personalized Medicine for Epilepsy” lecture highlights the importance of genetic testing in certain populations. Screening for HLA-B*1502 before starting carbamazepine is crucial for patients of:

• A. Northern European descent.
• B. African descent.
• C. Asian descent.
• D. Hispanic descent.

Answer: C. Asian descent.

16. Which ASM is generally considered to have a more favorable profile regarding teratogenicity and cognitive side effects compared to older agents?

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

Answer: D. Levetiracetam

17. The ketogenic diet is a non-pharmacological management option most commonly used in which special population with refractory epilepsy?

• A. Geriatric patients
• B. Pregnant women
• C. Children.
• D. Adults with new-onset focal seizures.

Answer: C. Children.

18. Polypharmacy is a major concern in the geriatric population. When managing epilepsy in an elderly patient, the pharmacist’s role is to:

• A. Add as many medications as possible.
• B. Screen for and manage potential drug-drug interactions between the ASM and the patient’s other medications.
• C. Ignore the patient’s other medications.
• D. Only focus on the anti-seizure medication.

Answer: B. Screen for and manage potential drug-drug interactions between the ASM and the patient’s other medications.

19. Why might neonates and infants require different dosing of ASMs compared to older children?

• A. Their metabolic enzymes and renal function are fully mature.
• B. They have immature hepatic and renal function, leading to slower drug clearance.
• C. They are not susceptible to side effects.
• D. They always require higher doses per kilogram.

Answer: B. They have immature hepatic and renal function, leading to slower drug clearance.

20. The decision to start an ASM in a pregnant woman with new-onset seizures requires a careful risk-benefit analysis, weighing the risk of the medication to the fetus against the risk of:

• A. Minor side effects for the mother.
• B. The cost of the medication.
• C. Uncontrolled seizures to both the mother and the fetus.
• D. The inconvenience of daily dosing.

Answer: C. Uncontrolled seizures to both the mother and the fetus.

21. A “Geriatric Drug Dosing Considerations” lecture is part of the PHA5878C curriculum, emphasizing the need to adjust therapy based on:

• A. The patient’s preference only.
• B. Age-related physiological changes.
• C. The patient’s hair color.
• D. The day of the week.

Answer: B. Age-related physiological changes.

22. Which ASM is a good option for an elderly patient on multiple medications because it has a low potential for drug interactions?

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

Answer: D. Levetiracetam

23. The management goal for a pregnant woman with epilepsy is to:

• A. Discontinue all ASMs immediately.
• B. Achieve seizure control using the safest possible agent at the lowest effective dose, preferably as monotherapy.
• C. Switch to polytherapy with at least three drugs.
• D. Use valproic acid as the first-line agent.

Answer: B. Achieve seizure control using the safest possible agent at the lowest effective dose, preferably as monotherapy.

24. Which of the following is a behavioral side effect of concern for some ASMs in the pediatric population?

• A. Improved school performance
• B. Irritability, aggression, or hyperactivity.
• C. Increased social interaction
• D. Enhanced focus and concentration

Answer: B. Irritability, aggression, or hyperactivity.

25. An elderly patient is more likely to experience a fall due to the CNS side effects of an ASM because of:

• A. Their enhanced muscle strength.
• B. Pre-existing gait instability and increased drug sensitivity.
• C. Their faster reaction times.
• D. Their low risk of comorbidities.

Answer: B. Pre-existing gait instability and increased drug sensitivity.

26. Management of epilepsy in women may be complicated by catamenial epilepsy, which refers to:

• A. Seizures that only occur at night.
• B. A change in seizure frequency in relation to the menstrual cycle.
• C. Seizures that are provoked by stress.
• D. The first seizure a person ever has.

Answer: B. A change in seizure frequency in relation to the menstrual cycle.

27. The

PHA5166L skills lab for third-year students includes specific modules on Geriatric and Pediatric Patient Care, reinforcing their status as key special populations.

• A. True
• B. False

Answer: A. True

28. An infant born to a mother who took an enzyme-inducing ASM like phenobarbital during pregnancy may be at risk for what condition shortly after birth?

• A. Hypertension
• B. Vitamin K deficient bleeding
• C. Hyperglycemia
• D. Jaundice

Answer: B. Vitamin K deficient bleeding

29. The management of epilepsy in a patient with renal impairment requires dose adjustment for which of the following drugs?

• A. Phenytoin
• B. Valproic acid
• C. Levetiracetam and gabapentin
• D. Carbamazepine

Answer: C. Levetiracetam and gabapentin

30. Which ASM should be used with caution in a child with absence epilepsy due to the risk of worsening or precipitating tonic-clonic seizures?

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

Answer: C. Carbamazepine

31. The “Plan” step of the PPCP for a pregnant patient with epilepsy would involve:

• A. Discontinuing all medications.
• B. Creating a patient-centered care plan that involves collaboration with the patient, an obstetrician, and a neurologist.
• C. Referring the patient to a different pharmacy.
• D. Only discussing non-pharmacological options.

Answer: B. Creating a patient-centered care plan that involves collaboration with the patient, an obstetrician, and a neurologist.

32. Bone loss and an increased risk of fractures is a long-term management concern for which special population on chronic therapy with older, enzyme-inducing ASMs?

• A. Neonates
• B. Adolescents
• C. Geriatric patients and postmenopausal women.
• D. Young adult males

Answer: C. Geriatric patients and postmenopausal women.

33. The principles of drug use during breastfeeding are covered in the curriculum and are important for managing epilepsy in postpartum women. A key factor to consider is:

• A. The drug’s molecular weight and protein binding.
• B. The potential for infant sedation or other adverse effects.
• C. The relative infant dose (RID).
• D. All of the above.

Answer: D. All of the above.

34. A pediatric patient with infantile spasms may be managed with which specialized therapies?

• A. Standard ASMs like carbamazepine.
• B. Adrenocorticotropic hormone (ACTH) or vigabatrin.
• C. A low-dose benzodiazepine.
• D. Phenytoin.

Answer: B. Adrenocorticotropic hormone (ACTH) or vigabatrin.

35. An elderly patient is particularly sensitive to the CNS side effects of which class of ASMs?

• A. Newer agents like levetiracetam.
• B. Barbiturates like phenobarbital.
• C. Valproic acid.
• D. Lamotrigine.

Answer: B. Barbiturates like phenobarbital.

36. For a woman with epilepsy planning a pregnancy, pre-conception management should ideally involve:

• A. Stopping all ASMs cold turkey.
• B. Switching to the most effective ASM monotherapy at the lowest effective dose and starting high-dose folic acid.
• C. Waiting until the second trimester to see a neurologist.
• D. Increasing the dose of valproic acid.

Answer: B. Switching to the most effective ASM monotherapy at the lowest effective dose and starting high-dose folic acid.

37. Which special population might require alternative dosage forms like oral solutions or dispersible tablets for easier administration?

• A. Young adults
• B. Middle-aged adults
• C. Pediatric and geriatric patients.
• D. Athletes

Answer: C. Pediatric and geriatric patients.

38. The risk of lamotrigine-induced rash is increased in pediatric patients, especially when co-administered with:

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

Answer: C. Valproic acid.

39. Managing epilepsy in a patient with intellectual disability requires a focus on:

• A. Using the most complex regimen possible.
• B. Simplifying the regimen to improve adherence and ensuring caregivers are properly educated.
• C. Assuming the patient cannot report side effects.
• D. Using only injectable medications.

Answer: B. Simplifying the regimen to improve adherence and ensuring caregivers are properly educated.

40. Why is therapeutic drug monitoring especially complex during pregnancy?

• A. Because drug clearance often decreases.
• B. Because physiological changes like increased plasma volume and increased drug clearance can alter ASM levels, requiring frequent monitoring and dose adjustments.
• C. Because labs are unable to process samples from pregnant women.
• D. Because drug levels remain perfectly stable throughout pregnancy.

Answer: B. Because physiological changes like increased plasma volume and increased drug clearance can alter ASM levels, requiring frequent monitoring and dose adjustments.

41. The

PHA5787C course covers drug use in pregnancy and lactation, providing a foundation for managing epilepsy in this special population.

• A. True
• B. False

Answer: A. True

42. Which ASM is associated with an increased risk of cleft palate in infants when taken during pregnancy?

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

Answer: B. Topiramate

43. A geriatric patient is at a higher risk for drug-drug interactions with ASMs because of:

• A. A lower number of comorbidities.
• B. Polypharmacy (the use of multiple medications).
• C. Faster drug metabolism.
• D. A stronger immune system.

Answer: B. Polypharmacy (the use of multiple medications).

44. A key goal when managing epilepsy in school-aged children is to:

• A. Select an ASM that has no impact on cognition or learning.
• B. Minimize cognitive side effects to avoid impairing academic performance.
• C. Allow the child to miss school frequently.
• D. Administer all medications at school.

Answer: B. Minimize cognitive side effects to avoid impairing academic performance.

45. The “Assess” step of the PPCP for an elderly patient with epilepsy would include a specific focus on:

• A. The patient’s fall risk.
• B. The patient’s social media habits.
• C. The patient’s favorite foods.
• D. The patient’s travel plans.

Answer: A. The patient’s fall risk.

46. When counseling the parents of a child newly diagnosed with epilepsy, it is important to:

• A. Provide complex medical information without simplification.
• B. Create a seizure action plan for school and home.
• C. Focus only on the positive aspects of the medication.
• D. Avoid discussing side effects to prevent worry.

Answer: B. Create a seizure action plan for school and home.

47. The management of epilepsy in a patient with hepatic impairment requires caution with which ASMs?

• A. Those primarily cleared by the kidneys, like levetiracetam.
• B. Those extensively metabolized by the liver, like phenytoin and valproic acid.
• C. All ASMs are safe in hepatic impairment.
• D. Only newer ASMs.

Answer: B. Those extensively metabolized by the liver, like phenytoin and valproic acid.

48. Why is monotherapy the preferred initial management strategy in most special populations?

• A. To increase the risk of drug interactions.
• B. To minimize the pill burden and the risk of additive adverse effects.
• C. It is not the preferred strategy.
• D. To make treatment more complicated.

Answer: B. To minimize the pill burden and the risk of additive adverse effects.

49. An important part of the care plan (“Plan”) for a woman with epilepsy who wishes to become pregnant is:

• A. Discontinuing all communication with her neurologist.
• B. Initiating valproic acid.
• C. Pre-conception counseling to optimize her ASM regimen and start folic acid.
• D. Waiting until she is pregnant to make any medication changes.

Answer: C. Pre-conception counseling to optimize her ASM regimen and start folic acid.

50. The comprehensive management of epilepsy in any special population requires:

• A. A “one-size-fits-all” approach.
• B. A collaborative, interprofessional team approach to individualize therapy and ensure safety.
• C. The pharmacist to make all decisions alone.
• D. The use of only the oldest available medications.

Answer: B. A collaborative, interprofessional team approach to individualize therapy and ensure safety.