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CP-130 FALL QUARTER 2003
TOPIC: Epilepsy Quiz

CC: LM is a 27 yo woman with a h/o complex partial seizures. She presents at epilepsy clinic today, and states that her
medication is “not working.” According to coworkers, they found her unconscious on the floor of the office last week. They
said that she was smacking her lips, picking at her clothes, and wandering through the cubicles prior to blacking out. She
regained consciousness after 1 to 2 minutes, but was groggy and confused. “I think this also happened while I was home alone.
I remember at least two instances where I found myself lying on the floor, and not knowing how I had gotten there. It’s
currently tax season, and I’ve been working non-stop. I didn’t have time to think about it, so I didn’t tell anyone.”

PMH: Complex Partial Seizures (s/p MVA 4 months ago)                Asthma x 10 years        Depression x 5 years

SH: LM is an accountant. She is not married, but has recently started a new relationship. She denies smoking, but admits to
drinking a few glasses of wine over the weekend to “unwind.” She also admits to drinking ~6 cups of coffee/day as she has
been increasingly drowsy. During the interview, she mentions that she is embarrassed and self-conscious about her gum
swelling.

FH: Mother – HTN, Osteoporosis         Father – Hyperlipidemia

Medication History:     Phenytoin (Dilantin®)              -200mg PO TID (stable on dose for 2-3 months)
                        Albuterol (Proventil®)              -2 puffs PO QID PRN SOB
                        Fluticasone (Flovent®)             -1 puff PO BID
                        Venlafaxine (Effexor XR®)           -75 mg PO QD
OTC Medications:        Calcium Carbonate (TUMS®)          -500 to 1000mgs PO PRN heartburn
                        Benzoyl Peroxide (Clearasil®)       -Apply to affected area QHS (started 2 weeks ago)
ALLERGIES: NKDA

Gen: Thin female, yawning

VS:     BP 114/80                HR 88                     T 36.4                  WT 58kg          HT 5’3”          RR 12

HEET: (+) nystagmus, (+) gingival hyperplasia                  Gu: deferred
COR: RRR                                                       Rect: deferred
Chest: CTA                                                     Ext: nl
ABD: NTND, (+)BS                                               Neuro: A&Ox3

LABS:
Na 138                         Hct 40                          Ast 20                          Glu 109
K 3.6                          Hgb 14                          Alt 23                          Ca 8.9
Cl 98                          WBC 5.4                         LDH 130                         PO4 3.8
HCO3 25                        Plts 265                        Alb 4.0                         Mg 2.2
BUN 18                         MCV 92                          T. Bili 1.1                     Uric Acid 3
CR 1.0

OTHER LABS:
EEG – focal epileptiform abnormalities in area of injury       Phenytoin 16 mcg/mL (10-20 mcg/mL)

Problem List:          1. Complex Partial Seizures      3. GERD                             5. Asthma
                       2. Contraception                 4. Depression
QUESTIONS: PLEASE READ CAREFULLY. ONLY PATIENT SPECIFIC ANSWERS RECEIVE CREDIT. (20PT
TOTAL)
1. List 4 lifestyle factors that may be exacerbating LM’s seizure disorder.
2. Please select an appropriate anti-epileptic for LM from the following list. List at least 4 advantages or disadvantages for
each of the listed medications.
         Phenytoin          Valproic Acid            Carbamazepine             Lamotrigine
3. Write an outpatient prescription for the anti-epileptic therapy that you recommend for LM.
4. Provide 5 counseling points for LM’s seizure disorder and anti-epileptic therapy.
5. LM states that she will be going for her yearly women’s health exam, and would like a recommendation for a birth control
pill. What can you tell her?
6. What can LM use for her recent bout of “heartburn”? LM states that she has been using TUMS® after almost every meal
now. List the advantages and disadvantages of the available treatment options.
1. List 4 lifestyle factors that may be exacerbating LM’s seizure disorder.
Some lifestyle factors that may be exacerbating LM’s seizure disorder include excessive stress, sleep deprivation, missed meals, and
ingestion of excessive amounts of caffeine and/or alcohol. LM must be counseled on these potential seizure precipitants. She must
also be advised to avoid any other activity that might trigger a seizure.

2. Please select an appropriate anti-epileptic for LM from the following list. List at least 4 advantages or disadvantages for
each of the listed medications.
*Phenytoin:                                         *Carbamazepine:
(+)first line therapy for partial seizures          (+)first line therapy for partial seizures
(+)long half-life, QD to BID dosing                 (+)linear PK, easier dosing
(-)LM experiencing SE’s                             (+)may be less sedating than PHT (pt specific)
   such as nystagmus, drowsiness,                   (-)DDI’s, induces OC metabolism (pt specific)
   acne, and gum hypertrophy (pt specific)          (-)short half-life, BID to TID dosing
(-)non-linear PK, dosing can be difficult
(-)DDI’s, induces OC metabolism (pt specific)
(-)already tried, and seizures not controlled
   (pt specific)

*Valproic Acid:                                       *Lamotrigine:
(+)fewer DDI’s than CBZ, PHT                          (+)well-tolerated
(-)2nd line therapy for parital seizures              (+)no DDI’s with OCs (pt specific)
b/c not as effective for complete control             (+/-)not approved as monotherapy, but probably effective
(-)SE’s may be undesirable in this pt                 (-)less experience than with PHT, CBZ
  (e.g. wt gain, alopecia, menstrual abnl’s)          (+)prob. less cognitive SE’s than other standard AEDs (pt specific)
  (pt specific)

NOTE: Patient specific answers are preferred. Please remember this whenever you SOAP out a case.

3. Write an outpatient prescription for the anti-epileptic therapy that you recommend for LM.
                         Patient’s Name            Date
                         Patient’s Address Allergy

Carbamazepine XR 200mg             #100        OR              Lamotrigine    25mg       #84
       Take 1 tab po bid,                                              Take 1 tab po bid for 2 weeks,
       increase as directed                                            then 2 tabs po bid for 2 weeks

                                               Signature
                                               DEA #
                                               Phone No.

4. Provide 5 counseling points for LM’s seizure disorder and anti-epileptic therapy.
*Carbamazepine is a medication used to control seizure disorders. Some of carbamazepine’s adverse effects include dizziness,
drowsiness, nausea, and anorexia. These adverse effects, however, can go away with time. If you notice more serious adverse effects,
please notify your physician or pharmacist immediately. You must avoid acitivities that are associated with precipitating seizures (see
Question 1). The dose of your medication may change in the future as we try to find the correct dose at which your seizures are
controlled. The medication being prescribed to you is an extended-release formulation. Do not be surprised at seeing a tablet shell in
your stool. Don’t break XR tablet. Also, since this medication may interact with other medications, it is always important to consult
your physician or pharmacist before starting any new medications/dietary supplements/and vitamins.
*Lamotrigine is a medication used to control seizure disorders. Some of lamotrigine’s adverse effects include dizziness, headache,
drowsiness, and nausea. These adverse effects, however, can go away with time. If you notice more serious adverse effects such as a
rash, please notify your physician or pharmacist immediately. You must avoid acitivities that are associated with precipitating seizures
(see Question 1). The dose of your medication may change in the future as we try to find the correct dose at which your seizures are
controlled. You can take your medication without regard to meals. Do not break the tablets. It must be swallowed as an intact tablet.
Also, since this medication may interact with other medications, it is always important to consult your physician or pharmacist before
starting any new medications/dietary supplements/and vitamins.

5. LM states that she will be going for her yearly women’s health exam, and would like a recommendation for a birth control
pill. What can you tell her?
Carbamazepine can interact with birth control pills by inducing their metabolism. Patients who are on AEDs such as carbamazepine,
phenytoin, phenobarbital, and primidone need to be warned about the potential of the decreased efficacy of birth control pills. This
can present as irregular bleeding, breakthrough bleeding, or pregnancy. If patients are on OCs, they should be advised to used an
alternative method of birth control such as condoms, spermicide, diaphragms, etc… Although the dose of birth control pills can be
increased, not very many clinicians choose this route because estrogen has been reported to exacerbate seizures in some women.
Women aged >35 or who smoke run the risk thromboembolic complications with the higher doses of OCs. Some AEDs have also
been associated with increasing the synthesis of SHBG (sex hormone binding globulin), and decreasing the levels of OC in the body.
Also, as a side note, Lamotrigine has the potential to interact with birth control pills. There have been case reports of lamotrigine
levels being altered by OCs. However, this has not been seen clinically, and is usually not taken into consideration when treating
patient who need OCs and are on Lamotrigine therapy.

6. What can LM use for her recent bout of “heartburn”? LM states that she has been using TUMS® after almost every meal
now. List the advantages and disadvantages of the available treatment option.
*Antacids:                                                        *Sucralfate:
(+)fast onset, rapid symptom relief                               (-)limited role for GERD
(+)inexpensive                                                    (-)constipation/diarrhea
(+/-)used for symptomatic relief and mild to moderate GERD        (-)nausea/GI discomfort
(-)short duration, frequent dosing                                (-)1 GRAM QID on an empty stomach
(-)DDI’s                                                          (-)DDI’s
(-)constipation/diarrhea
(-)pt not responding to therapy (pt specific)

*H2 Blockers:                                                           *Metoclopramide:
(+)available OTC                                                        (+)can be as efficacious as H2 Blockers
(+)all equally effective, cost effective, well-tolerated                (+)onset is 30-60 minutes after po administration
(+)sustained effect on nocturnal intragastric acidity                   (-)limited to pt’s failing PPI therapy, decreased peristalsis
(+)used for intermitent symptoms and meal-provoked heartburn               or delayed gastric emptying
    (pt specific)
(-)HA at higher doses                                                   (-)CNS effects, EPS (rare)
(-)diarrhea, constipation, dizziness
(-)DDI’s (cimetidine>ranitidine=nizatidine>famotidine)

*Proton Pump Inhibitors:
(+)well-tolerated
(-)HA, diarrhea, nausea, abdominal pain
(-)DDI’s (omeprazole)
(+/-)used in moderate/severe GERD
(-)pt did not fail H2 Blocker therapy (pt specific)

				
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posted:11/23/2011
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