Qus:1a.What are this patient’s drug therapy problems?

Ans:Use of anticonvulsants:-

Phenobarbital- Respiratory depression

Hypotension

Decreased level of consciousness

Longer half life

Carbamazepine-hyponetermia

Valproic acid-abnormal liver enzymes

Topiramate-ineffectivness

Phenytoin,lamotrigine,clonazepam- Hypotension, QT prolongation, Purple glove syndrome,adverseeffect profile, rash, fever, and fatigue are very serious, as they may indicate incipient Stevens–Johnson syndrome, toxic epidermal necrolysis, DRESS syndrome or aseptic meningitis.

a. Seizure lasting longer than 10 minutes or occurrence of second seizure.b. Difficulty in rousing at 20-minute intervals.c. Complaints of difficulty with visiond. Vomitinge. Persistent headache after a rest periodf. Unconsciousness with failure to respong. Unequal size pupils or excessively dilated

Qus:1b.what steps should be taken when the patient is first in the ED?

Ans:

Qus:2.What are the goals of pharmacotherapy in this case?

Ans:

A. Primary goal of drug therapy is the complete suppression of seizures in the absence of disabling side-effects. Prognosis of epilepsy has improved in last decade, and at present about 60-70% of newly diagnosed patients can be expected to achieve complete seizure control following institution of effective monotherapy (one drug).

B. When epilepsy cannot be controlled completely, the aim of treatment is to attain the best compromise between the desire to maximize seizure control and the need to keep side-effects within acceptable limits for the individual patient.

C. Therapy should maintain or restore the patient=s lifestyle and ability to lead an active life.

Qus:3.What pharmacotherapeutic options are available to treat status epilepticus?

Ans: Diazepam (10–20 mg at 2–5 mg/min in adults; 0.25–0.5 mg/kg at 2 – mg/min in children) Clonazepam (60.025 mg/kg;1 mg/5 min)Fosphenytoin (in adults, 15–20 mg/kg of phenytoinequivalents at 100–150 mg/min) Valproatea (20–25 mg/kgover 5–10 min followed by 2 mg/kg/h)Midazolam (LDb: 0.15–0.2 mg/kg, MD: 0.1–0.4 mg/kg/h)Propofol (LD: 1–2 mg/kg, MD: 6–12 mg/kg/h)

Qus:4.What is the best pharmacotherapeutic plan for this patient to treat status epilepticous?

Ans:

QUS:5.What clinical and laboratory parameters are needed to evalvate the therapy to ensure the best possible outcome?

Ans:

A. Select most appropriate drugB. Optimization of therapy requires individualization of dosageC. Monotherapy with the AEDs is preferred for most patientsD. Monitoring Therapy

Laboratory Tests

a. Baseline (i.e. prior to starting therapy) lab tests should include liver function tests (SGOT, SGPT, alkaline phosphatase), serum albumin, complete blood cell count with differential, urinalysis, and serum electrolytes.

b. In otherwise healthy and asymptomatic patients, routine laboratory monitoring after starting therapy is unnecessary with clinical laboratory tests only being repeated if indicated by the patient's clinical condition. For patients with abnormal baseline laboratory tests, further work up is required to evaluate their cause and follow-up monitoring performed as indicated. (i.e., for a patient with a low WBC started on carbamazepine, a CBC should be obtained every month for first 1-3 months, then quarterly for next year, and then every 6-12 months thereafter).

4. AED Plasma Concentrations

5.Assessement on bases of EEG

Qus:5.What patients –specific factors can interfere with phenytoin levels,and what can the patient (or those who care for the ) do to minimize them?

Ans: 1. Serum albumin < 3.2 Gm/dL

(Burn, hepatic cirrhosis, nephrotic syndrome, pregnancy, cystic fibrosis, and malnourished patients)

In patients with a serum albumin < 3.2 Gm/dL, the following formula may be used to adjust total phenytoin concentrations:

Adjusted Total Phenytoin Concentration = Sampled Total Phenytoin Concentration

(0.2 x Patient's Serum Albumin) + 0.1

2. Decreased renal function CrCl < 10 mL/minute

In patients with a CrCl less than 10 mL/minute, the following formula may be used to adjust total phenytoin concentrations:

Adjusted Total Phenytoin Concentration = Sampled Total Phenytoin Concentration

(0.1 x Patient's Serum Albumin) + 0.1

** A CrCl between 10-25 mL/minute may or may not effect free phenytoin levels.

3. Total bilirubin > 15 mg/dL

Bilirubin will significantly displace phenytoin from albumin when bilirubin levels increase above 15 mg/dL. This results in an increased free fraction of phenytoin.

4. Diabetes mellitus

Albumin can become glycosolated when diabetes is not controlled. Glycosolated albumin will not bind phenytoin as efficiently as normal albumin and the percentage of free phenytoin may increase.