NU 641 Discussion: Neurology

Sample Answer for NU 641 Discussion: Neurology Included After Question

Initial Post

In your initial post, please answer all the questions and provide your rationales with supportive evidence in a well-developed paragraphs using APA formatting, integrating two evidence-based resources to include clinical practice guidelines as well as the course textbook. (Do not use lay press Internet sites.)

Accompanied by her boyfriend, Shaynah Anderson, age 23, visits your office. Her boyfriend states, “She hasn’t been herself the last month. She has headaches and is completely confused and tired for no reason.” Shaynah denies using illicit drugs and any recent traumatic injuries. She thinks her problem started approximately a month ago when she was at a club dancing. Her friends told her that she became confused and began tugging at her clothes. Then she fell down and was unconscious for a few minutes. When she awoke, she felt extremely tired and did not know what was going on. Her boyfriend recalls that she had been hit in the head with a softball during a game the day before they went dancing. Past medical history discloses insulin use since early childhood (currently 10 units NPH in the morning and 10 units regular insulin before meals), Prilosec at bedtime, and Ibuprofen (1 or 2 tablets twice a day) for headaches. She is interested in becoming pregnant in the next 12 to 24 months. The patient says she has no allergies and does not drink or use recreational drugs or tobacco.

On physical examination, Shaynah is 5 foot 4 inches and 130 lb. Her temperature is 37°C, pulse rate 78, blood pressure 118/76, and glucose level 90. Skin appears normal. Head and neck are normal, chest is clear for anterior and posterior sounds, cardiovascular RRR and (2) r/m/g, and laboratory values are within normal limits. EEG findings include sharp-wave discharges. At a follow-up visit 2 months later, patient and her boyfriend report that things have gotten worse. The boyfriend states that as patient was eating dinner one night and she had a seizure. She was completely stiff for a short time, and then her arms and legs began moving. He believes that she was unconscious for a few minutes, patient says she could not remember what had happened when she woke up.

Diagnosis: Generalized Tonic-Clonic Seizure

  1. Which of the following should be true regarding your initial Adverse Effect Drugs (AED) regimen?
    1. Initial combination therapy is warranted due to increased success rates.
    2. Drugs that are taken two to three times daily are preferred due to a lower risk of seizure if a dose is missed.
    3. Levetiracetam is the preferred agent for all seizure types and patients.
    4. The risks of pregnancy must be discussed prior to starting any AED.
  2. Which of the following is the most appropriate initial antiepileptic regimen for this patient?
    1. Levetiracetam 500 mg PO daily
    2. Phenytoin 100 mg PO three times daily
    3. Pregabalin 50 mg PO three times daily
    4. Clobazam 5 mg PO twice daily
  3. The patient fails to respond and has significant side effects to her initial therapy. Her initial therapy is to be discontinued. Which of the following would be the most appropriate replacement?
    1. Valproic acid 500 mg twice daily
    2. Lamotrigine 100 mg twice daily
    3. Lacosamide 100 mg twice daily
    4. Rufinamide 200 mg twice daily
  4. After several different AEDs, the patient ends up on carbamazepine and phenytoin. The carbamazepine serum concentration on week 2 of therapy was 6 mcg/mL. The patient presents after 8 weeks of therapy with increased seizures and she is found to have a serum concentration of 2 mcg/mL. Which of the following is a likely cause?
    1. Autoinduction of CYP3A4.
    2. Patient has the HLA-B*1502 subtype.
    3. The oral contraceptive that she recently started.
    4. Co-administration with alcohol.
  5. Despite the use of oral contraception, the patient becomes pregnant. Her AED regimen consists of valproic acid and lacosamide. What is the most appropriate treatment intervention?
    1. Discontinue valproic acid and continue lacosamide monotherapy.
    2. Discontinue lacosamide and continue valproic acid monotherapy.
    3. Continue combination therapy.
    4. Discontinue valproic acid and add phenytoin.

Reply Posts

Choose two peer posts and reply in a well-developed paragraph (300–350 words) to each peer, integrating an evidence-based resource that is different than the one you used for the initial post.

Respectfully agree and disagree with your peers’ responses and explain your reasoning by including your rationales in your explanation.

Please refer to the Grading Rubric for details on how this activity will be graded.

The described expectations meet the passing level of 80%. Students are directed to review the Discussion Grading Rubric for criteria, which exceed expectations.

A Sample Answer For the Assignment: NU 641 Discussion: Neurology

Title: NU 641 Discussion: Neurology

Shaynah has mentioned that she would like to become pregnant in the next 12- 24 months. The risks of pregnancy must be discussed prior to strating any AED. For example, dilantin is a Pregnancy category D and the overall risk of malformation for children exposed to Dilantin is 10 % (Woo & Robinson 2020 p197). This is the case for most AED. There are previous recommendations that women who are taking Dilantin can have reduce the risks to the fetus by taking 400mcg of folic acid daily (Woo & Robinson 2020 p197). Newborns who have been exposed to phenytoin in utero may experience decreased levels of vitamin K and will need to receive it at birth (Woo & Robinson 2020 p197). In addition to the effect these drugs may have on the fetus they can also lower the efficacy of oral contraceptives (Waseem 2021).

The most appropriate initial antiepileptic regimen for this patient would be phenytoin 100mg PO three times a day. Hydantoins are the first line treatment choice for tonic- conic and partial complex seizures; additionally they are the least sedating drugs to treat seizure disorders (Woo & Robinson 2020 p197). After the initial start of the drug and receiving the loading dose she may receive 300mg of extended release dilantin or continue with the 100 mg TID (Woo & Robinson 2020 p 201).

Lamotrigine is an adjunct therapy that would be most effective while taking another drug (Woo & Robinson 2020 p209). Rufinamide is not a treatment medication for the type of seizures and is also used in combination with another drug (Woo & Robinson 2020 p210). Valproic acid is not commonly used for this type of seizure. This drug is usually well tolerated and most side effects are mild and transient (Woo & Robinson 2020 p254). This will be effective in treating Shaynah’s seizures with the smallest amount of side effects.
The therapeutic range for a carbamazepine serum concentration is between 4 to 12 mcg/ml (Woo & Robinson 2020 p206). The cause of the serum concentration of 2mcg weeks later is most likely caused by the autoinduction of CYP3A4. The auto- induction process takes about four weeks (Waseem 2021). This is why the level is lower weeks later as the autoinduction process was still happening. The sub-therapeautic level is often caused by auto- induction and small therapeutic range (Guo & Shaikh 2017). Often a low level means under treatment or non- compliance, which is less likely (Guo & Shaikh 2-17).

The carbamazepine that the patient is taking interacts with oral contraceptives, leading to break through bleeding, ovulations and pregnancy in women who are taking both medications (Waseem, 2021).
The most appropriate treatment intervention is to discontinue the valproic acid and continue lacosamide. If Valproic acid is used during the first trimester of pregnancy there is a listed side effect of neural tube defect- including spina bifida (Woo & Robinson 2020 p254). It is a pregnancy category D drug and it’s use should be restricted unless the woman’s life would be endangered without it (Woo & Robinson 2020 p254). Lacosamide is an FDA pregnancy category C drug. Studies have shown those taking it during pregnancy have had no teratogenicity and no major or minor congenital abnormalities (Khuda & Aljaafari 2018). Shaynah will need to get her seizures under control and compared to the other available options Lacosamide is the medication with the highest benefit and lowest risk.

References

Guo, R. & Shaikh, A.S (2017) Measurement and Comparison of Carbamazepine Plasma Levels for Assessment of Compliance, Safety and Toxicity. Institute of Clinical Pharmacology, Qilu Hospital of Shandong University, Junan China.
Khuda, I., & Aljaafari, D. (2018). Epilepsy in pregnancy: A comprehensive literature review and suggestions for saudi practitioners. Neurosciences Journal, 23(3), 185-193.
Waseem M. (2021). Carbamazepine toxicity. Medscape. Retrieved from https://emedicine.medscape.com/article/813654-overview
Woo, T, M., & Robinson, M. V. (2020). Pharmacotherapeutics for advanced practice nurse prescribers (5th ed.) Philadelphia, PA: F.A. Davis Company.

A Sample Answer 2 For the Assignment: NU 641 Discussion: Neurology

Title: NU 641 Discussion: Neurology

Shaynah Anderson (SA), a 23-year-old woman, comes in the office alongside her boyfriend with complaints of headaches and change in mental status, confused and unable to concentrate. Although the couple denies any recent trauma, they admit to SA suffering a head injury followed by an apparent generalized tonic-clonic seizure one month ago. Her past medical history is significant for DM type 1 and headaches. She takes insulin, Prilosec, and ibuprofen. She is interested in getting pregnant does not drink or use recreational drugs or tobacco.

On exam, SA is healthy, and all vital signs are within normal limits. Her EEG confirms brain irritability with findings of sharp-wave discharge “atypical” interictal epileptiform waves(Aanestad et al., 2020). This finding, in addition to her significant patient history, the diagnosis of generalized tonic clonic (GTC) seizure is made.

Diagnosis: Generalized Tonic-Clonic Seizure

Which of the following should be true regarding your initial Adverse Effect Drugs (AED) regimen?

1.   Initial combination therapy is warranted due to increased success rates-combo therapy is best when not responding, monotherapy is most appropriate d/t side effects

2.   Drugs that are taken two to three times daily are preferred due to a lower risk of seizure if a dose is missed-given lower doses lower the side effects, three times a day also decreases compliance.

3.   Levetiracetam is the preferred agent for all seizure types and patients-not true

4.   The risks of pregnancy must be discussed prior to starting any AED.

Health history is the most critical aspect in diagnosing a seizure disorder and establishing the cause and onset (McCance & Huether, 2019 p. 527). Therefore, in SA’s case, brain imaging, such as a Head CT or Brain MRI, would be immediately ordered due to her traumatic head injury from a softball nearly one month ago. Additionally, as a provider, it is essential to counsel women of childbearing age on the risks of fetal defects while on antiseizure medication therapy during pregnancy before starting any treatments. Although few treatment modalities are considered zero risk, knowing the level of danger for specific medications is valuable and must be considered. Allotey et al. (2019) report that women with epilepsy are more likely to die in pregnancy due to seizures than those who do not have this infliction. Women reported discontinuing their medication for fear of risk to the fetus. Thus, pregnant women and women of childbearing age with epilepsy need a tailored, multidisciplinary management plan.

Which of the following is the most appropriate initial antiepileptic regimen for this patient?

1.   Levetiracetam (Keppra) 500 mg PO daily-not correct, need BID pregnancy Cat C

2.   Phenytoin (Dilantin)100 mg PO three times daily- proper initial dose but pregnancy Cat D

3.   Pregabalin (Lyrica) 50 mg PO three times daily- adjunct therapy for partial-onset seizures 100 PO TID

4.   Clobazam (Onfi) 5 mg PO twice daily- adjunct therapy Lennox-Gastaut

Following SA’s definitive diagnosis of GTC taking into account her history of greater than one seizure and her electroencephalography (EEG) results, pharmacologic treatment should be initiated. Admittedly, choosing the correct answer from the options versus what we use in real-time in my inpatient neurology unit specializing in epilepsy and long-term monitoring of patients with seizure disorder was challenging. Anecdotally, for monotherapy Levetiracetam (Keppra) 500 mg PO BID, pregnancy category C, would be the first line of treatment for a young woman of childbearing age (MGH, 2013). However, this is not an option. Woo and Robinson (2020, p. 197) report that phenytoin, a hydantoins type drug, is the initial drug of choice for patients with tonic-clonic seizures. Hydantoins act on the influx of sodium ions into neurons and in turn, inhibit and stabilize irregular brain wave discharges. Phenytoin (Dilantin) is a known category D drug for pregnant women meaning fetal harm can be caused when used, yet Woo and Robinson (2020, p.197) still promote its use with concurrent folic acid treatment. The authors argue that is only a 10% risk of malformation. Phenytoin 100mg TID seems to be the answer warranted for this case study, but I would still prescribe Keppra 500 mg BID.

The patient fails to respond and has significant side effects to her initial therapy. Her initial therapy is to be discontinued. Which of the following would be the most appropriate replacement?

1.   Valproic acid (Depakote) 500 mg twice daily-not appropriate d/t desire to get pregnant

2.   Lamotrigine (Lamictal)100 mg twice daily-must ease into this dose

3.   Lacosamide (Vimpat) 100 mg twice daily-monotherapy for partial complex, adjunct to GTC

4.   Rufinamide (Banzel) 200 mg twice daily-adjunct to Lennox-Gastaut

Adjusting antiepileptic medications is common due to intolerable side effects and occasional ineffective treatment. In review of the above options for SA and her desire to become pregnant Valproic acid (Depakote) would be eliminated as a choice. Lacosamide (Vimpat) is used as monotherapy for partial complex and adjunct therapy to GTC, and Rufinamide (Banzel) is appropriate for adjunct treatment for Lennox-Gastaut syndrome. Therefore, Lamotrigine (Lamictal) would be the most suitable replacement. The dose must be incrementally brought up to 100mg BID starting at 25 mg every day for two weeks; in 3-4 weeks, the dosage would be increased to 50 mg per day, and in week five it can go up by 50 mg more per day (Woo & Robinson, 2020 p. 209)

After several different AEDs, the patient ends up on carbamazepine and phenytoin. The carbamazepine serum concentration on week 2 of therapy was 6 mcg/mL. The patient presents after 8 weeks of therapy with increased seizures and she is found to have a serum concentration of 2 mcg/mL. Which of the following is a likely cause?

1.   Autoinduction of CYP3A4.

2.   Patient has the HLA-B*1502 subtype.

3.   The oral contraceptive that she recently started.

4.   Co-administration with alcohol.

Autoinduction of CY34A4 for patients taking carbamazepine is a unique phenomenon. Carbamazepine is metabolized in the liver and can distinctively induce its own metabolism, known as autoinduction. Because of this occurrence, therapeutic levels may vary within the first several months of treatment despite good compliance (Woo & Robinson, 2020 p. 205).

Despite the use of oral contraception, the patient becomes pregnant. Her AED regimen consists of valproic acid and lacosamide. What is the most appropriate treatment intervention?

1.   Discontinue valproic acid and continue lacosamide monotherapy.

2.   Discontinue lacosamide and continue valproic acid monotherapy.

3.   Continue combination therapy.

4.   Discontinue valproic acid and add phenytoin

Valproic acid (Depakote) is considered one of the highest-risk teratogenic antiepileptic drugs. Because it may lead to major fetal congenital malformations, it must be immediately discontinued (Kuo et al., 2020). However, continuing monotherapy for this patient is imperative because seizures are the leading cause of maternal mortality in women with epilepsy (Allotey et al., 2019). Lacosamide (Vimpat) is listed as a pregnancy category C, but because it is still considered a reasonably new AED, teratogenicity during pregnancy is relatively unknown. Lacosamide is metabolized through several cytochrome P450 enzymes, which may increase during pregnancy; therefore, serum levels may be lowered. This must be taken into consideration during ongoing monitoring of SA (Zutshi et al., 2020).

Aanestad, E., Gilhus, N. E., & Brogger, J. (2020). Interictal epileptiform discharges vary across age groups. Clinical Neurophysiology, 131(1), 25-33. Interictal epileptiform discharges vary across age groups – ScienceDirect

Allotey, J., Fernandez-Felix, B. M., Zamora, J., Moss, N., Bagary, M., Kelso, A., … & Thangaratinam, S. (2019). Predicting seizures in pregnant women with epilepsy: Development and external validation of a prognostic model. PLoS medicine, 16(5), e1002802. Predicting seizures in pregnant women with epilepsy: Development and external validation of a prognostic model (nih.gov)

Kuo, C. Y., Liu, Y. H., Chou, I. J., Wang, H. S., Hung, P. C., Chou, M. L., … & Lin, K. L. (2020). Shifting valproic acid to levetiracetam in women of childbearing age with epilepsy: a retrospective investigation and review of the literature. Frontiers in Neurology, 11, 330. Frontiers | Shifting Valproic Acid to Levetiracetam in Women of Childbearing Age With Epilepsy: A Retrospective Investigation and Review of the Literature | Neurology (frontiersin.org)

McCance K.L. & Huether S.E. (2019). in ‘The neurological system’ Pathophysiology the biological basis for disease in adults and children (8th ed.) St. Louis, MI. Elsevier Inc.

MGH Center for Women’s Mental Health (2013, Nov 4th) Levetiracetam (Keppra) and Pregnancy Levetiracetam (Keppra) and Pregnancy (womensmentalhealth.org)

Woo, T, M., & Robinson, M. V. (2020). in ‘Drugs Affecting the Central Nervous System’ Pharmacotherapeutics for advanced practice nurse prescribers (5th ed.) Philadelphia, PA: F.A. Davis Company.

Zutshi, D., Millis, S. R., Basha, M. M., Daimee, M. A., & Srinivas, M. (2021). Lacosamide serum concentrations during pregnancy. Epilepsy & Behavior, 123, 108253. Lacosamide serum concentrations during pregnancy – ScienceDirect