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.

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

Thank you for sharing this wonderful post. It is impressive and interesting to read. Women with seizures encounter several challenges during pregnancy. Treating epilepsy during pregnancy characterizes a balance between seizure control and teratogenic risk. The data indicate that children born to epileptic women who are on AEDs have enhanced risk for major congenital malformations (MCM), neurodevelopmental disorders, and reduced intelligence quotient scores (Spiegel & Merius, 2020). Congenital malformations linked to exposure of fetus to AED are categorized as anatomic teratogenicity while behavioral or cognitive deficits are categorized as behavioral teratogenicity (Kim et al., 2019).

Pregnant women with seizures are discouraged from using anticonvulsant valproate because of risk of neural tube defects and other malformations to the limbs, heart, and genitals. Prenatal exposure to valproate can also lead to high risk of autism spectrum disorders and lower IQ in the lineage. Therefore, Lacosamide remains the best treatment of the partial-onset seizures for the client in this case. It can also be used alongside other drugs in the treatment of primary generalized tonic-clonic seizures (Rosenow et al., 2020). Lacosamide acts on the central nervous system to lower the frequency and severity of seizures.

References

Kim, H., Faught, E., Thurman, D. J., Fishman, J., & Kalilani, L. (2019). Antiepileptic drug treatment patterns in women of childbearing age with epilepsy. JAMA neurology, 76(7), 783-790. doi:10.1001/jamaneurol.2019.0447

Rosenow, F., Brandt, C., Bozorg, A., Dimova, S., Steiniger‐Brach, B., Zhang, Y., … & Kälviäinen, R. (2020). Lacosamide in patients with epilepsy of cerebrovascular etiology. Acta Neurologica Scandinavica, 141(6), 473-482. https://doi.org/10.1111/ane.13230

Spiegel, R., & Merius, H. (2020). Principles of epilepsy management for women in their reproductive years. Frontiers in Neurology, 11, 322. https://doi.org/10.3389/fneur.2020.00322