Advanced Pharmacology (NURS 5334) Mary Davis, DNP, MSN, ANP-BC, ADM-BC

Generalized tonic-clonic (GTC) seizures are manifested by convulsive episodes and a loss of consciousness. The motor effects are two-sided and start with short sustained contractions of muscles followed by stiffness and rhythmic jerking movements (Wells, Schwinghammer, DiPiro, & DiPiro, 2017, p. 532). The patient may have a loss of bowel and/or bladder control, a tendency to bite their tongue, or become cyanotic due to low oxygen saturations (Wells et. al., 2017, p. 532). GTC seizures are commonly followed by periods of intense sleep (Wells et. al., 2017, p. 532).  Enzyme-inducing antiepileptic drugs (AED), such as carbamazepine, can decrease the efficacy of other frequently prescribed drugs in the elderly (Ferlazzo, Sueri, Gasparini, & Aguglia, 2016). Therefore, a 68-year-old male on carbamazepine monotherapy would be at risk of drug-drug interaction if being treated with glucocorticoids, anticoagulants, analgesics, antiretrovirals, statins, antihypertensives, or immunosuppressants (Ferlazzo et. al., 2016). Osteoporosis is widely found in those aged 65 and over and epilepsy increases the risk for fractures and seizure-related injuries due to poor bone health; carbamazepine may reduce bone density by decreasing vitamin D metabolism (Ferlazzo et. al., 2016).  Recommended Drugs: List three recommended drugs as indicated for this diagnosis 1. Lamotrigine (Lamictal) (Burcham & Rosenthal, 2016, p. 224) SEIZURE CASE STUDY 3 2. Levetiracetam (Keppra) (Burcham & Rosenthal, 2016, p. 224) 3. Topiramate (Topamax) (Burcham & Rosenthal, 2016, p. 224)  Drug Categories and Subcategories: Identify the category of each recommended drug 1. Lamotrigine (Lamictal) Category: Anticonvulsant; Subcategory: Phenyltriazine (Vallerand, Sanoski, & Deglin, 2013, p. 760) 2. Levetiracetam (Keppra) Category: Anticonvulsant; Subcategory: Pyrrolidines (Vallerand, Sanoski, & Deglin, 2013, p. 778) 3. Topiramate (Topamax) Category: Anticonvulsant; Subcategory: Mood stabilizer (Vallerand, Sanoski, & Deglin, 2013, p. 1235)  Choose antibiotic from the above three recommended drugs to treat identified disease  Levetiracetam (Keppra)  Rationale Provide rationale, clinical guidelines, or evidence for the antibiotic selected as drug of choice This elderly patient is currently being treated for tonic-clonic seizures with monotherapy carbamazepine and though his epileptic events are well controlled, this medication has greater risks for the older population therefore, medication evaluation must be considered. The justification for changing AEDs is to decrease the risk for potential future metabolic side effects in older patients (Jobst, 2013). Levetiracetam is chosen for the following reasons: first, this medication is almost completely excreted by the kidneys, removing the risk for medication interactions (Crepeau & Sirven, 2017). Secondly, levetiracetam has relatively mild side effects including drowsiness and weakness deeming this AED to be one of the easier tolerated medications (Crepeau & SEIZURE CASE STUDY 4 Sirven, 2017). Some of the more unpleasant effects can be depression, anxiety, and irritability, though these may improve after the first few weeks of therapy (Crepeau & Sirven, 2017). Finally, levetiracetam is a superior treatment choice because carbamazepine increases the risk of osteoporosis with prolonged use (Crepeau & Sirven, 2017). According to research, the majority of patients who were well managed prior to switching medications, remained so with the new AED (Wick, 2014). Polytherapy should be considered if the patient’s current medication has been efficacious, adding a second drug then slowly the removing the first one has been shown to be the most rational approach (Ben-Menachem, 2014). Thus, in this case, levetiracetam would be given in addition to patient’s carbamazepine beginning with a low dose and intermittently increasing the dose until therapeutic level is attained, while simultaneously tapering carbamazepine (Vallerand et. al., 2013, p. 265) The ultimate goal would be for the patient to be well managed on levetiracetam monotherapy. During this period of dual therapy, the patient should be frequently monitored for medication interactions to prevent harm (Wick, 2014). Levetiracetam potentially interacts with carbamazepine by increasing its potential for toxic levels; however, this can be managed by simultaneously tapering the carbamazepine during the levetiracetam increases (Ben-Menachem, 2014).