Clinical Case Studies Week 3 (Epilepsy, COPD, Asthma) Flashcards
What are some non-pharmacological treatment options for epilepsy?
Lifestyle medications
Avoid stress, sleep deprivation, triggers
Seek and try to remove precipitants
Medication, alcohol
Counselling
Complianece with medications
Benefits of treatment
What is first line for:
A) focal (partial) seizures?
B) generalised tonic-clonic seziures
C) absence seizures
D) myoclonic seizures
E) infantile spasms
A)
cabamazepine
B)
valproate
C)
valproate or ethosuximide
D)
valproate
E)
prednisolone, tetracosactide
What is there a risk of with valproate?
Risk of hepatic failure (usually in 1st 6mths – can be fatal)
Which patients to avoid valproate in?
Avoid in women of child-bearing age
- Risk of birth defects and developmental delay in child
What are some AE of valproate? TDM?
Weight gain, PCO, hyperandrogenism in females, hair loss
Blood dyscrasias (esp thrombocytopenia) – FBC before tx
BMD, calcium and vitamin D
Multi-organ hypersensitivity
TDM = 40-100mg/L (up to 150mg/L in some people) Css trough level (3-5d)
Many drugs used in the treatment of epilepsy reduce the efficacy of hormonal contraception by inducing hepatic enzymes. What are examples of these drugs? How long do these effects of last for?
Carbamazepine
Oxcarbazepine
Phenytoin
- The effectiveness of these contraceptives may be reduced during therapy with, and for at least 4 weeks after stopping, enzyme-inducing antiepileptic drugs
What contraception is effective in epilepsy with women of childbearing age?
Effective contraception is provided by depot medroxyprogesterone acetate, progestin-releasing intrauterine contraceptive devices (eg Mirena) or copper intrauterine contraceptive devices.
What treatment for Tonic-clonic seizures where onset is unclear?
Use “broad spectrum antiepileptic” effective against both types –> first line – sodium valproate or levetiracetam (women of childbearing potential)
Counselling patients with epilepsy
Keep a seizure diary
Warn patients that abruptly stopping antiepileptic drugs can provoke status epilepticus
Seizures can be provoked by:
- Sleep deprivation
- Excess alcohol intake n
- Illicit drugs n
- Psychological stress n
- Other medication
> Have a management plan
> Counsel on contraception and pregnancy if appropriate
adverse reaction of AED summary
Dizziness, drowsiness and diplopia n
Hepatic failure and hyperammonaemic encephalopathy with valproate n
Agranulocytosis and ↓Na with carbamazepine n
Serious skin reactions SJS/TENS/DRESS – esp carbamazepine, lamotrigine, phenobarb, phenytoin, valproate n
Osteoporosis – phenobarb, phenytoin, carbamazepine, valproate n
Cosmetic changes with valproate and phenytoin n
Impaired cognition (esp phenobarb + topiramate) n
Suicidal ideation with AED’s n
Behavioural changes – levetiracetam, topiramate, perampanel, zonisamide n
Decreased sweating, hyperthermia – topiramate, zonisamide n
Metabolic acidosis and kidney stones – topiramate, zonisamide
Dose of carbamazepine?
Adult, oral, initially 100 mg twice daily; increase daily dose gradually by 100–200 mg every 2–4 weeks according to response
Dose of valproate?
Initially, oral 600 mg daily in 2 doses; increase every 3 days by 200 mg daily according to response.
What are some adverse reactions associated with AED’s? What to monitor for?
Dizziness, drowsiness and diplopia common adverse effects
association between some antiepileptics and an increased risk of suicidal thoughts and behaviour –> benefits will usually outweigh the risks in epilepsy
Vitamin D
Monitor Vitamin D in patients on long-term AED’s
> Risk factors for osteoporosis (↓BMD)
Agranulocytosis with carbamazepine
COPD from this card onwards
For managing a COPD exacerbation in primary care;
A) What to do when patient is feeling unwell (finding it harder to breathe than usual and experiencing either more coughing, more phlegm, thicker phlegm than usual)
B) What do when patient is feeling worse
C) What to do if infection (change in color/ volume of phlegm and with/without fever) is present along with part B
D) What do when patient is feeling better
A)
- they start using more short-acting bronchodilator (SABA) e.g. salbutamol 4-8 puffs (400-800 mcg), via MDI and spacer every 3-4 hours, titrated to response
B)
- 3-4 hourly SABA not relieving symptoms adequately
> Commence oral prednisolone 30-50mg daily for 5 days, then stop
C)
- Commence oral antibiotics (amoxicillin or doxycycline) for 5 days
D)
- Step down short-acting bronchodilator use
- Return to usual daily prescribed medicines
- Write or review and reinforce the use of the COPD Action Plan
What are the FOUR steps used in the pharmacotherapy of COPD?
Use a short-acting bronchodilator for short term relief of breathlessness (either a SABA or a SAMA)
For patients receiving a short-acting bronchodilator (SABA or SAMA) with persistent dyspnoea add a LABA# or LAMA* (or both if monotherapy is inadequate)
= Do not use LABA monotherapy if patients have an asthma-COPD overlap
* = If adding a LAMA the SAMA should be discontinued
- For patients with an FEV1 <50% predicted and ≥ 2 exacerbations in 12 months:
> Consider initiating an ICS + LABA/LAMA fixed dose combination
> For moderate to severe COPD with frequent exacerbations who are not receiving a LAMA consider adding a LAMA to ICS/LABA
> Balance risk of corticosteroids and risk of pneumonia
- For severe COPD (FEV1 <40% predicted), consider adding lowdose theophylline (100mg twice daily):
> Avoid long-term (>2 weeks) use of systemic corticosteroids
COPD symptoms
Characteristic symptoms are cough, sputum, and dyspnoea
Progressive with acute exacerbations
Persistent (not fully reversible: post-bronchodilator spirometry FEV1/FVC < 0.7) airflow limitations and gas-exchange abnormalities
- Smoking is the major risk factor and quitting smoking can have a major impact on disease progression
- SAMAs and LAMAs should not be used concurrently
What are the main treatment goals in COPD
Reduce symptoms
Improve exercise tolerance
Improve health related quality of life
Reduce frequency and severity of exacerbations & consequent decline in lung function
Slow disease progression
Long acting beta agonists (LABAs) –> 5 types
Formoterol (eformoterol)
Indacaterol
Salmeterol
Vilanterol (combination only)
Olodaterol (COPD only)
Dose for step 3
Dose for step 4?
Budesonide + formoterol (symbicort) 400 + 12 microgram formulation not suitable for use as reliever therapy
Use 200+6 microgram device for both maintenance and reliever therapy
