Chapter 100

chapter 100

On April 10, 1999, respondent Brandi R. Fox underwent Roux-en-Y gastric bypass surgery and post-surgical treatment.[1] The operation was performed by Dr. Herbert Gladen. During the surgery, Fox was under general anesthesia and unconscious. Fox went home following the surgery, but returned soon after the surgery because she felt ill.

Fox's condition worsened, moving Dr. Gladen to perform exploratory surgery a few days after the gastric bypass operation. The exploratory surgery revealed a perforation at the stapled closure of the small intestine, which caused fluid to leak into Fox's abdominal cavity. Dr. Gladen

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665 attempted to seal the perforation. In his operative report for the exploratory surgery, Dr. Gladen failed to identify a cause for the perforation. Fox required additional medical care and remained hospitalized until March 4, 2000.

 

Question 1

I'd like to know the possibility of giving these drugs in epileptics:

vincamine (Oxicebral), cinnarizine, piribedil (Trivastal) and

pentoxyphylline (Trental). I'd like to know if they are contraindicated.

Question 102

If an epileptic patient, treated with oxcarbazepine, develops a rash,

should this drug be withdrawn or the dosage decreased and then

increased gradually again?

Question 3

Does a patient with refractory epilepsy benefit from acetazolamide?

Question 4

What anti-epileptic drug is recommended for a child with epilepsy and

co-morbid attention deficit hyperactivity disorder (ADHD)? Can Ritalin

safely be used for treatment?

Question 5

What is the difference in efficacy and pharmacokinetics between sodium

valproate and valproic acid?

Question 6

Is it safe to give valproic acid to infants below 12 months of age?

Question 7

How many times must the liver transaminases (SGOT and SGPT) rise to

justify a discontinuation of valproic acid therapy in children? Which of

these enzymes is more sensitive and reliable in this situation?

Question 8

1. Does valproic acid block the photosensitivity phenomenon in reflex

epilepsy?

2. Can a patient with this photosensitivity be safely exposed to computer

games or other photic stimuli when receiving valproic acid treatment?

3. Does the photosensitivity phenomenon occur in partial seizures?

Question 9

1. Can an epileptic fit be induced in idiopathic and symptomatic focal

epilepsy syndromes by flickering lights?

2. Is valproate effective against the photosensitive phenomenon (seizure

induction by flickering light)?

Question 10

How much time should one give before a loading dose of phenytoin is

judged to be ineffective in controlling seizures and an alternative should

be instituted?"

1. Drugs in Epileptics:

 Vincamine (Oxicebral): Altogether, vincamine can be regarded as relatively safe for use in epilepsy patients but specific safety characteristics in epileptic patients are not well determined. There is no known contraindication for epilepsy in the use of the drug.

 

 Cinnarizine: This drug belongs to the calcium channel blocker group of drugs which is mainly indicated for the treatment of vertigo. It may also reduce the threshold for seizures and therefore should be used carefully or even not at all in patients with epilepsy.

 

 Piribedil (Trivastal): Piribedil is an agonist of dopamine receptor and is employed in the treatment of Parkinson’s disease. Its effect on epilepsy is not well documented but it is not usually contraindicated, but should be used with caution.

 

 Pentoxyphylline (Trental): Pentoxyphylline which is commonly used in peripheral vascular disease has no specific contra indication in epilepsy. But its use should be cautious because of the side effects on the central nervous system.

 

 2. Oxcarbazepine and Rash:

 Oxcarbazepine should not be dose reduced for rash but stopped altogether if a patient receiving the drug experiences a rash. Serious skin reactions have been seen with Oxcarbazepine and, hence, discontinuation is recommended to avoid severe side effects.

 

 3. Acetazolamide in Refractory Epilepsy:

 Acetazolamide is a carbonic anhydrase inhibitor and is sometimes used in the management of specific types of refractory epilepsy, mainly absence epilepsy. Its efficacy is not fixed and it is often administered together with other anti-epileptic drugs.

 

 4. Anti-Epileptic Drug for ADHD and Epilepsy:Anti-Epileptic Drug for ADHD and Epilepsy:

 Recommended Drug: For child with epilepsy and ADHD, levetiracetam or lamotrigine is usually recommended because they have less side effects.

 Ritalin (Methylphenidate): Nevertheless, Ritalin can be prescribed for ADHD in children with epilepsy, but this should be done with caution because of possible interactions. Close monitoring is required.

 5. Sodium Valproate vs. Valproic Acid:Sodium Valproate vs. Valproic Acid:

 Efficacy: Sodium valproate and valproic acid are as effective as they are different forms of the same drug. Sodium valproate is a prodrug which is metabolised into valproic acid in the body.

 Pharmacokinetics: Na valproate is absorbed at a slow rate and the dosing can be easier than the rapid release forms of VPA.

 6. Valproic Acid in Infants:

 Valproic acid may be administered to infants less than one year old, though with a certain degree of precaution. It should be used with caution because of adverse effects such as hepatotoxicity and teratogenicity.

 

 7. Liver Transaminases and Valproic Acid:Liver Transaminases and Valproic Acid:

 Transaminase Levels: More than three times elevation of liver transaminases (AST and ALT) should lead to discontinuation of valproic acid administration. A level of 2 to 3 times the upper limit of normal is often used.

 More Sensitive Enzyme: SGPT (ALT) is thought to be more sensitive and specific in the diagnosis of liver disease than SGOT.

 8. Photosensitivity and Valproic Acid:

 Blockage of Photosensitivity: Valproic acid has no selective impact on photosensitivity of reflex epilepsy.

 Exposure to Photic Stimuli: Valproic acid patients may undergo exposure to controlled photic stimuli; nonetheless, patient should be observed for side effects.

 Photosensitivity in Partial Seizures: Photosensitivity is rare in partial seizures but is increasingly seen in patients with generalised seizures.

 9. Seizure Induction by Flickering Lights:Seizure Induction by Flickering Lights:

 Flickering Lights and Epilepsy: Photic stimulation causes seizures in patients with idiopathic and symptomatic focal epilepsy syndromes.

 Valproate’s Effectiveness: Valproate is usually helpful in the management of seizures elicited by flashing lights and photosensitivity.

 10. Phenytoin Loading Dose Effectiveness:

 A loading dose of phenytoin should be assay within the first one day. If the seizures are not well controlled by this time then a different treatment should be considered.