Posttraumatic epilepsy and neurorehabilitation
Mark J. Ashley, David A. Hovda in Traumatic Brain Injury, 2017
It is likely that there are individual differences in response to, and tolerance of, any given antiepileptic drug. Therefore, additional medications should be tried in patients who have failed to respond to or who are unable to tolerate initial treatment. In all cases, the therapeutic plan should strive for a single antiepileptic drug regimen. Monotherapy has been shown to be more efficacious than polytherapy and minimizes toxicity, drug interactions, and cost.65 Patients who fail to respond to two or more AEDs used in appropriate doses are likely to remain resistant to pharmacotherapy. Other options, such as epilepsy surgery, should be considered in patients who are resistant to medication treatment. Surgical resections of epileptogenic zones in patients with TBI are often fraught with complications, including multifocality of epileptogenic foci, making localization difficult, as well as adhesions and scar tissue caused by previous injury or surgery.
Why Appropriate Antimicrobial Selection is Important: Focus on Outcomes
Robert C. Owens, Paul G. Ambrose, Charles H. Nightingale in Antibiotic Optimization, 2004
The ATS guideline notes that patients with mild-to-moderate disease presenting less than 5 days after hospitalization generally are infected with Haemophilus influenzae, Streptococcus pneumoniae, methicillin-susceptible S. aureus (MSSA), or other “core microorganisms” (i.e., antibiotic-susceptible bacteria). However, the presence of risk factors (e.g., recent abdominal surgery, diabetes mellitus, head trauma, history of high-dose corticosteroids) or local patterns of pathogen prevalence and antimicrobial susceptibility can alter the type of predominant infecting microorganism needing coverage. The duration of hospitalization prior to the onset of pneumonia is one of the most important determinants for potential infecting pathogens. The risk of infection with MRSA, P. aeruginosa, and Acinetobacter species is increased if nosocomial pneumonia presents after the patient has been hospitalized for more than 5 days (43). In patients with specific risk factors, prolonged hospitalization, or severe disease, combination antimicrobial therapy should initially target this broader spectrum of likely infecting bacteria. In addition, combination therapy is required in suspected infections due to P. aeruginosa to improve survival rates and reduce the development of antibiotic resistance (42). Monotherapy may be adequate in some cases of severe nonpseudomonal infection, but few studies have evaluated the efficacy of single agents in severe disease (44-48).
Antiepileptic Drugs Useful in the Treatment of Tonic-Clonic and Partial Seizures
Carl L. Faingold, Gerhard H. Fromm in Drugs for Control of Epilepsy:, 2019
It has been found that monotherapy is preferably in most patients.22-27 Nevertheless, rational polytherapy is indicated if monotherapy is unsuccessful.28-31 When it is necessary to administer two drugs, it is generally better to choose drugs with different mechanisms of action, but there are some exceptions to this principle as well. In agreement with the hypothesis that the staring spells which occur during some complex partial seizures resemble absence seizures in being due to paroxysmal activity in inhibitory pathways,1 it appears that the combination of carbamazepine or phenytoin with valproate, acetazolamide, or tricyclic antidepressants is particularly effective in patients with complex partial seizures refractory to monotherapy.32-36
Baseline characteristics and treatment pattern of type 2 diabetes patients in Jordan: analysis from the DISCOVER patient population
Published in Alexandria Journal of Medicine, 2020
Jihad A. Haddad, Muwafaq A. Al Hyari, Monther S. Al Momani, Ahmad A. Al Omari, Fawaz L. Ammari, Firas O. Annabi
More than half of the patients were initiated on monotherapy. Metformin alone or in combination with other oral antidiabetic agents were the most commonly prescribed therapies as a first-line treatment. Metformin alone was used as a first-line therapy in almost 50% of the patients and in combination with sulfonylurea in approximately one-third of the patients. The most commonly used second-line therapy was the combination of metformin and dipeptidyl peptidase-4 inhibitors (DPP-4i) with 29.9% followed by the triple therapy of metformin, sulfonylureas, and DPP-4i with 28% (Table 3). The most common reasons for changing first-line therapy were the lack of efficacy, weight gain, and physician preference. Efficacy, tolerability, weight, and hypoglycemia were the primary reasons reported for choosing the second-line therapy (Table 4).
An open-label randomized trial of intramuscular olanzapine versus oral clonidine for symptomatic treatment of opioid withdrawal in the emergency department*
Published in Clinical Toxicology, 2019
Lauren R. Klein, Jon B. Cole, Brian E. Driver, James R. Miner, JoAn R. Laes, Erik Fagerstrom, Marc L. Martel
The primary outcome in this study was the need for rescue medication, defined as the administration of additional medications to treat the patients’ symptoms during the encounter. While there are other outcomes that would have been reasonable to assess the patients’ symptomatic improvement, such as the COWS score [21] or the Clinical Institute Narcotic Assessment (CINA) score [22], we elected to use rescue medication administration, as many emergency providers may find this to be a practical, and clinically relevant outcome. Though there is value in knowing the difference in COWS score over time as a result of treatment, in the ED, there is an advantage to treating conditions with single doses of medication. Monotherapy should result in fewer side effects, and generally provides patients with the most rapid relief of the symptoms they came to the ED for (which may also improve patient satisfaction). Monotherapy may even result in a decreased length of stay since there are fewer interventions involved; though this study was not designed to detect differences in length of stay, the estimate for the olanzapine group was shorter for the clonidine group.
Selecting the appropriate pharmacotherapy for epilepsy in patients with Alzheimer’s disease
Published in Expert Opinion on Pharmacotherapy, 2018
Francesco Brigo
Starting an antiepileptic treatment is not always necessary or justified, particularly in case of acute symptomatic seizures (which by themselves do not entail a diagnosis of epilepsy due to low risk of seizure recurrence) or minor seizures with little impact on morbidity or low risk of falls and injures. In general, if an antiepileptic treatment is required to treat epilepsy in AD patients, a drug with following characteristics should be preferably selected [6,13,14]: 1. linear pharmacokinetics with scarce risk of accumulation; 2. elimination through renal excretion and lack of hepatic metabolism with consequent absent or negligible risk of drug interactions; 3. favorable tolerability profile with neutral or positive effects on memory and cognitive performance; 4. lack of negative effects on sleep architecture. Whenever possible, a monotherapy should be used to minimize the risk of drug interactions, and to improve tolerability and compliance [6]. The up-titration should be made slowly, starting with low dosages and employing the lowest effective dose to improve tolerability and avoid unwanted side effects.
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