ASM Adverse Effects and Monitoring (L3)

if AEs are occurring at the time of peak [plasma], switch to ________ ________ product so the peak conc. will happen slowly/gradually

extended release

if AEs are occurring at the time of peak [plasma], dose the ASM ________________ so the peak conc. will happen slowly/gradually

more frequently

if AEs are occurring at the time of peak [plasma], administer with __________ for slower absorption

food

_________ (ASM) can cause impaired thinking, behavioral changes, and difficulties finding words

TPM (Topiramate)

in order to decrease the cognitive AEs, consider using newer ASMs like ______, _______, or _______

LTG, OXC, LAC (LOL for best outcomes)

idiosyncratic AEs are unpredictable, not dose related, and can be life threatening

they are usually uncommon, with the exception of ______ _______

skin rash

all ASMs (except for _________) are associated with serious idiosyncratic reactions (ex: skin rash, SJS, TEN, aplastic anemia, hepatotoxicity, DRESS, etc.)

LEV (Keppra)

delayed hypersensitivity reactions are associated with __________ _______ ASMs (i.e. all but VPA and LEV)

aromatic ring

delayed hypersensitivity reactions are associated with aromatic ring ASMs. this includes all except for _______ which has a direct toxic effect of metabolite (and except for LEV ofc)

VPA

which 4 ASMs (aromatic ring ASMs) can cause delayed hypersensitivity reactions

CBZ, LTG, OXC, PHT

is there cross-reactivity among the aromatic ring ASMs (CBZ, LTG, OXC, and PHT)

yes (40-60%)

causes of increased susceptibility: genetic variability in immune response

HLA-B* 1502 in _________ (race/ethnicity) patients associated with idiosyncratic reactions to CBZ

Asian

causes of increased susceptibility: genetic variability in immune response

HLA-B* 1502 in Asian patients associated with idiosyncratic reactions to ______

CBZ

recommendations for managing/preventing idiosyncratic reactions: screen for risk factors

aromatic ASMs (CBZ, LTG, OXC, PHT): past reaction to other aromatic ASMs, _______ descent (HLA-B* 1502)

Asian

recommendations for managing/preventing idiosyncratic reactions: screen for risk factors

LTG: children > adults, concurrent _______ (ASM) use, high starting dose, rapid titration, reaction to one of the aromatic ASMs, Asian descent, HLA-B* 1502

VPA

recommendations for managing/preventing idiosyncratic reactions: screen for risk factors

T or F: routine labs should be followed-up on for all patients

F (if baseline labs are normal, routine follow-up is usually not necessary unless specifically indicated)

recommendations for managing/preventing idiosyncratic reactions: screen for risk factors

T or F: all patients should have baseline labs (chemistry, LFT, CBC) prior to starting ASMs

T (if baseline labs are normal, routine follow-up is usually not necessary unless specifically indicated)

characteristics of the skin rash idiosyncratic reaction that is often seen in aromatic ASMs (CBZ, LTG, OXC, PHT)

onset: _________ (how soon/long after initiation)

most commonly a mild, maculopapular rash

__________ upon d/c of the ASM

1-3 weeks, reversible

management of the skin rash idiosyncratic reaction that is often seen in aromatic ASMs (CBZ, LTG, OXC, PHT)

stop ASM, administer antihistamines, re-examine w/in 24 hrs

if possible, delay starting new ASM for __________ and instead cover the patient’s treatment with BZDs

3-7 days (usually these reactions get worse before they get better; don’t want to start a new ASM and blame the worsening SEs on that new med)

which 2 ASMs can cause weight gain

CBZ, VPA (LEV is weight neutral :))

guidelines for ASM drug monitoring: primary outcome is ________ _________ NOT drug level

clinical response

guidelines for ASM drug monitoring: primary outcome is clinical response NOT drug level

use published therapeutic ranges as a ________, NOT as a rule

guide (target)

management of the skin rash idiosyncratic reaction that is often seen in aromatic ASMs (CBZ, LTG, OXC, PHT)

stop ASM, administer antihistamines, re-examine w/in 24 hrs

if possible, delay starting new ASM for 3-7 days and instead cover the patient’s treatment with _______________

BZDs (benzodiazepines)