Choosing an Antiseizure Medication

Join me as I discuss the thought process that goes in to choosing an anti-seizure medication with epileptologist Dr. Rohit Marawar! He gives us some excellent advice in particular regarding anti-seizure medication in the older population. 

You can find Dr. Marawar online here:
Twitter: https://twitter.com/rohitmarawar
https://neurology.med.wayne.edu/profile/gg8831

Find me on Twitter @DrKentris or send me an email at theneurotransmitterspodcast@gmail.com

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The views expressed do not necessarily represent those of any associated organizations. The information in this podcast is for educational and informational purposes only and does not represent specific medical/health advice. Please consult with an appropriate health care professional for any medical/health advice.

Transcript

Dr. Michael Kentris [00:00:00]:

Hi, everybody. This is Doctor Michael Kentris with the neurotransmitters. And today, I'm fortunate to be joined by Rohit Marawar. Today, we're gonna be talking a little bit about, selection of anti seizure medications. So Dr Marawar from Wayne State, where you work in the epilepsy division. So just give us a little bit about your background there and what sorts of projects you're working on and so forth.

Dr. Rohit Marawar [00:00:27]:

Yeah. Thank you. Well, fantastic to be here and excited to talk about approach to anesthesia medications. so as you mentioned, I work at Wayne State University, Detroit Medical center in Detroit, Michigan for the past 6 years, mostly in the epilepsy division, but it's a typical academic position with the teaching research admin, as you imagine, in in addition to the clinical work. And, My specific interest is in epilepsy in the elderly and at the intersection of epilepsy and dementia. So some of the things that I do are a multi specialty epilepsy in older adult clinic. for the past 3 years with the services of a, pharmacist or a pharmacy resident, I should say. and that's been going well. And, I am doing few clinical trials in elderly, also some prospective observational studies, obviously, or I'll tell you with epilepsy.

Dr. Michael Kentris [00:01:29]:

Well, yeah, that's always, something that I think at least from the patient side, a lot of questions we get, at least from my own perspective, is that, you know, I'm I'm an older adult why am I developing a seizure at this stage in life? And that's that's I we can kinda come around back to that at the end, but I think that's, A very probably a very common question in your clinic in particular. Yes. But every epileptologist, at least in my experience, kinda, has their own let's say pet medications, their own kind of process that they tend to approach. And there's some similarities, but, Why don't you just walk us through kind of like how how your approach is to selecting someone with maybe a new diagnosis of epilepsy, and what may you would normally kind of lean towards and how you counsel these patients?

Dr. Rohit Marawar [00:02:17]:

Sure. So I think, maybe let's talk about from the perspective of, you know, someone who is new to epilepsy, like someone has a, like, a resident who is still getting used to figuring out which anesthesia medications to start. so as you said, I think for us to be able to figure out if someone has a diagnosis of epilepsy. And as we know that that has specific requirements, so to unprovoked seizures in the last 24 hours, not last, sorry. Let me cancel that. 2 unprovoked seizures, 24 hours apart. at least. Right. And then our 1 unproced seizure and the risk of a second unproced seizure being greater than 60% based on history and testing or a typical electroclinical epilepsy syndrome. So I think once you have established that this is epilepsy, and we want to start them on a anti seizure medication. And we're talking about adults here, not pediatric, because pediatric will have a different thought process and different approach. so in adult patients, so first, I think we need to figure out what kind of epilepsy is it? And, and, you know, the based on the, most recent nomenclature, only 4 types of epilepsy, which I love because it's simple. You know, either it's vocal, generalized are focal plus generalized or unknown, which is my favorite category because it's -- Right.

Dr. Michael Kentris [00:03:47]:

It's the most common one, usually

Dr. Rohit Marawar [00:03:49]:

put put put patient into unknown, sometimes because you don't know what's going on. but, I think if it's a focal epilepsy, anything except ethoseximide goes. Right? Ethosaximod is one of that, one of those medications, which is narrow spectrum, but only used in generalized epilepsy. So if it's a focal antiseizure medication, anything except ethosaximide goes, then out of the 3 other categories, is it generalized focal plus generalized or unknown, then you want to use a broad spectrum medication. So in in the broad spectrum medication means no narrow spectrum medication. So you throw out everything. You throw out your dalliantine, you throw out your carbamazepine, carbazepine, and, its derivatives like, aptium. So no no of those can be just then have prospector medications. So that's kind of one way of thinking about it, kind of, you can go about this as a ruling in or ruling out. you are this is kind of a way of ruling out. Okay. I don't want to use those medications.

Dr. Michael Kentris [00:05:03]:

Right.

Dr. Rohit Marawar [00:05:04]:

The next thing is then I personally tend to throw away all the old medications. I'm not gonna use them. So, Taliantin, phenobarbital, carbamazepine, valproid. I don't want to use them going forward because of their long term side effects, interaction with other medications. if they are obviously coming to me with, these medications on board and doing well, then, you know, I tend to continue them, but don't start time, and that would be my request and suggestion to everyone who's listening to this.

Dr. Michael Kentris [00:05:45]:

Well, it's always interesting to me when you get, a patient, you know, we're and from the maybe, you know, primary care doc kind of maybe a little more in the rural because both of us work in the Midwest. So there's, you know, certain areas of the country where there's a very much, you know, a lack of neurologists and you'll get, family doctor who maybe a little, you know, long in the tooth. And, they start someone on on Fenny Toan, Dilanton, And so whenever I see someone under the age of, like, sixty years old, who's on Dilantin, I'm like, how the heck did that happen? Yeah. but, but, yeah, there there definitely is some some questionable choice out there,

Dr. Rohit Marawar [00:06:27]:

in the wild, if you will. Yeah. Well, think the worst combination is finite time plus fun, phenobarbital. And I've seen a young, yeah, you know, people in their twenties on that. Yeah. and that's, and that's never good long term. I mean, these are great seizure controlling medication, good efficacy. Right. But, not good from a, safety or, tolerability standpoint.

Dr. Michael Kentris [00:06:52]:

And we are kind of blessed. I do. I know I'm veering off topic, but that's kind of Unfortunately, how I go cycling. But I I had we had an emergency medicine resident who was on rotation in, Haiti not too long ago, just, this last year. And he had a young, a, like, an eight, nine year old girl. And You know, as as you might one of the first questions you ask in some of, some foreign countries is what what anti seizure do you have available? And it was exactly those 2. It was Fenny Tom and Fino Barbitol. Yep. And he's like, even those have to be flown up from the Capitol. Oh, wow. I was just like, oh, that's that's a rough situation. Yeah. That's awesome. Yeah. Unfortunately, we're a little more blessed in the most parts of the United States to have more options that hopefully won't have those long term. -- I think we are definitely -- -- potential side effects. Yeah. Yeah. Definitely blessed. I think we need to be better at using that blessing.

Dr. Rohit Marawar [00:07:47]:

So maybe that's a bit of push. Well said. Well said. So, okay, I think we've talked about some of the, some of the process here. So moving on, then I think you have to think of the comorbidities that the patient has. So I kind of think of it as a positive sum or a negative sum. So a positive sum means you are going to have some kind of benefit if you choose that particular anti seizure medication. So, for example, if you're aiming for weight loss, in some patients or some patients might like to have weight loss than topiramate and sunisamide are good options. If a patient has migraines or other chronic headaches, then, topiramate or gabapentin might be good options. if someone has neuropathy, that you want to treat anyways, then gabapentin, pregabalin, even lamotrigine, oxcarbazepine, and vampire, or lcosamitis can be considered second choice, medications for neuropathy. If you're looking for mood stabilization, lamotrigine is again a good option. for many of these, even Depakote is a good option. Right? So for headache, for mood stabilization, but again, as I said, if if avoid Depakote. I think, that would be great, especially in young females. then you have to think about what potential side effects, this particular medication might have in this particular patient and then try to avoid So, for example, if you want to avoid weight gain, then don't start them on gabapentin or pregabalin. if you want to avoid weight loss, which can happen. A lot of older patients that I see, they all already have poor appetite, especially if they have dementia. you don't start them on topiramate or zenixamide. If you if you're already, worried about cognitive impairment, as in some of the patients that I see, I, again, avoid doctor Ahmed and Sonisamide because they can have cognitive, negative cognitive, side effects, especially word finding difficulties. If, if patient has established anxiety, depression, has agitation, it ability, short-temperedness, then avoid, CAPRA and avoid peramplifycompa. if, someone is a young female by, definitely, please avoid depakote, oral proic acid, because if they get pregnant, there are a lot of pregnancy related side effects, for the young ones on that. And if you can avoid topomax, I think that would be great too because I think after after a difficult topomax is probably the, medication that is most likely to have congenital, side effects. Yeah. So that's another kind of level of thinking. then I think this is coming to the next level, which is, I think, kind of the practical act practicality of prescribing of medication. So I think you have to think about the ease of use for the patient. use ease of acquiring the medication, whether that's cost related or insurance related, and then you have to think about adherence. So so, for example, brand name medications and the current brand name medications we have are Briviact, FICOMPA, Xcopre, Aptum, so these are probably 4 commonly used brand new medications right now, and these are great medications. And, but sometimes what happens is that they might not be covered by insurance, or there might be a high co pay. So do you want to go through that process and that's a question you have to ask yourself. And you also have to think about if the patient runs into a problem getting the medication, will they get back to you? because a lot of the patients that I see, they might not tell me that they had problem getting these medications. And, you know, you find out 3 months later that never started this medication. As they continue having uncontrolled seizures the entire time. Exactly. Yeah. Not not ideal. Yeah. Night eye. Not ideal. So, at least in my practice, I try to avoid brand name medications. There's absolutely nothing wrong with this brand name, but I think I've just learned from my mistakes that, that these scenarios happen. then you have to think about, once daily medications, which might be better for adherence, especially in people with cognitive impairment or people who are just busy and, you know, don't like medications twice a day. So then once daily medications would be CAPRA extended release, Lamotrigine extended release, Tokamax extended release, which is Trokendi. Mhmm. you have Oxtellar, which is oxcarbazvin, extended release, peramplandandaptium. So these are your kind of extended release once a day medication. you have to think about, medication interactions. If this is a patient who you want to, who is already on some medications and your radical 2nd medication or 3rd medication because we know there is interaction between Lamictal and Depakote. So Depakote will increase a limit to levels. so you have to keep that in mind. you have to, lot on fee and expropri have a lot of, side effects together. So, especially her drowsiness and sedation, abbreviate can

Dr. Michael Kentris [00:13:15]:

Yeah. Yeah. The epidiolex as well. The epidiolex as well. Yeah. Yeah.

Dr. Rohit Marawar [00:13:20]:

Exactly. With on fee. Yeah. So these medication interactions within the in, anti seizure medication world, you have to keep in mind. Plus, obviously, you have to keep in mind the other medications that the patient is stating non neurology. such as warfarin, maybe some chemotherapy agents. so these, again, are ripe for, medication interaction.

Dr. Michael Kentris [00:13:42]:

even really common things like statins, you know, especially with those older or patically metabolized ones. You know? I remember that's one of the classic, epilepsy board questions is, someone with refractory draw, what medication they are. I think that was carbamazepine. Yes. carbamazepine. Correct.

Dr. Rohit Marawar [00:14:01]:

Yeah. Yeah. And, yeah, I was going to bring it up in the question of the older older patient. Oh, no. That's fine. But that's that's a really good point because that has been shown now, like, these older medications, which which decrease the efficacy of statins by interacting against them. Right. They increase the risk of stroke. so, you know, it's yeah, again, good to avoid these older medications.

Dr. Michael Kentris [00:14:25]:

Yeah. Yeah.

Dr. Rohit Marawar [00:14:26]:

So I think that was a -- Yeah.

Dr. Michael Kentris [00:14:30]:

Yeah. It's it's right. So it's like what what should should we put everybody on load to Racetown? Right? There's no, no interaction with Kepra.

Dr. Rohit Marawar [00:14:41]:

Maybe we we can take a dig at our neurosurgeon colleagues and say that that is always the right answer.

Dr. Michael Kentris [00:14:47]:

It's It's rarely the wrong answer. I'll give him that.

Dr. Rohit Marawar [00:14:52]:

well, I think, A scenario that I have seen not infrequently is patients with TBI, especially for interlock TBI, that gets started on

Dr. Michael Kentris [00:15:03]:

It might be the wrong answer to that. Yeah. And then

Dr. Rohit Marawar [00:15:06]:

they come in, and they're all angry at you, and you are, like, wondering why are they angry at me? I didn't do anything. is my first time seeing you.

Dr. Michael Kentris [00:15:16]:

But, yeah, you know, I always I was when I because I have a lot of, we don't have neurology residents where I work, so I have internal medicine, emergency medicine, sometimes family. And You know, I just have to tell him, like, you know, love teracetam. That does have, you know, about, like, about a 10% incidence of neuropsychiatric side effects. Yeah. And those can be really bad sometimes all the way up to, like, Frank psychosis. So it can be it can be very debilitating. And if there's a history of a preexisting mood disorder or maybe TBI, traumatic brain injury. that could even be as high as 20% depending on what literacy you look at. So it's it's not inconsequential, but it is frequently overlooked.

Dr. Rohit Marawar [00:15:56]:

Yeah. And and I'm sure anyone who has been practicing epilepsy for a while, they would probably have, you know, at least a few patients who you know, whose personality completely changed or got better once they were taken off Capra.

Dr. Michael Kentris [00:16:12]:

Yes. Yes. That that has happened a few times. I'm curious what your thought is. I've tried this a few times based off of some of the, pediatric literature where you do, like, a low dose of vitamin B6. I've never had it worked successfully in an adult patient. I've tried it numerous times when I'm trying to, like, cross cross titrate and maybe it'll help ameliorate some of the side effects in the interim. Yeah. Oftentimes to no avail, unfortunately.

Dr. Rohit Marawar [00:16:38]:

Yeah. I I have tried that also. I tried it in adults. the problem is we don't know what the dose should be in adults. so I tried fairly high doses, checked their B6 levels that were, you know, above reference range, but my as has with you, my, experience was not consistent.

Dr. Michael Kentris [00:17:00]:

Mhmm. And then I always worry when I gotta give this person a B 6 neuropathy. Exactly. Trying to Yeah. It's like the best things usually is to get them off the medication to something else, hopefully. Right. But, but, yeah, so So kind of let's let's move a little bit. Like, kind of, you know, we've got someone maybe in the more geriatric population since that's kind of your your area of particular expertise, how do you go about I know, obviously, these same general principles are going to apply, but But how does your medication selection differ from someone who might be seeing just a more general adult population?

Dr. Rohit Marawar [00:17:39]:

I think, you have to keep in mind what is different, in the older adults as compared to younger adults. So So, you know, there are a few things. So first of all, their process of absorption and elimination is different. So they have less gastric option. They have, a decrease in serum albumin, which leads to decreased distribution. They have less, biotransformation in the liver, and they have less renal elimination. So, you know, the total combined effect of these changes. This physiologic age related changes is that they need lower levels of medications. So, you cannot just translate whatever you give in younger adults or whatever your first, target doses and just translate that directly to adults. You have to be a little bit mindful that they might not need that high of a dose and they're also more susceptible to side effects. That's a good point. So, the the problem with, or or I shouldn't say problem, but I think the the the difficulty in treating older adults is that you have you're kind of stuck between the rock and the hard place with many of these patients because even if we don't treat them, obviously, they'll have seizures. They'll have falls, and it's not safe. but even starting them on medications will lead to false between the side effects. So you have to be really careful about, how you manage them. But having said that, you know, regarding what, I should I I do or not do, again, avoid older medications, you know, like, you know, if it's if it's, dangerous in younger adults, it's even more so in older adults. especially with their polypharmacy, with the intramedication interactions, and the burden of side effects are going to have by being on so many medications. There are some specific examples that I would like to give for older adults. One is, hyponatremia with carbamazepine and oxcarbazepine. It's more common in older adults, especially if they're on diuretics, which many of our older adults are. hypertension. so the rate of hyponetrium is very high with ox specifically with oxcarbazabine. and then as we mentioned earlier, the enzyme induces, dilantin carbamazepine, oxcarbazepine, phenobarbital, they can in they can decrease the efficacy of, statins by increasing their metabolism, which means that they will you will have a hyperlipidemia or hypercholesterolemia because the statins are not not working as effectively, which means there will be increased risk of which has been proven by a study. So these are some specific examples that you have to keep in mind. And then, you know, many of these enzyme end users, they also increase metabolism of cardi cardiac anti rhythmic agents, antidepressants, anticoagulants, neuroleptics, So, again, you know, stay away from them if you can. Yeah. And some of those sodium channel drugs are in themselves antiarrhythmics

Dr. Michael Kentris [00:20:55]:

like pheneto and -- Oh, yeah. -- which, you know, Just an extra wrinkle to throw into the mix there. Absolutely.

Dr. Rohit Marawar [00:21:03]:

so so some basic principles avoid these older medications. And then when you start a medication, start low dose, go up slowly, and usually they will get efficacy given at a low dose. So for example, and, you know, when I started doing this, I was surprised that more in lev for Lamictal, most of the patients, they respond to a dose of, 100 milligrams daily or 50 milligrams twice a day. for Depakot, they respond sometimes at 500 milligrams or 750 milligrams daily, which is a much lower than what you would expect for a younger adult. The data for which medication to use in older adults is I would say somewhat limited. So there are a handful of trials between around 5th between 15 20 trials that were specific to older adults, and these are clinical trials that were randomized. and most of these clinical trials, they compared newer medications, and these were either VIMPA, CAPRA, or Lamictal to one of the older medications. and the most common older medication was carbamazepine or tachycardia. so, but, you know, the if you combine all of this together. So there were 2, systematic reviews and meta analysis that were published in epilepsy in 2019 which is kind of what I use for my guidance of, medication management. So the first one which was systematic review and meta analysis of all the clinical trials of elderly. they found that for seizure freedom, which was the one of the main endpoints, CAPRA was better than Lamictal, which was equal to tegretol. So Keppra was in essentially better than Lamictal and tegritol, which were the other 2 most commonly tested medications. As far as adverse effects, limictal was the best. So -- Right. -- if you based on this data, on these limited number of medications, you would say is probably the best followed by Lamictal followed by carbamazepine, but Kappa and Lamictal might be pretty close. Yeah. Then the second, systematic review, which was for just monotherapy, the previous systematic review for for for all monotherapy and add on therapy. For the monotherapy, which are 5 clinical trials, the overall efficacy was the same for Wimpat. sorry. Let me cancel that. Overall, the efficacy was better for Wimpat, than Lamictal. and then Keppra. And and carbamazepine was the worst for the side effects. So -- Interesting. It this was This was based on a network meta analysis. So it's not a real, you know, it's like comparing if you have a clinical trial that has a versus B and then, in other words, B versus C, then how do you compare A versus C? And that's by doing this network meta analysis. So it's based on those kind of analysis. But anyways, I think we can concur probably based on the results of these various, clinical trials and also these 2 systematic reviews is that the impact limit landscape are probably your best bet at this point. A bear in mind that we do not have data for or comparative data, I should say, for all the, newest medications.

Dr. Michael Kentris [00:24:27]:

Right. Right.

Dr. Rohit Marawar [00:24:29]:

So so at this point, I think at least my clinical practices, you know, capra Wimpat Lamictal, which makes it easy. but, you know, and now, Wimpat is a generic makes it really easy to prescribe. Previously, I used to have some issues with insurance and copay. but now it's, it easy. So I would probably say impact is probably my number one choice at this point, followed by Capra, and then let

Dr. Michael Kentris [00:24:57]:

I always find that interesting. I I maybe maybe I'm just using 2 higher doses. I tend to find, that Vimpat lives a little more sedating, in some people as opposed to, like, you know, Lamotrigine or, liveracetam. But, just you know, anecdotally, if you will. Right. Right.

Dr. Rohit Marawar [00:25:18]:

Sometimes it's also, I think, a matter of the, how you are increasing the medication, the rapidity of increasing the medication. I, I mean, unless, you know, patients are having frequency, I tend to do very slowly, especially in older patients. You know, I increase, like, in, like, 1 month. I, you know, so -- Okay. It's like almost twice twice as longer, longer than, compared to the usual schedules. Yeah. And and as we discussed, you know, you don't need a need to get to a very high dose in these patients in older adults. So you can afford to start slowly and increase slowly. And I think that probably will give you the best tolerability. And if patients are tolerating it, they are less likely to stop it without informing you, which is another issue that people run into. -- Right. -- stopping and not informing the physicians.

Dr. Michael Kentris [00:26:06]:

Do you have any issues with Locos Mine? I know that, you know, some some patients regard the pharmacy and they find out that, the Vimpass is scheduled medication. And they're like, oh, I don't wanna take this. You know, it's dangerous. is that anything that's, you know, again, just because you're dealing with maybe a little bit of an older generation, that might be a little different, perception on that aspect. Is that tied into your medication compliance in your population?

Dr. Rohit Marawar [00:26:34]:

not really. I don't think I've had that particular problem with the impact here. I've had the issue where it's not covered by insurance or it's expensive or something like that. Right. Right.

Dr. Michael Kentris [00:26:43]:

accelerating. Yeah. Well, that's cool. And Lycosmide doesn't have as much protein binding. That does make sense that it would work well in that population. I just always kind of, I I guess I was too gun shy, you know, pulling away from it just because of it's, you know, sodium channels, and I always try and stay away from some of the some of those. Yeah. Yeah. I I think if you go to a high dose, I'm sure, you know, you'll have of dizziness and loss of balance and develop. Yeah. Right. But I think at a low dose, it's tolerated pretty well. Awesome. That's cool. yeah, I'll have to keep that in mind going forward, on those particular patients. Now another aspect, you know, because I know, you know, when we're looking at the ideology for developing epilepsy in in an older population, we're seeing probably more neurodegenerative dementia type diagnosis coming kind of hand in glove with that. in patients with with behavioral issues, like, you know, delusions, hallucinations, etcetera, do you find that sometimes you are going back to those older medications like pro eight, or do sometimes are you able to as lamotrigine as effective in your experience for some of those behavioral issues?

Dr. Rohit Marawar [00:27:56]:

not so much Lamotrigine, but I've had anecdotally, I've had, good experiences with Depakote. and Gabapentin, for, if someone that has having behavioral issues and also have seizures, Dawn, then, you know, I've tried this, not as first line. I've tried to, you know, try to control the seizures with the usual anesthesia medications, which I think is best overall. But if they continue to have behavioral side effects, then I've, you know, you know, in a handful of patients I've used, depakot or gabapentin, And I would say the results have been, you know, fairly good. but if you look at the actual data, then, you'll find that the the data suggests that they are, you know, they're not effective, but that, personally, that has not been my experience. Yeah.

Dr. Michael Kentris [00:28:44]:

Yeah. And it's like, you know, you look at the general adult data for something like gabapentin. It's it's atrocious for CJ control. But there are, like you said, there are some studies that that show that in in elderly patients, it might even be a potentially 1st line medication for for epilepsy? Yeah. I will actually, if you look at the,

Dr. Rohit Marawar [00:29:04]:

guidelines, gabapentin and Lamictal are supposed to be the best for epilepsy in older adults, which I, you know, kind of disagree with. I don't think Gabapentin is the best. Yeah. But in in in a particular subset where you're trying to deal with behavioral issues, I think gabapentin might be a good, you know, good tool to have -- Mhmm. -- in your arsenal. Gotcha. Do you ever find, like, you know, your standard release versus, like, the gabapentin,

Dr. Michael Kentris [00:29:30]:

I can never say it, right, and a carbell. like, the long acting Gabapentin. And is it I'm not too stupid to be I'm I'm not pretty interested, so I I can't say. because I think that one's still pretty expensive. So that might that might be a reason not to. Yeah. But, yeah. Is it is it mostly like you're kinda using it tonight for, like, sundowning or, like, nighttime agitation or, just kind of standard, like, three times a day, are you saying? Yeah. So, yeah, depending on the

Dr. Rohit Marawar [00:29:55]:

requirement for the patient as as for sundowning, sometimes PRN, sometimes standing, in a patient, that I have with the lower body dementia and epilepsy, I use it as, like, stand, standing twice a day because he would have a lot of anxiety and also hallucinations, you know, throughout and that has helped even though it's not technically anti psychotic. At least it has helped him deal better with the anxiety related to the hallucination.

Dr. Michael Kentris [00:30:24]:

Nice. Yeah. That's a nice little trick. I'll I'll keep that one in mind. Yeah. Be mindful of my opponents. Oh, yeah. Right. So I I'm covering mostly inpatient neurology consults, the last year or so. And, Most seizures. I'm using air quotes here for our listeners, or, confusion, things like that. It's someone who's, like, gone into, like, an acute kidney injury type situation and that no one changed to their pregabalin or gabapentin doses. And it's like, the patient was fine, mental, mental alertness wise when they came in, and then over 3 days, they just kept getting worse and worse. And gosh, what's going on? Yeah. This guy, yeah, I don't know. But but, yes, now the the myoclonus thing is is a very, it's a very overlooked by a lot of people outside of neurology.

Dr. Rohit Marawar [00:31:21]:

Yes.

Dr. Michael Kentris [00:31:22]:

but, yeah, it could be, you know, like you said earlier, falls very, very problematic, in those situations and the mental status continues to deteriorate as long as that means you're like, is there dementia getting worse, or am I doing this with my medication and so on? Yeah. Absolutely. I think I think I am so biased,

Dr. Rohit Marawar [00:31:39]:

towards myoclonal cost by Gabapentin and pregabalin. Now that every time I'm on inpatient service, and I hear my diplomas. I look at their medication list first. I was like, the medication list and the renal function. Yeah.

Dr. Michael Kentris [00:31:53]:

Yeah. There's a lot of things that cause my opponents that, that I think people forget about. And, you know, it was a different conversation, but a don't know what my opponents or asterixes for that matter, looks like. And, yeah, that's, if you don't know what you're looking at, you're not gonna necessarily diagnose it correctly. Right? That's true. That's true. But it's it's always,

Dr. Rohit Marawar [00:32:17]:

it's a great, thing to, you know, to come up with in front of residence. They're always impressed. because then we just stop the pregabalin and grab a pen in the mindfulness course away. So it's, you know, for all those new attendings out there, this is a nice tool to impress your residents.

Dr. Michael Kentris [00:32:34]:

Absolutely. And, any any final thoughts in terms of, seizure medication selection, big do's don'ts that you haven't already hit on?

Dr. Rohit Marawar [00:32:46]:

Let me think. Let's cover the everything. Right? What what do you think? Did I miss something? Let's say let's say you've you've reached for,

Dr. Michael Kentris [00:32:56]:

you know, like, you know, Lycosamide. You've at what dose would you push, let's say, someone with, let's say, mild cognitive impairments or versus early Alzheimer's dementia? How hard would you push that in in an elderly patient in terms of, like, maybe dose increases? before you'd say this isn't working, and I think I'm pushing the risk for for increasing falls and so forth.

Dr. Rohit Marawar [00:33:25]:

Yeah. I think, Well, first of all, I think for Alzheimer's disease, if you suspect someone has Alzheimer's disease, Capra is probably the best medication as long as they are not having baseline agitation because -- Mhmm. -- we have some animal and now some human evidence also that Kepra can help with cognition, especially executive functioning and, visual spatial memory. So, I think that has been, proven in a randomized trial. So that in Alzheimer's disease, at least that's my first go to medication. Okay. As far as pushing the doors, yeah, it's always tricky. I think, I would, you know, I would if in an adult, I would give up at 2000 milligrams twice a day of Capra. In a older adult, I would probably give up at, you know, 1500 twice a day or even even before that. but again, I tend to increase it slowly. So for example, if someone, if you're seeing a younger adult at a 1000 milligrams twice a day capra, and you want to increase the dose, you would usually go to 1500 twice a day, right, if they're still having seizures. In a older adult, I would go to a 1500 rather than 1500 twice a day. So, again, you know, increase the dose slowly rather than don't just, copy based what you do with the underwriters.

Dr. Michael Kentris [00:34:49]:

Right. I do think that that is something we see a lot is And, you know, obviously, this this various significantly by situation, you know, how much benefit did you get from your first medication? And I know people talk about substitution versus add on therapy when we talk about, you know, our second seizure medication. Do you find that even if, let's say, someone had, you know, modest benefits from the 1st seizure medication, are you more likely to lean towards substitution versus add on just because of a polypharmacy aspect in in a more elderly population or is it really just individually dependent?

Dr. Rohit Marawar [00:35:29]:

I think it's individually dependent, depending on their comfort level, how much support I think they have at home. you know, in, like, in a nursing home setting, I might be, I might do substitution because you can you know, hopefully, depend on the nursing home, nurses too. -- optimistic

Dr. Michael Kentris [00:35:49]:

than I am, but

Dr. Rohit Marawar [00:35:52]:

that, the appropriate medication changes will be made, and if if if there is someone that I I I feel like, you know, it might be too confusing, winning of 1 -- Right. -- and increasing the other, then I might, you know, do do therapy, and then, if possible, win them off, one of the medications.

Dr. Michael Kentris [00:36:12]:

Makes sense. Well, I thank you so much for giving us these tips and tricks as as, you know, a lot of us in neurology know, we kind of we do see this big upswing as we get towards, later life with epilepsy. And, yeah, it's not copy paste, like you said. You know, we need to keep the pharmacodynamics and the, physiology of the patient in mind. And those are always good things to keep in mind, especially if we're used to more like early adults or middle aged adults, in our practice to make sure we're not over medicating our patients to a large extent.

Dr. Rohit Marawar [00:36:49]:

Absolutely.

Dr. Michael Kentris [00:36:51]:

Last question that just just came to mind, how often do you get folks who are coming in who are maybe already treated for epilepsy. And you're like, this patient is way over medicated, and you're just pulling, you know, like your magician pulling scarves out of it. You're just taking the medications off one after the other, over a period of weeks or months, because you think, like, this patients barely awake. They're just sitting here, and I think it's because of their medication regimen.

Dr. Rohit Marawar [00:37:22]:

I mean, fortunately, hasn't happened a lot in my practice in older patients. but once in a while, yes, you will see someone who is on, you know, sub maximal doses of 4 different antidepressants. Yeah. you know, this usually happens, in my experience, at least, when patients are in a nursing home, And I don't know why why it happens in that scenario. rather than patients who are independent, I don't see it as often, but, yeah, you will see 3 different medications. That's a max doses. So I try to I try to kind of simplify that. but it's always tricky. I think if anyone who has seen patients from nursing home, you always know that It's very difficult to know if they are having still having seizures or not or what's going on unless unless they are very dramatic generalized tonic chronic seizure. Sometimes it's very difficult to know.

Dr. Michael Kentris [00:38:11]:

Yeah. That is that is an excellent point. Yeah. It's not, that old Maxim, right, not everything that shakes as a seizure. But, yeah, it's it's definitely challenging when you don't have that accurate, story to get your management. Well, thank you so much. I really appreciate you taking the time to to talk with me, talk with us, and kind of give us some of these, tips and tricks that, that you've been using in this patient population. Now you also have some projects of your own. I know we, we met on Twitter -- via some mutual connections. And, I usually am quite enjoying what you're posting on there, but, do you have any projects you wanna plug for people who might be listening in, where they can find you and so forth?

Dr. Rohit Marawar [00:38:54]:

Well, you can definitely find me on Twitter. I'm trying to be active, trying to know, talk about things that we are usually not taught in, in academia. so, you know, if you are interested, follow me there, My, Twitter handle is at Rohitmarva. So that's my first name and last name. but, yeah, I think, I think I'm trying to, do something which I wish I had when I was a resident or a early career faculty. So I'm hoping that the other people are finding is for what I've been posting.

Dr. Michael Kentris [00:39:30]:

Awesome. Yeah. I know. I've, I've been finding it, say, somewhat inspirational. And, like you said, it's one of those things where I think the best thing I got for some of my attention, like, you need to know about medicine now. that you can learn about medicine when you graduate, like, what? In hindsight, that might be a little too late, but, At least they're leaning in the right direction, but now it's it's good. We're seeing a lot more, especially with social media and people like yourself, kind of trying to make sure that people are able to kind of strive for that work life balance and, you know, hopefully, be more satisfied, have more longevity in their careers, and all that good stuff.

Dr. Rohit Marawar [00:40:11]:

Exactly. I'm trying to promote the hashtag academic physician life. hasn't caught on fire yet, but, it hasn't gone well, but I'm hoping to.

Dr. Michael Kentris [00:40:20]:

Awesome. Awesome. I love it. well, thank you again. I appreciate it, and we'll have to we'll have to chat again at some point. Yeah. That would be wonderful. Thank you, Michael. This was wonderful. Thank you. If you enjoyed this podcast, please rate review and share it on Apple iTunes, Spotify, or wherever you get your podcasts, and please scribe for future episodes. You can reach me on Twitter at doctor Kentris. That's @drkentris or by email at the neurotransmitterspodcast@gmail.com with any questions or show suggestions.