Spencer Yost MD
https://anesthesia.ucsf.edu/people/spencer-yost
Gabapentin dosages: 800 mg, 600 mg, 400 mg, 300 mg, 100 mg
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Is there a dietitian who has experience with the ketogenic diet associated with this plan Acknowledgements Deloitte Access Economics acknowledges and thanks Epilepsy Australia for commissioning the report with support from the Australia Epilepsy Community Associations. The data used in the report was current at the time the report was released to Epilepsy Australia. Background Epilepsy is a serious neurologic condition that carries with it stigma, psychiatric comorbidities and high economic costs. It is the second most burdensome neurological condition, after dementia, accounting for 14. While epilepsy is a condition that affects people worldwide, nearly 80% of people living with epilepsy reside in lowand middle-income countries. Known risk factors include serious head injuries sustained during motor vehicle accidents, trauma or serious falls; strokes or brain haemorrhages; prolonged oxygen deprivation; brain infections and abnormalities; tumours; degenerative conditions such as dementia; and genetic factors. However, in half of all cases, the cause cannot be determined and the individual may never understand why they suffer from the condition. For those who live with epilepsy, the condition can be debilitating and have serious adverse effects on their personal life, ability to maintain employment, and quality of sleep. It may also pose serious danger to the individual themselves, due to the unpredictable nature of seizure events. Epilepsy is also associated with a number of comorbidities which can worsen the burden on people living with the condition, and those who provide care to them. In particular, epilepsy has been found to increase the likelihood of an individual experiencing depression and anxiety, fractures, motor vehicle accidents, cardiovascular disease, sleep disorders, neurodevelopmental disorders, and migraines. Prevalence and incidence In Australia, there is approximately a 10% population prevalence of individuals who have experienced one seizure during their lifetime. This adjusts the above figure downwards, accounting for cases of epilepsy that have gone into remission. Australian Burden of Disease Study: Impact and causes of illness and death in Australia 2011. Descriptive epidemiology of epilepsy: Contributions of population-based studies from Rochester, Minnesota.
Doses were adjusted to obtain serum levels ranging from 5 to 25 ng/mL about 2 to 6 hours after dosing. The most common side effects were fatigue and depression that resolved with decreasing dosing levels. The study group was 25 women with temporal lobe epilepsy matching the definition for catamenial epilepsy in the perimenstrual (n 11) or luteal (n 14) phases. The women were all started at 200 mg three times daily during their exacerbation phase. The results show that over a 3-month period, 72% of women reported a decrease in seizure frequency and that the average daily seizure frequency decreased by 55%. In a 3-year follow-up of the remaining 23 women, the mean reduction in focal and generalized seizures was 54% and 58%, respectively. Common and usually dose-related adverse effects include paresthesias, drowsiness, nausea, malaise, fatigue, and diuresis. Their main use is for abortive therapy due to the development of habituation and tolerance with chronic, long-term use. However, they have long been used as a practical and safe intermittent treatment approach for catamenial seizure exacerbations. Clobazam is the only benzodiazepine studied for the treatment of catamenial epilepsy, and has been shown to be effective (129). Clobazam, at 20 to 30 mg/day, cyclically taken 2 to 4 days premenstrually has been shown to reduce catamenial seizures as well as decrease the tolerance associated with continual use. Clobazam, however, is not available in the United States, but this data does support the use of intermittent benzodiazepines in the treatment of catamenial epilepsy. Chapter 44: Hormones, Catamenial Epilepsy, Sexual Function, and Reproductive Health in Epilepsy 547 randomized clinical trial has been performed and is under analysis. As of this writing, natural progesterone is not approved for use in the treatment of seizures; however, it is used as an off-label medication. It is not a stretch to expect that sexual function of men and women with epilepsy could be affected. While this subject is usually avoided by the clinician and the patient alike, it is an important aspect to consider.
Diseases
Non-specific serotonin antagonists (cyproheptadine, chlorpromazine, methysergide) have also been used for treatment. It is still not at all clear why many patients can take two, or sometimes several, serotonergic drugs together without problems, while a very small number develop this serious toxic reaction, but it certainly suggests that there are other factors involved that have yet to be identified. The full story is likely to be much more complex than just the simple additive effects of two drugs. The pumping actions of P-glycoprotein can be experimentally induced or inhibited by some herbal medicines. So for example, the induction (or stimulation) of the activity of P-glycoprotein by capsicum, within the lining cells of the gut, causes digoxin to be ejected into the gut more vigorously. In contrast, some extracts of danshen appear to inhibit the activity of P-glycoprotein, and may therefore increase digoxin levels. It is for this reason that it is used as a probe substrate for P-glycoprotein activity, and the effects of herbal medicines on this particular drug have been studied. Sometimes the drugs directly compete for particular receptors but often the reaction is more indirect and involves interference with physiological mechanisms. These interactions are much less easy to classify neatly than those of a pharmacokinetic type. In contrast to additive interactions, there are some pairs of drugs with activities that are opposed to one another. For example, the coumarins can prolong the blood clotting time by competitively inhibiting the effects of dietary vitamin K. If the intake of vitamin K is increased, the effects of the oral anticoagulant are opposed and the prothrombin time can return to normal, thereby cancelling out the therapeutic benefits of anticoagulant treatment. It has been proposed that the vitamin K content of herbal medicines may be sufficient to provoke this interaction, but in most cases of normal intake of the herb, this seems unlikely. See Alfalfa + Warfarin and related drugs, page 23, for further discussion of this potential interaction. These words have precise pharmacological definitions but they are often used rather loosely as synonyms because in practice it is often very difficult to know the extent of the increased activity, that is to say whether the effects are greater or smaller than the sum of the individual effects. The reasons for this effect are not fully understood, but the serotonin syndrome is thought to occur as a result of over- Drawing your own conclusions the human population is a total mixture, unlike selected batches of laboratory animals (same age, weight, sex, strain, etc.
Flow-limited drugs have high extraction rates, and clearance is limited primarily by blood flow. Most anticonvulsants are capacity-limited drugs, as their extraction ratios are low (0. The rate of metabolism of capacity-limited drugs depends on the concentration of free drug at hepatic enzyme receptor sites and thus on the extent of protein binding. Capacity-limited, binding-sensitive drugs, such as phenytoin, valproic acid, and carbamazepine, are greater than 85% bound to plasma proteins at therapeutic concentrations; therefore, alterations in plasma protein concentration and binding characteristics can significantly alter their hepatic clearance (23,24). Capacity-limited, bindinginsensitive drugs, such as ethosuximide, have a low affinity for plasma protein (usually less than 30% at therapeutic concentrations), and clearance is only minimally affected by changes in protein binding. The following model, combining the principles of intrinsic metabolic capacity and blood flow, has been proposed (25): Clh = Q * Fb * Clint Q + Fb * Clint stant. The extraction ratio (E) may be derived by dividing hepatic blood flow into total hepatic clearance (27): Cl = E Q When combined hepatic and renal clearance occurs, clearances are additive. Although hypoalbuminemia is frequently a feature of liver disease, drug binding to plasma proteins may be decreased even without measurable changes in albumin concentration (Table 47. Mechanisms similar to those causing decreased protein binding in renal insufficiency have been suggested (28,29). Because intrinsic clearance varies with the type and duration of liver disease, the effects of changes in protein binding in capacity-limited, binding-sensitive drugs are complex. If hepatic disease lowers binding without changing intrinsic clearance, total drug concentration will ultimately fall because the rate of metabolism of these drugs depends on the free fraction. If liver disease reduces intrinsic clearance, total drug concentration may remain the same or increase as the free concentration increases. This can result in enhanced response or toxic effects at lower than expected drug levels and may explain the increased incidence of adverse reactions to medications such as valproic acid in liver disease (30). Capacity-limited, binding-insensitive drugs can be considered relatively pure indicators of intrinsic clearance. However, tissue binding to substances such as ligandin may contribute where Clh is the volume of blood cleared by the liver per unit time, Q is total hepatic blood flow, Fb is the fraction of drug bound to protein and cells, and Clint is the intrinsic metabolic clearance (23,24,26). High Low Unknown High Contraindicated Considerable Unknown Unknown Dosage adjustment Unnecessary or slight reduction Unnecessary or slight reduction Unnecessary or slight reduction Unknown Unknown Reduction Unnecessary Reduction Reduction Contraindicated Reduction Reduction/Contraindicatedb Reduction T, Reduced; -, unchanged; c, increased. The effect of liver disease on the content and function of such binding proteins is poorly understood.
Carbfree and low carb varieties that are easy to find include: Pictures of carbfree and low carb varieties have been removed for publication. Amounts are per serving-not per container-unless of course there is only one serving per container, as in a 1oz bag of chips or a small yogurt container. Remember you can have up to 20 grams net carbs for the whole day (unless otherwise specified). Dietary Fiber (if there is any): Fiber is a type of carbohydrate that is very important for health, but it does not get digested and metabolized the same way other carbs like sugar do. If soluble and insoluble fiber are listed under Dietary Fiber, only subtract Dietary Fiber grams. If you have two servings, double the grams of carbohydrates (or net/available carbs, if there is fiber). The Food and Drug Administration made rounding rules to be used when reporting the quantities of nutrients in foods. This applies to the Nutrition Facts labels and is used by food journalists and recipe writers who report the nutritional composition of their published recipes. These manufacturers are subtracting the sugar alcohols grams from the total carbohydrate amount. They are a derived from sugar and are still considered a type of Picture of an example of a low carb carbohydrate. They are commonly used in the food industry in sugarfree, reducedsugar, and diabetic foods because they do not contribute as many calories as sugar does. Yet, each sugar alcohol is different and some will contribute just 1 calorie fewer than sugar. It is suspected that people will metabolize and digest sugar alcohols differently. To get the correct number of carbohydrates, turn the package over and read the Nutrition Facts label for the total carbohydrate and fiber grams. For more information about sugar alcohols, please visit the Sugar Alcohols Fact Sheet at Foods without labels include most fresh fruits and vegetables-the kind you bag yourself at the store. During your first month on the diet, you may learn the carbohydrates in produce by using food lists (provided here) or by eating packaged produce that has the carbohydrate content already on the label.
Syndromes
Experimental evidence (a) Anxiolytic effect In various animal models, the anxiolytic effects were additive for diazepam and baicalin,2 and synergistic for diazepam and hesperidin. Importance and management Contrary to what was predicted from in vitro studies using tangeretin, a single dose of tangerine juice did not appear to alter the pharmacokinetics of midazolam. In contrast, grapefruit juice, which contains different flavonoids, does increase levels of some benzodiazepines. However, grapefruit juice also affects the levels of some calcium-channel blockers, but studies with the flavonoid naringin have found no interaction, suggesting that naringin is not the primary active constituent of grapefruit juice (see calciumchannel blockers, below). Therefore individual flavonoids might not be anticipated to increase benzodiazepine levels. Furthermore, although evidence is preliminary, it is possible that high doses of some individual flavonoids such as hesperidin and baicalin might have additive anxiolytic effects with benzodiazepines, suggesting a possible pharmacodynamic interaction. This suggests that, until more is known, some caution might be appropriate if citrus bioflavonoids are used with benzodiazepines, bearing in mind the possibility of increased benzodiazepine effects. Lack of correlation between in vitro and in vivo studies on the effects of tangeretin and tangerine juice on midazolam hydroxylation. Clinical evidence In a crossover study in 10 healthy subjects, changes in caffeine pharmacokinetics and physiological responses (resting energy expenditure, oxygen consumption and respiratory exchange ratio) were measured after an acute dose of caffeine 200 mg with or without naringin 100 or 200 mg. Naringin did not alter either the pharmacokinetics of caffeine or the physiological responses to caffeine. Naringin does not alter caffeine pharmacokinetics, energy expenditure, or cardiovascular haemodynamics in humans following caffeine consumption. F Flavonoids + Calcium-channel blockers Supplements of specific citrus bioflavonoids do not appear to affect the pharmacokinetics of calcium-channel blockers to a clinically relevant extent. Grapefruitfelodipine interaction: effect of unprocessed fruit and probable active ingredients. An interaction occurred when the flavonoid was given 30 minutes before the calcium-channel blocker, but not when it was given simultaneously. Clinical evidence In a study in 8 healthy subjects, a single 300-mg dose of ciclosporin was given four times: alone, with oral quercetin 5 mg/kg, 30 minutes after oral quercetin 5 mg/kg or after a 3-day course of quercetin 5 mg/kg twice daily.
Occipitotemporal epilepsies: evaluation of selected patients requiring depth electrode studies and rationale for surgical approaches. Depth electrode investigations in patients with bitemporal epileptiform abnormalities. The localizing value of depth electroencephalography in 32 patients with refractory epilepsy. Lateralized seizure termination: relationship to outcome following anterior temporal lobectomy. Safety of intrahippocampal depth electrodes for presurgical evaluation of patients with intractable epilepsy. Insertion of subdural strip electrodes for the investigation of temporal lobe epilepsy. Intracranial electroencephalography with subdural grid electrodes: techniques, complications, and outcomes. Clinical outcome after complete or partial cortical resection for intractable epilepsy. Subdural electrodes in the evaluation for epilepsy surgery in children and adults. Intraventricular monitoring for temporal lobe epilepsy: report on technique and initial results in eight patients. Responses to single pulse electrical stimulation identify epileptogenesis in the human brain in vivo. However, any lesion should not be assumed to be the source of the seizures ("dual pathology"), as some are often incidental. Scenarios When Intracranial Localization May Be Limited Although most cases of extratemporal onset involve difficult intrahemispheric localization, lateralization is occasionally at issue. This is particularly common in seizures arising from the supplementary sensorimotor area, where symptomatology and midline epileptiform discharges indicate mesial frontal onset, but lateralization is unclear in the absence of imaging abnormalities or clinical lateralizing signs (55). When the noninvasive presurgical evaluation does not sufficiently narrow the possibilities for localization, invasive studies may be of limited benefit. Presurgical evaluation strategies in patients with localization-related epilepsy remain variable and controversial.
However, there are potential factors associated withliving with epilepsy and seizures that may increase the risk of early death. The good news is that there are many resources available to help support you, your child and family. The resources listed in this section are the ones families with newly diagnosed children typically find most helpful. Every newly diagnosed parent should contact their local Epilepsy Foundation affiliate to find out what services are available in your area. The Web site also has the most comprehensive, reliable information on epilepsy available online. This site has easy-to-use tools that allow patients and parents to create personalized reports of seizure activity and medication history to share with their medical team. The Center provides assistance to individual families, workshops, and materials for parents and professionals. While services vary from community to community, 2-1-1 provides callers with information and referrals to human services agencies for everyday needs and in times of crisis. Books For Parents: Epilepsy: Patient and Family Guide (2008) by Orrin Devinsky, M. Brainstorms: Epilepsy on Our Terms - Stories by Children with Seizures and Their Parents (2008) by Steven Schachter, M. Brainstorms: Epilepsy in Our View-Stories from Friends & Families of People Living with Epilepsy (2008) by Steven C. The Ketogenic Diet: A Treatment for Children and Others with Epilepsy, Fourth Edition (2007) by Jennifer Freeman, John Freeman, M. Epilepsy is a medical condition that produces seizures that can affect mental and physical functions. Many illnesses or severe injuries can affect the brain enough to produce a single seizure.
In 1975, 24% of practicing pediatricians routinely admitted children after a first febrile seizure; a decade later, 20% still followed this practice (56). However, a more recent evaluation (57) found a decline in the rate of admission with the decision to admit most frequently occurring in those with prolonged seizures. Complex Febrile Seizures the concept of a "complex" febrile seizure originated with epidemiologic studies indicating that several patient- and seizure-related variables predicted higher rates of subsequent epilepsy: seizure duration longer than 15 minutes, focal seizure manifestations, seizure recurrence within 24 hours, abnormal neurologic status, and afebrile seizures in a parent or sibling (58). Six percent of patients with two or more risk factors developed afebrile epilepsy by the age of 7 years, compared with only 0. Studies conducted at the Mayo Clinic also reveal a less favorable prognosis for patients with complex febrile seizures (49). Seventeen percent of neurologically impaired children with complex febrile seizure manifestations developed epilepsy by the third decade, compared with 2. The occurrence of focal, recurrent, and prolonged seizures raised the risk for afebrile episodes to nearly 50%. Children with complex febrile convulsions may subsequently exhibit a variety of afebrile seizure patterns. In the Mayo Clinic experience (59), 29 cases of afebrile epilepsy developed in a cohort of 666 patients with febrile seizures. Seizures were classified as focal in 16 patients and of temporal origin in 10 patients. In a retrospective analysis of 504 children with epilepsy, Camfield and colleagues (60) found a 14.
Importance and management the clinical relevance of these increased levels is unclear, but as the increases were only moderate (serum concentration increased by 62%) it seems likely to be small. B Bromelain + Tetracycline Bromelain appears to moderately increase tetracycline levels. Clinical evidence In a crossover study, 10 subjects were given tetracycline 500 mg, either alone or with bromelain 80 mg. Bromelain appeared to increase the serum levels of tetracycline by up to about fourfold. Higher serum and urine levels were also found when the study was repeated using multiple doses of the two preparations. Importance and management the clinical significance of this interaction is unclear but higher levels of tetracycline may result in an improved outcome, and also an increased risk of adverse effects. Die Resorption von Tetracycline in Gegenwart von Bromelinen bei oraler Application. For information on the pharmacokinetics of individual flavonoids present in broom, see under flavonoids, page 186. Constituents the flowering tops contain flavonoids including scoparin (scoparoside), and the quinolizidine alkaloid sparteine. For information on the interactions of individual flavonoids present in broom, see under flavonoids, page 186. Use and indications Broom is used traditionally for cardiac disorders including 85 Buchu Agathosma betulina (Bergius) Pillans (Rutaceae) B Synonym(s) and related species Bucco, Diosma, Round buchu, Short buchu. For information on the pharmacokinetics of individual flavonoids present in buchu, see under flavonoids, page 186. Constituents Buchu leaf contains a volatile oil composed of diosphenol (buchu camphor), pulegone, isopulegone, 8-mercapto-pmethan-3-one, menthone, isomenthone and others, and the flavonoids diosmin, hesperidin, rutin and others.
Boss, 62 years: Strips can cover widespread areas through multiple burr holes, but mobility of the strips can be a problem and blind insertion of the strips may be impeded by subdural scarring or other structural lesions.
Kapotth, 51 years: Post-implantation Adverse Events (10% Incidence or Higher) by Treatment Group (Aaronson et al.
Sancho, 36 years: As in the case of gabapentin, anticonvulsant efficacy appeared with a delay after entry of pregabalin into the brain, as measured by microdialysis, and persisted to some extent as interstitial brain concentrations fell (49).
References
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