integrating an evidence-based resources
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The purpose of this week’s discussion post is to describe two diagnoses and the medications used for their symptoms. This week I will be focusing on migraines and insomnia. Both conditions are neurological by nature and have negative effects on people’s lives. They interfere with activities of daily living as well as mental and physical health.
Migraines are defined as either a classic migraine that has momentary focal symptoms-with aura or a common migraine that has specific symptoms- without aura (Woo & Robinson, 2020). Although the exact catalyst for migraines is not clear there are various theories that help to navigate the course of treatment. Some theories include heightened brain activity from genetics, intracranial vasodilation, and a sensitivity to trigeminovascular systems which causes alterations in structure and function (Woo & Robinson, 2020). Treatment course depends on if migraines are acute or chronic and if the patient has success with preventing or aborting symptoms. One drug class used for acute/abortive migraines are analgesics (Woo & Robinson, 2020). Aspirin and Naprosyn are often used as first line recommendations for acute migraines. It was found that the use of high dose aspirin (900-1,300mg) was successful in aborting, as well as preventing, the symptoms of an acute migraine attack without associated nausea (Alpert, 2020). Aspirin helps alleviate symptoms by interfering with prostaglandins and platelet activity as well as possibly effecting the serotonin activity (Woo & Robinson, 2020). Of course, high doses of aspirin have a long list of warning to teach the patient. Gastrointestinal bleeding, ulcers, and discomfort should be educated and reported. Aspirin is also contradicted in pregnancy, children, prior to surgeries, with any active bleeds or ulcers, and caution with hepatic dysfunction (Woo & Robinson, 2020). The patient should report any signs of bleeding, dizziness, hearing issues, or new pain. The use of aspirin should also be avoided if taking anticoagulants, antihypertensives, NSAIDs, and glucocorticoids (Woo & Robinson, 2020). Naprosyn or naproxen is the other analgesic that is used for the treatment of migraines. Naproxen is used for menstrual specific migraines as well and is contradicted in the last trimester of pregnancy (Woo & Robinson, 2020). Caution should be taken with naproxen with comorbidities such as kidney disease, ulcers, and gastritis. This medication has similar side effects and interactions as aspirin. Gastrointestinal bleeds being the most common. Medication interactions include antihypertensive, antithrombotic, antidepressants, and corticosteroids (Cooney et al., 2015). Being a COX inhibitor, naproxen works for migraines by decreasing pain and inflammation.
Another drug class utilized for migraines are beta blockers. One beta blocker used for migraines include propranolol which is a beta-1 and beta-2 antagonist. This drug works by preventing chronic migraines from occurring and the exact reason how is not clear, but it is believed it is from effecting the catecholaminergic system and brain serotonin receptors (Linde & Rossnagel, 2017). This medication would begin with a 3 month trial and be reassessed every 6 months (Woo & Robinson, 2020). Propranolol can cause a decrease in heart rate as well as respiratory distress so should be avoided in patients with underlying respiratory illnesses or preexisting heart conditions such as bradycardia. Adverse drug reactions include lethargy and depression (Woo & Robinson, 2020). These drugs should also be used in caution with diabetics and be tapered. Another beta blocker that acts only on the beta-1 receptor is metoprolol. Metoprolol is selective for beta-1 so cardiac comorbidities should try alternative methods as this can cause more issues such as bradycardia (Woo & Robinson, 2020). This drug also has many drug interactions because it is metabolized through CYP450.
Insomnia is difficulty falling or remaining asleep which consequently results in a decrease in ability to function during the daytime (Krystal et al., 2019). There are many causes of insomnia including medication reactions, hormone imbalances, mental illness, diabetes, chronic pain, and stress. Because the pathology of insomnia is multifaceted there are numerous medications recommended depending on the cause. One medication group are benzodiazepines. Benzodiazepines work by targeting the GABA receptors which induce sedation and a disease in anxiety (Krystal et al., 2019). Alprazolam or Xanax is known as one of the short-acting benzodiazepines used for insomnia. Another long-acting benzodiazepine utilized is clonazepam. Both medications have the same mechanism of action as stated above. And there are similar interactions as well. All benzodiazepines are CNS-depressants and can cause dependency (Woo & Robinson, 2020). Xanax has a higher prevalence of this than that of a long-acting medication such as clonazepam. These medications can cause respiratory depression, cardiac rates to slow, dizziness, altered mental status, hypotension, or depression (Woo & Robinson, 2020). Clonazepam has a side effect of increased salivation. These medications should not be taken with other depressants or digoxin (Woo & Robinson, 2020).
The other class of medications that is utilized for insomnia are antidepressants. Trazadone is one of the most used antidepressants for insomnia and is no longer used as much for depression (Jaffer et al., 2017). Trazadone is a serotonin antagonist and reuptake inhibitors (SARI) and interferes with the serotonin receptor as well as the histamine 1, and alpha receptors (Jaffer et al., 2017). The main side effects of this medication are sedation, headaches, dizziness, and tolerance. Less commonly trazadone can cause dry mouth, hypotension, QT prolongation, suicidal ideation, and hallucinations (Shin, 2020). Caution should be taken with MAOIs, triptans, TCA, and fentanyl. This drug is also metabolized by the liver and kidneys so those functions should be monitored (Shin, 2020). Another antidepressant that can be used for insomnia treatment is sertraline (Zoloft). This medication is in the selective serotonin reuptake inhibitors (SSRIs) class of antidepressants and works by inhibiting the serotonin reuptake which increases serotonin levels (Singh, 2020). This mediation has a lot of side effects including fainting, GI upset, perspiration, xerostomia, altered mental status, hallucinations, sexual dysfunctions, and drowsiness (Singh, 2020). There is also an increased risk for bleeds, prolonged QT intervals, suicide ideation, and should be taken in caution with elderly populations (Singh, 2020). Because of all these risks this would not be a first line choice for an off-label use such as insomnia but does benefit certain people.
A seizure is a transient disruption in brain electrical function which are classified differently (McCance, Huether & Rote,2014). Seizures happen when two events occur in a group of neurons. A burst of action is produced by depolarization of the neuron caused by extracellular calcium that opens the sodium channel, which generates repetition (McCance, Huether & Rote,2014). The firing increases and the amplitude becomes greater. The discharge goes to the neurons surrounding and spreads through corticocortical synapses (McCance, Huether&Rote,2014). The firing will spread through pathways to areas in the brain like the basal ganglia, thalamus, and the brainstem, which comes to a tonic phase of muscle contraction and increased muscle tone , and loss of consciousness( McCance,Huether &Rote,2014). There are different types of seizures, they are classified by symptoms and site of origin. Seizures can be initiated due to hypoglycemia, fatigue, emotional and physical stress, lack of sleep, hyponatremia, environmental stimuli, stimulants, alcohol withdrawal, hyperventilation, or blinking lights (McCance, Huether &Rote,2014). Epilepsy is a diagnosis for when seizures continue to reoccur for no known reason, the cause cannot be found (McCance, Huether & Rote,2014).
The three major drug classes of antiepileptic drugs to treat seizures are hydantoins, iminostilbenes, and succinimides (Woo& Robinson,2016).
Examples of hydantoins are phenytoin or Dilantin (mostly used), ethotoin or peganone, and fosphenytoin or cerebyx. These drugs work by stabilizing electrical discharge in the brain by effecting the influx of sodium into the neuron during depolarization, which slows the spread and disruption in electrical function (Woo & Robinson,2016). The rate is usually oral, and these medications are absorbed slowly in the small intestine but enters the brain quickly. These medications are good because levels can be measured for a therapeutical goal of 10-20mcg/ml. When administering hydantoins iv, they must be administered with caution and not too fast because it can cause cardiovascular reactions. Patients should not be prescribed iv if they have sinus bradycardia, sinoatrial block, second- and third-degree blocks, and must be used in caution with patients who have liver disease or renal disease (Woo & Robinson,2016). Side effects of hydantoins are agitation, confusion, dizziness, ataxia, headache, drowsiness, nausea, vomiting, anorexia. Patients should be educated to take exactly as prescribed and not to miss any doses. Patients should not stop this medication abruptly. Patients should be advised that their urine may change in color to pink or red, or reddish brown and not to be alarmed (Woo & Robinson,29016).
Examples of iminostilbenes are carbamazepine or Tegretol, oxcarbazepine or Trileptal and treat epilepsy, bipolar disorder, and some neuralgias (Woo & Robinson,2016). These medications depress transmission in the nucleus of the thalamus, slowing the spread of abnormal activity (Woo & Robinson,2016). Carbamazepine can decrease WBC’s and depress bone marrow leading to leukopenia, thrombocytopenia, and aplastic anemia (Woo & Robinson,2016). CBC should be monitored closely. Side effects of Carbamazepine include thyroid function impairment, and hepatic damage. LFT and TSH should be monitored closely. Most common side effects include, dizziness, diplopia, fatigue, nausea (Woo & Robinson,2016). When patients are prescribed carbamazepine, they should be taught to report sore throat, bruising, and fever. The medication can cause fatigue so they should be on alert to be careful as these medications can be sedating (Woo & Robinson,2016).
Bell’s palsy is the most common cause of acute spontaneous peripheral facial paralysis which is unilateral. Common symptoms include the eyebrow sagging, inability to close the eye, and drooping at the affected corner of the mouth, which is drawn to the unaffected side (Ronthal & Greenstein,2020). The etiology of Bells Palsy remains unknown (McCance, Huether & Rote,2014). Bells Palsy could be caused by herpes simplex reactivation in facial cranial nerve VII (McCance, Huether & Rote,2014).
Treatment for Bells Palsy includes short term oral glucocorticoid. Prednisone 60 mg daily x 5 days followed by a 5-day taper of 10mg per day until completed is recommended (Ronthal & Greenstein,2020). Glucocorticoids inhibit the immune and inflammatory by their actions at several sites (Woo & Robinson,2916). When using short term patient may experience insomnia, mood swings and dyspepsia (Ronthal & Greenstein,2020). If a patient has diabetes, they should be educated that the patient will experience hyperglycemia (Ronthal & Greenstein,2020). In severe cases of Bells Palsy, the patient face will be asymmetric at rest, no motion to forehead, and incomplete closure of the eye (Ronthal & Greenstein,2020). With severe cases it is recommend to co -administer anti-viral medication valacyclovir with prednisone. It is unclear if anti-viral therapy adds benefit with new onset bells palsy. It is not recommended to treat with anti-viral medication alone (Ronthal & Greenstein,2020). Mild cases of Bells Palsy should be treated with prednisone alone. Mild case consists of normal facial symmetry at rest and slight weakness noted in face (Ronthal & Greenstein,2020).
Valacyclovir is rapidly converted to acyclovir after administration, the mechanism of action is the same as acyclovir. It is active against the herpes simplex virus. It distributes to areas in the brain, the lung, herpetic lesions, saliva, semen, and kidney (Woo & Robinson,2016). Renal failure has been reported, use with caution in patients with kidney disease. Thrombotic thrombocytopenic purpura has been reported. There are few side effects with acyclovir, but some include headache, rash, and nausea vomiting (Woo & Robinson,2016). Education includes should be taken at the earliest sign of disease; medication should be taken with plenty of fluids to maintain hydration to help avoid renal failure (Woo & Robinson,2016).