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EMPOWER Episode 4 – Rapid Oral Loading of Antiepileptic Drugs (AEDs) in the Emergency Department
Show Notes:
- Core content from this episode discussed in:
- DiPiro’s Pharmacotherapy, 9th Edition, Chapter 40
- Goodman and Gilman’s The Pharmacological Basis of Therapeutics, 12th Edition, Chapter 21
- Selection portions of Winter’s Basic Clinical Pharmacokinetics, 3rd Edition
- ACEP Clinical Policy (updated in 2014):
- Huff JS, Melnick ER, Tomaszewski CA,et al. Clinical policy: critical issues in the evaluation and management ofadult patients presenting to the emergency department with seizures. Ann Emerg Med 2014; 63(4):437-47.e15.
- Includes brief summaries of articles related to rapid oral loading of antiepileptic drugs covered in this episode (carbamazepine, oxcarbazepine, lamotrigine, valproic acid, and levetiracetam)
- Compare to previous policy from 2004
- More #FOAMed on rapid oral loading of AEDs:
- Post on Academic Life in Emergency Medicine discussing rapid oral loading of phenytoin in the emergency department by Bryan Hayes, PharmD
Every time I come to this blog, you guys are talking about perineal pruritus…I would suggest that the lamotrigine article referenced was underpowered to detect the adverse rash effect of the drug as it only enrolled 24 patients and we are talking about a somewhat uncommon side effect. Additionally, they only enrolled patients on chronic LTG therapy for 6 months or greater with no history of rash. Finally, the mean number of days off the drug was only 4.9, although drug levels were negligible before the load (makes sense based on the PK and only 1 pt was on VPA, and that was held as well.)So, if you are really going to use this pilot study at all, your patient population would be rather limited, in addition to this study being underpowered for adverse effects. I've got to agree, just give fosphenytoin. Man, I love that drug. Well, that and IV APAP. All I've got to do is switch a couple regimens over to PO per day and I am making back my salary…
Hi Steve, Thanks for the comment!I agree that the study sure did have some limitations but I think at the end of the day, the risk of the rash ADR largely outweighs any benefit of loading. We'll do a special episode dedicated to perineal pruritus just for you!