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Have movement disorder. Which vitamin tablet should be taken along with recovon?

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Kindly forward this query to Dr XXXXXXX Sundarakumar who reviewed this case a week back.

Subsequent to your previous communication we had discussed with our Nuero Physician,who had agreed to drop Pacitane and Recovon.

I would like to clarify here,over these 30 years,the present epileptic drug combination is arrived after several permutation and combination with other epileptic medicines such as Gardinol,Valporin,Zenoxa,Topaz,Topomac etc.The present combination is working and we wish to keep the same.

As regards her movement disorder is concerned,as stated in my first communication heredity is one factor,where in their family "Huntington Corea" disorder exists.In her case this disorder came into light more prominently since last 4-5 years but at tolerable level and this is intensified with the use Pacitane and Clonotril.The moment we withdrew Pacitane her condition improved very much.

Presently she is being given Recovon(25mg) 1/2-1/2 (morning and night)along with Eptoin and Tegritol.

During your last communication you had suggested to use Vitamin E.Kinly name the tablet which can be used with Recovon.We wish to minimise these movements if not eliminate.

Rgds,
XXXXXXX
Posted Sun, 25 Nov 2012 in Mental Health
 
 
Answered by Dr. Jonas Sundarakumar 8 hours later
Hello again XXXXXXX,

I'm glad that my advise was helpful to you and that your wife's symptoms have improved after stopping Pacitane. I would agree with you that if she her epilepsy has been controlled with this combination of anti-epileptics, after many other previous unsuccessful combinations, then it would be better to stick to this combination.

Regarding the Vitamin E, it is available as Capsule Evion and 400 mg once a day would be an appropriate dose for her.

Regards,
Dr. Jonas Sundarakumar
Consultant Neuro-Psychiatrist
Above answer was peer-reviewed by
 
Follow-up: Have movement disorder. Which vitamin tablet should be taken along with recovon? 3 hours later
Dr XXXXXXX Sundarkumar,

Thanks,once again the .The following difficulties are being experienced by the patient.

1 Difficulty in sleeping,though not always.
2 Difficulty in swallowing though not always.

Can the dosage be altered to one in the morning only (25 mg Revocon).I am keeping a gap of 1hr between epileptic medicines and movement disorder medication.

Regards,
XXXXXXX
 
 
Answered by Dr. Jonas Sundarakumar 12 hours later
Dear XXXXXXX,

Revocon has a short duration of action i.e. about 6 - 8 hours and that is the reason why it is given twice or thrice a day. Considering the fact that we need this medication to act mostly when she is awake it would be a better idea to take 1/2 in the morning and 1/2 in the afternoon (instead of the night dose).

You can continue to maintain a time gap between the anti-epileptics and the movement disorder medication.

The difficulty in swallowing is likely to be part of the movement disorder itself (this has been welll reported to occur in several types of movement disorders, including Huntington's chorea). You can instruct her to chew her food well before swallowing and avoid hard, dry or sharp foods. If the swallowing difficulty becomes severe, then the next step would be to adjust the medication for the movement disorder.

As far as the occasional sleeping difficulty is concerned, I would suggest that it is better to avoid additional medication unless the problem is frequent and distressing. This is because, she is already on multiple medication and it's better to keep the drug interactions to a minimum. She can try some simple sleep hygiene techniques like:
- Following strict timings for going to sleep and waking up
- Avoiding day time naps
- Trying mild physical exercise in the evenings
- Allowing a gap of at least 1 hour before dinner and bed time
- Restricting coffee, tea or fluid intake after 6 p.m.
- Trying a hot water body bath 1/2 an hour before bedtime

Regards,
Dr. Jonas Sundarakumar
Consultant Neuro-Psychiatrist
Above answer was peer-reviewed by
 
Follow-up: Have movement disorder. Which vitamin tablet should be taken along with recovon? 8 hours later
Dear Dr. XXXXXXX Sundarakumar,

Thanks for your kind guidance.In order not to confuse the subject,I had not asked for clarification on the following problem presently being faced.

As stated in my earlier replies after discontinuing Clonotril,Pacitane her condition improved several fold.Now she is taking only Recovon(twice a day @1/2 tablet of 25 mg).

However after first dose in the morning Eptoin,Tegritol,Lacosam and vitamin tablets such as Folvite 5 mg,Gemcal and antiacid followed by Recovon after 1-1.5 hrs patient is still unstable i.e.,cannot stand or sit and she has to lye down only,and need to be carefully escorted to toilet etc.Her speech is not clear and is slurred.This state remains till say 3-4 hrs,after which the patient can do her things independently.First dose in the morning is at 7am,Recovon at 9-9.30am.

This does not happen in the afternoon (3 pm) where she takes 300mg of Teg and 100 mg of eptoin only and also most probably in the night where she takes Eptoin100,Teg400,Lacosam50,antiacid (9 Pm) till she goes to bed around 10.30pm.
Recovon is at 9.30pm
Morning she is fresh and normal.

1.Why she is unstable in the morning after first dose?
2.When I start Vitamin E will there be any side effects.

Kindly clarify

Rgds,
XXXXXXX
 
 
Answered by Dr. Jonas Sundarakumar 15 hours later
Dear XXXXXXX,

1) Regarding your first question, like I had mentioned in my earlier reply, there is a possibility that her anti-epileptic medication could be worsening her dyskinetic movements, which is why she is having prominent symptoms after about 1 to 1.5 hours (the usual time taken for the medication to get absorbed and reach significant blood levels). Between the previous night's dose and the next morning's dose there is a gap of about 10 hours, where the medication levels keep declining and are relatively low in the blood by early morning (before the morning dose). When the morning doses are given, there may be a sharp rise in the blood levels of the medication, which may cause a worsening of the dyskinetic movements. Moreover, her afternoon dose is a little less and after the night dose, she would be going to sleep. So, that could be why she doesnt have the symptoms after the afternoon or night dose. Additionally, certain dyskinesias / dystonias are (by themselves) worse in the mornings and get better as the day progresses. So, a combination of the above two factors may be the reason why her symptoms are more prominent in the morning.

2) Vitamin E is generally safe and most people do not have any side effects. However, like with any medication, a very small percentage of people can develop some side effects such as nausea, stomach upset, headache, etc. and so its better to be vigilant. If she has any significant side effects, or an allergic reaction, then she should stop the medication and seek medical attention.

Regards,
Dr. Jonas Sundarakumar
Consultant Neuro-Psychiatrist
Above answer was peer-reviewed by
 
Follow-up: Have movement disorder. Which vitamin tablet should be taken along with recovon? 33 minutes later
Dear Dr XXXXXXX Sundarakumar,

Thanks again for your reply.I have a feeling morning dosage of epileptic drugs is high.Earlier before hospitalization and treatment I was not giving Lacosam in the morning.Only one tablet is given in the night.During treatment they made it twice and most of the time she was lying.

After returning from hospital things were going on like that and not much attention was given to this problem.To day in the morning she was normal up to 9.30 am later complained giddiness,so she was put to bed.All the while she did not tell me what is happening,but today she used the word giddiness.That gave me the clue to her discomfort.

Can I shift Lacosam to afternoon and see?

Earlier also when tegritol dose was increased(1000 to 1200) she used to feel giddy and after some bed rest she used to return to normalcy.So tegritol dosage was later reduced to 1100 mg.

Thanks and regards,

XXXXXXX
 
 
Answered by Dr. Jonas Sundarakumar 13 hours later
Dear XXXXXXX,

It is possible that the morning dose of medication could be contributing to her recent symptoms and the guiddiness also could very well be due to this. All three medication can cause drowsiness / "guiddiness".

Now, regarding re-shuffling their doses...
- Eptoin has a short duration of action and hence, has to be given thrice daily (so its not advisable to touch that)
- Lacosam has a long duration of action of about 13 hours; so there's no harm in shifting the morning dose to the afternoon.
- Tegretol: a small part of the morning dose can be shifted to the night or a "controlled release" (CR) preparation can be used. This will ensure more smoother blood levels and avoid rapid peaks of the drug levels following intake.

Regards,
Dr. Jonas Sundarakumar
Consultant Neuro-Psychiatrist
Above answer was peer-reviewed by
 
Follow-up: Have movement disorder. Which vitamin tablet should be taken along with recovon? 6 hours later
Dear Dr XXXXXXX Sundarkumar,

Thanks for your kind reply.I shall shift morning dose of Lacosam to afternoon and retain the others as being given now.Tegretol 400 and 300mg tablets are of CR only.

When I start E vitamin in which dose I include?(morning/afternoon/night). I hope it won't cause any acidity problem.

Kind regards,
XXXXXXX
 
 
Answered by Dr. Jonas Sundarakumar 15 hours later
Dear XXXXXXX,

You can give Vitamin E along with the night dose of medication and giving it after food will avoid any acidity problem.

Regards,
Dr. Jonas Sundarakumar
Consultant Neuro-Psychiatrist
Above answer was peer-reviewed by
 
Follow-up: Have movement disorder. Which vitamin tablet should be taken along with recovon? 12 hours later
Dear Dr XXXXXXX Sundarakumar,

Thanks for prompt replies which are very helpful to manage the patient,also your assistance has given me full understanding of abnormal situations the patient experiences,and gave me more confidence to handle her with out endangering her safety.

Kind regards and best wishes

XXXXXXX
 
 
Answered by Dr. Jonas Sundarakumar 9 minutes later
Dear XXXXXXX,

I'm glad that my guidance was educative and beneficial to you. Kindly leave a review if you are happy with my service.


Best wishes,
Dr. Jonas Sundarakumar
Consultant Neuro-Psychiatrist
Above answer was peer-reviewed by
 
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