Brief Answer:
Possible side effect from medication

Detailed Answer:
Good afternoon. My name is Dr. Dariush Saghafi and I am a neurologist in the XXXXXXX Ohio area.

I understand that your sister from a seizure disorder that has been previously taking carbamazepine but recently switched to Keppra.there is apparently some swelling in her joints and hand and has come about since the switch to the new medication.

Your concern revolves around the possibility of the swelling as being related to the new medicationas well as what to do about it at this time.

Have you advised the doctor who prescribed the medication? If not, you should put a call into them and get their advice I had of making a changes or doing anything on your own even if you have gotten advice from a network such as this one. The rule of thumb is to always check with the treating physician before making any changes or intervening on a patient.

In the same light, giving Benadryl or any other medication especially to a patient with a seizure disorder would not be a wise thing to do without prior instruction and knowledge of her treating physician.

Having said that one of the questions I may ask the treating physician if I were in your position would be to explain the necessity of switching to Keppra from the carbamazepine if in fact, her seizures were under very good or excellent control. In other words, while it is true that carbamazepine as well as many if not all antiepileptic drugs taken by mouth can have deleterious side effects on the liver if given in high doses and for long periods of time,in my patients I tend to favor keeping their medication regimen stable if the seizures are under very good or excellent control unless there is absolute that damage is being done that needs to be stopped or reversed.

In the case of Keppra, side effects do include commonly joint pains and swelling which varies in location and severity. Many of the side effects of Keppra will lesson or become less obvious or intrusive with time. Therefore, if she has only been on the medication for very short period of time and the doctor is convinced that this is the best thing for her the side effects may resolve.

in conclusion, I would recommend the following:

1. Contact treating physician to advise of potential side effects from Keppra and ask for advice on intervention at this time.

2. Ask treating physician if the necessity to switch from carbamazepine to Keppra is on the basis of laboratory evidence indicating imminent damage to the liver or is it simply based on a concern that the liver may be affected in the future?

3. Ask treating physician for rationale in switching medication only if seizures are under very good to excellent control. In the case where your sister's seizures are not being well-controlled then, the switch may very well be to her benefit anyways independent of the side effects she may be experiencing at this time.

I hope the above information has been useful to your quest for knowledge on this topic and if so, I would greatly appreciate some written feedback as well as a star rating to indicate that I have satisfactorily addressed your concerns.

Also, if you do not have further questions or comments on this thread I would also greatly appreciate if you would close the query on your end so that the network may process, archive, and properly credit this case for future reference.

Please do not hesitate to contact me directly in the future by looking me up on this network and sending questions to my specific attention (Dariush Saghafi, M.D.).

This case required 60 minutes physician specific time for review, research, and final draft documentation for envoy.

All the best to you and your sister. I would be happy if you keep me informed of the results of your inquiry to the physician and the final decisions.

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Brief Answer:
Thanks for the updates

Detailed Answer:
Dear Ms. XXXXXXX Dr. Saghafi back at you here on Healthcaremagic and I thank you for those questions and updated information which gives me a bit more to go on. First of all, sorry for all the bad grammar in that last send. I was working off the iPhone which has a tiny screen. I'm going to get that new one (the 6+) which has a much sweeter screen. So, now I'm on my computer and hopefully, won't seem like such an illiterate! LOL.

So, let's catch things up a bit.

First of all, your sister has a seizure disorder..is that correct?

Secondly, she's been WELL CONTROLLED on carbamazepine for years. Is that correct? By WELL CONTROLLED, I mean she has not had any seizures now for either a very long time or if she does they are only once in a great while perhaps, if she misses a dose of her medication, or something really odd happens....like the moon and the stars suddenly become confused, and somehow that trips your sister up.....you understand what I mean....WELL OR EXCELLENTLY controlled. It's really important that you tell me that bit of information.

Thirdly, she's been taking Keppra or Levetiracetam now for about 3 weeks and continues to suffer from swelling and joint pains that she never had previously and have no clear cut other explanation. In other words, she has not developed symptoms of gout, rheumatoid arthritis, joint infection, or something else has she? Is that correct?

Fourthly, her routine blood work (to the best of everyone's knowledge) does not show the presence of liver DAMAGE or other blood abnormalities attributable to carbamazepine. The doctor's MAIN REASON for wanting to switch drugs is the concern for liver damage in the future. Is that correct?

So, please answer those questions for me to the best of your ability.

Now, answer this question...is the doctor treating your sister a neurologist? Are they a specialist in epilepsy (i.e. an epileptologist?) or is it simply her private physician making this recommendation for switching the drug?

When is the last time you took your sister to see either a neurologist or epileptologist to see how things were going? What else is going on with your sister in terms of medical conditions. Is she bed or wheelchair bound? Did she suffer a stroke, meningitis, or a brain bleed in the past?

I AGREE with the concept of not trying to change things around in a person with an epileptic disorder which is being excellently controlled unless there is a compelling reason to do so. The risk in changing to something else is that the control over the seizure disorder could be lost and even if one goes back to the old regimen sometimes control just never seems to come back the same way it was before the switch was made.

Carbamazepine in the long term can cause cognitive deterioration. In others, short term memory could suffer and other brain functions could be duller or not as sharp. Processing time may be slower meaning that it could take her longer to understand or think of things or how to solve problems, etc. It doesn't mean she will become demented nor does it increase her chance of getting a dementia. It simply can (and probably has already) blunted her speed of thinking or processing. But guess what? ALL ANTIEPILEPTIC MEDICATIONS do the same thing.

Carbamazepine also can have deleterious effects on her bone marrow and slow down production of blood cells such as white cells and other formed elements. This can have an impact on the immune system and is something to look at with routine blood draws. Severe affectation of the bone marrow is not common over the long term but this is definitely a potential consequence. There can also be some possible interactions with Vitamin D and calcium absorption and utilization in the body which could lead to osteopenia or osteoporosis. The evidence for this is not exactly robust but it is put out there as a moderate risk. Then, there are behavioral changes which can occur in the long run which include agitation, depression, and mood swings which could involve bouts of rage and extreme irritability not otherwise explained by the patient's normal personality. Those are the major consequences to systems in the body. Not a pretty long term side effect profile is it? But again, as I have to point out....show me ANY antiepileptic drug that stands head and shoulders above any other when it comes to POTENTIAL LONG TERM CONSEQUENCES. There ain't any that measure out to be the perfect drug.....it's futile to try and put one up against another in that light. I wouldn't worry about it, really.

The bottom line is that she has been stable with her seizures, has not experienced any real metabolic downsides to date in terms of liver function and other blood work and so I think all that should be taken into consideration before suddenly changing to another agent.

Do you know what the cause of her seizures are in the first place? How long has she had them and was she ever fully investigated for a cause to her seizures since being put on the medication? Are these seizures from childhood or did she acquire them as a result? The reason I ask is because typically, if we have someone with convulsions for which no identifiable cause is known and we put them on medications to control events and they are excellently controlled for at least 2 years then, we try and consider withdrawing the medication altogether. Obviously, it would be preferable for a person to NOT be taking these medications if at all possible. So I don't know if she's ever been approached with the idea of stopping her medications altogether.

It would be nice to know what her neurologist's opinion is in this case if she's seen one in the past.

Finally, I know you've already given your sister Benadryl for this condition of swelling which you believe is a side effect of the medication but honestly, giving her further doses of the antihistamine without checking with her doctor is not advisable. Please consider putting a call in to the prescribing physician to explain what's going on for more definitive advice.

Please don't forget that your written feedback as well as a STAR RATING to this question is greatly appreciated if you've found the information of value. And again,
CLOSING THE QUERY on your end so that the network may process, archive, and properly credit this case for future reference as well garners my thanks.

Please do not hesitate to contact me directly in the future by looking me up on this network and sending questions to my specific attention (Dariush Saghafi, M.D.). You may also get to my specific webpage at:

http://doctor.healthcaremagic.com/doctors/dr-dariush-saghafi/68474

This case required 60 minutes physician specific time for review, research, and final draft documentation for envoy.

All the best to you and your sister. I would be happy if you keep me informed of the results of your inquiry to the physician and the final decisions.

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Brief Answer:
Little reason in my opinion to have switched

Detailed Answer:
Thank you for the informative details.

Well, then, it's a mystery to me why a neurologist would feel compelled to change someone who's been absolutely stable on an appropriate medication to something unknown and at a dosage which has to be titrated and even at the end of that titration not really know whether or not she is at the same balanced levels for seizure control as she's been for years with the carbamazepine.

I would challenge anybody to be able and prove that the switch from carbamazepine to Keppra is clearly BETTER for the purpose of avoiding liver toxicity when there isn't even any evidence of toxicity to begin with and in the face of the fact that Keppra as a side effect can cause the same toxicity (though it is considered a rare event). Still, hepatotoxicity is a potential problem in some patients and it is usually unexpected and remains subclinical until damage is fairly advanced.

I'm afraid that if the doctor's rationale is as you say then, I'm at a loss for an explanation. I think the risk of changing someone in this type of setting is far greater than the potential benefit and therefore, should be avoided.

As far as changing the dose of the carbamazepine that really should be guided by blood levels as well as the status of the "scar" you mentioned on the brain. Now, of course, I'm going to ask you what the scar is due to because generally speaking scars do not disappear.

She must've had either a stroke, a brain bleed, infection/abscess, or an injury to the head (concussion, penetrating wound, or something) and so the # of pills of carbamazepine should be in conjunction with blood levels of the drug. Again, my preference in someone who is under excellent control is to EITHER leave everything as is or if changes must occur to look at her as a possible candidate to go without medication.

Of course, if the MRI shows the clear presence of a scar on the brain (e.g. GLIOSIS or ENCEPHALOMALACIA) then, she cannot be considered for coming off her medications at all and they should be continued for life.

My advice to you in the future is to not be afraid of calling the doctor over a weekend to let them know about reactions to medications. Allergic reactions as side effects can be particularly problematic as they sometimes can lead to respiratory difficulties and crises as well as skin rashes which can become complicated in short amounts of time.

Most doctors' offices have weekend answering services as well as someone on call for the practice for situations that as this. It's well worth the opinion of someone associated with the practice so that you don't have to be left with the doubt of giving medication that may cause problems. Remember, it is never advisable to give a seizure patient ANYTHING such as medication, OTC or otherwise, without clearing with the treating physician. Going out of control on the basis of using a medication that could've been avoided could mean a trip or even a stay in the hospital.

Also, I would not be hesitant in the future to speak up against anybody (even a neurologist) who suggests that her medication regimen be changed unless she has had a decompensation or if new information comes out which delineates clear and major risks to her well being which were not heretofore known such as risks of cardiac death or renal failure, etc. etc. Otherwise, it is never really considered a good move to change stable seizure patients to other drugs just for convenience or to avoid potential complications which are present anyways in virtually every anti-epileptic drug available.

Please don't forget that your written feedback as well as a STAR RATING to this question is greatly appreciated if you've found the information of value. And again,
CLOSING THE QUERY on your end so that the network may process, archive, and properly credit this case for future reference as well is of great value to myself.

You can always contact me :

http://doctor.healthcaremagic.com/doctors/dr-dariush-saghafi/68474

This case required 36 minutes physician specific time for review, research, and final draft documentation for envoy.

Cheers!

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