Brief Answer:
I would explain as follows:

Detailed Answer:

Hello!

Welcome back on HCM!

In such case, as I have explained you before, it is recommended to follow an escalating increase of Gabapentine daily dose.

300 mg twice daily is a minimal dose, and we stayed on that after your confirm that the mom's pain symptomatology was improved, but the daily maintenance dose for Gabapentine is much higher.

You could increase the daily dose by 300 mg every 2-3 days and maintain the dose with a satisfactory effect on pain relief. This strategy of increasing Gabapentine daily dose up to 1800 mg/day (max daily dose) is recommended in such case until the optimal maintenance dose is reached.

Only after concluding that Gabapentine strategy is insufficient we can think of more potent alternatives such as Carbamazepine, etc

Nevertheless, it is necessary to follow a dose increase of Gabapentine, and only after that to re-discuss the possibility of switching to Carbamazepine.

That's my opinion.

You need to discuss with your attending physician about the above mentioned issues.

I remain at your disposal for further explanations id needed.

Hope to have been helpful to you!

Wishing a pleasant weekend,

Kind regards,

Dr. Iliri

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Brief Answer:
My opinion:

Detailed Answer:

Hi again,

I recommend the above increasing dose strategy for Gabapentine.

Anti-inflammatory drugs could be an additive option as long as they show to be effective (which in fact has not happened so far).

Coming to this point, you need to consult a neurologist (besides your GP or internist) to discuss all the above issues.

Best wishes,

Dr. Iliri

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Brief Answer:
I would recommend as follows:

Detailed Answer:
Hello again!

Yes, you can start on carbamazepine, but you should know that while increasing the dose of carbamazepine, gabapentine should be reduced slowly until stopping it.

I would recommend starting carbamazepine 200mg in the evening for 5 days and then increase the dose to 200mg twice daily for other 5days and then continue with 200mg three times daily.

Further dose increase may be needed based on her symptoms.

Meanwhile, I would recommend reducing gradually the dose of gabapetine with 300 mg every 2 days, until stopping it.

Anyway you should know that carbamazepine can reduce the effect of her antihypertensive therapy, increasing her blood pressure and leading to a need of higher doses of antihypertensive drugs.

I recommend you to closely monitor her blood pressure during this period of time.

If she doesn't tolerate the dose of 200mg of carbamazepine from the beginning (and adverse effects like weakness, gait disturbances, dizziness, uncontrolled hypertension, etc.) occur, it may be necessary to start with a lower dose of 100mg (half a tablet) and increase the dose with 100mg every 5 days, increasing based on her tolerance and the pain control.

You should discuss with her doctor on the above issues.

Hope to have been helpful!

Best regards!

Dr. Iliri

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Brief Answer:
I would recommend as follows:

Detailed Answer:
Hello again!

I would recommend taking 100mg of carbamazepine (1/2tablet), in order to avoid possible adverse effects.

What is the total dose of gabapentine that she has taken today?

I am at your disposal for any other uncertainties.

Feel free to ask at any time!

Greetings!

Dr. Iliri

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Brief Answer:
I recommend as follows :

Detailed Answer:
Hello!

I recommend starting carbamazepine 100 mg in the evening and continue taking 300 mg Gabapentine three times daily for 5 days.

Then after increasing to 200mg of carbamazepine in the evening, you should start reducing the dose of Gabapentine by 300 mg every two days.

This gradual switch to carbamazepine is made to avoid possible adverse effects.

Hope to have been helpful!

Regards!

Dr.Iliri

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Brief Answer:
Hope you will soon feel better.

Detailed Answer:

Hi again,

I am sorry to hear about your relative's lost. Judging through internet it's quite difficult to conclude about the right responsible cause of that fatal complication.

Facing the severe arterial hypotension probably an acute pulmonary embolism (in such case you should know that almost half of such patients do not reach alive the hospital), a massive LV myocardial infarction or RV infarction could be deducted.

All the above are not rarely fatal diagnosis even in specialized hospitals.

Nevertheless, other possible causes could be responsible.

I believe that the clinical judgment of the assisting physicians could be more correct regarding the etiological diagnosis, as they have checked several tests during their emergency medical assistance.

Wishing you a good health,

Kind regards,

Dr. Iliri

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Brief Answer:
It is a very low probability for such a low dose of Carbamazepine.

Detailed Answer:

Hi,

Thought carbamazepine may rarely cause cardiac arrhythmia or thromboembolism, I don't believe it could be carbamazepine. It was started in such a small dose that it could hardly exert any serious adverse effects.

Could you please prescribe how did her clinical status (her complaints and other signs) prior the fatal event?

Regards,

Dr. Iliri

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Brief Answer:
A masive pulmonary embolism could be a rationale cause.

Detailed Answer:

Hello,

One of the most probable clinical scenarios seems to be pulmonary embolism. Nevertheless, other above mentioned alternatives could be possible, as well.

A massive cerebrovascular accident could not be excluded.

There seems that all the possible alternatives are highly life-threatening and regardless the medical assistance not rarely everything results unfortunately unsuccessful.

Sending to you my cordial condolences,

Take care of yourself,

Dr. Iliri

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Brief Answer:
Explanations as follows:

Detailed Answer:
Dear,

As your mum in law has experienced sudden respiratory distress the most probable cause of the fatal end may have been a massive thrombus that has obstructed the pulmonary blood circulation to such an extent that has produced collapse and subsequent death.

But, as I said above other alternatives may be possible (they also may appear with shortness of breath), such as a large myocardial or cerebral infarction.

That's my opinion on her most probable causes of death.

Please let me know if there remains any uncertainties.

Which part you don't understand?

I remain at your disposal for further explanations if necessary.

Kind regards,

Dr. Iliri

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Brief Answer:
I would recommend as follows:

Detailed Answer:
Dear XXXX!

Regarding your blood pressure readings (125/97), I would explain that besides several causes like diabetes, obesity, dyslipidemia, a physical inactivity, an important reason for such increased diastolic blood pressure may be an increased anxiety.

Can you please what is your body weight? What about your blood lipid profile?

Do you perform regularly physical activity?

What is your heart rate actually?

Taking into consideration the psychological stress of the latest days and the sleep deprivation, I would recommend starting an anxiolytic like alprazolam 0.25mg during the day.

If you have an elevated heart rate, low doses of propranolol would be also helpful.

You should closely monitor your blood pressure, several times during the day.

Meanwhile, I would recommend avoiding caffeine intake and try to regulate your sleeping regime.

Hope to have been helpful!

Greetings!

Dr. Iliri

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Brief Answer:
I recommend as follows:

Detailed Answer:

Hello again!

I would recommend performing more physical activity which is also very helpful against anxiety.

An anxiolytic like alprazolam or low doses of propranolol would be helpful.

It is important to closely monitor your blood pressure in the next week.

Greetings!

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