Self-Care for Central Nervous System Disorders

Case 1: Antiepileptic Medications and Bone Health

Q: OT, a 43-year-old woman, is seeking a recommendation for a vitamin D supplement. She reports having a seizure disorder for which she has been prescribed and has been compliant with phenytoin therapy for many years. OT reports a recent fall and a wrist fracture, and she is following up with her primary care provider for further evaluation and screening for osteoporosis. She remembers being told after her fracture to pick up a calcium and vitamin D supplement and would like a recommendation for such a product. OT understands that these agents can slow the progression of bone disease and improve bone function, which may reduce her risk of subsequent fractures. What can you suggest regarding supplement use for her?

A: Support for bone health represents an important consideration for patients with epilepsy. Chronic use of antiepileptic medications, particularly carbamazepine, phenobarbital, phenytoin, and primidone, agents known to induce hepatic CYP450 isoenzymes, may predispose individuals to bone abnormalities, including reductions in serum vitamin D levels because of enhanced vitamin D metabolism, reduced bone mineral density, and increased risk of fracture.¹ There are no specific guidelines for the use of calcium and vitamin D supplementation in individuals with epilepsy who are prescribed antiepileptic medications. Evaluation of serum values for calcium, vitamin D, and other markers of bone function, such as parathyroid hormone and phosphorus, may help guide optimal supplementation and therapy. Because OT recently experienced a fracture, underscore the importance of her following up with her physician for further evaluation of her bone health, as initiation of prescription medications and lifestyle interventions may be warranted. Although this patient’s epilepsy is well controlled, encourage her to follow up with her neurologist and primary care physician regarding recommendations for evaluation for osteoporosis and consideration for reevaluation of antiepileptic drug selection. Recommend, in the interim, that OT follow national dietary guidelines for her age and gender for calcium (1000 mg per day) and vitamin D (600 IU per day).²

Case 2: Antiepileptic Medications and Dental Hygiene

Q: WR, a 32-year-old woman, has a question about oral hygiene. She explains that she has a seizure disorder and has tried multiple medications over the years. WR recently started taking phenytoin to try to optimize management of her seizures. She received counseling and education from her neurologist about the potential adverse effects associated with this medication and would like a recommendation for the best tooth care items for preventing the development of dental issues associated with this drug. WR denies allergies to medications and reports no other significant medical history. What counseling can you provide regarding prevention of potential dental adverse effects associated with phenytoin use?

A: Individuals with epilepsy are at an increased risk of experiencing a number of dental issues, including an increased risk of dental caries secondary to bite injury to the tongue, oral trauma, and xerostomia.³ Antiepileptic medication use is additionally attributed to a number of adverse effects of the oral mucosa, including bleeding gums, delayed healing, and gingival hyperplasia.³ Gingival hyperplasia, in particular, is thought to result from both epithelial and submucosal tissue damage, with risk factors including dental plaque accumulation, gingival inflammation, and poor dental hygiene.^3,4 Patients who take antiepileptic drugs or other medications that may predispose them to gingival enlargement, such as calcium channel blockers and cyclosporine, should be educated about the importance of daily brushing to control plaque, regular flossing, and periodic professional cleaning.^3-5 Remind WR about the importance of routine dental hygiene, and encourage her to follow up with a dental health professional if she develops any new dental complaints or changes in her dental health.

Case 3: Natural Remedies for Anxiety Relief

Q: TW, a 32-year-old woman, is seeking advice about self-treatment for anxiety. She reports worrying about finances, the health of several elderly family members, and her job and work performance. TW is unable to sleep restfully at night and describes having difficulty falling asleep because her mind is always racing. Her sleeplessness is interfering with her ability to function at work each day. TW denies other medical problems and allergies to medications. She has not yet discussed these symptoms with a mental health specialist or her primary care provider and, in lieu of medications, would like a recommendation for an herbal supplement or a tea to help alleviate her symptoms. What suggestions for self-care for anxiety can you provide?

A: Anxiety and anxiety disorders represent the most common mental illnesses in the United States, affecting an estimated 40 million Americans, or 18.1% of the adult population.⁶ Self-care—including implementing lifestyle modifications such as avoiding alcohol, eating well, participating in physical exercise, and stopping smoking, if applicable—plays an important role in the management of anxiety symptoms.^6,7 Although self-care represents an important aspect of anxiety management, remind this patient that medical evaluation and prescription-only pharmacologic interventions are effective options in the treatment of anxiety disorders that are interrupting an individual’s daily life. Behavioral therapy and counseling may be able to help improve TW’s resilience and ability to cope with the number of factors she describes as contributing to her symptoms. Although several herbal medications and herbs are believed to alleviate mild anxiety symptoms and promote sleep, use of these agents is not without risk. As an example, kava, long recognized for promoting relaxation, has been cited for increasing the risk of severe liver injury.⁸ Recommend lifestyle interventions and relaxation therapy to help TW cope with her symptoms, but also let her know that if those symptoms persist or become more debilitating or frequent, physician consultation is advised.

Case 4: Antihistamine for Multiple Sclerosis

Q: TR, a 34-year-old woman, is seeking information about an OTC option for correcting vision damage associated with multiple sclerosis (MS). She reports that she has been intermittently suffering from visual impairment, which her neurologist thinks is associated with complications of MS. TR has been researching visual changes and impairment in patients with MS online and came across a study suggesting that an OTC antihistamine, clemastine, could have a positive effect on her vision, and she would like help in determining whether this treatment is appropriate. What information can you provide her about using clemastine?

A: Optic neuritis, characterized by episodes of acute or gradual vision changes such as blurred vision, loss of color vision, pain with ocular movement, and, in rare cases, blindness, is a common symptom affecting individuals suffering from relapsing-remitting MS.⁹ Inflammation of the optic nerve is thought to cause these symptoms, and the demyelination characteristic of MS may also interfere with transmission of vision input to the brain.⁹ Visual symptoms may be temporary and improve in days to weeks with or without intervention. Steroids are often used for targeting underlying inflammation and managing flare-ups of this condition. Clemastine, an OTC antihistamine, is being researched as a potential therapy with myelin-repairing properties for correcting optic neuritis symptoms in clinical trials, and it seems that its use has resulted in symptom improvement in a small number of patients.¹⁰ Remind TR that this is not an approved indication for the use of OTC clemastine and that the doses used in the studies conducted far exceed the OTC product strengths available.¹⁰ For more information about this treatment option, encourage her to speak with a neurologist.

Mary Barna Bridgeman, PharmD, BCPS, BCGP, is a clinical associate professor at the Ernest Mario School of Pharmacy at Rutgers University in Piscataway, New Jersey, and an internal medicine clinical pharmacist at Robert Wood Johnson University Hospital in New Brunswick, New Jersey.

Rupal Patel Mansukhani, PharmD, is a clinical associate professor at the Ernest Mario School of Pharmacy, and a transitions-of-care clinical pharmacist at Morristown Medical Center in New Jersey.

References

• Arora E, Singh H, Gupta YK. Impact of antiepileptic drugs on bone health: need for monitoring, treatment, and prevention strategies. J Family Med Prim Care. 2016;5(2):248-253. doi: 10.4103/2249-4863.192338.
• Calcium/vitamin D. National Osteoporosis Foundation website. nof.org/patients/treatment/calciumvitamin-d/. Accessed February 2, 2018.
• University of Washington School of Dentistry. Oral health fact sheet for dental professionals: adults with epilepsy. dental.washington.edu/wp-content/media/sp_need_pdfs/Epilepsy-Adult.pdf. Accessed February 2, 2018.
• Mejia LM. Drug-induced gingival hyperplasia. Medscape website.emedicine.medscape.com/article/1076264- overview?pa=EsLGSG3VSteoBpFBHdToxkt0VysHCpoJmQd7Zzw%2FVhsddmUvV64 Rt5uX4FSgUja2kmqv2rQ%2BqGQ912rFh5TcMYdHiuSJDifRp%2BEZ0GL%2FEKg% 3D. Published December 9, 2016. Accessed February 1, 2018.
• Gum disease. American Dental Association website. mouthhealthy.org/en/az- topics/g/gum-disease. Accessed February 1, 2018.
• Facts and statistics. Anxiety and Depression Association of America website. adaa.org/about-adaa/press-room/facts-statistics#. Accessed February 2, 2018.
• National Institute of Mental Health. Any anxiety disorder. nimh.nih.gov/health/statistics/prevalence/any-anxiety- disorder-among- adults.shtml. Updated November 2017. Accessed February 2, 2018.
• National Institutes of Health. Drug record — kava kave (piper methysticum). livertox.nih.gov/KavaKava.htm. Updated January 18, 2018. Accessed February 21, 2018.
• Optic neuritis: when MS affects your vision. WebMD website. webmd.com/multiple- sclerosis/guide/optic-neuritis- ms-vision#1. Accessed February 2, 2018.
• Green AJ, Gelfand JM, Cree BA, et al. Clemastine fumarate as a remyelinating therapy for multiple sclerosis (ReBUILD): a randomized, controlled, double-blind, crossover trial. Lancet. 2017;390(10111):2481-2489. doi: 10.1016/S0140-6736(17)32346- 2.