Levetiracetam - pregnancy considerations

 Hi!

Levetiracetam, used primarily for seizures control, is also used off-label for SAH, status epilepticus, seizure prophylaxis in craniotomy and traumatic brain injury.

Dosing is increased in pregnancy and closely monitored regularly due to various physiologic effects, especially in third trimester. (levitate dose of levetiracetam) :-

- increased volume of distribution, Vd (increase in plasma volume, CO)

- increased renal excretion (increase in GFR; levitate the rate)

- rapid and almost complete absorption via GIT  (unlike other drugs with decreased absorption in pregnancy)

- low risk of adverse effects and fetal malformations when used in monotherapy. (low with mono, high with poly)

- Levetiracetam is NOT metabolized by liver; Cyt P450 independent. Bioavailability 100%. (unlike other antiepileptics - hepatic metabolism increases in pregnancy)

Levetiracetam crosses placenta and can be detected in the newborn. (leve leaves mother)

The newborns are at greater risk of SGA and low APGAR score.

Protein-binding of the drug is low (<10%). So, decrease in albumin concentration during pregnancy does not significantly affect the drug concentration. (low pro)

That's all

- Jaskunwar Singh

Glomerulonephritis associated with infectious diseases mnemonic

Hepatitis B: Membranous glomerulonephritis

Hepatitis C: Membranoproliferative glomerulonephritis

HIV: Focal segmental glomerulosclerosis

By IkaN

Embryology of eye mnemonic

Hello friends!

Here's is the simplest way to remember embryology of eye.

*Out of all layers (ecto,meso, endo), the endoderm doesn't contribute to the embryology of eye.

* Mesoderm forms - extraocular muscles

* Rest of the structures are derived from ectoderm.

* Surface ectoderm forms the structures which are visible to us from outside like Corneal epithelium

Conjunctival epithelium

 Lacrimal gland

 Lens ( important)

*Neuroectoderm forms neural structures like

Retina

Ciliary body ( not muscles)

Iris - both sphincter and dilator pupillae

Optic nerve

* Neural crest derivatives are 

Meninges of optic nerve

Schwann cells

Ciliary ganglion

Ciliary muscles 

For the remaining derivatives, watch the following picture.

Thank you.

Dr. Madhuri Reddy. 

Kartagener syndrome mnemonic

 Hi!

Kartagener syndrome (primary ciliary dysfunction, aka immotile cilia syndrome) mnemonic :-

Toxoplasmosis classic triad mnemonic

 Hi!

Toxoplasmosis classic triad in neonates mnemonic: CATS 

- CAlcifications (intracranial)

- Tension hydrocephalus

- See (Chorioretinitis)

Also, check out this video mnemonic by IkaN

- Jaskunwar Singh

ARDS management mnemonic

 Maintenance “DOSE”

Dry Lungs - “Dry lungs -Happy lungs”

• Maintain negative fluid balance to reduce pulmonary edema

Open but not Over-distended 

Management of asymptomatic carotid atherosclerotic disease and carotid artery stenosis mnemonic

Super short post!

A) Asymptomatic

≥80% stenosis: Carotid endarterectomy

≤79% stenosis: Medical management

Mnemonic AGES: Asymptomatic Greater than Eighty Surgery

B) Symptomatic

≥70% stenosis: Carotid endarterectomy

Mnemonic SSS: Symptomatic Seventy Surgery

50%-69% stenosis

Male: Carotid endarterectomy

Female: Medical management

Mnemonic MMM: Males Manage More than fifty with surgery

<50% stenosis: Medical management

That's all!

-IkaN

Creatinine clearance in elderly - basic notes

 Hi!

Elderly people have a decrease in creatinine clearance (CrCl), which means an increase in serum Cr. It is observed that annual rate of this decrease in CrCl is approximately 1 ml/min. after the age of 50 years.

Therefore, it is important to calculate the dose and dosing intervals of nephrotoxic drugs (eg., aminoglycosides) in these patients in order to prevent the precipitation of ARF.

In general,

CrCl <100 ml/min is abnormal.

However, CrCl <10 ml/min signifies the onset and worsening of acute renal failure.

Note -

• GFR is directly proportional to CrCl.

• GFR decreases by age, but not always accompanied by rise in Cr.

• Cockcroft-Gault formula is commonly referred to for calculating CrCl.

CrCl = (Ucr × V)/Pcr (~GFR)

• Double the Cr = Half the GFR.

Note that those patients with signs of worsening diabetes and resulting glomerulopathies, an increase in both GFR and CrCl is seen, which thus causes hyper filtration injury. 

That's all

- Jaskunwar Singh

Rigler's triad mnemonic

 Hi!

Rigler's triad in gall stone ileus mnemonic:

GALL in GIT

Belimumab mnemonic

What is belimumab?

Belimumab is a  monoclonal antibody directed against soluble B lymphocyte stimulator (BLyS).

Belimumab is used in the treatment of? 

Systemic Lupus Erythematosus (SLE)

Mnemonic: Belly Selly SLE (rhymes! sing it enough times and you will never forget)

At present, belimumab is indicated as add-on therapy in adults with active, antinuclear antibody or anti-dsDNA-positive SLE with a high degree of disease activity in the skin and/or musculoskeletal systems that remain moderately to severely active despite optimized standard immunosuppression. 

Patients with severe lupus nephritis or active CNS lupus are not the candidates for belimumab.

That's all!

-IkaN

Direct oral anticoagulants (DOACs) dosing for stroke prevention in atrial fibrillation mnemonic

Hi everyone!

Here are some DOAC dosing mnemonics for atrial fibrillation! 

RivarOxaban: Once daily

Apixaban: Twice daily 

Dabigatran: Twice daily

EdOxaban: Once daily

Mnemonic: Drugs with O have Once-daily dosing. 

Rivaroxaban: 20 mg once daily with the evening meal (creatinine clearance [CrCl] >50 mL/minute); or 15 mg once daily with the evening meal (CrCl ≤50 mL/minute).

Mnemonic: R without the straight line | looks like 2 to me for 20 mg!

Apixaban: 5 mg twice daily (CrCl >50 mL/minute); or 2.5 mg twice daily for those with any two of the following: age ≥80 years, body weight ≤60 kg, or serum creatinine ≥1.5 mg/dL.

Mnemonic: Apixa has 5 letters for 5 mg!

Dabigatran: 110 mg BID or 150 mg BID (CrCl >30 mL/minute).

European labeling suggests dose reduction in patients older than 75 years (eg, 150 mg orally once per day or 110 mg orally twice per day).

Edoxaban: 30 mg (weight ≤60 kg) or 60 mg (weight >60 kg) orally once daily.

That's all!

Remember that the dosing varies for VTE treatment and prophylaxis so do not apply these mnemonics for VTE.

-IkaN

Formulation, absorption and associated side effect of dabigatran

Did you know that the absorption of dabigatran etexilate is dependent on an acid environment in the stomach?

This is why it is formulated together with tartaric acid pellets. These pellets provide an acidic environment, which increases drug dissolution and absorption, regardless of variations in gastric pH. This is also why the absorption is not affected by the coadministration of a proton pump inhibitor.

A lower pH is associated with dyspepsia, esophagitis, and plays a part in the increased risk of gastrointestinal bleeding.

-IkaN

Simvastatin combination with fibrates in clinical practice

 Hi!

High-yield in clinical practice:

DO NOT combine simvastatin with gemfibrozil (class-X interaction; high risk of acute liver damage and rhabdomyolysis). Inhibition of CYP450 enzyme by gemfibrozil plays the role in increasing levels of simvastatin 2-3x.

Combination of simvastatin with fenofibrate is relatively safer, although close observation and regular monitoring is required (class-C interaction). Serum levels of simvastatin remain unchanged.

- Jaskunwar Singh