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under category ‘A’ by MHRD, Gol Accredited with

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NGSM Institute of Pharmaceutical Sciences

CASE PRESENTATION SUBMITTED AS A PARTIAL FULFILLMENT
OF THE M. PHARM PROGRAMME
Name of the student : Nafeesa Shakoora S A.

University register number : NU22PHPP08

Course : M Pharm

Specialization : Pharmacy Practice

Semester : 2st

Year : 2022-2023

Subject : Pharmacotherapeutics II.

Topic : Case on alzheimers.

Date of submission : -06-2023

Signature of the student Signature of the staff in charge

Date: Date:
 CASE ON EPILEPSY AND ALZHEIMERS
PROBLEM LIST
▪ Breaking through seizure – epilepsy .
▪ Alzheimer’s
SOAP Analysis
SUBJECTIVE EVIDENCE
▪ C/o GTCS X 1 episode .
OBJECTIVE EVIDENCE
▪ Medical history : k/c/o epilepsy and Alzheimer on medication .
▪ Medication history : Tab. Clobazam 5mg 0-0-1.
▪ General examination : patient is drowsy , decreased mobility ,word output less and not
following simple commands .
▪ Laboratory tests :
▪ RBS : 154 mg/dl
ASSESSMENT:
▪ Final diagnosis: Based on subjective and objective evidence, the present case is found to
breaking through seizure – epilepsy and alzheimers .
▪ Etiology :
▪ Risk factors :
▪ Age .
▪ Family history
▪ Genetics (heredity)
▪ Is therapy indicated?
▪ Yes, therapy is indicated in this patient to prevent complications like inability to recognize
family members ,inability to understand language ,inability to perform the basic activities of
daily life, such as eating and dressing, falls and broken bones ,malnutrition and dehydration
,failure of body systems , bedsores ,muscle contractures ,infection.
Standard treatment algorithm

Current therapy:
SL.NO BRAND GENERIC DOSE FREQUENCY DURATION
NAME NAME
1 INJ. LEVIPIL LEVETIRAC 500mg 1-0-1 D1
ETAM
2 INJ. PANTOP PANTAPRAZ 40mg 1-0-1 D1-D4
OLE
3 TAB. CLOBAZAM 5mg 1-0-0 D1-D4
CLOBAZAM
4 TAB . LEVETIRAC 500mg 1-0-1 D2-D3
LEVIPIL ETAM
5 TAB. ALZIL DONEPEZIL 5mg 0-1-0 D1-D3
+MEMANTIN
E
ASSESSMENT OF CURRENT THERAPY
INJ. LEVIPIL , LEVETIRACETAM , 500mg , 1-0-1, D1
TAB. LEVIPIL , LEVETIRACETAM,500mg, 1-0-1,D2-D3
▪ CATEGORY :Antiseizure Agent
▪ INDICATION : It is used in the treatment of different forms of epilepsy
▪ MOA :binding to synaptic proteins which modulate neurotransmitter release.
▪ STD DOSE : oral - 3000 mg daily
IV – 4000 mg
▪ ADRS: fatigue, somnolence, dizziness, and infection
▪ JUSTIFICATION:This multicenter, randomized, double-blind, placebo-controlled, parallel-group
study enrolled adults and children (4 to 65 years) with IGE experiencing ≥3 GTC seizures during
the 8-week baseline period, despite receiving stable doses of one or two antiepileptic drugs .
Patients were randomized to levetiracetam Of 229 patients screened, 164 were randomized.
Levetiracetam produced a greater mean reduction in GTC seizure frequency per week over the
treatment period than placebo. Adjunctive levetiracetam is an effective and well-tolerated
antiepileptic drug for treating generalized tonic- clonic seizures in patients with idiopathic
generalized epilepsies.

TAB.PAN ,PANTAPRAZOLE,40mg,1-0-1,D1-D4
▪ CATEGORY: proton pump inhibitor
▪ INDICATION : Prophylaxis of Gastric irritation
▪ STANDARD DOSE : 20 to 40 mg once daily
▪ MOA : In the gastric parietal cell of the stomach, pantoprazole covalently binds to the H+/K+ ATP
pump to inhibit gastric acid and basal acid secretion.
▪ ADRs: headache, dizziness, vomiting, diarrhoea.
▪ JUSTIFICATION : 36 subjects received pantoprazole in a three-way crossover design study.
Ambulatory 24-h intragastric pH and distal esophageal pH were monitored at baseline and on the
last day of each treatment period. Safety was evaluated by incidence and severity of adverse
events. Pantoprazole demonstrated a linear dose- dependent suppression of gastric acidity over the
dose range 10-40 mg. All pantoprazole doses were well tolerated. Pantoprazole demonstrates a
dose-related effect in the range 10-40 mg once daily. The once-daily dose of 40 mg provides the
highest and most consistent control of gastric pH.
TAB. CLOBAZAM , CLOBAZAM, 5mg , 1-0-0 , D1-D4
▪ CATEGORY :Antiseizure Agent, Benzodiazepine
▪ INDICATION : It is used in the treatment of different forms of epilepsy
▪ MOA : Enhancement of the inhibitory effect of GABA on neuronal excitability results by
increased neuronal membrane permeability to chloride ions. This shift in chloride ions results in
hyperpolarization and stabilization.
▪ STD DOSE : maximum 40 mg/day.
▪ ADRS: Drowsiness (16% to 25%), lethargy (10% to 15%), drooling (13% to 14%), aggressive
behavior (8% to 14%), irritability (11%)
▪ JUSTIFICATION:This study was performed on the patients prescribed antiepileptic medication
who had clobazam as last added drug in their treatment regimen during October 2010 - March
2012. Of the 417 consecutive patients, 132 (31.7%) were on clobazam treatment for more than
four years (median 6 yr, range 4-15 yr). No seizure for previous 12 months was considered as
seizure free and was observed in 151 (36.2%) patients. There was no improvement in seizure
control in 32 (7.7%) patients. A decrease in seizure severity without any change in seizure
frequency was observed in 76 (18.2%) patients. Our results provide valuable information about
the clinical use of clobazam as add-on antiepileptic drug therapy in the management of patients
with epilepsy.

TAB. ALZIL , DONEPEZIL +MEMANTINE, 5MG , 0-1-0, D1-D3

▪ DONEPEZIL
▪ CATEGORY : Acetylcholinesterase Inhibitor
▪ INDICATION :Treatment of mild, moderate, or severe dementia of the Alzheimer type
▪ MOA : Donepezil reversibly and noncompetitively inhibits centrally active acetylcholinesterase,
the enzyme responsible for hydrolysis of acetylcholine.
▪ STD DOSE:23 mg/day
▪ ADRS:Diarrhea (5% to 15%) ,nausea (3% to 19%)

▪ MEMANTINE
▪ CATEGORY :N-Methyl-D-Aspartate (NMDA) Receptor Antagonist
▪ INDICATION : Treatment moderate, or severe dementia of the Alzheimer type
▪ MOA : Memantine binds to the intra-pore magnesium site, and thus functions as an effective
receptor blocker only under conditions of excessive stimulation
▪ STD DOSE: 20 mg per day in two divided doses
▪ ADRS: constipation (3% to 5%), diarrhea (5%), vomiting (2% to 3%) ,headache (6%)
▪ JUSTIFICATION:Of 936 records screened, we included 54 trials in this analysis. The combination
therapy was more effective in improving cognition , 95% credible interval −10.73 to 0.86 in the
Alzheimer's Disease Assessment Scale-Cognitive Subscale;. Memantine was more acceptable than
placebo .Memantine plus donepezil showed superior outcomes for cognition, global assessment,
daily activities, and neuropsychiatric symptoms, but lower acceptability than monotherapy and
placebo. Combination therapy may be more cost-effective, because memantine slows the
progression of AD.

PLANNING
▪ General treatment goals:
▪ Educate the individual living with dementia and the family
▪ Appropriate treatment to help manage the psychiatric and behavioral sequence .
▪ Patient specific goals:
▪ Reduce the symptoms.
▪ Maintain quality of life.
▪ Therapeutic monitoring parameters:
▪ MRI
▪ CT Scan
▪ Monitoring of language , orientation ,motor skills and memory.
▪ Toxicity monitoring parameters:
▪ Levetiracetam –Renal impairment .
▪ Points to patient:
▪ About the disease:
▪ You are suffering from alzheimer diseases, Alzheimer’s disease is a brain disorder that slowly
affect memory and thinking skills and, eventually, the ability to carry out the simplest tasks .
▪ Discharge medication :
SL. BRAND NAME GENERIC NAME DOSE FREQUENCY DURATION
NO
1 TAB.CLOBAZAM CLOBAZAM 5mg 1-0-0 TO
CONTINUE
2 TAB . LEVIPIL LEVETIRACETAM 500mg 1-0-1 TO
CONTINUE

3 TAB. ALZIL M DONEPEZIL 5mg 0-1-0 TO

+MEMANTINE CONTINUE

▪ About medication:
▪ Tab. Clobazam 5mg 1-0-0 should be taken in the morning to continue.
▪ Tab . Levipil500mg 1-0-1 should be taken twice a day morning and night to continue .
▪ Tab . Alzil M 5 mg 0-1-0 should be taken in afternoon to continue .
▪ Lifestyle modification:
▪ People with AD may get upset and disoriented. A home that is quiet and restful can help the patient
▪ Have a healthy diet with a lot of sea food , fruits and vegetables , whole grain , seeds and nuts and olive
oil.
▪ People with AD will have a harder time taking care of themselves. Caregivers will need to check for
things like their hunger, thirst, and emotions.
▪ Follow up:
▪ Review after 2 weeks in MED 4OPD on a Thursday and in neurology OPD .
REFERENCES:
1. Berkovic SF, Knowlton RC, Leroy RF, Schiemann J, Falter U. Placebo-controlled study of
levetiracetam in idiopathic generalized epilepsy. Neurology. 2007 Oct 30;69(18):1751-60.
2. Tutuian R, Katz P O, Bochenek W, Castel D O. Dose-dependent control of intragastric pH by
pantoprazole, 10, 20 or 40 mg, in healthy volunteers. Aliment Pharmacology Therapy. 2002; 16(4):829-
836.
3. Joshi R, Tripathi M, Gupta P, Gupta YK. Effect of clobazam as add-on antiepileptic drug in patients
with epilepsy. The Indian Journal of Medical Research. 2014 Aug;140(2):209.
4. Guo J, Wang Z, Liu R, Huang Y, Zhang N, Zhang R. Memantine, donepezil, or combination therapy—
what is the best therapy for Alzheimer’s disease? A network meta‐analysis. Brain and Behavior. 2020
Nov;10(11):e01831.