A case study on Rheumatoid arthritis with cervical myelopathy with recent onset on seizures.

1. R A W ITH CER VICA L M YELO PATHY W ITH SEIZ U R E DISO R DER
By faith I mean a vision of good one cherishes and the enthusiasm that pushes one to seek its fulfillment regardless of obstacles.
CASE STUDY
RIDDHI
PAWASKAR

2. 01 Work Summary
02 Hospital Introduction
03 Successful Medical Cases
04 Work Plan
Subjective data
NAME: LMN AGE: 51 SEX: F DOA: 01/12/19
CHIEF COMPLAINTS:
i. Numbness with tingling sensation in both lower limbs
ii. Pain ++
RA seizure CM-Riddhi 2

3. 20%
25%
15%
40%
65%
OBJECTIVE DATA
Medical history
k/c/o RA with seizure with cervical
myelopathy since 2Y
LRTI : 20/9/19
Chronic mastoiditis: 13/4/17
Otitis media: 17/3/17
Positive Family history for seizures
No significant Social H/O or allergies
RA seizure CM-Riddhi 3

4. 20%
25%
15%
40%
65%
OBJECTIVE DATA
Medical history
k/c/o RA with seizure with cervical
myelopathy
LRTI : 20/9/19
Chronic mastoiditis: 13/4/17
Otitis media: 17/3/17
Positive Family history for seizures
No significant Social H/O or allergies
 GENERAL: Moderate
 Pt. on ventilator endotracheal tubing with BIPAP
 Foley’s catheter
 VITALS: BP:130/80 Temp: 98F SpO2: 98%
 CVS: S1 S2 no murmur
 CNS: drowsy, obeys, moves all limbs
 RS: AE bilateral crepts+
 GI: soft, tender
 EXT: severe ache, altered sensation
 PAS: 7/10
RA seizure CM-Riddhi 4

5. PREVIOUS MEDICATIONS
LRTI : 20/9/19
RA seizure CM-Riddhi 5
MEDICATIONS CONSTITUENT
1) Tab . Zorax CV BD Acyclovir 400mg
2) Tab. Ultracet OD Paracetamol/Acetaminophen
(325mg) + Tramadol (37.5mg)
3) Tab. Xysal OD Levocetirizine 5mg
4) Syp Vitacan 5ml BD MULTIVITAMIN WITH CO Q10 &
LYCOPENE
5) Otrivin nasal drops SOS Xylometazoline 0.1%

6. PREVIOUS MEDICATIONS
OTITIS MEDIA WITH MASTOIDITIS
: 17/3/17
RA seizure CM-Riddhi 6
MEDICATIONS DISCHARGE MEDICATIONS
1) Tb Levipil –levetiracetam 500mg OD 1) Tb. Septran DS Trimethoprim (80 mg) +
Sulfamethoxazole (400 mg)
2) Tb.Zerodol 2) Tb. Tempina-650mg BD
3) Tab.Rabtab LSR BD 3) Tb Levipil –levetiracetam 500mg OD
4) Candibiotic ear drop (Medicine
composition: Lidocaine, Beclometasone, Clotrimazole, Chlo
ramphenicol) 3dropsX QID
4) Tb. Cazole- Fluconazole 150mg OD
5) Stamlo Beta
Amlodipine (5 mg) + Atenolol (50 mg)
5) Tb Furent-Nitrofurantoin 100mg BD
6) Otrivin nasal drops 6) Stamlo Beta

7. LAB INVESTIGATION: MRI
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RA seizure CM-Riddhi 7
CERVICAL SPINE:
 Cervical spondylitis with partial disc degeneration
 Widening of atlanto-occipital & atlanto-axial joints and erosion of odontoid with
posterior displacement
 Mild cervico-medullary compressive myelopathy consistent with Atlanto-Axial
dissociation due to RA
 Posteriocentral disc protrusions C3-4 & C6-7
 Mild cord and exiting bil. C4, C7–nerve root compressions

8. LAB INVESTIGATION
HAEMOTOLOGY
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RA seizure CM-Riddhi 8
i. Hb: 13g/ dL
ii. ESR: 68ML/HR
iii. NEUT: 90%(40-70%)
iv. LYM: 8%(20-45%)
v. WBC: 13100/cumm
vi. MCHC: 30.44 fl(32-36)
vii. MCH: 24.86 fl(27-32fl)
 S.BUN- 4.5mg/dL (5-25mg/dL)
 S.Creat- 0.7mg/dL (0.8-1.4mg/dL)
 SGPT- 27 U/L (upto 40 IU/L)
 SGOT- 18 U/L (upto 40 IU/L)
 RBG: 116 mg/dL(60-120mg/dL)
 S.Na:122mEq/L(125-135mEq/ L)

9. LAB INVESTIGATION
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RA seizure CM-Riddhi 9
URINALYSIS
• Yellow, clear
• RBC: 3-4/hpf
• Proteins , sugar, ketone
bodies, Bile salts &
pigments: Ab
• Urobilinogen: 0.2
• Pus cells: 5-6/hpf
• Epithelial cells: 4-5/hpf
• Crystalloids,bacteria:Ab
ECG
Sinus tachycardia with
QT Prolongation

10. LAB INVESTIGATION
CULTURE SENSITIVITY TEST
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RA seizure CM-Riddhi 10
E.coli isolated
 RESISTANT:
 Ampicillin
 Salbactam
 Co trimaxazole
 Ceftzidime
 Ceftriaxone
 Cefoperazone
 Cefepime
 Cefotaxime
 Tazobactam
 Gatifloxacin
 Levofloxacin
 Norfloxacin
 Ofloxacin
 Tetracyclin
 INTER MEDIATE –
SENSITIVE:
 Amikacin
 Meropenem
 Netilmycin
 Piperacillin-Tazobactam
 SENSITIVE:
 Nitrofurantoin(78%)
 Imepenem(80%)
 Gentamycin(82%)
 Colistin(86%)

11. BP:128/81
HR:75
RR: 19
Inj. XTUM
stopped due to
allergy.
Inj. CLAVUM
started
Tb. Etiozola
OD,rest ct all
BP 130/80
BP: 130/80
Inj NORAD
tapered off by
0.5ml/hr
BP: 110/70
PR 80/min
Progress Chart
Tramadol BD jt. pain
BP,SpO2 N
Giddiness
drowsy
Dyspnea decreased
afebrile
No new complaints No new complaints
RA seizure CM-Riddhi 11

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PATIENT NAME: XYZ HOSP. NO:
AGE: yr WEIGHT: kg SEX:
M/F:Male
DATE OF ADMISSION: 11 /02/18
DATE OF DISCHARGE: 14/02/18
COMPLAINTS ON ADMISSION :

MEDICAL HISTORY :
MEDICATION HISTORY : -
SOCIAL HISTORY:
FAMILY HISTORY: NS
PREVIOUS ALLERGIES: N/S
PHYSICAL EXAMINATION: moderately build and nourished, conscious and co-operative
GENERAL - no P I C C L E
VITAL SIGNS - PR: 90 /min ; BP : 110/80mmhg, R.R:- N/A,
HEENT - N/S
CVS - S1 S2 heard; no murmurs
RS - N/S
GIT - N/S
GU - N/S
EXT - reflexes were normal.
CNS - conscious and oriented
PROVISIONAL DIAGNOSIS:
ROUTINE BIOCHEMICAL INVESTIGATIONS HAEMATOLOGY
Urea: mg/dl
S.Cr :mg/dl
Na: mEq/L
K: mEq/L
FBS:
PPBS:
RBS:
Tch :
TGs :
T Bili:
D Bili:
T. Prot:
Alb:
Glob:
AST:
ALT:
ALP:
HIV
HBSAG
RBC : Retics:
WBC: Hb:
N: PCV:
L: MCV:
M: MCH:
E: MCHC:
B: ESR:
Platelets:.
ECG IMAGING:
XR
USG
URINE ANALYSIS
pH: WBC:
Protein RBC:
Sugars: EP.
Blood: Casts:
Crystals:
Stool –
CT
MRI
DRUG WITH DOSE & ROUTE DURATION OF THERAPY
GENERIC NAME BRAND NAME
1
2
3
4
5
6
7
8
9
8
8
√ √ √ √
√
√ √ √ √
√ √ √ √
√
DISCHARGE MEDICATIONS:
DISCHARGE MEDICATIONS:
Patient not discharged
DAY INVESTIGATIONS
D1
D2
D3
PR – beats/min
BP – mmHg
PR – 80 beats/min
BP – mmHg
PR – 86 beats/min
BP – 100/80 mmHg
REVIEW:
Visit after 1 week
DRUG TREATMENT CHART: PROGRESS CHART:
Medication Dose and duration 1 2 3 4 5
+

13. ¤ GENERIC: Norepinephrine (2mg/Ml)
¤ CATEGORY: Alpha/Beta Agonist
¤ MOA:. Stimulates beta1-adrenergic receptors and alpha-adrenergic receptors causing increased contractility and heart rate as well as
vasoconstriction, thereby increasing systemic blood pressure and coronary blood flow; clinically, alpha effects (vasoconstriction) are
greater than beta effects (inotropic and chronotropic effects)
¤ INDICATIONS. Cardiogenic Shock ,hypotension,ACLS, septic sock: The 2016 Surviving Sepsis Campaign: International Guidelines for
Management of Sepsis and Septic Shock recommends norepinephrine as the first-choice vasopressor for management of septic shock
¤ CONTRAINDICATIONS: during anesthesia with cyclopropane,,sinus tachycardia,
¤ ADVERSE EVENTS: headache, anxiety, arrhythmias, bradycardia, respiratory difficulty, ischemic injury, or extravasation at the infusion
site.,plasma volume depletion, gangrene
¤ PREGNANCY: US FDA pregnancy category: C
¤ STD. DOSE: Initial dose: 8 to 12 mcg/min continuous IV infusion
Maintenance dose: 2 to 4 mcg/min continuous IV infusion( each ml contains 80 micrograms noradrenaline tartrate equivalent to 40
micrograms noradrenaline base)
Duration of therapy: Continue infusion until adequate blood pressure and tissue perfusion are maintained without therapy.
¤ Phentolamine is the local antidote for peripheral ischemia resulting from extravasation of norepinephrine
01

14. ¤ GENERIC: Levitaracetam
¤ CATEGORY: Anti epileptic
¤ MOA:. inhibition of voltage-dependent N-type calcium channels; facilitation of GABA-ergic inhibitory transmission through
displacement of negative modulators; reduction of delayed rectifier potassium current; and/or binding to synaptic proteins which
modulate neurotransmitter release.
¤ INDICATIONS: Focal (partial) onset, Juvenile myoclonic epilepsy, Primary generalized tonic-clonic seizures, Subarachnoid hemorrhage,
traumatic brain injury( short term seizure prophylaxis) STATUS EPILEPTICUS
¤ CONTRAINDICATIONS: Hypersensitivity (eg, anaphylaxis, angioedema) to levetiracetam or any component of the formulation
¤ ADVERSE EVENTS: infection, neurosis, drowsiness, asthenia, headache, nasopharyngitis, nervousness, abnormal behavior, aggressive
behavior, agitation, anxiety, apathy, depersonalization, depression, fatigue, hostility, hyperkinetic muscle activity, mental disorders,
outbursts of anger, personality disorder, emotional lability, irritability, laceration, and mood changes.
¤ PREGNANCY: US FDA pregnancy category: C
¤ STD. DOSE: IV: Initial: 500 mg twice daily; increase every 2 weeks by 500 mg/dose based on response and tolerability to a maximum of
1.5 g twice daily.
02

15. ¤ GENERIC: TRAMADOL
¤ CATEGORY: Analgesic, Opioid
¤ MOA:. Tramadol and its active metabolite (M1) binds to μ-opiate receptors in the CNS causing inhibition of ascending pain pathways,
altering the perception of and response to pain; also inhibits the reuptake of norepinephrine and serotonin, which are
neurotransmitters involved in the descending inhibitory pain pathway responsible for pain relief
¤ INDICATIONS. Osteoarthritis, septic arthritis, RLS,Osteomyelitis
¤ CONTRAINDICATIONS: pediatric patients <12 years; postoperative management in pediatric patients <18 years who have undergone
tonsillectomy and/or adenoidectomy; significant respiratory depression; acute or severe bronchial asthma in the absence of
appropriately monitored settings and/or resuscitative equipment; GI obstruction, including paralytic ileus (known or suspected);
concomitant use with or within 14 days following MAO inhibitor therapy.
¤ ADVERSE EVENTS: pruritus, agitation, anxiety, constipation, diarrhea, hallucination, nausea, tremor, vomiting, and diaphoresis, insomnia
¤ PREGNANCY: US FDA pregnancy category: Not Assigned
¤ STD. DOSE: 50 to 100 mg orally every 4 to 6 hours as needed for pain
-For patients not requiring rapid onset of analgesic effect: Initial dose: 25 mg orally once a day; titrate in 25 mg increments every 3
days to reach a dose of 25 mg four times a day; thereafter increase by 50 mg as tolerated every 3 days
Maximum dose: 400 mg per day
03

16. ¤ GENERIC: ETIZOLAM
¤ CATEGORY: BENZODIAZEPINE
¤ 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 (a less excitable state) and stabilization. Benzodiazepine receptors
and effects appear to be linked to the GABA-A receptors in limbic and reticular system
¤ INDICATIONS: Insomnia, Oral sedation prior to outpatient dental procedure, anxiety, disorder
¤ CONTRAINDICATIONS: Hypersensitivity to triazolam, other benzodiazepines, or any component of the formulation; concurrent therapy with
strong cytochrome P450 3A (CYP 3A) inhibitors (eg, itraconazole, ketoconazole, nefazodone, lopinavir, ritonavir).
¤ ADVERSE EVENTS: dizziness, insomnia, rebound insomnia, headache, and irritability., dystonia, syncope
¤ PREGNANCY: US FDA pregnancy category: X
¤ STD. DOSE: Initial dose: 0.25 mg orally once a day at bedtime
Maintenance dose: 0.125 to 0.25 mg orally once a day
Maximum dose: 0.5 mg/day
Duration of therapy: 7 to 10 days
04

17. ¤ GENERIC: DEXAMETHASONE 4 mg/mL (1 mL)
¤ CATEGORY: Anti-inflammatory Agent
Antiemetic
Corticosteroid, Systemic
¤ MOA:. Dexamethasone is a long acting corticosteroid with minimal sodium-retaining potential. It decreases inflammation by
suppression of neutrophil migration, decreased production of inflammatory mediators, and reversal of increased capillary permeability;
suppresses normal immune response. Dexamethasone's mechanism of antiemetic activity is unknown.
¤ INDICATIONS: synovitis of osteoarthritis, rheumatoid arthritis, acute and subacute bursitis, acute gouty arthritis, epicondylitis, acute
nonspecific tenosynovitis, and posttraumatic osteoarthritis., allergic, hematologic (eg, immune thrombocytopenia), dermatologic,
neoplastic, rheumatic, autoimmune, nervous system, renal, and respiratory origin; primary or secondary adrenocorticoid deficiency (not
first line); management of shock, cerebral edema,
CONTRAINDICATIONS: Hypersensitivity to dexamethasone or any component of the formulation; systemic fungal infections
Documentation of allergenic cross-reactivity for corticosteroids is limited.
¤ ADVERSE EVENTS: alteration in glucose tolerance, behavioral and mood changes, increased appetite, and weight gain; the incidence
generally correlates with dosage, timing of administration, and duration of treatment. polycythemia, abnormal coagulation,
polymorphonuclear leukocytosis
¤ PREGNANCY: US FDA pregnancy category C-BENEFIT SHOULD OUTWEIGH THE RISK
¤ STD. DOSE: Parenteral: dose: 0.5 mg to 9 mg IV or IM per day in divided doses every 12 hours
05

18. ¤ GENERIC: HYDROCORTISONE
¤ CATEGORY: Corticosteroid, Systemic
¤ MOA:May depress the formation, release, and activity of endogenous chemical mediators of inflammation (kinins, histamine, liposomal
enzymes, prostaglandins) through the induction of phospholipase A2 inhibitory proteins (lipocortins) and sequential inhibition of the
release of arachidonic acid. Hydrocortisone has low to intermediate range potency (dosage-form dependent).
¤ INDICATIONS: immune thrombocytopenia, warm autoimmune hemolytic anemia), allergic, gastrointestinal (eg, Crohn disease, ulcerative
colitis), inflammatory, neoplastic, neurologic (eg, multiple sclerosis), rheumatic (eg, antineutrophil cytoplasmic antibody-associated
vasculitis, dermatomyositis/polymyositis, gout [acute flare], mixed cryoglobulinemia syndrome, polyarteritis nodosa, rheumatoid
arthritis, systemic lupus erythematosus), and/or autoimmune origin.
¤ CONTRAINDICATIONS: systemic fungal infection,hypersensitivity, ITP
¤ ADVERSE EVENTS: Pancreatitis, HTN, Weight loss, seizures, eosinophilia
¤ PREGNANCY: US FDA pregnancy category: C
¤ STD. DOSE: 80 to 100 mg IM once a week for 1 to 4 week
06

19. ¤ GENERIC: Ceftriaxone (1000 mg) + Sulbactam (500 mg)
¤ CATEGORY: Antibiotic, Cephalosporin
¤ MOA: Inhibits bacterial cell wall synthesis by binding to one or more of the penicillin-binding proteins (PBPs)
¤ INDICATIONS: Pyelonephritis, noscomical pneumonia, UTI,
¤ CONTRAINDICATIONS: hypersensitivity to ceftolozane/tazobactam, piperacillin/tazobactam, other members of the beta-lactam class
¤ ADVERSE EVENTS: Fever, irregular heartbeat, dizziness, abdominal pain
¤ PREGNANCY: US FDA pregnancy category Not Assigned
¤ STD. DOSE: 1.5 g IV every 8 hours
Duration of therapy: 7 days
07

20. ¤ GENERIC: Amoxicillin ( 500mg) + Clavunate ( 125mg)
¤ CATEGORY: Antibiotic, Penicillin
¤ MOA: Inhibits bacterial cell wall synthesis by binding to one or more of the penicillin-binding proteins (PBPs)
¤ INDICATIONS: Aspiration Pneumonia, Bacterial Infection, Bone infection, Deep Neck Infection, Endocarditis, Epiglottitis, Intraabdominal
Infection, Joint Infection, Kidney Infections, Meningitis, Pelvic Inflammatory Disease, Peritonitis, Pneumonia, Sinusitis, Skin and
Structure Infection, Skin or Soft Tissue Infection, Surgical Prophylaxis and Urinary Tract Infection.
¤ CONTRAINDICATIONS: hypersensitivity to any members of the beta-lactam class, history of cholestatic jaundice or hepatic dysfunction
with amoxicillin/clavulanate potassium therapy, Severe renal impairment (creatinine clearance <30 mL/minute) and hemodialysis
patients,mononucleosis
¤ ADVERSE EVENTS: Fever, irregular heartbeat, dizziness, abdominal pain
¤ PREGNANCY: US FDA pregnancy category B
¤ STD. DOSE: 500 mg orally every 8 hours or 875 mg orally every 12 hours for 7 to 10 days
07

21. ¤ GENERIC: FUROSEMIDE
¤ CLASS: Diuretic
¤ MOA: Primarily inhibits reabsorption of sodium and chloride in the ascending loop of Henle and proximal and distal renal tubules,
interfering with the chloride-binding cotransport system, thus causing its natriuretic effect
¤ INDICATIONS: Management of edema associated with heart failure, cirrhosis of the liver (ie, ascites), or renal disease (including nephrotic
syndrome); acute pulmonary edema.
¤ CONTRAINDICATIONS: Hypersensitivity to sulfonamide-derived drugs; complete renal shutdown; hepatic coma and precoma; uncorrected
states of electrolyte depletion, hypovolemia, dehydration, hyperbilirubinemiaor hypoten
¤ ADVERSE EVENTS: electrolyte depletion, painful urination, syncope, SIADH
¤ PRECAUTIONS: Furosemide is a potent diuretic which, if given in excessive amounts, can lead to a profound diuresis with water and
electrolyte depletion.
¤ PREGNANCY: US FDA pregnancy category C
¤ STD. DOSE: Initial dose: 20 to 40 mg IV (slowly over 1 to 2 minutes) or IM once; may repeat with the same dose or increase by 20 mg no
sooner than 2 hours after the previous dose until the desired diuretic effect has been obtained.
Maintenance dose: Administer the dose that provided the desired diuretic effect once or twice a day.
08

22. ¤ Generic– Pantoprazole
¤ MOA–It is a proton pump inhibitor,inhibits H,K ATPase enzyme which secretes HCl in parietel cells of stomach
¤ Indications-Ulcers and reflux oesophagitis,GERD,Zollinger-Ellison syndrome
¤ Contraindication- Hypersensitivity
¤ Side effects- Headache, diarrhea, dizziness
¤ Pregnancy–US FDA pregnancy category Not Assigned:This drug is only recommended for use during pregnancy when
there are no alternatives and the benefit outweighs the risk.
¤ Warnings–Prolonged treatment (greater than 24-36 months) may cause vitamin B12 deficiency.
¤ Std. Dose–20-80 mg/day
¤ cause vitamin B12 deficiency.
.
09

23. ¤ GENERIC: Ondansetron
¤ CATEGORY: Anti emetic
¤ MOA: Ondansetron is a selective 5-HT3-receptor antagonist which blocks serotonin, both peripherally on vagal nerve terminals and
centrally in the chemoreceptor trigger zone
¤ INDICATIONS: CINV, Post operative nausea/vomitting,pregnancy associated nausea,vomitting. Gastric pareisis
¤ CONTRAINDICATIONS: Hypersensitivity, concomitant use with apomorphine
¤ ADVERSE EVENTS: confusion, dizziness, fever, fatigue, gastric pain
¤ PREGNANCY: US FDA pregnancy category: B
¤ STD. DOSE: recommended dose: 0.15 mg/kg IV, with the first dose (infused over 15 minutes) 30 minutes before the start of
emetogenic chemotherapy and subsequent doses given 4 and 8 hours after the first dose.
-Maximum dose: 16 mg per dose
10

24. ¤ MOA: The bacterial degradation of lactulose resulting in an acidic pH inhibits the diffusion of NH3 into the blood by causing the
conversion of NH3 to NH4+; also enhances the diffusion of NH3 from the blood into the gut where conversion to NH4+ occurs; produces
an osmotic effect in the colon with resultant distention promoting peristalsis
¤ INDICATIONS: acute & chronic constipation, hepatic encephalopathy
¤ CONTRAINDICATIONS: Patients requiring a low galactose diet
¤ ADVERSE EVENTS: Gaseous distention, belching, flatulence, borborygmi, abdominal discomfort (e.g.,
cramping). Dehydration and hyponatremia in infants.
¤ PREGNANCY: pregnancy category B
¤ STD. DOSE: Initial dose: 15 mL orally once a day. Therapy should be continued until normal bowel function resumes.
11

25. POINT TO PATIENT
About disease
Rheumatoid arthritis is disorder of joints
including severe pain and deformation
About medications
• Take medications as
prescribed
• Do not skip more than single
dose a day
• Report any adverse events,
this may be due to
medications
About lifestyle modification
About diet
RA seizure CM-Riddhi 25

26. POINT TO PHYSICIAN

27. POINT TO PHYSICIAN
 GENERALLY AVOID: Concomitant use of opioids with benzodiazepines or other central nervous system (CNS) depressants, may result in
profound sedation, respiratory depression. MANAGEMENT: The use of opioids in conjunction with benzodiazepines or other CNS
depressants should generally be avoided unless alternative treatment options are inadequate. If coadministration is necessary, the
dosage and duration of each drug should be limited to the minimum required to achieve desired clinical effect. Patients should be
monitored closely for signs and symptoms of respiratory depression and sedation. Severe cases of benzodiazepine withdrawal,
primarily in patients who have received excessive doses over a prolonged period, may result in numbness and tingling of extremities,
hypersensitivity to light and noise, hallucinations, and epileptic seizures.
 MONITOR CLOSELY: Concomitant use of 5-HT3 receptor antagonists with tramadol may potentiate the risk of serotonin syndrome
and/or reduce the analgesic efficacy of tramadol. Serotonin syndrome has been reported with both 5-HT3 receptor antagonists and
tramadol, and combined use of these drugs may increase the risk.
 MONITOR CLOSELY: Treatment with 5-HT3 receptor antagonists has been associated with dose-dependent prolongation of the QT
interval. Tramadol may also prolong the QT interval, and theoretically, coadministration of multiple agents that can prolong the QT
interval may result in additive effects and increased risk of ventricular arrhythmias such as torsade de pointes and sudden death. Cases
of torsade de pointes have been specifically reported.
 MONITOR: Limited data suggest that furosemide and possibly other loop diuretics may potentiate the nephrotoxicity of some
cephalosporins. The exact mechanism of interaction is unknown, although furosemide has been shown to increase the plasma
concentrations and/or reduce the clearance of several cephalosporins such as cephaloridine and ceftazidime.
 ETIZOLAM & LEVETIRACETAM: MANAGEMENT: During concomitant use of these drugs, patients should be monitored for potentially
excessive or prolonged CNS and respiratory depression. Cautious dosage titration may be required, particularly at treatment initiation.
Ambulatory patients should be counseled to avoid hazardous activities requiring mental alertness and motor coordination until they
know how these agents affect them, and to notify their physician if they experience excessive or prolonged CNS effects that interfere
with their normal activities.
 FUROSEMIDE & PANTOPRAZOLE: Monitoring of serum magnesium levels is recommended prior to initiation of therapy and periodically
thereafter if prolonged treatment with a proton pump inhibitor is anticipated or when combined with other agents that can cause
hypomagnesemia such as diuretics

28. POINT TO PHYSICIAN
 MONITOR: The concomitant use of corticosteroids and agents that deplete potassium (e.g., potassium-wasting diuretics, amphotericin
B, cation exchange resins) may result in increased risk of hypokalemia. Corticosteroids can produce hypokalemia and other electrolyte
disturbances via mineralocorticoid effects, the degree of which varies with the agent (from most to least potent: fludrocortisone -
cortisone/hydrocortisone - prednisolone/prednisone - other glucocorticoids) and route of administration (i.e. systemic vs. local).

29. Thank You