SPECIAL REPORT: BEST PRACTICES
The problem of polypharmacy is commonly ignored in sufferers with vital traumatic mind harm (TBI). Within the acute setting—which incorporates the emergency division, important care unit, and hospital flooring—consideration is appropriately fastened on survival and medical stabilization. To that finish, interventions vary from neurosurgical to pharmacological. In a typical extreme TBI situation, it isn’t uncommon for a affected person to bear a number of surgical procedures (eg, craniotomy/craniectomy, ventricular drains, varied orthopedic procedures to deal with polytrauma, tracheostomy, gastrostomy tube placement).
The science behind the acute administration of TBI is evolving, and any intervention that improves survival and reduces long-term morbidity is worth it. However as sufferers recuperate, most of the pharmacological interventions grow to be counterproductive and must be discontinued. TBI is more and more acknowledged as a power illness with power impairments. Due to this fact, nearly all of take care of the affected person with TBI happens submit hospital. This care is commonly extremely fragmented and plenty of alternatives to scale back medicines and keep away from polypharmacy and comorbidity could be missed.
Many classes of medicine regularly utilized in sufferers with TBI can contribute to polypharmacy. Some medicines sedate and cloud the sensorium, probably limiting restoration. This group contains antipsychotics, anxiolytics, antiepileptics, and opiates. One other group contains preventive medicines, whether or not for deep venous thrombosis (DVT) and pulmonary embolism (PE), seizures, or complications. Yet one more group is perhaps known as comfort medicine; for instance, as-needed antiemetics. There are additionally medicines directed at particular and frequent related circumstances equivalent to syndrome of inappropriate antidiuretic hormone secretion (SIADH), cerebral salt losing, autonomic dysfunction, neurogenic bowel/bladder, and so forth. This text will try to deal with every medicine briefly. What’s necessary for scientific practitioners to know is that each successive analysis is a chance to reexamine the medicine listing for necessity.
A few of the most problematic contributors to polypharmacy are the commonest: sedating medicines. Antipsychotics, usually utilized in acute settings to handle behavioral problems of TBI, or in uncommon circumstances precise psychosis, are typically detrimental to TBI restoration in the long run, until the affected person is identified with psychosis. Equally, benzodiazepines are typically detrimental until used for very particular and time-limited functions equivalent to acquiring diagnostics, performing procedures, and the like. As well as, like opiates, the addictive potential of those medicines in a affected person with TBI and related impulsivity is excessive. Opiate medicines are sadly regularly crucial in sufferers with TBI, not less than briefly, as there’s regularly related polytrauma. These medicines carry recognized and diverse dangers as talked about, together with addictive potential. Consciousness of the person dangers of every of those medicines, in addition to the cumulative results of polypharmacy involving a number of brokers, is paramount. Restoration from TBI is already troublesome for a affected person combating impaired sensation resulting from impairments in imaginative and prescient, proprioception, stability, spatial consciousness, language, vertigo, and so forth. Pointless sedation from medicine doesn’t enhance the method.
Antiepileptic medicine is regularly initiated prophylactically throughout acute take care of any affected person who has a TBI with intracranial bleeding, and continued use is suitable for sufferers who do expertise seizure dysfunction submit TBI. Nevertheless, in sufferers and not using a historical past of seizure submit TBI, tips recommend that this isn’t really useful past 7 days.1 Many antiepileptics have vital drug-drug interactions, pharmacokinetic affect, and different hostile results. Older antiepileptics equivalent to carbamazepine, oxcarbazepine, phenytoin, and phenobarbital have vital results on cytochrome P450 enzymes. This results in pharmacokinetic results and danger for adjustments in serum drug ranges. Valproic acid can equally have an effect on circulating drug ranges by means of different mechanisms. Newer antiepileptics have much less dramatic impact on serum drug ranges however many stay hepatically metabolized, and due to this fact drug ranges must be monitored and dosage adjusted. Luckily, levetiracetam, thought-about a first-line agent by many for administration of epilepsy submit TBI, doesn’t regularly alter the serum degree of different medication in scientific apply. Along with seizure prophylaxis or administration, a few of these medicines are additionally generally used for varied different functions within the TBI inhabitants, together with headache prevention (eg, topiramate), behavioral intervention (eg, lamotrigine, valproic acid), or neurogenic ache administration (eg, gabapentin, pregabalin). These could be efficient and useful, however as sufferers enhance clinically over time, ongoing use must be addressed.
Many sufferers with TBI undergo from immobility as a consequence, whether or not transiently or long run. In both occasion, acute immobility confers danger for DVT/PE, which some sufferers do expertise throughout their sickness.2 Sufferers are generally discharged on prophylaxis for therapy of DVT/PE. This can be with both heparin, low molecular weight heparin, warfarin, or one of many novel anticoagulants. All these medicines carry their very own hostile impact profiles, and plenty of have vital polypharmacy dangers resulting from drug-drug interactions and pharmacokinetic impacts. In circumstances the place a affected person’s mobility improves, prophylaxis must be discontinued appropriately. Different people with anticipated long-term immobility nonetheless don’t profit from prophylaxis indefinitely, as a result of the danger for DVT/PE on this context wanes over time. Acceptable tips associated to the period of therapy for DVT or PE must be adhered to, with medicine discontinued when acceptable.3
TBI can be regularly related to different secondary problems. Issues of homeostasis such because the SIADH or cerebral salt losing may end up in the addition of fluid restriction or the usage of salt tabs and/or fludrocortisone. It isn’t unusual for this situation to stay unresolved on the time of discharge from the hospital. Nevertheless, most frequently this situation will resolve over time with restoration, and these interventions can then be discontinued.
Numerous different medicines, used throughout acute care to handle hypertension, hyperglycemia, nausea/vertigo, and so forth, are regularly prescribed on the time of discharge. With affected person enchancment, these can even unnecessarily contribute to polypharmacy. This listing is exhaustive, however the major goal right here is to spotlight the useful function of a care supplier paying shut consideration throughout every go to to the medicine listing and the continued indications (or lack thereof).
Lastly, as sufferers proceed by means of the restoration course of, nonetheless different medicines could be added. Antidepressants, headache prevention or abortive medicines, antiepileptics, and plenty of others could also be clinically indicated, some even completely. Nevertheless, in all circumstances, vigilance on behalf of all therapy suppliers as to the polypharmacy issues stays very important.
Dr Ashley is a neurologist and chief medical officer for the Centre for Neuro Abilities.
References
1. Carney N, Totten AM, O’Reilly C, et al. Tips for the administration of extreme traumatic mind harm, fourth version. Neurosurgery. 2017;80(1):6-15.
2. Mohseni S, Talving P, Lam L, et al. Venous thromboembolic occasions in remoted extreme traumatic mind harm. J Emerg Trauma Shock. 2012;5(1):11-15.
3. Ortel TL, Neumann I, Ageno W, et al. American Society of Hematology 2020 tips for administration of venous thromboembolism: therapy of deep vein thrombosis and pulmonary embolism. Blood Adv. 2020;4(19):4693-4738.
