Alprazolam dosage forms for dilantin

By | 04.02.2018

Elderly especially sensitive to benzodiazepine effects; higher plasma levels exhibited because of reduced clearance. If you wish to stop taking this medication, first talk to your health care provider, then taper off by slowly decreasing your daily dose. Do not use a household spoon because you may not get the correct dose. Drug interactions resulting in decreased effectiveness of nondepolarizing neuromuscular blocking agents have been reported. To minimize the possibilities of this serious side effect, alprazolam should be taken only as prescribed and not with any other drugs that affect brain chemicals unless they are prescribed by a doctor who is aware of all the medications a patient is taking. Consult your doctor for more details.

Term memory: Alprazolam dosage forms for dilantin

Alprazolam dosage forms for dilantin Xanax alprazolam 0.25 mg discussion synonym
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If that is the only change you have made in your daily activities, it may be considered as a possibility. The medication Xanax comes in the following strengths: My 14 year old daughter has depression and was prescribed Xanax. According to the prescribing information for Xanax alprazolam , safety and effectiveness have not been established in patients younger than 18 years of age.

You may want to contact your daughter's health care provider to discuss treatment options. For additional information regarding Xanax alprazolam , you may want to visit our website. I take Xanax daily, but I'm worried that it could be addictive. Is this a problem for people? Xanax is used daily on a routine basis. It may be habit-forming, but some people are more prone to this than others. If you wish to stop taking this medication, first talk to your health care provider, then taper off by slowly decreasing your daily dose.

I was taking Xanax a couple of years ago, not daily but only when needed. My brother-in-law suggested Paxil instead, but I never felt like it was doing anything for me. Now I'm on meds through another doctor, but I still don't feel like these are helping. Is there any reason I shouldn't go back on Xanax? Unfortunately, your question doesn't have a simple answer.

Treatment with these types of medications is very patient-specific, and it's often based on trial and error. If you have had previous success with Xanax alprazolam , you may want to contact your doctor and discuss this treatment option again. You should also discuss your concerns and reasons for switching treatments and decide, with your doctor, which treatment option best meets your individual needs. Is it safe for me to use Xanax?

Studies have shown evidence of risk to the fetus in mothers taking Xanax alprazolam. This medication can cause birth defects in an unborn baby. You should check with your doctor to see if an alternative medication can be used based on your health status. Can I still use Xanax while I am pregnant? Studies have shown positive evidence of human fetal risk in mothers taking Xanax alprazolam. The following link will provide additional information on pregnancy.

I have extreme anxiety and panic attacks and am currently on alprazolam 1 mg three times a day. I have been on it for years and have actually only take 2 mg a day. Is alprazolam XR a better way to go? I know that this drug is addicting, but I have been on this for years and have never had to up my dosage and it is a godsend for me. I am extremely anxious and go to therapy twice a month. Xanax XR alprazolam XR is an extended-release formulation of alprazolam.

It is commonly dosed once a day and indicated for patients with panic attacks. It is not indicated for anxiety disorder. For anxiety, alprazolam immediate release is often taken as needed because the onset is quick and duration is short. For frequent panic attacks, alprazolam can be taken around the clock to prevent attacks, which may be triggered by certain situation or condition. When alprazolam immediate release is taken around the clock, it may produce unwanted side effects due to fluctuation in blood concentration.

The difference between the Xanax XR and immediate release is that the XR formulation has a slower rate of absorption, longer duration and has a more constant blood level. A dose of 0. The Xanax XR may provide a more consistent and lower effective concentration, therefore resulting in a lower required dose with less side effects.

Whether switching to Xanax XR is appropriate or not is a decision between the prescriber and the patient. Factors worth considering are dependency, tolerability of current medication and cost. For further information, please refer to the following links. What are the effects of taking Xanax and over-the-counter drugs, such as vitamin C, Caltrate, zinc, and Metamucil? There are no known drug interactions found between Xanax alprazolam and the following over-the-counter medications: Talk to your doctor if you have any concerns about your prescription or over-the-counter medications.

Do not start or stop any medications or treatments without first talking to your doctor. I believe you will find the following links at everydayhealth. Is long term use 20 years of Xanax harmful? I wouldn't say that it is harmful. Obviously it depends on the dose and frequency the medication is taken. In many cases, taking a Xanax alprazolam would be preferable than having alcoholic beverage for some people.

I always recommend having yearly check ups with your physician and having both kidney and liver function tests performed. However, I have yet to run into any serious consequences for people using Xanax for 20 years. Abusing the medication is a different story. Feel free to visit us here for more information: What are the possibilities of having a seizure if you take Xanax?

According to Clinical Pharmacology, when taken at the recommended dose, an uncommon side effect of Xanax Alprazolam is seizures. This side effect was reported in less than 1 percent of patients taking alprazolam in clinical studies. With short-term and long-term use of alprazolam, patients may experience withdrawal symptoms including seizures. If you experience a seizure while taking alprazolam, it is considered a serious side effect and you should contact your doctor immediately. To minimize the possibilities of this serious side effect, alprazolam should be taken only as prescribed and not with any other drugs that affect brain chemicals unless they are prescribed by a doctor who is aware of all the medications a patient is taking.

It is also important to not take the medication with alcohol. I take 6 mg of Xanax a day, along with calcium, Estroven with a multivitamin in it and flaxseed oil. Am I doing okay with what I am taking? Xanax alprazolam is a highly potent, short-acting benzodiazepine primarily used to treat moderate to severe anxiety disorders e. Generally speaking, drug interactions fall into three main categories: Drug-disease interactions may occur when an existing medical condition makes certain drugs potentially harmful.

Antacids calcium may decrease the serum concentration of benzodiazepines, however, no action is required. For more detailed information, consult with your physician or pharmacist for guidance based on your specific condition and current medications, particularly before taking any action. How long does it take to get Xanax out of your system? The average half life of Xanax alprazolam for adults is approximately The immediate release formulation has a half life range of 6. Half life is defined as the amount of time it requires for approximately one half of the medication to be out of the system.

Most sources state that it takes half lives for a medication to be completely removed from the body after stopping the medication. Therefore it would take approximately 56 hours for the medication to be out of the system. This is just an estimate as there are wide ranges in the half life values for Xanax and elimination of a medication is based on many patient specific variables. Talk with your health care provider regarding questions and concerns you have about prescription medications.

What's the difference between tramadol and Xanax? Tramadol is in a drug class called opiate agonists. Tramadol is used for the management of moderate to moderately severe pain. Tramadol works by altering pain sensation in the body. Xanax alprazolam is in a drug class called benzodiazepines. Xanax is used in the treatment of anxiety disorders and panic disorders.

Xanax is thought to work by affecting brain chemicals and lessening abnormal brain excitement. Xanax is a pregnancy category D. Xanax can cause birth defects in an unborn baby. Xanax should not be taken during pregnancy without the doctor. I have been taking Xanax for 5 years. What are the withdrawal symptoms and how long do they last? Xanax is indicated for anxiety.

Common side effects of Xanax include drowsiness, dizziness, dry mouth, muscle weakness, and blurred speech. Xanax may be habit-forming and should only be taken as the doctor prescribed. Symptoms of anxiety and restlessness may return once the Xanax is discontinued. Withdrawal symptoms may occur after using Xanax for a long period of time. Withdrawal symptoms include blurred vision, loss of appetite, diarrhea, trouble concentrating, and numbness and tingling.

This is not a complete list of the side effects associated with Xanax. For more specific information, consult with your doctor or pharmacist for guidance based on your health status and current medications, particularly before taking any action. When your doctor prescribes a new medication, be sure to discuss all your prescription and over-the-counter drugs, including dietary supplements, vitamins, botanicals, minerals, and herbals, as well as the foods you eat.

Always keep a current list of the drugs and supplements you take and review it with your healthcare providers and your pharmacist. If possible, use one pharmacy for all your prescription medications and over-the-counter products. This allows your pharmacist to keep a complete record of all your prescription drugs and to advise you about drug interactions and side effects.

Tell your health-care provider about any negative side effects from prescription drugs. You can also report them to the U. Food and Drug Administration by visiting www. I have been taking Xanax for several years. I have been taking the 2 mg dose three times a day. I'm having a hard time finding a doctor and had to cut down very suddenly. I am almost out of Xanax. What can happen to me? Symptoms of anxiety or restlessness may return once Xanax is stopped. If Xanax has been taken for a long period of time, withdrawal symptoms may occur.

These symptoms include blurred vision, trouble concentrating, loss of appetite, muscle twitching, diarrhea, and tingling. Is it all right to take Xanax and then take Ambien about 30 minutes later? Will there be any interactions between the two? During use of both of these drugs, you and your doctor should watch for any excessive depression of the central nervous or respiratory symptoms. Avoid hazardous activities requiring complete mental alertness and motor coordination until you know how these two affect you.

Take your medications exactly as prescribed by your doctor. According to Pfizer, the manufacturers of Xanax, there are no gluten ingredients in the brand name Xanax tablets or the generic Greenstone brand. However, the company cannot guarantee that the ingredients they obtain from their suppliers are not tainted with gluten. How long would Xanax 2mg stay in the body if only one was taken? The elimination half-life is about Therefore in healthy adults, it would take about 56 hours to be eliminated from the body.

However, the elimination of drugs depends on certain factors such as age, dosage, weight and the health of the individual. Therefore the elimination of drugs can be very patient specific. Will my body build up a tolerance for Xanax if I need to take it daily? Benzodiazepines are classified as controlled medications. Tolerance to a medication means that a person may have to take a higher dose of the medication over time to achieve the same results or benefits as before.

According to the U. Drug Enforcement Agency, repeated use of large doses, or daily use of therapeutic doses of benzodiazepines may lead to tolerance and physical dependence. Suddenly stopping a benzodiazepine is not recommended. Withdrawal symptoms can occur if a benzodiazepine is discontinued suddenly. Withdrawal symptoms depend on the dose and length of therapy. These symptoms may include: The dose of a benzodiazepine may need to be slowly tapered if a patient needs to discontinue the medication.

What are Xanax and Valium used for? How do they work? Diazepam is used for anxiety and sometimes muscle spasms. Common side effects associated with diazepam include drowsiness, muscle weakness, and dry mouth. Other side effects may include headache, blurred vision and speech, nausea and memory problems. Typically Valium stays in the system long than Xanax. It is also important when your doctor prescribes a new medication, be sure to discuss all your medications and over-the-counter drugs, including dietary supplements, vitamins, botanicals, minerals and herbals, as well as the foods you eat.

Also keep a current list of the drugs and supplements you take and review it with your healthcare provider and your pharmacist. I have been taking Xanax for 3 to 4 years. Do I need to be weaned off and how? Is it wise to stop cold-turkey? Xanax alprazolam is a benzodiazepine used for the treatment of anxiety disorders. Withdrawal symptoms can occur with abrupt discontinuation of Xanax especially in patients on high doses or those who have been on the medication long term.

Withdrawal symptoms from stopping Xanax too quickly may include; tremor, sweating, trouble sleeping, muscle cramps, stomach pain, vomiting, or unusual behavior. According to the packaging information, abrupt discontinuation of Xanax should be avoided. It is recommended to decrease the dose by 0. Your doctor will be able to recommend a dosage taper for you. It is important to learn how to cope with everyday stress. Some alternative ways to help deal with stress include exercise taking a walk, yoga , enjoying some fresh air, spending time with friends or family that you enjoy, and focusing on the positive things in life.

Your healthcare provider may be able to provide you with other suggestions. If you need to use Xanax, but don't feel you need it every day, is that acceptable? Xanax alprazolam is a sedative that belongs to the class of drugs known as benzodiazepines. It is a short-acting medicine for anxiety disorders. The use of Xanax on an as-needed basis is common practice as it allows for more patient control over symptoms, may be helpful for short-term situations that cause fear or anxiety, and may decrease the overall use of the medication.

However, it is important that you follow the directions provided by your doctor and use Xanax as labeled. Xanax can be habit forming. Do not change your dosage without speaking to your doctor first. Always keep a current list of the drugs and supplements you take and review it with your health care providers and your pharmacist. My mom's friend just had a very bad stroke and she has lupus so she is on prescription medication such as Valium, Percocet, methadone, and a few more.

Can an overdose of Xanax be the reason she had this stroke? There's also a possibility that she could has had an alcoholic beverage. There is no mention of stroke due to overdose in the prescribing information for Xanax. Some of the problems that can occur when there is an overdose of Xanax include: Death from overdose of Xanax has also occurred in combination with alcohol use.

For more specific information, consult with a doctor for guidance based on her health status and current medications, particularly before taking any action. I picked up my Xanax 1 mg. They gave me the oval blue pill form with "" and "V" on the bottom. It's the same size as Xanax 1 mg, but I've never seen one like it. Is it the same? The pill you described as blue, oval-shaped and marked " V" is identified to be alprazolam 1 mg Xanax manufactured by Qualitest Pharmaceuticals Inc.

There are numerous manufacturers of generic medications on the market, and sometimes the manufacturers supplying the generics to your local pharmacy change. The active ingredient in this medication is still alprazolam, which means it should work the same. However, the inactive ingredients may be different from other generics you have been getting. Some patients react differently and negatively to a different generic medication than the one they have been taking.

If that is the case with you, consult with your pharmacist for guidance, particularly before taking any action. I take Xanax and have been diagnosed with glaucoma. What other medications are safe with this condition? When anxiety cannot be treated with benzodiazepines, such as Xanax alprazolam , other medications, such as Buspar buspirone or antidepressants, such as the SSRIs selective serotonin reuptake inhibitors , Prozac fluoxetine , Zoloft sertraline , Paxil paroxetine , or Celexa citalopram , or the SNRIs serotonin-norepinephrine reuptake inhibitors Cymbalta duloxetine or Effexor venlafaxine can be used.

Antidepressants work because they act on neurotransmitters that are involved in depression and in anxiety. Side effects from these groups may include nausea, dizziness, insomnia, gas, and impotence. Earlier generation antidepressants, such as MAO monoamine oxidase inhibitors and TCA tricyclic antidepressants can also be used for anxiety, but they have more side effects, include cardiovascular, so they are not used as much.

In addition to medications, anxiety can often be successfully treated with psychotherapy alone, or along with medication. Psychotherapy can help a person find the triggers to their anxiety and help them find ways to cope with the issues. There are two types of therapy. One focuses on behavior and how to change behavior to cope. The other is cognitive therapy, which helps a person alter their thoughts to minimize the symptoms of anxiety.

A general practitioner can recommend a psychologist who can help manage anxiety with the best treatment option for that person. What are the long-term effects of Xanax? Long term use of Xanax can lead to physical or psychological dependence on the medication. Patients who have been on Xanax long term that plan to stop the medication need to taper the dose down slowly to avoid or lessen the amount of withdrawal symptoms experienced.

Consider an alternative to phenytoin if the patient or an immediate family member has a carbamazepine hypersensitivity, barbiturate hypersensitivity, succinimide hypersensitivity, or oxazolidinedione hypersensitivity. Hypersensitivity reactions to phenytoin have been reported in patients who previously experienced hypersensitivity to fosphenytoin, barbiturates, or carbamazepine. Phenytoin, carbamazepine, and phenobarbital are all metabolized to hydroxylated aromatic compounds via the cytochrome P hepatic oxidative enzymes; arene oxide intermediates are formed during metabolism and are thought to be responsible for cross-sensitivity among these anticonvulsants in susceptible individuals.

Some individuals may have a reduced ability to detoxify the intermediate toxic metabolites e. However, studies of familial reactions have also shown that allergies to one anticonvulsant may not translate to allergies to others. There is no way to predict with certainty which patients will exhibit cross-sensitivity. DRESS, also known as Multiorgan hypersensitivity, has been reported in patients taking antiepileptic drugs, including phenytoin.

Some of these events have been fatal or life-threatening. Eosinophilia is often present. Because this disorder is variable in its expression, other organ systems not noted here may be involved. It is important to note that early manifestations of hypersensitivity, such as fever or lymphadenopathy, may be present even though rash is not evident. If such signs or symptoms are present, the patient should be evaluated immediately. Phenytoin should be discontinued if an alternative etiology for the signs or symptoms cannot be established.

These signs and symptoms should be reported even if mild or occurring after extended use. Patients who have or are suspected to have a hypersensitivity syndrome should stop phenytoin immediately and begin alternative therapy. Phenytoin may cause life-threatening serious rash, including Stevens-Johnson syndrome and toxic epidermal necrolysis. Patients who have or are suspected to have a hypersensitivity syndrome, including such serious skin conditions, should stop phenytoin immediately and begin alternative therapy.

HLA-B , the variant allele of human leukocyte antigen B, has been associated with an increased risk of hypersensitivity in response to phenytoin treatment. The FDA is evaluating preliminary data suggesting that Asian patients, specifically those with Han Chinese, Filipino, Malaysian, South Asian Indian, and Thai ancestry, who test positive for HLA-B , are at an increased risk for developing these potentially fatal conditions while receiving phenytoin.

A similar precaution was issued for carbamazepine with subsequent changes to the product labeling; it is now recommended that patients with ancestry in genetically at-risk populations be screened for the presence of HLA-B prior to initiating carbamazepine therapy. The strength of association between phenytoin and serious hypersensitivity reactions is weaker than that of carbamazepine and similar reactions because of the limited number of studies and observations in the literature.

However, until further information becomes available, it is recommended to avoid the use of phenytoin in patients who test positive for HLA-B and are phenytoin naive, unless the benefits outweigh the risk. Antiepileptic drugs AEDs , including phenytoin, increase the risk of suicidal ideation, thoughts or behavior in patients taking these drugs for any indication. Pooled analyses of placebo-controlled clinical trials mono- and adjunctive therapy of 11 different AEDs showed that patients randomized to one of the AEDs had approximately twice the risk adjusted RR 1.

In these trials, which had a median treatment duration of 12 weeks, the estimated incidence rate of suicidal behavior or ideation among 27, AED-treated patients was 0. There were 4 suicides in drug-treated patients in the trials and none in placebo-treated patients, but the number is too small to allow any conclusion about drug effect on suicide. The increased risk of suicidal thoughts or behavior was observed as early as 1 week after starting drug treatment and persisted for the duration of treatment assessed.

Because most trials included in the analysis did not extend beyond 24 weeks, the risk of suicidal thoughts or behavior beyond 24 weeks could not be assessed. The risk of suicidal thoughts or behavior was generally consistent among drugs in the data analyzed. The finding of increased risk with AEDs of varying mechanisms of action and across a range of indications suggests that the risk applies to all AEDs used for any indication. The risk did not vary substantially by age 5 to years of age in the clinical trials analyzed.

The relative risk for suicidal thoughts or behavior was higher in clinical trials for epilepsy than in clinical trials for psychiatric or other conditions, but the absolute risk differences were similar for the epilepsy and psychiatric indications. Epilepsy and many other illnesses for which AEDs are prescribed are themselves associated with morbidity and mortality and an increased risk of suicidal thoughts and behavior. Should suicidal thoughts and behavior emerge consider whether the emergence of these symptoms in any given patient may be related to the illness being treated.

Patients and caregivers should be informed of the increased risk of suicidal thoughts and behaviors and should be advised to immediately report the emergence or worsening of depression, the emergence of suicidal thoughts or behavior, thoughts of self-harm, or other unusual changes in mood or behavior. Phenytoin should be prescribed in the smallest quantity consistent with good patient management in order to reduce the risk of overdose.

When, in the judgment of the clinician, the need for dosage reduction, discontinuation, or substitution of alternative antiepileptic medication arises, this should be done gradually. However, in the event of an allergic or hypersensitivity reaction to phenytoin, rapid substitution of alternative therapy may be necessary. In this case, alternative therapy should be an antiepileptic drug not belonging to the hydantoin chemical class. Phenytoin is not effective for petit mal absence seizures.

If tonic-clonic grand-mal and absence petit mal seizures are present, combined drug therapy is needed. Phenytoin and other hydantoins are not indicated for seizures due to hypoglycemia or other metabolic causes e. Appropriate diagnostic procedures should be performed as indicated. Phenytoin is contraindicated in patients with a history of prior acute hepatotoxicity attributable to phenytoin.

Cases of acute hepatotoxicity, including infrequent cases of acute hepatic failure, have been reported with phenytoin. Other common manifestations include jaundice, hepatomegaly, elevated serum transaminase concentrations, leukocytosis, and eosinophilia. The clinical course of acute phenytoin hepatotoxicity ranges from prompt recovery to fatal outcomes.

In these patients with acute hepatotoxicity, phenytoin should be immediately discontinued and not re-administered. Use phenytoin cautiously in patients with hyperbilirubinemia, which may manifest clinically as jaundice. Bilirubin displaces phenytoin from protein-binding sites, resulting in increased free phenytoin concentrations. Hypoalbuminemia also results in increased free phenytoin concentrations, which may increase the likelihood of drug toxicity. Hypoalbuminemia is common in the critically ill, as well as in patients with malnutrition, burns, and renal or hepatic disease.

In these patients, the monitoring of serum phenytoin concentrations should be based on the unbound fraction of the drug. Phenytoin is eliminated via hepatic metabolism and should be used with caution in any patient with hepatic dysfunction. A small percentage of individuals metabolize phenytoin slowly. Slow metabolism may be due to limited enzyme availability and lack of induction; slow metabolism appears to be genetically determined. Reduced phenytoin clearance may increase the frequency and severity of adverse events.

Dose adjustments may be necessary in patients with hepatic disease or genetic polymorphism; if early signs of central nervous system toxicity develop, check serum concentrations immediately. Baseline and periodic evaluations of liver function, particularly in patients with a history of hepatic disease, must be performed during treatment.

Phenytoin should be discontinued if there is evidence of new or worsening hepatotoxicity. Use phenytoin with caution in patients with hematological disease or pre-existing blood dyscrasias. Although uncommon, phenytoin can cause hematological toxicity, which may exacerbate or worsen other hematological abnormalities. Hematopoietic complications, some fatal, have occasionally been reported. These have included thrombocytopenia, leukopenia, granulocytopenia, agranulocytosis, and pancytopenia with or without bone marrow suppression.

Baseline and periodic hematologic counts should be obtained; if a patient develops abnormalities, the patient should be closely monitored. Discontinuation of phenytoin should be considered if significant bone marrow suppression develops. In view of isolated reports associating phenytoin with exacerbation of porphyria, caution should be exercised in using phenytoin in patients suffering from this disease.

There have been a number of reports suggesting a relationship between phenytoin and the development of lymphadenopathy local or generalized including benign lymph node hyperplasia, pseudolymphoma, lymphoma, and Hodgkin's disease. Although a cause and effect relationship has not been established, the occurrence of lymphadenopathy indicates the need to differentiate such a condition from other types of lymph node pathology. In all cases of lymphadenopathy, follow-up observation for an extended period is indicated and every effort should be made to achieve seizure control using alternative antiepileptic drugs.

In general, intramuscular administration of phenytoin is not recommended because of the risk of aseptic tissue necrosis, abscess formation, and erratic absorption. Due to delayed and erratic absorption, intramuscular administration should never be used in the treatment of status epilepticus. Parenteral phenytoin has an alkaline pH pH range approximately 10 to 12 and causes a high degree of local irritation and pain. Intramuscular administration of phenytoin is not recommended unless intravenous access and other treatment alternatives e.

Acute ethanol ingestion may increase phenytoin serum levels while chronic ethanol ingestion can induce hepatic oxidative enzymes which metabolize phenytoin, decreasing serum concentrations. Such parameters may need to be considered when treating patients with a history of alcoholism or acute intermittent binge drinking ethanol intoxication. In addition, concomitant use of phenytoin and ethanol can decrease the ability to perform tasks requiring mental alertness.

Alcohol intoxication may alter seizure control in epileptic patients. Phenytoin may cause blurred vision, dizziness, drowsiness, and fatigue. Patients should be aware of the early symptoms of phenytoin toxicity such as problems with speech, walking or coordination. Accordingly, at the first sign of acute toxicity, measuring of plasma concentrations is recommended. A dosage reduction is indicated if plasma concentrations are excessive; if symptoms persist, termination of phenytoin therapy is recommended.

Patients with renal disease, renal impairment or renal failure leading to uremia should be monitored for phenytoin toxicity. High serum concentrations of urea displace phenytoin from protein-binding sites. Due to an increased fraction of unbound phenytoin, the interpretation of total phenytoin plasma concentrations should be made with caution. Unbound 'free' phenytoin concentrations may be more useful in these patient populations. Phenytoin can stimulate glucagon secretion and can impair insulin secretion.

Either of these effects could cause hyperglycemia. There are case reports of hyperglycemia occurring as a result of phenytoin administration. Blood sugar should be monitored closely when phenytoin is administered to patients with diabetes mellitus. Patients with thyroid disease, especially hypothyroidism, should be monitored for signs of underactive thyroid. Phenytoin stimulates hepatic enzyme activity, which may cause an increased degradation of circulating concentrations of thyroid hormone T3 and T4 , with an accompanying increase in thyroid-stimulating hormone TSH.

The chronic use of phenytoin in patients with epilepsy has been associated with decreased bone mineral density osteopenia, osteoporosis, and osteomalacia and bone fractures. Phenytoin induces hepatic metabolizing enzymes which may enhance the metabolism of vitamin D and decrease vitamin D levels. This action may lead to vitamin D deficiency, hypocalcemia, and hypophosphatemia. Consideration should be given to screening with bone-related laboratory and radiological tests as appropriate and initiating treatment plans according to established guidelines.

Phenytoin, as with some other antiepileptic drugs AEDs has been very rarely reported to exacerbate symptoms of myasthenia gravis. The chronic use of phenytoin may cause gingival hyperplasia. Patients should be instructed on proper oral and dental hygiene in order to minimize the development of gingival hyperplasia and its complications e. Adherence to scheduled dental examinations and routine dental care is encouraged to limit the risk of gum disease and potential tooth loss.

Local soft tissue irritation, ranging from tenderness to extensive necrosis, and inflammation can occur at the site of administration with and without extravasation of intravenous phenytoin. Edema, discoloration and pain distal to the injection site "purple glove syndrome" have been reported. To minimize the risk for these adverse effects, administer phenytoin directly into a large peripheral or central vein through a large-gauge catheter.

Confirm the patency of the catheter prior to each dose using a sterile saline flush. Phenytoin use may require extra care in the geriatric patient. The liver is the chief site of biotransformation of phenytoin; elderly patients may show early signs of reduced biotransformation and toxicity. Phenytoin serum level determinations may be necessary to achieve optimal dosage adjustments.

Phenytoin serum levels sustained above the optimal range may produce confusional states similar to delirium or encephalopathy, or rarely induce irreversible cerebellar dysfunction; the geriatric patient should be carefully monitored for symptoms of acute toxicity. Adverse reactions to parenteral phenytoin occur more often in patients who are elderly, critically ill, or those with pre-existing hypotension or severe myocardial insufficiency.

According to the Beers Criteria, anticonvulsants are considered potentially inappropriate medications PIMs in geriatric patients with a history of falls or fractures and should be avoided in these patient populations, with the exception of treating seizure and mood disorders, since anticonvulsants can produce ataxia, impaired psychomotor function, syncope, and additional falls. If phenytoin must be used, consider reducing use of other CNS-active medications that increase the risk of falls and fractures and implement other strategies to reduce fall risk.

According to the OBRA guidelines, some anticonvulsants may be used to treat disorders other than seizures e. The need for indefinite continuation in treating any condition should be based on confirmation of the condition and its potential cause s. Periodic assessment of drug concentrations and evaluation of symptoms should be used to adjust doses. It should be noted that significant signs and symptoms of toxicity can occur at normal or low serum concentrations, and symptom control for seizures or behavior can occur at subtherapeutic serum concentrations.

Obtaining serum medication concentrations may assist in identifying toxicity. High or toxic serum concentrations should become a consideration for dosage adjustments. Anticonvulsants may cause liver dysfunction, blood dyscrasias, and serious skin rashes requiring treatment discontinuation. When an anticonvulsant is being used to manage behavior, stabilize mood, or treat a psychiatric disorder, the facility should attempt periodic tapering of the medication or provide documentation of medical necessity in accordance with OBRA guidelines.

Phenytoin is a known teratogen, and a recognizable pattern of malformations has been observed. Several cases of malignancies, including neuroblastoma, have been reported in pediatric patients whose mothers received phenytoin during pregnancy. Fetal deaths and congenital malformations occurred in 3. Congenital malformations in the phenytoin group included agenesis of corpus callosum, ventricular septal defect, hydronephrosis and extra renal pelvis, and undescended testicle.

Additionally, neonatal coagulation defects have been reported in neonates with in utero exposure to phenytoin and appear to result from drug-induced vitamin K deficiency in the fetus. Administration of vitamin K to the mother before obstetric delivery and to the neonate at birth can prevent this defect. Plasma clearance of phenytoin is generally increased during pregnancy, peaking in the third trimester and returning to baseline a few weeks or months after delivery.

An increase in seizure frequency may occur during pregnancy because of altered phenytoin pharmacokinetics. Monitor serum phenytoin concentrations periodically to guide appropriate adjustment of dosage. Postpartum, restoration of the original dose will probably be indicated. Counsel pregnant women and women of childbearing potential that use of phenytoin during pregnancy can cause fetal harm, and when appropriate, about alternative therapeutic options.

Patients must call to enroll in the registry. Information on the registry can also be found at the website at www. Phenytoin is secreted in low concentrations in human milk. Breast-feeding is not recommended for women taking phenytoin. Consider the developmental and health benefits of breast-feeding along with the mother's clinical need for phenytoin and any potential adverse effects on the breast-fed infant from phenytoin or the underlying maternal condition.

Milk to plasma ratios of phenytoin range from roughly 0. However, infant adverse events from phenytoin monotherapy have rarely been noted, and the risks to the infant are thought to be minimized if maternal serum concentrations are kept within accepted therapeutic ranges. The risk for adverse effects such as sedation in the infant appears to be higher in patients taking multiple antiepileptic drugs.

Previous American Academy of Pediatrics recommendations considered phenytoin usually compatible with breast-feeding.

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