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Hi, everybody. This is Doctor Michael Ken Trees with the neuro transmitters. And today I'm fortunate to be joined by Dr Roett Marijuana. Today we're going to be talking a little bit about selection of anti seizure medications. So doctor um Ror from Wane State, uh where you work in the epilepsy division. So just give us a little bit about your background there and uh any special projects you're working on so forth. Yeah. Well, uh fantastic to be here and excited to talk about approach to anti seizure medications. Uh So, as you mentioned, I work at Wane State University, Detroit Medical Center in Detroit, Michigan for the past six years, uh mostly in the epilepsy division, but it's a typical academic position with teaching research admin, as you might imagine in in addition to the clinical work, and uh my specific interest is in epilepsy in the elderly and at the intersection of epilepsy and dementia. So some of the things that I do are a multi specialty epilepsy and older adult clinic for the past three years with the services of a pharmacist or a pharmacy resident, I should say. Um and that's been going well and uh have doing few clinical trials and elderly and also some prospective observational studies. Um obviously uh epilepsy. Well, you know, that's always uh something I think at least from the patient side, a lot of questions we get, at least from my own perspective is that, you know, I'm, I'm an older adult. Why am I developing a seizure at this stage in life? And that's, that's we can kind of come around back to that at the end. But I think that's uh very, probably very common question your clinic in particular. But every epileptologist, at least in my experience kind of has their own, uh let's say pet medications, uh their own kind of process that they tend to approach and there's some similarities. But uh why don't you just walk us through kind of like how, how your approaches to selecting someone with maybe a new diagnosis of epilepsy. Uh and what medications you would normally kind of lean towards and how you counsel these patient's. Sure. So I think maybe let's talk about from the perspective of uh you know, someone who is new to epilepsy, like someone has like a resident who is still getting used to figuring out which antiseizure medications to start. Um So as you said, I think for us to, we need to figure out if someone has a diagnosis of epilepsy and as we know that that has specific requirements. So two unprovoked seizures in the last 24 hours, not last. Sorry, let me cancel it. Two and two unprovoked seizures, uh 24 hours apart at least and then or one unprovoked seizure and the risk of a second unprovoked seizure being greater than 60% based on history and testing are atypical electronical epilepsy syndrome. So I think once you have established that this is epilepsy and we want to start them on an anti seizure medication. And we're talking about adults here, not pediatric, because pediatric will have a different thought process and different approach. Uh So in adult patient's, so first, I think we need to figure out what kind of epilepsy is it. And uh and uh you know, based on the most recent nomenclature, there are only four types of epilepsy, which I love because it's simple, you know, either it's focal uh generalized or focal plus, generalized or unknown, which is my favorite category because it's uh it's easy to uh put, put, put patient into unknown uh sometimes because you don't know what's going on. Uh But uh I think if it's a focal epilepsy, uh anything except ethosuximide goes right. Ethosuximide is one of that one of those medications which is narrow spectrum but only used in generalized epilepsy. So if it's a focal antiseizure medication, anything except ethosuximide cause, then out of the three other categories, is it generalized, focal plus, generalized or unknown, then you want to use a broad spectrum medication. So, in, in the broad spectrum medication means no narrow spectrum medication. So you throw out everything to throw out your Dilantin, you throw out your carBAMazepine, Oxycarbazepine and uh it's derivatives like Aptiom. So, no, none of those. And we just then have broad spectrum medications. So that's kind of one way of thinking about it. Kind of, you can go about this as a ruling in or ruling out. So you are, this is kind of a way of ruling out. Okay. I don't want to use those medications. The next thing is then, uh, I personally tend to throw away all the old medications. I'm not going to use them. So, uh, talent and PHENobarbital, carBAMazepine, well, pride, I don't want to use them going forward because of their long term side effects, uh, interaction with other medications. Uh, so I never start them. Um, I'll start the patient's on any of these older medications. If they're obviously coming to me with, uh, these medications on board and doing well, then, you know, I tend to continue them but don't start them. And that would be my request and suggestion to everyone who's listening to this. Uh, it's always interesting to me when you get a patient, you know, referred in from the maybe, uh, you know, primary care doc kind of maybe a little more in the rule because both of us work in the Midwest. So there's, you know, certain areas of the country where there's a very much a, you know, lack of neurologists and you'll get, uh, family doctor who might be maybe a little, you know, long in the tooth and, uh, they start someone on, on many tone Dilantin. Uh, and so whenever I see someone under the age of, like, 60 years old who's on Dilantin, I'm like, how the heck did that happen? Uh, but, but, yeah, there, there definitely is some, some questionable choice out there in the wild if you will. Yeah. Well, I think the worst combination is Finito and plus fun PHENobarbital. And I've seen, yeah. Yeah. You know, people in the twenties on that, uh, and that's, uh, that's never a good long term. I mean, these are great seizure controlling medication, good efficacy but not good from, uh, safety or tolerability standpoint. And we are kind of blessed. I do. I know I'm veering off topic but that's kind of, unfortunately how I go something. But I, I had, we had an emergency medicine resident who was on rotation in Haiti not too long ago just this last year. And he had a young, like an 89 year old girl and, you know, as you might, one of the first questions you ask in some of, uh, some foreign countries is. What, what the anti seizure medications do you have available? And it was exactly those two, it was funny tone and PHENobarbital and he's like, even those have to be flown up from the capital. And I was just like, that's, that's a rough situation. But yeah, unfortunately, we're a little more blessed in the most part of the United States to have more options that hopefully won't have those long term. I think we are definitely potential side effects. Yeah, definitely blessed. I think we need to be better at using that blessing. Maybe. Well said, well said so. Okay. So I think we've talked about some of the uh some of the process here. So moving on, then I think you have to think of the comb or abilities that the patient has. So I kind of think of it as a positive some or a negative some. So a positive some means you are going to have some kind of benefit if you choose that particular antiseizure medication. So for example, if you're aiming for the weight loss in some patients or some patient's might like to have weight loss, then topiramate and Zonisamide are good options. Uh If uh patient has migrants or other chronic headaches, then uh topiramate or gabapentin might be good options. Uh If someone has neuropathy that you want to treat anyways, then gabapentin, pregabalin, even lamoTRIgine, oxcarbezapine and Vimpat or lacosamide, those can be considered second choice uh medications for neuropathy. If you're looking for mood stabilization, lamoTRIgine is again a good option. Uh for many of these, even Depakote is a good option, right? So for headache, for mood stabilization. But again, as I said, if you can avoid Depakote, I think that would be great, especially in young females. Uh then you have to think about what potential side effects uh this particular medication might have in this particular patient and then try to avoid that. So for example, if you want to avoid weight gain, then don't start them on gabapentin are pregabalin if you want to avoid weight loss, which can happen a lot of older patient that I see they already have poor appetite, especially they have dementia, you don't start them on two parameters. Zonisamide. If you, if you're already um worried about cognitive impairment as in some of the patients that I see, I again avoid topiramate and zonisamide because they can have cognitive negative cognitive side effects, especially uh word finding difficulties. If uh if patient has established anxiety, depression has agitation, irritability, short tempered nus uh then avoid uh Keppra and a white perampanel slash Fycompa. Uh If someone is a young female by definitely, please avoid difficult or valproic acid. Uh because if they get pregnant, a lot of pregnancy related side effects uh for the young ones on that. And if you can avoid Topamax, I think that would be great too because I think after after difficult Topamax is probably the um medication that is most likely to have congenital uh side effects. So that's another kind of level of thinking. Then I think this is coming to the next level, which is I think kind of the practical practicality of prescribing a medication. So I think you have to think about the ease of use for the patient, uh, use the ease of acquiring the medication, whether that's cost related or insurance related. And then you have to think about adherence. So, so for example, brand new medications and the current brand new medications, we have our Briviact five compound exco pre Aptiom. Uh, so those are probably four commonly used brand new medications right now. And these are great medications. And, uh, but sometimes what happens is that they might not be covered by insurance or there might be a high copay. So, do you want to go through that process? And that's a question you have to ask yourself and you also have to think about if the patient runs into a problem getting the medication, will they get back to you? Because a lot of the patient that I see, they might not tell me that they had a problem getting these medications. And, you know, you find out three months later that they never started this medication as they continue having uncontrolled seizures the entire time. Exactly. Not, not ideal. Yeah, not ideal. So, at least in my practice I try to avoid brand new medications, there's absolutely nothing wrong with this brand name, but I think I've just learned from my mistakes that these scenarios happen. Uh, then you have to think about once daily medications which might be better for adherence, especially in people with cognitive impairment or people who are just busy and, you know, don't like medications twice a day. So then once daily medications would be Keppra extended release, lamoTRIgine extended release, uh Topamax extended release, which is true candy. Um, you have Oxtellar, which is OXcarbazepine extended release, uh Perampanel and Aptiom. So these are your kind of extended release once a day medication. Uh You have to think about medication interactions. If this is a patient who you want to, who is already on some medications and you're adding a second medication or third medication because we know there is interaction between LaMICtal and difficult, so difficult will increase LaMICtal levels. So you have to keep that in mind. Uh you have to um on fee and Xcor pre have a lot of uh side effects together. So uh especially drowsy and sense oration, uh previ act can interact. Yeah, the dialects as well. The Epiduo Alex as well. Yeah, exactly with the onfi Yeah. So these medication interactions within the Antiseizure medication world, you have to keep in mind. Plus, obviously, you have to keep in mind the other medications that the patient is taking non neurology such as uh Warfarin, maybe some chemotherapeutic agents. Um So these again are ripe for uh medication interaction even really common things like statins, you know, especially with those older automatically metabolized ones. You know, I remember that's one of the classic uh epilepsy board questions is, uh, someone with refractory cholesterol. Uh, what medication they're on? I think it was carved muscle pain. Yes. Covering the question. Correct. Yeah. And, uh, I was going to bring it up in the discussion of older patient. No, no, that's okay. But that's, that's a really good point because that has been shown now, like these older medications which, which decreased the efficacy of statins by interacting against them. They increase the risk of stroke. Uh, so, uh, you know, it's, uh, yeah, again, good to avoid these older medications. Yeah. Yeah. So I think that was, uh, yeah, it's right. So it's like, what, what should we put everybody on levetiracetam? Right? There's no, uh, no interactions with Keppra. Maybe we can take a dig at our neurosurgeon colleagues and say that that is always the right answer. It's rarely the wrong answer. I'll give them that. Yeah. Uh, well, I think, uh, a scenario that I have seen not infrequently is patient's with TBI, especially for Antelope TB that get started on camera. That might be the wrong answer. They come in and they're all angry at you. And you're like, wondering why are they angry at me? I didn't do anything. This is my first time seeing you. Yeah. But yeah, I always, um, I was when I, because I have a lot of, uh, don't have neurology residents where I work. So I have internal medicine, emergency medicine, sometimes family and you know, I used to tell them like, you know, levetiracetam that does have, you know, about like about a 10% incidence of neuropsychiatric side effects. Uh and those can be really bad sometimes all the way up to like Frank psychosis. So it can be, it can be very debilitating. Uh and if there's a history of a pre existing mood disorder or maybe a TBI traumatic brain injury, uh that could even be as high as 20% depending on what the literature to look at. So, it's, it's not inconsequential, but it is frequently overlooked most of the time. And I'm sure anyone who has been practicing epilepsy for a while, they would probably have, you know, at least a few patient's who, uh, you know, who's personality completely changed or got better once they were taken off Keppra. Yes. Yes. That, that has happened a few times. I'm curious what your thought is. I've tried this a few times based off of some of the pediatric literature where you do like a low dose of vitamin B six. I've never had it work successfully in an adult patient. I tried it numerous times when I'm trying to like cross cross titrate. Maybe it'll help ameliorate some of the side effects in the interim. Oftentimes to no avail. Unfortunately. Yeah, I have tried that also. I tried it in adults. The problem is we don't know what the dose should be in adults. Uh, so I tried fairly high doses, checked er B six levels that were, you know, above reference range. But my, as, as with you, my uh experience was not consistent. Hmm. And then I always worry when I got to give this person A B six neuropathy trying to, yeah, it's like the best things you used to get them off the medication to something else, hopefully. But yeah, so, so kind of let's, let's move a little bit like kind of, you know, we've got someone maybe in the more geriatric population since that's kind of your area of particular expertise. How do you go about? I know obviously the same general principles are going to apply. But, but how does your medications selection differ from someone who might be seeing just a more general adult population? I think you have to keep in mind what is different um, in the older adults as compared to younger adults. So, uh, so, you know, there are a few things. So first of all, their process of absorption and elimination is different. So they have less gastric absorption, they have uh decrease in serum albumin, which leads to decrease the distribution. They have less bio transformation in the liver and they have less renal elimination. So, uh, you know, the total combined effect of these changes, this physiologic age related changes is that they need lower levels of medications. So, um, you cannot just translate whatever you give in younger adults or whatever your first, uh, target doses and just translate that directly to adults. You have to be a little bit mindful that they might not need that high of a dose and they're also more susceptible to side effects. Uh, so, uh, the, the problem with, uh, I shouldn't be a problem but I think the, the, um, the difficulty in treating older adults is that you have, you're kind of stuck between a rock and a hard place with many of these patient's because even if we don't treat them, obviously, they'll have seizures, they will have falls and it's not safe, but even starting them on medications will lead to false with the side effects. So you have to be really careful about how you manage them. Uh But having said that, uh you know, regarding what I should I do or not do again, avoid older medications, you know, like, you know, if it's, if it's dangerous in younger adults, it's even more so in older adults, especially with their problem pharmacy, uh medication interactions, uh and the burden of side effects are going to have by being on so many medications. There are some specific examples that I would like to give for older adults. One is uh hyponatremia with carBAMazepine and OXcarbazepine. It's more common in older adults, especially if they're on diuretics, which many of our older adults are for hypertension. Um So the rate of hyponatremia is very high with, specifically with Oxcarbezapine. Uh and then, as we mentioned earlier, uh the enzyme inducers, Dilantin, carBAMazepine, oxcarbezapine PHENobarbital. They can uh they can decrease the efficacy of uh statins by increasing their metabolic. Um which means that they will, you will have a hyper lipidemia hypercholesterolemia because the statins are not, not working as effectively, which means there will be increased risk of stroke, which has been proven by a study. So these are some specific examples that you have to keep in mind. And then you know, many of these enzyme inducers, they also increase metabolism of cardio cardiac anti arrhythmic agents. Uh antidepressants, anticoagulants, neuroleptics. So again, you know, stay away from them if you get and some of those sodium channel drugs are in themselves antiarrhythmics like many tone oh yeah, which you know, just an extra wrinkle to throw into the mix there. Absolutely. Uh So, so some basic principles avoid these older medications. And then when you start a medication, start low dose, go up slowly and usually they will get efficacy even at a low dose. So for example, and you know, when I started doing this, I was surprised that more in love for LaMICtal, most of the patient's, they respond to a dose of 100 mg daily or 50 mg twice a day. Uh for Depakote, they respond sometimes at 500 mg of 750 mg really, which is a much lower than what you would expect for a younger adult. The data for which medication to use in older adults is I would say somewhat limited. So there are a handful of trials between, between 15 and 20 trials that were specific to older adults and these are clinical trials that were randomized. Uh And most of these clinical trials, they compared newer medications and these were either of impact Keppra or LaMICtal to one of the older medications. And the most common older medication was carBAMazepine or TEGretol. Uh So, but you know that if you combine all of this together, so there were two systematic reviews and meta analysis that were published in epilepsy in 2019, which is kind of what I use for my guidance of uh medication management. So the first one which was systematic review and meta analysis of all the clinical trials of elderly. Uh they found that for seizure freedom, which was the one of the main uh end points. Uh Keppra was better than LaMICtal, which was equal to TEGretol. So Keppra was essentially better than LaMICtal and TEGretol, which with other two most commonly tested medications as far as adverse effects, LaMICtal was the best. So if you based on this data on this limited number of medications, you would say Keppra is probably the best followed by LaMICtal for follow back up the mess up in. But Keppra and LaMICtal might be pretty close. Then the second uh systematic review which was for just mono therapy. The previous systematic review for, for was for all monotherapy and add on therapy for the mono therapy, which are five clinical trials. The overall, the efficacy was the same for Vimpat. Uh Sorry, let me cancel that overall, the efficacy was better for Vimpat. Uh then LaMICtal and then Keppra and, and carBAMazepine was the worst for the side effects. So interesting, this was this was based on a network meta analysis. So it's not, you know, it's like comparing if you have a clinical trial that has A versus B and then in other words, A B versus see, then how do you compare A versus see? And that's by doing this network meta analysis. So it's based on those kind of analysis. But anyways, I think we can concur probably based on the results of these various clinical trials. And also these two systematic reviews is that Vimpat LaMICtal and Keppra probably your best bet at this point bear in mind that we do not have data for comparative data, I should say for all the newest medications. Uh So, so at this point, I think at least my clinical practices, you know, Keppra, Vimpat LaMICtal, which makes it easy. Uh But you know, and now uh Vimpat is generic which makes it really easy to prescribe. Previously. I used to have some issues with insurance in copay, but now it's it's easy. So I would probably say Vimpat is probably my number one choice at this point. Uh followed by Keppra and then I always find that interesting. I, maybe, maybe I'm just using too high of doses. I tend to find, uh, Vimpat lives a little more sedating, um, in some people as opposed to, like, you know, uh, lamoTRIgine or levetiracetam, but just, you know, anecdotally if you will. Right. Right. Uh, sometimes it's also, I think a matter of the, how you are increasing the medication, the rapidity of increasing the medication. I am mean, unless, you know, patient's are having frequent seizures, I tend to do very slowly, especially in older patients. You know, I increased like in like one month, I, you know, okay, almost twice, twice as long or longer than compared to the usual schedules. Yeah. And, and as we discussed, you know, you don't need a need to get to a very high dose in these patient's in older adults. So you can afford to start slowly and increase slowly. And I think that probably will give you the best tolerability and if patient's are tolerating it, they are less likely to stop it without informing you, which is another issue that people run into. Right, stopping and not, not informing the physicians. Do you have any issues with glucosamine? I know that, you know, some, some patient's like go to the pharmacy and they find out that, uh, the vimpat's is scheduled medication and they're like, oh, I don't want to take this, you know, it's dangerous. Um, is that anything that, you know, again, just because you're dealing with maybe a little bit of an older generation that may be a little bit different, uh, uh, perception on that aspect is that tied into your medication compliance in your population. Uh, not really. I don't think I've had that particular problem with empathy. I've had the issue where it's not covered by insurance or it's expensive or something like that. Fascinating. Yeah. Well, that's cool. And the coast might, doesn't have as much protein binding. That does make sense that it would work well in that population. I just always kind of, I guess I was to gun shy, you know, pulling away from it just because of its uh sodium channels and I always try and stay away from some of the, some of the uh I think if you go to a high dose, I'm sure, you know, you'll have lots of dizziness and loss of balance and diplopia. But I think at the low dose it's tolerated pretty well. Awesome. Well, that's cool. Um Yeah, I'll have to keep that in mind going forward on those particular patient's. Now another aspect, you know, because I know uh you know, when we're looking at the etiology for developing epilepsy in an older population, we're seeing probably more nerve degenerative dementia uh type diagnoses coming kind of hand in glove with that um in patience with, with behavioral issues like, you know, delusions, host nations, etcetera. Do you find that sometimes you are going back to those older medications like valproate or do you sometimes are you able to, as lamoTRIgine as effective in your experience for some of those behavioral issues? Um, not so much lamoTRIgine, but I've had anecdotally. I've had good experiences with Depakote and gabapentin, uh, for, uh, if someone has, having behavioral issues and also have seizures, um, so on, then, you know, I've tried this, not as first line, I've tried to, you know, try to control the seizures with the usual antiseizure medications, which I think is best overall. But if they continue to have behavioral side effects and have, you know, you know, in a handful of patients have used Depakote or gabapentin and I would say the results have been, you know, fairly good. Uh But if you look at the actual data, then um you'll find that the data suggests that they are, you know, they're not effective, but that personally, that has not been my experience. Yeah. Yeah. And that's like, you know, you look at the general adult data for something like gabapentin. It's, it's atrocious for seizure control. But there are like you said, there are some studies that show that in, in elderly patient's, it might even be a potentially first line medication for, for epilepsy. Yeah, I will actually, if you look at the guidelines, gabapentin and LaMICtal are supposed to be the best for epilepsy in older adults, which I, you know, kind of disagree with. I don't think gabapentin is the best but in, in a particular subset where you're trying to deal with behavioral issues, I think gabapentin might be a good, uh, you know, a good tool to have in your arsenal to. Do you ever find like, you know, your standard release versus like the gabapentin? Uh I can never say it. Right. Enacarbil, like the long acting gabapentin, is it? Uh, so like I can say because I think that one's still pretty expensive. So that might, that might be a reason not to. But uh is it, is it mostly like you're kind of using at night for like sundowning or like nighttime agitation or just kind of the standard like three times a day? Yeah. So yeah, depending on the requirement for the patient as for sundowning, sometimes prn sometimes standing um in a patient that I have with Lewy body dementia and epilepsy. Uh I use it as like stand standing twice a day because he would have a lot of anxiety and also hallucinations uh you know, throughout and that has helped even though it's not technically anti psychotic, at least it has helped him deal better with the anxiety related to the hallucinations? Nice. Yeah, that's a nice little trick. I'll keep that one in mind. Yeah. But be mindful of myoclonus. Oh yeah. Right. So I'm covering mostly inpatient neurology consults the last year or so and uh most seizures, I'm using air quotes here for our listeners, uh, or, uh, confusion and things like that. It's someone who's like, gone into like an acute kidney injury type situation and that no one changed their pregabalin or gabapentin doses. And it's like the patient was fine, mental, uh, mental alertness wise when they came in and then over three days they just kept getting worse and worse and gosh, what's going on. Uh, yeah, I don't know. Uh, but, but yes, no. Uh, the myoclonus thing is, is a very, uh, very overlooked by a lot of people outside of neurology. Um, but it could be, you know, like you said earlier falls very, very problematic uh, in those situations and the mental status continues to deteriorate as long as that. And then like, is there dementia getting worse or am I doing this with my medication and so on? Yeah, absolutely. I think, I think I'm so biased towards my colon is caused by gabapentin and pregabalin. Now every time I'm on in patient service and I hear my clonus, I look at their medication list first. I was like medication list and the renal function. Yeah. Yeah. There's a lot of things that cause my clone is that, uh I think people forget about and you know, there's a different conversation but a lot of people don't know what Myoclonus or asterixis for that matter, uh, looks like. And, um, yeah, that's, uh, if you don't know what you're looking at, you're not gonna necessarily diagnose it correctly. Right. That's true. That's true. But it's always, uh, it's a great, uh, thing to, uh, you know, to come up with in front of residents. They're always impressed because then you stop the pregabalin and gabapentin, the Micardis goes away. So, it's, you know, for all those new attendings out there, this is a nice tool to impress your residents. Absolutely. And any, any final thoughts in terms of seizure medication selection, uh big dues don't that you haven't already hit on, let me think, covered everything, right? What do you think? Let's say, let's say you've, you've reached for, you know, uh like, you know, lacosamide, you've uh what dose would you push? Let's say someone with, let's say mild cognitive impairment or versus early Alzheimer's dementia. How hard would you push that in, in an elderly patient in terms of like maybe dose increases? Um before you say this isn't working and I think I'm pushing the risk for, for increasing falls and so forth. Yeah, I think uh well, first of all, I think for Alzheimer's disease, if you suspect someone has Alzheimer's disease, Keppra is probably the best medication as long as they're not having baseline agitation because uh we have some animal and now some human evidence also that Keppra can help with cognition, especially executive functioning and visual spatial memory. So I think that has been proven in a randomized trial. So that in Alzheimer's disease. At least that's my first go to medication as far as pushing the dose. Uh, yeah, it's always tricky. I think I would, you know, I would, if, if in a younger adult I would give up at 2000 mg twice a day of Keppra in a older adult, I would probably give up at, you know, 1500 twice a day or even, even before that. But again, I tend to increase it slowly. So for example, if someone, if you're seeing a younger adult at 1000 mg twice a day of Keppra and you want to increase those, you would usually go to 1500 twice a day, right? If they're still having seizures in older adult, I would go to 1000 and 1500 rather than 1500 twice a day. So again, you know, increase the dose slowly rather than don't just uh copy based what you do with younger girls, right? I do think that that is something we see a lot is any, obviously this this various significantly by situation, you know, how much benefit did you get from your first medication? And I know people talk about uh substitution versus add on therapy when we talk about, you know, our second seizure medication. Um Do you find that even if let's say someone had, you know, modest benefits from the first seizure medication, are you more likely uh to lean towards substitution versus add on just because of the polypharmacy aspect in, in any more elderly population or is it really just individually dependent? I think it's individually dependent depending on their comfort level. How much support I think they have at home. Uh, you know, in, like, in a nursing home setting, I might be, uh, might do substitution because you can, you know, hopefully, uh, depend on the nursing home, uh, a little more optimistic than I am, but that the appropriate medication changes will be made. Uh in if, if, if there is someone that I, I feel like, you know, it might be too confusing, winning off one and increasing the other, then I might, you know, do dual therapy and then if possible win them off one of the medications make sense. Well, thank you so much for giving us these tips and tricks as, as uh you know, a lot of us in neurology know we kind of, we do see this big upswing as we get towards uh later life with epilepsy. And, you know, it's not copy paste, like you said, you know, we need to keep the pharmaco dynamics and the uh physiology of the patient in mind. And those are always good things to keep in mind, especially if we're used to more like early adults or middle aged adults uh in our practice to make sure we're not overmedicating our patient's to a large extent. Absolutely. Last question that just just came to mind. Uh how often do you get folks who are coming in who are maybe already treated for epilepsy? And you're like, this patient is way over medicated and you're just pulling, you know, like you're a magician pulling scarves out of that. You're just taking the medications off one after the other, uh, over a period of weeks or months because you think like this patient's barely awake, they're just sitting here and I think it's because of the medication regimen. I mean, fortunately hasn't happened a lot in my practice in older patient's. Uh but once in a while, yes, you will see someone who is on, you know, some maximal doses of four different antiseizure medications. Uh You know, this usually happens in my experience at least when patient's are in a nursing home and why, why it happens in that scenario rather than patient's are independent. I don't see it as often. But yeah, you will see three different medications that some maximal dose is. So I try to, I try to kind of simplify that, but it's always tricky. I think if anyone who has seen patient from nursing home, you always know that it's very difficult to know if they're having still having seizures or not or what's going on. Unless, unless they are very dramatic generalized tonic clonic seizures. Sometimes it's very difficult to know that is, that is an excellent point. Yeah, it's not that old maxim, right? Not everything that shakes as a seizure. Um, but yeah, it's, it's definitely challenging when you don't have that accurate story to guide your management. Well, thank you so much. I really appreciate you taking the time to, to talk with me, talk with us and kind of give us some of these tips and tricks that, that you've been using in this patient population. Now, you also have some projects of your own. I know we uh we met on Twitter via some mutual connections and uh I usually am quite enjoying what you're posting on there. But do you have any projects you wanna plug for people who might be listening in uh where they can find you and so forth? Well, you can definitely find me on Twitter. I'm trying to be active trying to, you know, talk about things that we are usually not taught in uh in academia. Uh So, you know, if you are interested, follow me there, uh My uh Twitter handle is at Rohit Marijuana. So that's my first name and last name. Uh But yeah, I think uh I think I'm trying to do something which I wish I had when I was a resident or a early career faculty. Um So I'm hoping that the other people are finding useful what I've been posting. Awesome. Yeah, I know, I've, I've been finding it uh somewhat inspirational and uh like you said, it's one of those things where I think the best thing I got from my tenants, like you need to know about medicine now so that you can learn about medicine when you graduate. Like, in hindsight, that might be a little too late. But, uh, at least they were leaning in the right direction. But now it's, it's good. We're seeing a lot more, especially with social media and people like yourself, kind of trying to make sure that people are able to kind of strive for that work life balance and, uh, you know, hopefully be more satisfied, have more longevity in their careers and all that good stuff. Exactly. I'm trying to promote the hashtag academic physician life. It hasn't caught on fire yet, but it hasn't gone wildly, but I'm hoping. Awesome. Awesome. I love it. Uh, well, thank you again. I appreciate it and I will have to, we'll have to chat again at some point. Yeah, that would be wonderful. Thank you, Michael. This was wonderful. Thank you. If you enjoyed this podcast, please rate review and share it on Apple itunes, Spotify or wherever you get your podcasts and please subscribe for future episodes. You can reach me on Twitter at Doctor Ken Trees. That's Drkentris or by email at the Neuro transmitters podcast at gmail dot com with any questions or show suggestions.