NAPLEX Question of the Week: Managing Side Effects

This question focuses on management of ADRs associated with AEDs.

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A 37 year old female presents in July around 7:30 PM to her local community pharmacist in the Southern United States for consultation. She complains of fever (103 F), body aches, cough, and generalized rash on both lower extremities. She currently takes omeprazole 20mg daily, atorvastatin 40mg daily, levothyroxine 112mcg daily, and lamotrigine 100mg daily (started 2 weeks ago). Her vaccinations are all up to date.  Which of the following best represents appropriate initial management for her symptoms?

A. Ibuprofen 400mg TID PRN for fever

B. Acetaminophen 1g TID PRN for fever

C. Dextromethorphan 10mg q4h PRN cough

D. Hydrocortisone 1% BID for rash

E. Refer to emergency room for definitive management

Answer with rationale:

The correct answer is E. NAPLEX competency statement 3.1 refers to knowledge of when to triage or send a patient for medical referral. This patient's current symptoms and history are strongly suggestive of a serious adverse reaction to lamotrigine that could be a hypersensitivity reaction or Stevens Johnson Syndrome, both of which could be fatal. Prompt referral for management including most importantly discontinuing lamotrigine therapy is the best answer at this time.  Several things are important to note in this case pointing toward lamotrigine as the culprit. First, it is July and therefore flu like illness is not likely, especially in a patient who is up to date on all vaccines. Second, her lamotrigine was started one week ago at a much higher than normal starting dose (typically 25mg). The other therapy choices (A, B, C, and D) are incorrect as this is more consistent with treating typical low-risk illnesses such as cold, influenza, or mild dermatologic reaction. 

Christopher M. Bland

Clinical Professor, University of Georgia College of Pharmacy

Dr. Christopher M. Bland is a Clinical Professor at the University of Georgia College of Pharmacy at the Southeast GA campus in Savannah, GA. Dr. Bland has over 20 years of academic and clinical experience in a number of clinical areas. He is a Fellow of both the Infectious Diseases Society of America as well as the American College of Clinical Pharmacy. He is co-founder of the Southeastern Research Group Endeavor, SERGE-45, with over 80 practitioners across 14 states involved. Dr. Bland serves as Associate Editor for the NAPLEX Review Guide 4th edition as well as Editor-In-Chief for the Question of the Week. He has provided live, interactive reviews for more than 10 Colleges/Schools of Pharmacy over the course of his career.