Need advice plz

[gobby]

I'd like to ask for your opinion, please: A 60 yr-old asian male patient of mine was recently diagnosed with epilepsy. He has had Lamictal 25 mg (once per day, increased to bid today) added two months ago to his usual drug cocktail ( for over 1 yr) of the following:

- Detrol LA 4 mg (once a day)
- Metamorphin (aka Glucophage) 850 mg (bid)
- Vasotec 10 mg (bid)
- Norvasc 5 mg (once per day)
- Indur 60 mg ( ii tabs bid )
- Therazosin 5 mg (once per day)
- Advair 250 micrograms ( fluticozone 250 micrograms + salmeterol 50 micrograms) - 1 times per day
- Flomax CR 0.4 mg ( once per day)
- Arthrotec 7.5 mg (ddiclosenal 75 micrograms + misoprostol 200 micrograms) - bid
- Zocor (Synvastatin) 20 mg (once per day)
- Vitamin B 12 ( 1-2 times per day )

Within the last 6-8 weeks, his chief complaint is a gradual loss of taste in his mouth. In addition, he explains that his tongue, "has gone numb" and he experiences nausea when eating. I asked him if during tasing food whether he posesses a 'metallic' taste or a 'burning' sensation and he replied, "No". Thus, he no longer enjoys eating, has consequently lost over 25 lbs and is very miserable.

Upon clinical examination there were no significant findings intraorally, neither on the epithelium of the tongue nor the vesibule of the buccal mucosa. The mouth appears normal with sufficient saliva. I've checked the CPS as well as consulted with a team of pharmacists, and the results are that Lamictal 25 mg (latest drug) is causing nausea and xerostomia as a secondary effect. His family doctor referred him to me (dentist) and also a neurologist. The only other drug that may cause a decrease in taste would be the drug taken for his asthma condition, Advair. Although, he's been taking this drug for years.

So, the only realistic conclusion here is that: Could the xerostomia (dry mouth syndrome) due to Lamictal, my patient is experiencing, be affecting him so radically as to the point of losing almost all of his taste sensation ? Is this concept feasible ? Or, does Lamicatal have a deleterious side affect (decreasing taste) as it interacts with the rest of the drug cocktail - The pharmacists don't seem to think so as current interactions have been verified.

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[eh384]

The first thing that comes to mind is vitamin B-12 deficiency. He has all the typical symptoms. I bet he's not taking his pills. Another option may be diabetic neuropathy. Check his sugar levels.
Evan

 

[capisce?]

On his list of meds, the vasotec jumps out to me. ACE inhibitors like vasotec or more commomly captopril are commonly associated with taste disturbances and metallic tastes. It's likely a combination of that with the xerostomic effect of a few of those meds.

It's also worth noting that for pain control you need to avoid chronic acetominophen use with patients on lamictal because it lowers the active levels in the bloodstream and decreases the seizure threshold.

I also agree with the above poster regarding B12, I'd check his compliance.

 

[gobby]

I have found out thatHe self medicates and has provided me with a short list, to date

-Tylenol, Extra Strength, 500 mg : 4 times per day
-Benadryl, 25 mg : 3-4 times a week; Although he also mentioned within the same sentence that he takes it daily for seasonal allergies(?) - diabetic amnesia ? as a result of low blood sugar, perhaps).

It appears as if my patient is a little confused about the dosage and administration of the latter drug. I know that, in his retired moments, golf is his life. Anyhow, I believe that Benedryl (antihistamine) has additive effects to the xerostomia; But, does Tylenol or Benedryl have grave interactions contributing to the lack of taste or numbness of the patient's tongue ?

Furthermore, the patient has not been monitoring his blood glucose levels. The last time a recording was taken, at the end of June / 07, it was done professionally by a clinic and was reported at normal levels, so he says. When I asked him about B12, he says that he's taken the pills on a regular basis except on two occasions when he, "ran out" recently - he can't remember exactly when. He did this on two (2) occasions: Both times he admitting to a delay of 1-2 days prior to refilling the prescription.

I asked him to get a blood glucose done asap. He said he couldn't do it today - (?golf, I presume, takes precedence ?) I had asked him to get it done by tomorrow, July 17th/07, latest, so that I could get the information. Do you think that a delay 1-2 days of B12 on two recent occasions would create such drastic side effects ?

Based on the information, I have provided other than blood glucose level, do you have a clearer picture of what is at hand ? I'm also worried that he takes Tylenol 4 times a day and, that'll lower active effects of Lamictal. I'll post the blood glucose levels separately.

I'd appreciate your input here again.

Thanks in advance


PS: please note that the patient doesn't have a 'metallic' taste. Taste is altered to the point where food tastes bland and feels uncomfortable chewing the bolus in his mouth for cannot distinguish specific tastes that he could identify before. Thx.