How to manage a patient with allergic rhinitis, nasal polyp, hyperbilirubinemia, erectile dysfunction, and peripheral neuropathy on perampanel, tadalafil (Cialis), and multivitamin?

Management of Complex Multi-System Patient on Perampanel

This patient requires immediate systematic evaluation of hyperbilirubinemia and peripheral neuropathy while optimizing allergic rhinitis and nasal polyp management with intranasal corticosteroids as first-line therapy.

Allergic Rhinitis and Nasal Polyp Management

First-Line Treatment

• Initiate intranasal corticosteroids (fluticasone, mometasone, or budesonide) as the most effective medication class for controlling all four major symptoms: sneezing, itching, rhinorrhea, and nasal congestion 1, 2
• Instruct the patient to direct sprays away from the nasal septum to prevent irritation and bleeding, with periodic examination of the nasal septum for mucosal erosions 1
• Maximum efficacy requires several days of consistent daily use 2

Adjunctive Therapy

• Add nasal saline irrigation as non-pharmacological adjunctive therapy to relieve congestion and facilitate clearance of nasal secretions 1, 2
• Consider a short course (5-7 days) of oral corticosteroids for significant nasal polyposis if intranasal corticosteroids prove inadequate 1
• Avoid topical nasal decongestants or limit strictly to 3-5 days maximum to prevent rhinitis medicamentosa 1, 2

Surgical Consideration

• If medical therapy fails to control nasal polyps after adequate trial, refer to otolaryngology for surgical evaluation 1

Critical Evaluation of Hyperbilirubinemia

Immediate Assessment Required

• Determine if hyperbilirubinemia is conjugated or unconjugated through fractionated bilirubin testing 3
• Perampanel is metabolized hepatically and requires dose adjustment in hepatic impairment: maximum 6 mg daily in mild hepatic impairment, 4 mg daily in moderate hepatic impairment, and contraindicated in severe hepatic impairment 4
• Evaluate for Dubin-Johnson syndrome (ABCC2 gene mutations) or Rotor syndrome (SLCO1B1 and SLCO1B3 gene mutations) if conjugated hyperbilirubinemia is present, as these conditions increase susceptibility to drug toxicity 3

Drug Interaction Concern

• If hyperbilirubinemia represents hepatic dysfunction, perampanel dose must be reduced immediately based on severity 4
• Monitor for perampanel-related psychiatric symptoms (aggression, hostility, irritability, anger) which are dose-dependent and may worsen with hepatic impairment 4

Peripheral Neuropathy Evaluation

Essential Workup

• Despite normal vitamin B12 levels, evaluate for other causes: diabetes mellitus (fasting glucose, HbA1c), thyroid dysfunction (TSH), heavy metal exposure, and medication-induced neuropathy
• Perampanel commonly causes neurologic effects including dizziness, gait disturbance, somnolence, and fatigue (≥5% incidence), which may be confused with or exacerbate peripheral neuropathy symptoms 4
• Consider whether "burning sensation in legs and fingers" represents perampanel adverse effects versus true peripheral neuropathy

Management Strategy

• If perampanel is contributing to neurologic symptoms, consider dose reduction or alternative antiepileptic medication
• Warn patient about increased fall risk, as perampanel causes falls as a common adverse reaction 4

Erectile Dysfunction Management

Current Therapy Assessment

• Continue tadalafil as prescribed for erectile dysfunction
• Be aware that perampanel 12 mg daily may decrease effectiveness of hormonal contraceptives containing levonorgestrel through drug interactions 4
• Evaluate whether erectile dysfunction is related to peripheral neuropathy, vascular disease (given non-specific ST-T changes on ECG), or medication effects

Cardiovascular Consideration

• Non-specific ST-T changes on ECG with normal echocardiogram require risk factor assessment (lipid panel, blood pressure monitoring, smoking status)
• Ensure tadalafil is not contraindicated based on cardiovascular status

Medication Reconciliation and Monitoring

Perampanel-Specific Warnings

• Monitor closely for serious psychiatric and behavioral reactions including aggression, hostility, irritability, and anger, particularly during dose titration 4
• Reduce perampanel dose if psychiatric symptoms occur; discontinue immediately if symptoms are severe or worsening 4
• Advise patient to use caution when driving or operating machinery due to neurologic effects 4

Drug Interaction Vigilance

• If patient requires carbamazepine, oxcarbazepine, or phenytoin (moderate/strong CYP3A4 inducers), perampanel clearance increases and dose adjustment is necessary 4
• Monitor for suicidal behavior and ideation as with all antiepileptic drugs 4

Follow-Up Algorithm

Immediate Actions (Within 1-2 Weeks)

• Fractionated bilirubin, comprehensive metabolic panel, and hepatic function assessment
• Neurologic examination to differentiate perampanel adverse effects from true peripheral neuropathy
• Initiate intranasal corticosteroids for allergic rhinitis and nasal polyps 1, 2

Short-Term Follow-Up (2-4 Weeks)

• Reassess rhinitis symptom control and quality of life 1
• Evaluate response to intranasal corticosteroids; if inadequate, consider step-up to short course oral corticosteroids for nasal polyps 1
• Review perampanel dosing based on hepatic function results 4

Long-Term Management (Monthly Initially)

• Monitor for perampanel psychiatric adverse effects and neurologic symptoms 4
• Assess need for allergen immunotherapy if pharmacologic therapy for allergic rhinitis is ineffective 1, 2
• Consider otolaryngology referral if nasal polyps remain refractory to medical management 1