Critical Actions
Prioritized by urgency — 19 total actions
STOP IMMEDIATELY (2)
Magnesium reduces rosuvastatin absorption by 54% when taken together.
Solution: Crestor at bedtime (10 PM), Magnesium at midday (12 PM).
RESOLVED: Depakine is being tapered and will be stopped completely by ~7 Apr 2026 per Prof. Hosny. Separation rule no longer needed once Depakine is stopped.
Solution: Protein at midday (12 PM), VPA with morning (8 AM) and evening (8 PM) meals.
URGENT (7)
Current fluid intake 2L/day — monitor serum osmolality (279, borderline low). Consider 1.5L/day if SIADH confirmed.
RESOLVED: Quetiapine has been STOPPED per Prof. Hosny (07 Mar 2026). No longer need to monitor levels.
CYP3A4 de-induction takes ~2-3 weeks. Monitor for excessive sedation.
ANC 0.7 = Grade 3 neutropenia. Standard threshold for stopping CBZ is ANC <1000-1500.
Fever protocol: Any fever >38°C with ANC <0.7 = immediate ER visit.
Baclofen is being tapered (Prof. Hosny, 07 Mar 2026) and will be stopped by ~28 Apr 2026. Continue separation until baclofen is fully stopped. Current dose: 7.5mg AM + 10mg PM.
Take baclofen ≥1hr before or ≥2hrs after protein meals/whey shakes. Schedule baclofen at consistent times (e.g. 8AM, 8PM). Monitor spasticity when increasing protein. Analogous to L-DOPA/protein interaction in Parkinson's.
RESOLVED: Dr. Ahmed Alous (13 Mar 2026) confirmed ammonia level is acceptable — was drawn from vein (venous), not artery. Venous ammonia is expected to be higher. Plus Depakine is being tapered/stopped, further reducing ammonia risk.
Increase protein by ~5g/week. Check fasting + 2-4hr postprandial ammonia at each step. L-carnitine MUST start concurrently (urea cycle support). Distribute protein evenly: 25-30g/meal, never >40g/sitting. Ammonia constraint disappears after VPA fully tapered.
All changes start 17 Mar 2026: QUETIAPINE: STOPPED immediately DEPAKINE (Valproic Acid): • 17 Mar – 7 Apr: 250mg evening only • After 7 Apr: STOP completely BACLOFEN: • 17 Mar – 31 Mar: 7.5mg morning + 10mg evening • 31 Mar – 14 Apr: 5mg morning + 10mg evening • 14 Apr – 28 Apr: 2.5mg morning + 10mg evening • After 28 Apr: STOP completely ARICEPT (Donepezil): • 17 Mar – 31 Mar: 5mg daily • After 31 Mar: STOP completely ESCITALOPRAM: START 10mg daily (mood enhancement) Follow-up: Prof. Hosny — 7 Apr 2026
Per Dr. Ahmed Alous (13 Mar 2026): Give Neupogen (Filgrastim) injection subcutaneously ONLY if ANC (Absolute Neutrophil Count) drops below 0.5 x10³/μL. Current ANC: 0.8 (Feb 28, 2026). Keep injection on hand. Monitor ANC with weekly CBC.
HIGH PRIORITY (4)
14+ hours in bed = catastrophe for sarcopenia. 1 week bed rest = 1.4kg muscle loss. Start 30 min seated x 4 times/day.
ALL meals and supplements consumed while SEATED UPRIGHT (10-32% better amino acid absorption).
RESOLVED: Quetiapine stopped and replaced by Escitalopram 10mg daily for mood per Prof. Hosny (07 Mar 2026).
Current: sleeping ~2AM. 4-phase plan: gradually shift to 11PM-7AM over ~2 weeks.
Golden rules: NO naps 7-9 PM, morning light therapy 30 min, all food while seated upright.
L-Carnitine is the most urgent supplement addition — directly addresses urea cycle impairment driving borderline hyperammonemia.
1,000mg BID. Check free + total carnitine at baseline. VPA depletes carnitine → shifts metabolism to hepatotoxic ω-oxidation → impairs urea cycle → ammonia rises. Must start BEFORE protein increase to make it safe. Continue until VPA fully discontinued + carnitine normalized.
ROUTINE (3)
Already started ~Feb 15. Sarcopenia, neuroprotective, anticonvulsant potential. Creatinine will rise 0.2-0.3 mg/dL = NORMAL.
Protein gap ~10-25g/day. Leucine threshold not met. Monitor ammonia 2 weeks after start.
ANC 0.7 = immune support needed. Iron absorption (ferritin 19.4). No drug interactions.
ADVISORY (3)
Lowers SBP 3-8 mmHg. With baseline SBP 90, even 3 mmHg compromises cerebral perfusion.
Preserved subcortical vocalization pathway = candidate for MIT/LSVT LOUD. Motor apparatus intact.
Post-TBI hypothalamic damage in 25-50% of severe TBI. Tests: Morning Cortisol + ACTH, IGF-1.