Med malpractice reviewer: fall after Ativan and Tramadol prescriptions

[lobelsteve]

Cognitive dissonance…
Did you read the case report in the thread pal?
I said pretty clearly remeron and tramadol are contraindicated, and likely caused SS. Remeron or any other atypical antipsychotic doesn’t have to be a ssri to cause SS bro…

Let’s me more clear my friend : you're an idiot to prescribe remeron with tramadol .

And since you made it personal, it is unlikely you are even close to my level of training friend. Happy to have that sword fight…

Remeron and tramadol. No big deal. Honestly. Do you know how many 1000’s of patient/yrs of therapy to have one case of SS?

Epidemiology​

Serotonin syndrome is observed across the full range of age groups, from neonates all the way through to the elderly, with an increasing incidence likely to represent the increasing use of serotonergic drugs in clinical practice.7,12,13 The percentage of adults taking antidepressants in the United States nearly doubled between 1999 and 2010, increasing from 6% to 10.4%.14 In 2016, the Toxic Exposure Surveillance System, which receives case descriptions from emergency departments, inpatient settings, and office-based practices, reported 54 410 incidences of exposures to selective serotonin reuptake inhibitors (SSRIs; 43% of which were single exposures), with 102 deaths (the ninth most common cause of fatality in drug overdoses in the United States in this period). This represented an 18% increase in cases between 2002 and 2016 and an 8% increase in the number of deaths.15-17 Large case series suggest that moderate SS occurs in approximately 15% of poisonings with SSRIs.18 A recent study found that close to half of U.S. Food and Drug Administration (FDA) Adverse Event Reporting System (FAERS) SS reports involved a single drug (depending on the diagnostic criteria used), which is, perhaps, a little surprising, given the common perception of a multidrug aetiology.19

The true incidence of SS, however, is unknown, as is the number of cases that are mild, moderate, or severe. There are a number of reasons for this: it is a relatively uncommon condition that cannot be easily picked up in randomised clinical control trials,20 and the condition is under-recognised and under-reported by physicians (85% of general physicians [GPs] were not familiar with the condition in one survey,21 and mild cases are often dismissed or self-limiting).20


I am aware of a case of Paxil 25mg as sole agent causing death from SS.

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[MitchLevi]

This is a classic case of some dude who scored high on his boards and needs that to validate himself against his peers. Most, if not the overwhelming majority of whom practice differently.

So he makes ludicrous threats like he will compare his training accolades to those who are debating him.

The conversation is a joke and I can guarantee the readers of this thread would get more out of this if we started discussing training protocols aimed at boosting endurance while holding onto fast twitch fibers...BTW, everyone should be spending at least 11 min per week in an ice bath.

 

[sunshinefl]

Are you okay friend? I said remeron and tramadol interact significantly. I don’t care about your heart rate …

“It has been suggested that more than 85% of physicians are unaware of the existence of SS or of which drugs or drug combinations are capable of causing it.”

LOL at your quote that 85% of physicians are unaware of the existence of serotonin syndrome.

 

[10KHertz]

LOL at your quote that 85% of physicians are unaware of the existence of serotonin syndrome.

It’s directly from Steve’s reference above , tool.

Rates of SS rising , epidemiology unknown , lethality documented . Symptoms unrecognized by most physicians . You want to continue to routinely write ssri/snri/atypical antipsychotics with tramadol, go ahead. I won’t protect you during your medical review …

As for fitness , bro I’d destroy any one of you . Top singles player in my state . So flex all you want . just a bunch of disgruntled tools . Go back to measuring your calves , sounds like fun… 😂

No Steve, tramadol and remeron don’t jive. Not a good medical choice :

Scores	∑ Points
Serotonergic Effects a	4

Symbol (a): Increased risk from 5 points. Please answer additional questions. See text.
Recommendation: The risk of a serotonergic syndrome is increased

Rating: Mirtazapine and tramadol modulate the serotonergic system to a moderate extent.

 

[Agast]

I’ve prescribed duloxetine and Tramadol in conjunction and click the little “ignore” box about interactions. Any time I prescribe a new medication I tell patients to stop it if it makes them feel weird. I’m never going to run a marathon and I have no idea how we ended up discussing that. As for the original patient, he is an unreliable narrator and I doubt he followed his medication instructions the way he was supposed to which likely caused the fall.

 

[10KHertz]

I’ve prescribed duloxetine and Tramadol in conjunction and click the little “ignore” box about interactions. Any time I prescribe a new medication I tell patients to stop it if it makes them feel weird. I’m never going to run a marathon and I have no idea how we ended up discussing that. As for the original patient, he is an unreliable narrator and I doubt he followed his medication instructions the way he was supposed to which likely caused the fall.

Warnings are there for a reason. Means there is a better medical option out there. Lots of narcissistic doctors think ignoring warning because it’s routine is a defense . I like your post . It allows for alternative views, something lacking in these times .

As
For basic pharmacokinetics and dynamics both Bactrim and Ativan effect the same liver cytochrome p450 subset. If interest in learning and improving one’s clinical judgement read these :

Get to Know an Enzyme: CYP2C9

An in-depth look at CYP2C9, an enzyme involved in many clinically important drug interactions.

www.pharmacytimes.com

https://www.accessdata.fda.gov/drugsatfda_docs/label/2013/017377s068s073lbl.pdf

If you just want to be a idiot, continue to flex about calves and other masculine nonsense …

 

[BobLoblaw78]

LOL at your quote that 85% of physicians are unaware of the existence of serotonin syndrome.

Wow! 85% of physicians don't know about kidnappers and hostages becoming mutually depressed?

 

[Ducttape]

i have used tramadol with SSRIs but there is more “informed consent” with the combination of these drugs than other Non-opioid combinations.

Please use cautiously, and let patients know that this is a possible risk.

also, one can use the possibility of SS to limit dosage. Clearly, no one here prescribes more than 400 mg tramadol a day.

Lack of efficacy of tramadol does not imply that a pure opioid is the next step. It may also mean that patients need to consider relying purely on non-opioid therapy.

 

[ObsequiousAplomb]

Warnings are there for a reason. Means there is a better medical option out there. Lots of narcissistic doctors think ignoring warning because it’s routine is a defense . I like your post . It allows for alternative views, something lacking in these times .

As
For basic pharmacokinetics and dynamics both Bactrim and Ativan effect the same liver cytochrome p450 subset. If interest in learning and improving one’s clinical judgement read these :

Get to Know an Enzyme: CYP2C9

An in-depth look at CYP2C9, an enzyme involved in many clinically important drug interactions.

www.pharmacytimes.com

https://www.accessdata.fda.gov/drugsatfda_docs/label/2013/017377s068s073lbl.pdf

If you just want to be a idiot, continue to flex about calves and other masculine nonsense …

You really are quite childish. What are you, a first year pharmacy student?

The sources you cite do not say that Ativan and Bactrim prolong the metabolism of each other.

I don't prescribe tramadol, at all, for any reason. I'm a psychiatrist. That's an opioid used for acute or chronic pain. I wouldn't use Ultram for a detox, either. The only opioid I would ever find myself prescribing is buprenorphine. I leave the rest of the opioids (and a fair amount of the buprenorphine) to my esteemed colleagues who are more appropriate to prescribe them, given their status within specialties that routinely utilize them.

As a psychiatrist and not a GP, as that article was referring to, it would be impossible for me not to know that Remeron, Ultram, other opioids, atypical antipsychotics, anti-emetics, SSRIs, SNRIs, MAOis, TCAs, linezolid, or any medications that interact with them can contribute to serotonin syndrome. If you had read my previous posts in this thread you would know I am a psychiatrist and that Steve is a pain management specialist. I wonder if you think psychiatrists and pain management physicians are GPs? Did you also realize that the 85% number came from a survey from more than 25 years ago, in another country?

I never at any point in this conversation said or implied that Remeron cannot contribute to serotonin syndrome. YOu magically asserted that I was calling Remeron an SSRI and that I was somehow saying that SS is impossible with that combination. You also claimed that PO Ativan and PO Bactrim have an interaction which any first year pharmacy student could correct you on. You seem to have major reading comprehension deficits. You also elected to attack my intelligence and then brag about your exercise routines. You then have the gall to claim that our experience and clearly firmer grasp of the material means that we are the ones who are wrong.

The rambling, tangential, disorganized, absurd, narcissistic, and grandiose nature of your comments in this thread leave me obligated to encourage you to consider seeing a psychiatrist. Perhaps you can flex your sub-graduate-level knowledge of pharmacokinetics and pharmacodynamics to them, too? I for one love having patients with this little insight. It means there's plenty of work to do.

 

[10KHertz]

You really are quite childish. What are you, a first year pharmacy student?

The sources you cite do not say that Ativan and Bactrim prolong the metabolism of each other.

I don't prescribe tramadol, at all, for any reason. I'm a psychiatrist. That's an opioid used for acute or chronic pain. I wouldn't use Ultram for a detox, either. The only opioid I would ever find myself prescribing is buprenorphine. I leave the rest of the opioids (and a fair amount of the buprenorphine) to my esteemed colleagues who are more appropriate to prescribe them, given their status within specialties that routinely utilize them.

As a psychiatrist and not a GP, as that article was referring to, it would be impossible for me not to know that Remeron, Ultram, other opioids, atypical antipsychotics, anti-emetics, SSRIs, SNRIs, MAOis, TCAs, linezolid, or any medications that interact with them can contribute to serotonin syndrome. If you had read my previous posts in this thread you would know I am a psychiatrist and that Steve is a pain management specialist. I wonder if you think psychiatrists and pain management physicians are GPs? Did you also realize that the 85% number came from a survey from more than 25 years ago, in another country?

I never at any point in this conversation said or implied that Remeron cannot contribute to serotonin syndrome. YOu magically asserted that I was calling Remeron an SSRI and that I was somehow saying that SS is impossible with that combination. You also claimed that PO Ativan and PO Bactrim have an interaction which any first year pharmacy student could correct you on. You seem to have major reading comprehension deficits. You also elected to attack my intelligence and then brag about your exercise routines. You then have the gall to claim that our experience and clearly firmer grasp of the material means that we are the ones who are wrong.

The rambling, tangential, disorganized, absurd, narcissistic, and grandiose nature of your comments in this thread leave me obligated to encourage you to consider seeing a psychiatrist. Perhaps you can flex your sub-graduate-level knowledge of pharmacokinetics and pharmacodynamics to them, too? I for one love having patients with this little insight. It means there's plenty of work to do.

Psychiatrist recommending a psychiatrist, classic... My life is pretty great actually. thanks for asking . Just a simple ivy trained pain MD try to make it in this world.

And yes you don’t understand SS or cytochrome subset inhibition clearly …

 

[ateria radicularis magna]

Ego is a helluva drug

 

[Agast]

Ego is a helluva drug

I’m waiting for the silverbacks to start comparing who has the hottest wife/girlfriend

 

[Dr. Ice]

I believe the real KOLs are “too polished” to compare those “asserts” they would rather shine the leads and watch them glimmer like a diamond at the next conference. After all, that’s what pays for it all…