Topiramate

[medhead1990]

Curious what everyone’s experience has been with topiramate and it’s many many off label uses. I had a conversation with someone the other day who frequently used it for weight loss, mdd, ocd, sleep, Alcohol deprenence and other off label uses. I’ve never really used it because in my minds eye there’s always something that is “better“ in each given category of use and frankly I’m just not very familiar with it. What has the group seen by way of efficacy in all of its off label uses? My understanding is often the stupor (hence the dopamax nickname ) it causes is the rate limiting step.

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[WisNeuro]

We notice a pretty significant improvement in cognition when our patients get off it. In some of our older folks, they go from looking demented to looking mostly normal off the drug. Definitely one of our red flag drugs on the medlist when we see people.

 

[clozareal]

The cognitive blunting effect is dose-dependent and often happens at higher doses of 400mg or above. I tend not to go above 150mg and it's been really helpful for my patients with alcohol use disorder to cut down on drinking, those on antipsychotics to reduce cravings. I feel the cognitive dulling is similar to what I see with patients on pregabalin/gabapentin at the higher doses. I don't see cognitive dulling at doses of 25-100mg and in fact, people tell me they are able to think more clearly with less anxiety, better sleep, less alcohol use, etc. Topiramate is one of these paradoxical drugs that can help and cause issues with cognition, depression, and even psychosis.

There is a meta analysis of 12 RCTs for topiramate for schizophrenia which shows some efficacy for both positive and negative symptoms: Efficacy and tolerability of topiramate-augmentation therapy for schizophrenia: a systematic review and meta-analysis of randomized controlled trials - PubMed

It's also been studied in OCD, bulimia/binge eating, cocaine/meth use disorders, PTSD, borderline personality disorder. It doesn't work as an antimanic agent though.

 

[mistafab]

I use it in binge eating disorder with good success. It is usually at lower doses (50-100 TDD) and doesn't tend to have the dopamax effects at that level.

Binge-Eating Disorder in Adults: A Systematic Review and Meta-analysis

The best treatment options for binge-eating disorder are unclear.To summarize evidence about the benefits and harms of psychological and pharmacologic therapies for adults with binge-eating disorder.English-language publications in EMBASE, the Cochrane ...

www.ncbi.nlm.nih.gov

I find it will either work for the patient, or not. There doesn't seem to be a dose-effect curve when I've pushed up doses from my limited observational data (~10 trials, 1/2 found effective/clinical improvement). The research trials used larger doses than I usually use, I just didn't see much benefit when utilized that way (and more side effects).

 

[Merovinge]

The cognitive blunting effect is dose-dependent and often happens at higher doses of 400mg or above. I tend not to go above 150mg and it's been really helpful for my patients with alcohol use disorder to cut down on drinking, those on antipsychotics to reduce cravings. I feel the cognitive dulling is similar to what I see with patients on pregabalin/gabapentin at the higher doses. I don't see cognitive dulling at doses of 25-100mg and in fact, people tell me they are able to think more clearly with less anxiety, better sleep, less alcohol use, etc. Topiramate is one of these paradoxical drugs that can help and cause issues with cognition, depression, and even psychosis.

There is a meta analysis of 12 RCTs for topiramate for schizophrenia which shows some efficacy for both positive and negative symptoms: Efficacy and tolerability of topiramate-augmentation therapy for schizophrenia: a systematic review and meta-analysis of randomized controlled trials - PubMed

It's also been studied in OCD, bulimia/binge eating, cocaine/meth use disorders, PTSD, borderline personality disorder. It doesn't work as an antimanic agent though.

Are you using Topamax instead of Naltrexone in AUD cases preferentially? Combining them? Or after failing naltrexone/Vivitrol?

I think it's a pretty underwhelming medication beyond it's carbonic anhydrase inhibition but I wonder how much of that is regional, as I never saw it prescribed psychiatrically at any of the sites I did medical school, residency, or fellowship at.

 

[Sushirolls]

Never use it.
Agree with OP, so many better options.

 

[Stagg737]

Imo it's a great drug at the right doses (I don't typically go higher than 100mg) for the right patients. I also agree with those above that it very rarely has cognitive blunting effects in my patients at doses I use. When it does, the patients tend to be those who are very sensitive to meds and have reactions to 5mg of buspar. Things I use it for:

1. Antipsychotic induced metabolic syndrome if unable to tolerate metformin (has the best data for this after metformin)
2. Trauma-related nightmares if prazosin is ineffective or unable to be tolerated. Topiramate is 2nd/3rd line for me along with mirtazapine and clonidine. Yes, there are other options, but specifically for nightmares topiramate 50-100mg is much lower risk than many of them and will actually work and not just completely snow someone.
3. AUD if they've failed naltrexone and also if gabapentin or acamprosate aren't better options (I've found the latter to be mostly worthless). A Cochrane meta-analysis also found that it is actually superior to naltrexone in terms of risk of severe relapse.
4. BED/weight loss typically when it can also help something else (I have very rarely used it for BED by itself).
5. Anxiety/insomnia IF there is another primary issue we are addressing with topiramate (oftentimes headaches/migraines). I'd rather just use one med that will help 2-3+ problems than 3 different meds that may or may not work for each individual problem and can cause polypharmacy issues. I've found it to be very hit or miss with these issues, so more of something to keep in my hat for tricky patients than something I'd regularly consider.

I do not use it for OCD, other non-alcohol SUDs, depression, or BPD. I generally avoid it in geri patients or patients who are already on multiple CNS depressants unless I'm trying to get them off of those other meds (was particularly helpful for getting one patient off of benzos, I remember because PCP was not happy I started it). I'm also fairly quick to discontinue if they're not having a noticeable benefit at 50-100mg.

We notice a pretty significant improvement in cognition when our patients get off it. In some of our older folks, they go from looking demented to looking mostly normal off the drug. Definitely one of our red flag drugs on the medlist when we see people.

What doses are these patients typically on? I imagine that even low doses at 100mg daily or less can cause significant issues in your elderly population, but for younger patients (<60yo) I rarely seen significant cognitive problems with low doses and like Clozareal often see the opposite when they're functioning better.

Are you using Topamax instead of Naltrexone in AUD cases preferentially? Combining them? Or after failing naltrexone/Vivitrol?

I think it's a pretty underwhelming medication beyond it's carbonic anhydrase inhibition but I wonder how much of that is regional, as I never saw it prescribed psychiatrically at any of the sites I did medical school, residency, or fellowship at.

Won't speak for Cloz, but naltrexone is always my first line unless there's a good reason they can't take it (severe liver disease, on opiates for pain, etc). Every addictions trained doc I've talked to has also pretty much felt similarly, that naltrexone is the go-to for AUD unless contraindicated.

 

[clozareal]

Are you using Topamax instead of Naltrexone in AUD cases preferentially? Combining them? Or after failing naltrexone/Vivitrol?

I think it's a pretty underwhelming medication beyond it's carbonic anhydrase inhibition but I wonder how much of that is regional, as I never saw it prescribed psychiatrically at any of the sites I did medical school, residency, or fellowship at.

The data for me seems stronger than the data for naltrexone, disulfiram, and antabuse but they are definitely my strong considerations as FDA approved options since topiramate isn't. I would use it if there's a significant anxiety, insomnia, trauma, or mood component to their AUD. It doesn't matter whether they have a variation in the GRIK1 gene since two recent well designed RCTs showed that there was no difference. I tell them all those options and the benefits/risks of each one, make a recommendation based on my experience and what I think their values are, and then let them make the decision. I'm not using topiramate preferentially over naltrexone.

I start at 25mg at bedtime and then go up to 50-100mg. I don't usually use doses above 150mg if I can help it to avoid the cognitive dulling event (which is theoretically above 400mg but I've seen it at 200mg whereas when I dropped the dose a bit).

 

[WisNeuro]

What doses are these patients typically on? I imagine that even low doses at 100mg daily or less can cause significant issues in your elderly population, but for younger patients (<60yo) I rarely seen significant cognitive problems with low doses and like Clozareal often see the opposite when they're functioning better.

Most often seeing 100mg/day, most often for migraine control, but still seeing the occasional rx for weight loss in the 60+ population. Have seen some significant changes in as low as 50mg/day in this population. Definitely agree that the dose response has a higher floor in a younger population, even some good work by David Loring looking at this. But, I'd imagine it's pretty similar to things like anticholinergic effects. Oxybutynin in a 45 year old looks a lot different with the same dosage in a 74 year old.

 

[psycho-matic]

Curious what everyone’s experience has been with topiramate and it’s many many off label uses. I had a conversation with someone the other day who frequently used it for weight loss, mdd, ocd, sleep, Alcohol deprenence and other off label uses. I’ve never really used it because in my minds eye there’s always something that is “better“ in each given category of use and frankly I’m just not very familiar with it. What has the group seen by way of efficacy in all of its off label uses? My understanding is often the stupor (hence the dopamax nickname ) it causes is the rate limiting step.

It has very good efficacy in Tourettes Syndrome. Should be tried before anti-psychotics in my opinion. If tolerated, it can be very effective.

 

[Stagg737]

I start at 25mg at bedtime and then go up to 50-100mg. I don't usually use doses above 150mg if I can help it to avoid the cognitive dulling event (which is theoretically above 400mg but I've seen it at 200mg whereas when I dropped the dose a bit).

This is also my practice, and will go up to 100mg QHS and 50mg for daytime dosing, but generally don't go higher.

 

[DOswag]

This thread right here highlights one of the things I love about psychiatry but early in my career was daunting. I've used topiramate for several of these off label uses and I saw it used that way while I was in training. Mood disorders, substance use, weight loss, sleep etc. But when I was an intern we had one attending that would use it frequently on inpatient then the very next month we would switch attendings but were in the same location. The next attending hated it and literally never used it. I was so confused. I love though that there's not necessarily a right or wrong answer on med choices for a lot of things we treat and you have multiple options to reach for now.

 

[Merovinge]

This thread right here highlights one of the things I love about psychiatry but early in my career was daunting. I've used topiramate for several of these off label uses and I saw it used that way while I was in training. Mood disorders, substance use, weight loss, sleep etc. But when I was an intern we had one attending that would use it frequently on inpatient then the very next month we would switch attendings but were in the same location. The next attending hated it and literally never used it. I was so confused. I love though that there's not necessarily a right or wrong answer on med choices for a lot of things we treat and you have multiple options to reach for now.

If nothing else, having a deep repertoire of treatment resistant options is a big part of being a specialist. It might not be first, second, or third line but knowing where the evidence can at least point past that is really helpful. I didn't think I would be prescribing Nuvigil for ADHD but had modest success using it as a 6th line agent this past month...

 

[clozareal]

Most often seeing 100mg/day, most often for migraine control, but still seeing the occasional rx for weight loss in the 60+ population. Have seen some significant changes in as low as 50mg/day in this population. Definitely agree that the dose response has a higher floor in a younger population, even some good work by David Loring looking at this. But, I'd imagine it's pretty similar to things like anticholinergic effects. Oxybutynin in a 45 year old looks a lot different with the same dosage in a 74 year old.

Migraines, alcohol use, anxiety, trauma, insomnia, OCD, depression, and metabolic syndrome (especially if it leads to microvascular dysfunction) can all affect cognition. Antipsychotics can affect cognition. It's weighing the risks and benefits not only of the different medications against each other, but also against what the disorder itself is causing.

Anticholinergic agents like oxybutynin are on latest version of Beers list. Topiramate is not.

I just read David Loring's paper. The study said that up to 96mg/day does not affect cognition after 24 weeks (although did at 6 weeks which got better). However, at 194mg and above it did affect it. This corresponds to my experience of cognitive dysfunction happening around 200mg, but not at 150mg, but this paper doesn't look at ~150mg dosing. I typically try to stick to 100mg or less anyways. Thanks for the reference.

 

[WisNeuro]

Migraines, alcohol use, anxiety, trauma, insomnia, OCD, depression, and metabolic syndrome (especially if it leads to microvascular dysfunction) can all affect cognition. Antipsychotics can affect cognition. It's weighing the risks and benefits not only of the different medications against each other, but also against what the disorder itself is causing.

Anticholinergic agents like oxybutynin are on latest version of Beers list. Topiramate is not.

I just read David Loring's paper. The study said that up to 96mg/day does not affect cognition after 24 weeks (although did at 6 weeks which got better). However, at 194mg and above it did affect it. This corresponds to my experience of cognitive dysfunction happening around 200mg, but not at 150mg, but this paper doesn't look at ~150mg dosing. I typically try to stick to 100mg or less anyways. Thanks for the reference.

At least in terms of Loring's paper, it looked at a relatively young group of individuals. This is understudied in elderly populations.

 

[Stagg737]

At least in terms of Loring's paper, it looked at a relatively young group of individuals. This is understudied in elderly populations.

As are most medications. Early elderly like 65-75 yo there's data, but good luck finding solid data on treating almost anything in patients 80yo+. One of my IM attendings in med school was geri boarded and he said that the data for pretty much everything after 75 is weak at best and after 85 yo is basically garbage. Honestly, at that point I'm only really concerned with maintaining quality of life and acute mortality risks, part of why I've always disliked geriatric medicine and psych.

 

[WisNeuro]

As are most medications. Early elderly like 65-75 yo there's data, but good luck finding solid data on treating almost anything in patients 80yo+. One of my IM attendings in med school was geri boarded and he said that the data for pretty much everything after 75 is weak at best and after 85 yo is basically garbage. Honestly, at that point I'm only really concerned with maintaining quality of life and acute mortality risks, part of why I've always disliked geriatric medicine and psych.

Definitely, so we usually have to go with case reports and anecdotal info. But ask most general neuropsych people what happens to their patients when they get a med reconciliation, particularly with these drugs, and you'll get a lot of "reversible dementia" type accounts. This would be a perfect opportunity to collaborate with a geriatrician and possibly pharmacists, but there is not a lot of money or incentive to put in the time, money, and effort for these.

 

[clozareal]

Definitely, so we usually have to go with case reports and anecdotal info. But ask most general neuropsych people what happens to their patients when they get a med reconciliation, particularly with these drugs, and you'll get a lot of "reversible dementia" type accounts. This would be a perfect opportunity to collaborate with a geriatrician and possibly pharmacists, but there is not a lot of money or incentive to put in the time, money, and effort for these.

Yeah we definitely need more data but it looks like in the data for epilepsy for up to 200mg/day of those age 65+ had 12% report cognitive deficits, but this was based on self report rather than neuropsychological batteries. This was one of the main reasons for discontinuing the medications and rightly so, but this is a minority of elderly taking topiramate.

 

[WisNeuro]

Yeah we definitely need more data but it looks like in the data for epilepsy for up to 200mg/day of those age 65+ had 12% report cognitive deficits, but this was based on self report rather than neuropsychological batteries. This was one of the main reasons for discontinuing the medications and rightly so, but this is a minority of elderly taking topiramate.

Yeah, I'd be skeptical of self-report. We have a pretty robust literature of self-reported cognitive status not lining up very well with objective testing and/or collateral informant regarding issues with i/ADLs.

 

[vanfanal]

N=1. Good outcome as augmentation for clozapine for a patient with schizophrenia who was in the hospital for several months and for whom augmentation with SGAs didn’t seem to work. There seems to be the equal potential that it can also worsen psychosis???

 

[clozareal]

N=1. Good outcome as augmentation for clozapine for a patient with schizophrenia who was in the hospital for several months and for whom augmentation with SGAs didn’t seem to work. There seems to be the equal potential that it can also worsen psychosis???

Seems like it can cause or improve psychosis, but I think the causing psychosis is when they aren't already on an antipsychotic, on topiramate for epilepsy, and the episodes are brief. The data makes it seem as though it's much more likely to help with antipsychotic augmentation for schizophrenia than actually causing psychosis, however. I wonder if it's part of the cognitive deficit side effect profile.

 

[medhead1990]

Great information everyone thank you I really appreciate it. With all the above I definitely think I’ll at least try it for a few things and see if it sticks. It sounds like both results and side effects (cognitive slowing) happen pretty quickly, Which makes it nice to experiment with. If it works great! If it doesn’t work great, move along.

 

[the5thelement]

I have used it with limited success on obese bipolar patients with migraine headaches.

 

[whopper]

Topiramate has a place but it's never a first-line choice for me. Weight loss, alcohol abuse, Bipolar Disorder-it has evidenced based data in all areas.

One warning from clinical experience I've seen several times happen-it can mess up the liver's ability to process Valproic Acid and ammonia. The Vaproic acid can slightly elevate ammonia but usually not significantly. With Topiramate anticipate it happening significantly. Almost every patient I've seen on Valproic Acid and Topiramate end up getting hyperammonemia.

I had a case where a patient showed up to the unit manic and the psychiatrist made her delirious because he had the patient on both meds and never checked the serum ammonia level. He never discharged her cause she was confused the entire time not realizing HE CREATED THE PROBLEM.

So I show up to the unit, not as a treating doctor, but as a forensic evaluator, I notice this, but because I'm not the treating doctor I cannot order the labs. So I call up the treating psychiatrist and he never returned my phone calls. I told the nurse what I thought was going on and she told me she'll tell the doctor. I bring up in court that IMHO she was delirious. Her own defense attorney then questioned the quality of the care she was receiving in the hospital. The judge ordered that my opinion be sent to the treating doctor.

So it's a few weeks later and she's transferred to the state hospital cause she hasn't gotten better in weeks and is under my care. I do an ammonia level. She's got hyperammonemia-I stop Topiramate and 2 days later she clears up. That idiot psychiatrist kept her delirious for weeks. I don't fault him for initially missing this. I fault him for someone giving him the needed trail of breadcrumbs-calling him up 5x, his nurse telling him, a defense attorney and a judge telling him, and he blew it all off at the cost of this patient's health keeping her sick for weeks. If an effing judge called me up and told me the forensic evaluation brought up something alarming you sure as heck are right to believe I'd be freaking out. So for this other doctor to do nothing really blew my mind. (While I didn't get verification from the nurse, I did get verification from the lawyer and judge they made attempts to contact this doctor but he never returned their calls).

 

[clozareal]

Topiramate has a place but it's never a first-line choice for me. Weight loss, alcohol abuse, Bipolar Disorder-it has evidenced based data in all areas.

One warning from clinical experience I've seen several times happen-it can mess up the liver's ability to process Valproic Acid and ammonia. The Vaproic acid can slightly elevate ammonia but usually not significantly. With Topiramate anticipate it happening significantly. Almost every patient I've seen on Valproic Acid and Topiramate end up getting hyperammonemia.

I had a case where a patient showed up to the unit manic and the psychiatrist made her delirious because he had the patient on both meds and never checked the serum ammonia level. He never discharged her cause she was confused the entire time not realizing HE CREATED THE PROBLEM.

So I show up to the unit, not as a treating doctor, but as a forensic evaluator, I notice this, but because I'm not the treating doctor I cannot order the labs. So I call up the treating psychiatrist and he never returned my phone calls. I told the nurse what I thought was going on and she told me she'll tell the doctor. I bring up in court that IMHO she was delirious. Her own defense attorney then questioned the quality of the care she was receiving in the hospital. The judge ordered that my opinion be sent to the treating doctor.

So it's a few weeks later and she's transferred to the state hospital cause she hasn't gotten better in weeks and is under my care. I do an ammonia level. She's got hyperammonemia-I stop Topiramate and 2 days later she clears up. That idiot psychiatrist kept her delirious for weeks. I don't fault him for initially missing this. I fault him for someone giving him the needed trail of breadcrumbs-calling him up 5x, his nurse telling him, a defense attorney and a judge telling him, and he blew it all off at the cost of this patient's health keeping her sick for weeks. If an effing judge called me up and told me the forensic evaluation brought up something alarming you sure as heck are right to believe I'd be freaking out. So for this other doctor to do nothing really blew my mind. (While I didn't get verification from the nurse, I did get verification from the lawyer and judge they made attempts to contact this doctor but he never returned their calls).

Sounds like a slam dunk malpractice case.

 

[mistafab]

Topiramate has a place but it's never a first-line choice for me. Weight loss, alcohol abuse, Bipolar Disorder-it has evidenced based data in all areas.

One warning from clinical experience I've seen several times happen-it can mess up the liver's ability to process Valproic Acid and ammonia. The Vaproic acid can slightly elevate ammonia but usually not significantly. With Topiramate anticipate it happening significantly. Almost every patient I've seen on Valproic Acid and Topiramate end up getting hyperammonemia.

I had a case where a patient showed up to the unit manic and the psychiatrist made her delirious because he had the patient on both meds and never checked the serum ammonia level. He never discharged her cause she was confused the entire time not realizing HE CREATED THE PROBLEM.

So I show up to the unit, not as a treating doctor, but as a forensic evaluator, I notice this, but because I'm not the treating doctor I cannot order the labs. So I call up the treating psychiatrist and he never returned my phone calls. I told the nurse what I thought was going on and she told me she'll tell the doctor. I bring up in court that IMHO she was delirious. Her own defense attorney then questioned the quality of the care she was receiving in the hospital. The judge ordered that my opinion be sent to the treating doctor.

So it's a few weeks later and she's transferred to the state hospital cause she hasn't gotten better in weeks and is under my care. I do an ammonia level. She's got hyperammonemia-I stop Topiramate and 2 days later she clears up. That idiot psychiatrist kept her delirious for weeks. I don't fault him for initially missing this. I fault him for someone giving him the needed trail of breadcrumbs-calling him up 5x, his nurse telling him, a defense attorney and a judge telling him, and he blew it all off at the cost of this patient's health keeping her sick for weeks. If an effing judge called me up and told me the forensic evaluation brought up something alarming you sure as heck are right to believe I'd be freaking out. So for this other doctor to do nothing really blew my mind. (While I didn't get verification from the nurse, I did get verification from the lawyer and judge they made attempts to contact this doctor but he never returned their calls).

This is beyond dereliction of duty. This is deliberate indifference.

 

[whopper]

Something I and others on my unit pointed out to this patient once she got better.
Same doctor a few weeks later had a patient on Lithium who was on dialysis. Same doc a few months later was trying to have patient force-medicated with a depot antipsychotic without a trial of an oral med. For the first time in years, the court's forensic evaluator (me) recommended the court not to follow the doctors recommended meds for forced-administration. I told the court before an depot is injected, an oral med has to be tried per FDA guidelines cause if there's a bad reaction that med is now trapped in the patient's body for months.

The FDA guidelines say this for pretty much all depot shots.
And yet despite this the depot for Naltrexone contains no such warning and I've seen patients given a depot-Naltrexone get a months' long bad reaction to it. Some were sent to the hospital. What the effing disconnect was between the FDA between depot meds and depot-Naltrexone don't ask me cause the same "try an oral first" rule should be applied with depot Naltrexone.

 

[Merovinge]

Something I and others on my unit pointed out to this patient once she got better.
Same doctor a few weeks later had a patient on Lithium who was on dialysis. Same doc a few months later was trying to have patient force-medicated with a depot antipsychotic without a trial of an oral med. For the first time in years, the court's forensic evaluator (me) recommended the court not to follow the doctors recommended meds for forced-administration. I told the court before an depot is injected, an oral med has to be tried per FDA guidelines cause if there's a bad reaction that med is now trapped in the patient's body for months.

The FDA guidelines say this for pretty much all depot shots.
And yet despite this the depot for Naltrexone contains no such warning and I've seen patients given a depot-Naltrexone get a months' long bad reaction to it. Some were sent to the hospital. What the effing disconnect was between the FDA between depot meds and depot-Naltrexone don't ask me cause the same "try an oral first" rule should be applied with depot Naltrexone.

The rate of significant side effect to naltrexone pales in comparison to the antipsychotics, not even in the same stratosphere. I still give oral first to make sure there is no allergic reaction but I can easily see why people would treat this differently.

 

[forchinet121]

Topiramate has a place but it's never a first-line choice for me. Weight loss, alcohol abuse, Bipolar Disorder-it has evidenced based data in all areas.

One warning from clinical experience I've seen several times happen-it can mess up the liver's ability to process Valproic Acid and ammonia. The Vaproic acid can slightly elevate ammonia but usually not significantly. With Topiramate anticipate it happening significantly. Almost every patient I've seen on Valproic Acid and Topiramate end up getting hyperammonemia.

I had a case where a patient showed up to the unit manic and the psychiatrist made her delirious because he had the patient on both meds and never checked the serum ammonia level. He never discharged her cause she was confused the entire time not realizing HE CREATED THE PROBLEM.

So I show up to the unit, not as a treating doctor, but as a forensic evaluator, I notice this, but because I'm not the treating doctor I cannot order the labs. So I call up the treating psychiatrist and he never returned my phone calls. I told the nurse what I thought was going on and she told me she'll tell the doctor. I bring up in court that IMHO she was delirious. Her own defense attorney then questioned the quality of the care she was receiving in the hospital. The judge ordered that my opinion be sent to the treating doctor.

So it's a few weeks later and she's transferred to the state hospital cause she hasn't gotten better in weeks and is under my care. I do an ammonia level. She's got hyperammonemia-I stop Topiramate and 2 days later she clears up. That idiot psychiatrist kept her delirious for weeks. I don't fault him for initially missing this. I fault him for someone giving him the needed trail of breadcrumbs-calling him up 5x, his nurse telling him, a defense attorney and a judge telling him, and he blew it all off at the cost of this patient's health keeping her sick for weeks. If an effing judge called me up and told me the forensic evaluation brought up something alarming you sure as heck are right to believe I'd be freaking out. So for this other doctor to do nothing really blew my mind. (While I didn't get verification from the nurse, I did get verification from the lawyer and judge they made attempts to contact this doctor but he never returned their calls).

You have run ins with the worst doctors lol

 

[ObsequiousAplomb]

Something I and others on my unit pointed out to this patient once she got better.
Same doctor a few weeks later had a patient on Lithium who was on dialysis. Same doc a few months later was trying to have patient force-medicated with a depot antipsychotic without a trial of an oral med. For the first time in years, the court's forensic evaluator (me) recommended the court not to follow the doctors recommended meds for forced-administration. I told the court before an depot is injected, an oral med has to be tried per FDA guidelines cause if there's a bad reaction that med is now trapped in the patient's body for months.

The FDA guidelines say this for pretty much all depot shots.
And yet despite this the depot for Naltrexone contains no such warning and I've seen patients given a depot-Naltrexone get a months' long bad reaction to it. Some were sent to the hospital. What the effing disconnect was between the FDA between depot meds and depot-Naltrexone don't ask me cause the same "try an oral first" rule should be applied with depot Naltrexone.

It's interesting you're always saying oral instead of short acting. I was trained to give Haldol Lactate BID for 3 days before the first Dec injection for involuntary patients.

 

[whopper]

Mistafab-I suspect you're spoiled (enjoy it while it lasts, and this is nothing against you) considering where you're at. Where you are at you have a team of psychiatrists who are way better than what you'll see elsewhere unless you work at a top institution.

I was spoiled too during my forensic training. I'm working with great lawyers, judges, top forensic psychiatrists and psychologists in the country. Then I move to our current city-and I see inmates on a 10 month waiting list to be seen by an evaluator while in jail for competency to stand trial. While I was in Cincinnati they would've been seen within 3 days.

I remember in this rural area the local forensic psychologist did sanity evaluations and competency to stand trial evaluations in the same report. I was asked to do the same. So I'm in court and I tell the judge if the evaluee is found not competent to stand trial they're not supposed to have an NGRI report cause they're not competent to choose NGRI as an option. He made remarks of something to the effect of, "our psychologist has been doing this for years, I don't see the problem." The real answer is this psychologist is trying to double charge for 1 report and the judge is an idiot, but I'm in court and I can't say he's an idiot. So I provide a copy of the AAPL guidelines, and appropriate court cases etc. He literally says he's not going to read what I provided and asks me again to do something completely inappropriate-that is do a competency and NGRI report all at once.

Work at one of the local community hospitals for a few weeks...then get back to me.

I'm currently working on a legal case where a doctor diagnosed a patient without even seeing him all based on a family member's account, and that family member has a bad agenda. Guy was shipped off to a medical facility against his will. The guy had to get a lawyer to get him out of that facility and is suing.

Just to give an example of stuff I'm seeing as majority problems-I don't see physicians recommending prevention of C difficile infections when prescribing antibiotics, significant amounts simply medicating with Zolpidem when a patient has a sleep issue with no warning of addiction, doctors providing benzos with no addiction warnings or warnings to not mix with alcohol, prescribing birth control to women who still smoke and above age 35 with no warning, doctors prescribing stimulants to women of child-bearing age with no warning it's teratogenic, psychiatrists not take vitals, weight, and patient's placed on Venlafaxine who already has bad Hypertension, psychiatrists who place patients on several meds and don't document what effects that med had on the patient, PCPs who give out antibiotics to anyone who asks even when it's clear the patient has a viral infection....

I'm sure you read the following thread...

Tired of this

Here’s the med list for my consult today: Diazepam 10 mg daily Xanax 0.5 mg qid Hydrocodone 7.5 mg qid Ambien 10 mg at hs So sick of dealing with this

forums.studentdoctor.net

The point being that this is not some bad 1% of doctors that hardly happens. This is the normal reality. IF you're not seeing this you're very lucky and likely at a top institution where the overwhelming majority are very good-which in your case is what is going on. (I've met Mistafab in-person).

 

[ObsequiousAplomb]

Mistafab-I suspect you're spoiled (enjoy it while it lasts, and this is nothing against you) considering where you're at. Where you are at you have a team of psychiatrists who are way better than what you'll see elsewhere unless you work at a top institution.

I was spoiled too during my forensic training. I'm working with great lawyers, judges, top forensic psychiatrists and psychologists in the country. Then I move to our current city-and I see inmates on a 10 month waiting list to be seen by an evaluator while in jail for competency to stand trial. While I was in Cincinnati they would've been seen within 3 days.

I remember in this rural area the local forensic psychologist did sanity evaluations and competency to stand trial evaluations in the same report. I was asked to do the same. So I'm in court and I tell the judge if the evaluee is found not competent to stand trial they're not supposed to have an NGRI report cause they're not competent to choose NGRI as an option. He made remarks of something to the effect of, "our psychologist has been doing this for years, I don't see the problem." The real answer is this psychologist is trying to double charge for 1 report and the judge is an idiot, but I'm in court and I can't say he's an idiot. So I provide a copy of the AAPL guidelines, and appropriate court cases etc. He literally says he's not going to read what I provided and asks me again to do something completely inappropriate-that is do a competency and NGRI report all at once.

Work at one of the local community hospitals for a few weeks...then get back to me.

I'm currently working on a legal case where a doctor diagnosed a patient without even seeing him all based on a family member's account, and that family member has a bad agenda. Guy was shipped off to a medical facility against his will. The guy had to get a lawyer to get him out of that facility and is suing.

Just to give an example of stuff I'm seeing as majority problems-I don't see physicians recommending prevention of C difficile infections when prescribing antibiotics, significant amounts simply medicating with Zolpidem when a patient has a sleep issue with no warning of addiction, doctors providing benzos with no addiction warnings or warnings to not mix with alcohol, prescribing birth control to women who still smoke and above age 35 with no warning, doctors prescribing stimulants to women of child-bearing age with no warning it's teratogenic, psychiatrists not take vitals, weight, and patient's placed on Venlafaxine who already has bad Hypertension, psychiatrists who place patients on several meds and don't document what effects that med had on the patient, PCPs who give out antibiotics to anyone who asks even when it's clear the patient has a viral infection....

I'm sure you read the following thread...

Tired of this

Here’s the med list for my consult today: Diazepam 10 mg daily Xanax 0.5 mg qid Hydrocodone 7.5 mg qid Ambien 10 mg at hs So sick of dealing with this

forums.studentdoctor.net

The point being that this is not some bad 1% of doctors that hardly happens. This is the normal reality. IF you're not seeing this you're very lucky and likely at a top institution where the overwhelming majority are very good-which in your case is what is going on. (I've met Mistafab in-person).

You do know that stimulants aren't teratogenic at prescription doses, right? The only evidence of them causing small birth weight or other defects is in IV methamphetamine users...

 

[Celexa]

The FDA guidelines say this for pretty much all depot shots.
And yet despite this the depot for Naltrexone contains no such warning and I've seen patients given a depot-Naltrexone get a months' long bad reaction to it. Some were sent to the hospital. What the effing disconnect was between the FDA between depot meds and depot-Naltrexone don't ask me cause the same "try an oral first" rule should be applied with depot Naltrexone.

I don't think it's a stretch to say the only patients the system gives fewer ****s about than psych patients are substance use patients.

 

[whopper]

You do know that stimulants aren't teratogenic at prescription doses, right? The only evidence of them causing small birth weight or other defects is in IV methamphetamine users...

Depends on the source you read. None of them are human studies that meet a standard to accept this as extremely likely, unless there's one I missed. Due to the FDA already saying avoid them in pregnancy, now the burden of proof to show they're safe is in the new data coming having to be very strong. I've seen some studies showing the risk reported may have been overblown, but not enough to overcome the FDA warning.

 

[ObsequiousAplomb]

Depends on the source you read. None of them are human studies that meet a standard to accept this as extremely likely, unless there's one I missed. Due to the FDA already saying avoid them in pregnancy, now the burden of proof to show they're safe is in the new data coming having to be very strong. I've seen some studies showing the risk reported may have been overblown, but not enough to overcome the FDA warning.

The FDA says category C, which all things considered isn't much of a "warning" not to do.

 

[clausewitz2]

Depends on the source you read. None of them are human studies that meet a standard to accept this as extremely likely, unless there's one I missed. Due to the FDA already saying avoid them in pregnancy, now the burden of proof to show they're safe is in the new data coming having to be very strong. I've seen some studies showing the risk reported may have been overblown, but not enough to overcome the FDA warning.

I think you are maybe not up to date on the literature. A very perfunctory google search shows papers going back to at least 2007 suggesting that amphetamines in therapeutic doses have no real malformation risk associated with them. The OB/GYNs in my part of the world, at least the academic ones, don't have a serious issue with pregnant women taking stimulants if they legitimately have ADHD. There are reproductive psychiatrists on this forum who are better qualified than me but I have yet to meet a perinatal psych person who thinks normal ADHD dosing of stimulants is something to be incredibly worried about.

It's always risk versus benefit when it comes to pregnancy so you can't say it's blanket safe or anything like that but depakote these are not.

 

[dozitgetchahi]

There was a pain management doc at my first job as a rheumatologist who would liberally use topiramate for neuropathic pain. I heard mixed reviews on its efficacy from the patients. She kept the doses pretty low (usually less than 75mg/day or so).

 

[whopper]

There are reproductive psychiatrists on this forum who are better qualified than me but I have yet to meet a perinatal psych person who thinks normal ADHD dosing of stimulants is something to be incredibly worried about.

Which is a reason why as an attending I still like being on this forum. You may have me starting to rethink this....

 

[aim-agm]

Which is a reason why as an attending I still like being on this forum. You may have me starting to rethink this....

I like you being on this forum. Please don't rethink it.

 

[forchinet121]

I like you being on this forum. Please don't rethink it.

I think he’s saying he’s rethinking his stance on stimulants in pregnancy

 

[Celexa]

Which is a reason why as an attending I still like being on this forum. You may have me starting to rethink this....

Chiming in as a current CL fellow (for 2.5 more weeks, not that I'm counting) currently working in a perinatal clinic to confirm, we are ok with appropriate dose stimulants for a clear indication. It is also my pracrice to seize on the life change moment to reconsider polypharmacy and get rid of non beneficial medications, particularly benzos and stimulants, but for someone with clear ADHD and meaningful impairment without their medication we let them decide and give our blessing if they want to continue.

 

[Stagg737]

Which is a reason why as an attending I still like being on this forum. You may have me starting to rethink this....

Primary concern I've heard for stimulants during pregnancy is HTN/pre-eclampsia in patients at risk. I'll double check with the academic repro psychiatrists I work with, but I believe they continue stimulants for patients with ADHD who have been stable on them long-term.

 

[forchinet121]

Chiming in as a current CL fellow (for 2.5 more weeks, not that I'm counting) currently working in a perinatal clinic to confirm, we are ok with appropriate dose stimulants for a clear indication. It is also my pracrice to seize on the life change moment to reconsider polypharmacy and get rid of non beneficial medications, particularly benzos and stimulants, but for someone with clear ADHD and meaningful impairment without their medication we let them decide and give our blessing if they want to continue.

Safe to say that we can continue pretty much everything except for depakote if the patient feels it helps?

 

[ObsequiousAplomb]

Safe to say that we can continue pretty much everything except for depakote if the patient feels it helps?

Honestly, by the time they know they're pregnant and schedule an appointment with you they're past the major teratogenic phase for the most part and the benefits of stopping are probably outweighed by the risk of decompensation, provided they were stable.

 

[calvnandhobbs68]

Honestly, by the time they know they're pregnant and schedule an appointment with you they're past the major teratogenic phase for the most part and the benefits of stopping are probably outweighed by the risk of decompensation, provided they were stable.

Yeah the time to talk about risks of that stuff is before they're pregnant...by the time someone finds out their pregnant it's getting to be a bit late. Kind of like folate supplementation.

Also yeah whopper some of that stuff is a bit overboard. Just off the top of my head:
- We continue stimulants in pregnancy all the time for real deal ADHD and there's not any real reason to counsel patients on "teratogenic" effects of stimulants vs many of the other medications we prescribe (looks like a lot of that was already said though). I actually just doubled checked this with the perinatal psych line this year to make sure I was doing the right thing when this came up again. From my understanding with them, it's also mostly about just limiting polypharmacy and exposures if we can since there isn't great info about risks.
- I don't know a ton of people who are counseling about C diff when they give a 10 day course of amoxicillin
- Conversely, antibiotic overprescribing is real but also the amount of people coming into PCP offices and pissed that they don't walk out with an antibiotic prescription for their sniffly nose is real....it's the "you don't have ADHD" of primary care offices and it's taxing to have that conversation multiple times a day

 

[vanfanal]

When you guys say “real” or “clear” adhd, can you describe it? Because quite honestly I don’t know if I’ve seen it yet. 💁🏽‍♂️

 

[Stagg737]

When you guys say “real” or “clear” adhd, can you describe it? Because quite honestly I don’t know if I’ve seen it yet. 💁🏽‍♂️

Think never-ending hypomania without a sleep disturbance and you're in the neighborhood. Lot's of statements like "Sorry, what was the question?" and having to repeat yourself. Lots of forgetting to do things that seem obvious/simple. Hyperactive symptoms are usually pretty obvious, inattentive ones less so but easy to spot if you ask the right questions.

 

[Celexa]

Think never-ending hypomania without a sleep disturbance and you're in the neighborhood. Lot's of statements like "Sorry, what was the question?" and having to repeat yourself. Lots of forgetting to do things that seem obvious/simple. Hyperactive symptoms are usually pretty obvious, inattentive ones less so but easy to spot if you ask the right questions.

Yes, this. In terms of real world manifestations, frequent car accidents (usually minor, but not great!), job-compromising performance errors (ie nurse who starts making med errors).

Of course in the absence of severe anxiety or mood disorder etc that would otherwise account. But these are usually pretty high functioning people at base line who are euthymic outside of the context of whatever the ADHD is compromising in their life.

I'm certainly Team ADHD Is Overdiagnosed, but it definitely exists...

 

[Stagg737]

Yes, this. In terms of real world manifestations, frequent car accidents (usually minor, but not great!), job-compromising performance errors (ie nurse who starts making med errors).

Of course in the absence of severe anxiety or mood disorder etc that would otherwise account. But these are usually pretty high functioning people at base line who are euthymic outside of the context of whatever the ADHD is compromising in their life.

I'm certainly Team ADHD Is Overdiagnosed, but it definitely exists...

In addition to this, lots of missing deadlines or barely getting things done and then often obvious mistakes in details d/t last minute rushing. Not saying procrastination = ADHD, but imo very unusual NOT to have that with the presence of all other ADHD symptoms in the obvious patients.

 

[forchinet121]

Yes, this. In terms of real world manifestations, frequent car accidents (usually minor, but not great!), job-compromising performance errors (ie nurse who starts making med errors).

Of course in the absence of severe anxiety or mood disorder etc that would otherwise account. But these are usually pretty high functioning people at base line who are euthymic outside of the context of whatever the ADHD is compromising in their life.

I'm certainly Team ADHD Is Overdiagnosed, but it definitely exists...

Why would a nurse randomly start making med errors if they’ve had ADHD since they were a child? They didn’t develop ADHD while they were a nurse