When to prescribe what medication

[tvelocity514]

Hi all,

My school has clinical faculty assigned to groups of 8. I'm a current M2 and mine this year is a psychiatrist. I went and shadowed him today and was really interested in the practice of psychiatry, but the medication management was a little confusing. For example, pt comes in with ADD problems and has been on adderall XR 20mg in am and 15mg non extended in the afternoons (for past 2 years.. I guess she came in because she was tired of the HR always being increased). She had no other complaints besides her increased HR. Vitals were 117HR and 145/95BP (healthy BMI but I don't remember what it was). As the psychiatrist continued to ask questions, I tried to think of what I would do (as a lowly 2nd year). The patient was on no other medications but did say she drank caffeine sometimes in the early am. PMH: asthma only. The psychiatrist decided to change prescriptions from adderall to vyvanse. I'm confused as to why you wouldn't want to prescribe a B1 antagonist with the adderall instead of changing to another stimulant? I asked him after the patient left and he said that vyvanse might not increase heart rate as much. But I'm still confused as to why a stimulant change vs a B1 antag (bc of her BP which apparently normally ran 120-130 systolic in past he said but maybe the increase could be due to the stimulant?). I know side effects of beta blockers include hypotension but she didn't have low BP. Do all stimulants not have the potential to increase HR? Is this a normal occurrence in psychiatry to have multiple possibilities for prescribing medications? Or maybe I am completely off track and you would never prescribe a B1 antagonist with a stimulant. Any help would be greatly appreciated. Thanks!

Tvelocity

---

Members don't see this ad.

 

[Shikima]

How do you like to bake your cakes? Is it the same recipe as other people?

 

[tvelocity514]

How do you like to bake your cakes? Is it the same recipe as other people?

Lol no I promise I don't use the same recipe as other people. (I'm a he not a she, no asthma). I would just ask my mentor but I asked a lot of questions earlier and he is in charge of our grade for clinical knowledge and skills and I don't want him to remember me as the guy who didn't know anything and then I get a worse grade. Any help of how to slip that Q into random conversation without it coming across as a dumb medical student would be greatly appreciated instead! (I'm still learning the balance between when a med student should talk to an attending and when they should never approach them with questions)

 

[clausewitz2]

Lol no I promise I don't use the same recipe as other people. (I'm a he not a she, no asthma, but I do take medicine for ADHD but no HR above 100). I would just ask my mentor but I asked a lot of questions earlier and he is in charge of our grade for clinical knowledge and skills and I don't want him to remember me as the guy who didn't know anything and then I get a worse grade. Any help of how to slip that Q into random conversation without it coming across as a dumb medical student would be greatly appreciated instead! (I'm still learning the balance between when a med student should talk to an attending and when they should never approach them with questions)

As an M2 this sort of question is going to come across as genuine interest rather than ignorance, because nobody expects you to know anything yet. Just make sure you phrase it in a way that it doesn't sound like you are challenging his or her decision.

 

[tvelocity514]

As an M2 this sort of question is going to come across as genuine interest rather than ignorance, because nobody expects you to know anything yet. Just make sure you phrase it in a way that it doesn't sound like you are challenging his or her decision.

That's true - I didn't even think about the fact that they could take it as I'm challenging their decision. I'll lead off with the fact that we weren't taught some of the specific things about certain medications and I couldn't find it in first aid or other review books so that he knows I shouldn't know that information. Thank you!

 

[deleted314290]

Why start 2 meds when 1 may do the trick? Less is better.

 

[tvelocity514]

Why start 2 meds when 1 may do the trick? Less is better.

Yeah that's true. I've heard that saying - it was just weird he switched two meds that do the same thing (stimulant) for HR. But I should think of that first. Thanks!

Last question but he also said that I need to learn to not shake my head at all. ( I usually nod when talking to a pt). Is this something that most students go through and it is more of a learned behavior type of thing? I'm definitely going to try and be more cognizant of this in the future. I actually didn't realize I did it so much.

 

[wolfvgang22]

Taking the patient off a long acting stimulant and a short acting stimulant to a single longer acting, possibly more bioavailable stimulant with a smoother curve is less likely to drive up the heart rate. Let's say you put this patient on metoprolol. In a week she has a syncopal episode. Not a good feeling if that happens. Yes, I've done such a dumb thing before.
Try not to go around medicating away side effects if you can avoid them in the first place. Polypharmacy is best avoided when possible.

 

[wolfvgang22]

Yeah that's true. I've heard that saying - it was just weird he switched two meds that do the same thing (stimulant) for HR. But I should think of that first. Thanks!

Last question but he also said that I need to learn to not shake my head at all. ( I usually nod when talking to a pt). Is this something that most students go through and it is more of a learned behavior type of thing? I'm definitely going to try and be more cognizant of this in the future. I actually didn't realize I did it so much.

There is nothing wrong with nodding in understanding. I do it at key times. Example: patient says "I saw a lot of terrible things in Iraq, doc, it was awful", I'll nod my head in supportive empathy. I don't over do it. I dont shake my head "no" much. But I'm not doing psychoanalysis, either. I am always aware of what I'm doing.

Some psychiatrists try to emulate a "blank slate", because they are working from a psychoanalytic frame. It's big among older psychiatrists, psychiatrists trained in east coast psychoanalytic programs, or sometimes insecure psychiatrists that are afraid of connecting with a patient. Telling a student to never nod is an over reaction. You aren't going to be doing psychoanalysis in an inpatient or typical outpatient medication management setting much.

I had an old school attending tell me never to nod, as he was trained that way. In my opinion he was just hazing me. Beck and Rogers nod all the damn time, so do I.

That said, do what your attending says while you're working for him as long as it doesn't harm the patient any. You can develop your own therapeutic style as you go along.

 

[birchswing]

Could a beta blocker with a stimulant cause unopposed alpha effect?

I know about the risk with beta blockers and excess caffeine, epinephrine, or recreational drugs like cocaine, but I'm unfamiliar with the risk with ADD stimulants.

 

[tvelocity514]

Taking the patient off a long acting stimulant and a short acting stimulant to a single longer acting, possibly more bioavailable stimulant with a smoother curve is less likely to drive up the heart rate. Let's say you put this patient on metoprolol. In a week she has a syncopal episode. Not a good feeling if that happens. Yes, I've done such a dumb thing before.
Try not to go around medicating away side effects if you can avoid them in the first place. Polypharmacy is best avoided when possible.

Thank you for the explanation! It makes complete sense. It all goes back to the fact that you need to treat the underlying cause and not the symptoms. Thanks again!

-Yeah my mentor never nods or shows any emotion at all. It's actually really hard to connect with him unfortunately. His reason for why I should never nod my head is that if a pt comes in and says that her dad abused her every Thursday at 7pm when she was a child 20 years ago, you don't want to look sad or show any sign that could be construed as "aww I'm sorry" etc in that example - Because the patient could have actually really liked it bc that was the only time that she was able to spend time with her father. Thus, by showing any head nods or not, it could make the patient feel that they are wrong in feeling how they do and that is to be avoided at all costs. It makes sense, but I was nodding my head at him explaining another concept to me when he brought it up - and I was just nodding my head to show him I was engaged and understood what he was saying (which I usually do unfortunately), so it was really interesting that he said it then.

 

[wolfvgang22]

Yeah, you can chase your own tail for a long time trying to hold a psychoanalytic frame, lol. You won't learn much walking on egg shells around patients. Communicate directly and tactfully with a kind, professional attitude with patients. Realize patients can take you many ways, good and bad and think about ways to respond that will be supportive and helpful, not judgemental. There will always be misunderstanding here and there between folks. This is "grist for the mill" as my psychoanalytic teacher called it, and an opportunity to model for the patient in real time how a mature adult deals with such every day situations as you interact with the patient.

This may be very difficult to do with a grossly psychotic person, of course.

 

[shan564]

The issue with prescribing a beta blocker is that it's one more medication to monitor. You have to watch their BP to make sure it doesn't drop. You also have to remember that beta-blockers do have long-term side effects (i.e. heart block), and they're not FDA-approved for managing asymptomatic tachycardia.

As for how to make a decision - it's complicated, and there are several factors involved.

As for why you might expect Vyvanse to be different from Adderall XR - lots of reasons. As an M2, I always used to think that you could predict what a drug would do based on its mechanism. As you get more experience, you realize that drugs often do things you don't expect because the body is way too complicated for us to be able to figure out exactly what things will do.

As for the actual differences between Vyvanse and Adderall XR - mostly pharmacokinetics. Also note that pharmacokinetics can vary from person to person, but Vyvanse generally has a shorter Tmax and half-life. The dosing availability is also somewhat different - for instance, 30mg of Vyvanse is equivalent to about 12-13mg of Adderall XR, which is not a dose that you can prescribe - so it could be that switching is helpful primarily because you're getting a stimulant dose that is more specifically appropriate for that patient.

As for what to do as an M2 - ask questions. A common misconception among med students is that we care how much you know (I thought this when I was a student). In reality, I'm more likely to give a high grade to a student who asks a lot of good questions and goes out of his/her way to learn independently (i.e. demonstrating an interest in learning/developing) than a student who knows a lot but doesn't ask questions (i.e. demonstrating an opinion that he/she already knows everything). From the attending's perspective, all students know practically nothing, so they probably won't notice the knowledge difference between an average student and a mildly above average student - if his knowledge is 100 units, an M2's knowledge ranges between 10-15 units, and it's hard to notice the difference between 10 and 15 when you're at 100. That said, I rarely come across a student who knows a lot AND asks a lot of questions, and those students get the highest grades... but they usually know a lot BECAUSE they ask a lot of questions, and their questions demonstrate their knowledge.

 

[birchswing]

The issue with prescribing a beta blocker is that it's one more medication to monitor. You have to watch their BP to make sure it doesn't drop.

Wouldn't there be a possibility of a non-selective beta blocker increasing BP when used with a stimulant?

 

[sunlioness]

I don't write for blood pressure meds. Wait. Let me rephrase that. I don't treat hypertension. (I write for clonidine, prazosin, and propranolol at low doses for other indications). If I prescribe a med that causes it, I either try something else or work together with PCP to manage it. But always try something else first when possible.

I'll treat some s/e on my own. Of course, cogentin and stuff, but that's within my scope. I'll also write for metformin, which arguably isn't. But I won't kill anyone with it.

Autocorrect wanted to change "clonidine" to "cloned on my way!"




Sent from my iPhone using Tapatalk

 

[sunlioness]

-Yeah my mentor never nods or shows any emotion at all. It's actually really hard to connect with him unfortunately. His reason for why I should never nod my head is that if a pt comes in and says that her dad abused her every Thursday at 7pm when she was a child 20 years ago, you don't want to look sad or show any sign that could be construed as "aww I'm sorry" etc in that example - Because the patient could have actually really liked it bc that was the only time that she was able to spend time with her father. Thus, by showing any head nods or not, it could make the patient feel that they are wrong in feeling how they do and that is to be avoided at all costs.

Oh good lord. So instead you make the patient feel unheard. "I was telling him about what my dad did and he acted like it was no big deal. He didn't care."

Waaay better, right?

I always let my sadness show and say,"I'm sorry that happened to you." If that was the only time she got to spend with her dad, that's still sad. She deserved better. And the "positive" isn't necessarily invalidated by openly acknowledging that the whole thing highly sucked.

I wouldn't argue with him though. Do what he says. Get your grade. Develop your own hopefully more compassionate style later.


Sent from my iPhone using Tapatalk

 

[tvelocity514]

The issue with prescribing a beta blocker is that it's one more medication to monitor. You have to watch their BP to make sure it doesn't drop. You also have to remember that beta-blockers do have long-term side effects (i.e. heart block), and they're not FDA-approved for managing asymptomatic tachycardia.

As for how to make a decision - it's complicated, and there are several factors involved.

As for why you might expect Vyvanse to be different from Adderall XR - lots of reasons. As an M2, I always used to think that you could predict what a drug would do based on its mechanism. As you get more experience, you realize that drugs often do things you don't expect because the body is way too complicated for us to be able to figure out exactly what things will do.

As for the actual differences between Vyvanse and Adderall XR - mostly pharmacokinetics. Also note that pharmacokinetics can vary from person to person, but Vyvanse generally has a shorter Tmax and half-life. The dosing availability is also somewhat different - for instance, 30mg of Vyvanse is equivalent to about 12-13mg of Adderall XR, which is not a dose that you can prescribe - so it could be that switching is helpful primarily because you're getting a stimulant dose that is more specifically appropriate for that patient.

As for what to do as an M2 - ask questions. A common misconception among med students is that we care how much you know (I thought this when I was a student). In reality, I'm more likely to give a high grade to a student who asks a lot of good questions and goes out of his/her way to learn independently (i.e. demonstrating an interest in learning/developing) than a student who knows a lot but doesn't ask questions (i.e. demonstrating an opinion that he/she already knows everything). From the attending's perspective, all students know practically nothing, so they probably won't notice the knowledge difference between an average student and a mildly above average student - if his knowledge is 100 units, an M2's knowledge ranges between 10-15 units, and it's hard to notice the difference between 10 and 15 when you're at 100. That said, I rarely come across a student who knows a lot AND asks a lot of questions, and those students get the highest grades... but they usually know a lot BECAUSE they ask a lot of questions, and their questions demonstrate their knowledge.

Thank you very much for writing this. I really did have all of those misconceptions you stated that you had as an M2. It was very helpful to read all of this and get some clarification. Thank you!!

 

[milesed]

When it comes to se's of meds, it's best to try and fix the root of the problem instead of adding another to combat the se (if possible). If my patient, I'd have switched to a long acting methylphenidate like Concerta instead of using a different version of an amphetamine based stimulant (adderall and Vyvanse are same base med). The patient may have failed concerta, attending may have thought the short acting adderall was causing high HR, etc.

I'd ask the attending in an appropriate manner and see what he/she says.