A weird turn of events for a patient amidst covid....

[randomdoc1]

So, over a year ago, I inherited a patient, 75 yo on nortriptyline. Being a bright eyed and bushy tailed MD who recently finished residency, I ordered a level and discussed with her risks, benefits, and side effects of this medication in the elderly. Well, we've all had the moment of being told "I've been on this for years and don't wanna change nothing!". Reluctantly, she got the level, which was supratherapeutic (but pt herself denied SE). I then ordered an EKG...which she was not thrilled about, that was fortunately WNL. Given that she'd only had one SSRI and no other medication trials, we discussed more ideal alternatives or decreasing the dose. This elderly woman was quite prickly from the get go. She opted to stay the course and we did agree to continue but with the agreement that ideally we should start looking at other options. It was evident she was quite avoidant of the topic...well one day she got hospitalized for esophagitis due to nortriptyline. As we started to discuss more in depth SSRIs and SNRIs, she expressed more frustration with my evolving practice. "I don't like all this use of electronic communication and I hate those text reminders and the texts about my prescriptions!" "You and you young kids these days!" I assured her we can adjust the settings to her preference but it was likely the pharmacy texting her about prescriptions. Anyways, she transferred care (thank goodness) to an older psychiatrist as she wanted a good old fashioned one who relied more on phone calls, etc. etc. Well, amidst COVID19, she can't see see him now for her first appointment to establish any kind of care. My office in the meantime has offered telepsychiatry but I just thought it was an interesting sequence of events for this stubborn little old lady.

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[Sushirolls]

Glad my practice has been electronic heavy from the start for the past year, and as I switch to telepsych now, I anticipate a smooth switch over.

 

[wolfvgang22]

Sounds like literally every day in my practice.

 

[nexus73]

So, over a year ago, I inherited a patient, 75 yo on nortriptyline. Being a bright eyed and bushy tailed MD who recently finished residency, I ordered a level and discussed with her risks, benefits, and side effects of this medication in the elderly. Well, we've all had the moment of being told "I've been on this for years and don't wanna change nothing!". Reluctantly, she got the level, which was supratherapeutic (but pt herself denied SE). I then ordered an EKG...which she was not thrilled about, that was fortunately WNL. Given that she'd only had one SSRI and no other medication trials, we discussed more ideal alternatives or decreasing the dose. This elderly woman was quite prickly from the get go. She opted to stay the course and we did agree to continue but with the agreement that ideally we should start looking at other options. It was evident she was quite avoidant of the topic...well one day she got hospitalized for esophagitis due to nortriptyline. As we started to discuss more in depth SSRIs and SNRIs, she expressed more frustration with my evolving practice. "I don't like all this use of electronic communication and I hate those text reminders and the texts about my prescriptions!" "You and you young kids these days!" I assured her we can adjust the settings to her preference but it was likely the pharmacy texting her about prescriptions. Anyways, she transferred care (thank goodness) to an older psychiatrist as she wanted a good old fashioned one who relied more on phone calls, etc. etc. Well, amidst COVID19, she can't see see him now for her first appointment to establish any kind of care. My office in the meantime has offered telepsychiatry but I just thought it was an interesting sequence of events for this stubborn little old lady.

Just imagine if you were a lazier psychiatrist. You could have just documented the patient had been tolerating nortriptyline for years and was doing well.

 

[clausewitz2]

Just imagine if you were a lazier psychiatrist. You could have just documented the patient had been tolerating nortriptyline for years and was doing well.

What did you switch her too, out of curiosity?

 

[randomdoc1]

What did you switch her too, out of curiosity?

She left before I could switch her...lol. I was discussing SNRIs since it has the norepinephrine reuptake inhibition and may be the closer of the other medication possibilities to what she is used to. But yes, the esophagitis was not cool, she had a mild tear too and really had a hard time eating. It sounds like it was complications of the excessive dryness of the mucus membranes.

 

[clausewitz2]

She left before I could switch her...lol. I was discussing SNRIs since it has the norepinephrine reuptake inhibition and may be the closer of the other medication possibilities to what she is used to. But yes, the esophagitis was not cool, she had a mild tear too and really had a hard time eating. It sounds like it was complications of the excessive dryness of the mucus membranes.

Do you have any case reports or anything of nortriptyline causing esophagitis? I hadn't ever seen that listed as a known side effect anywhere and can't find any case reports/series. given the frequency with which GI likes to use it for things like recalcitrant GERD and IBS I would expect to there to be a number of them.

I assume you are mainly trying to avoid anticholinergic AEs - any thought to desipramine? Easier sell since it is also a TCA but extremely minimal ACH-related action.

 

[Candidate2017]

Sounds like literally every day in my practice.

I feel this is literally everyday for everyone if OP's post said "Xanax" instead of "nortriptyline"

 

[clausewitz2]

I feel this is literally everyday for everyone if OP's post said "Xanax" instead of "nortriptyline"

I don't necessarily subscribe to the party line myself but I recognize how lucky I am that the benzo jihad swept through my area about five years before I started residency. Only a few pockets of apostasy remain.

 

[splik]

I have never heard of TCAs causing esophagitis. i don't believe it.

 

[J ROD]

I inherited a guy on temazepam 60 nightly that was in his mid 90’s. He had been on it for over 20 years maybe longer. Took me about a year to get him to agree to come off after I built rapport. Amazingly he was able to transition to trazodone 100. Appears from what I could gather he was never tried on that. You don’t always have to change folks medicine but do question it when you see things that are not in the best interest of the patient. And as a pharmacist I have to advocate less polypharmacy.