Another complex pt - Parkinsons and bipolar - how to treat?
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How long has the patient been on olanzapine?
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Yeah, if the guy is an insomniac. That **** is so sedating, I cringe every time a geriatric patient gets within 20 yards of the stuff. A broken hip waiting to happen. Though I guess it doesn't exacerbate any extrapyramidal effects...so maybe it is the best course. Hell...I dunno...
...which causes tremor in toxicity. Kinda shady to try in a Parkinson's patient...or maybe not. I agree with the above...consult a psych pharmacist or geriatric psych specialist. Too many theoretical issues to freestyle on.
Doses doses doses, please.
And hx if available. (obviously not possible w/ everyone).
I can't tell you how many times I've seen some poor dude out there started on park. meds when the tremors actually originated from their psyche meds. We kept park. meds on to protect from NMS (neuroleptic malignant syndrome for those wondering what that abbreviation is), withdrew the antipsych, and boom. No more tremors with the help of benztropine. Started pt on some med I can't remember right now for the psyche issue while ***slowly withdrawing*** park meds as tolerated w/ the blessing of psyche unit.
btw: everything I said isn't a "recommendation." It's more of an "example." B/c, as I recall, SDN isn't a source of clinical recommendations... too much of a liability I think. But I have been seeing quite a number of these types of posts lately... so...
Official recommendation Consult psyche. =P
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Just as an interesting thought...
On my inpatient behavioral psych rotation, we had a patient who was started on Ativan and Seroquel for schizoaffective bipolar disorder, and shortly after started presenting with symptoms that looked like NMS. We messed around with his meds for about 2 weeks, but nothing was working, and he was still having on and off symptoms.
Turns out, he was getting ecstacy from a visitor...apparently the effects of the drug almost exactly mimics NMS. Not to mention it's almost impossible to catch that on a urine tox due to the extremely short half-life.
On my inpatient behavioral psych rotation, we had a patient who was started on Ativan and Seroquel for schizoaffective bipolar disorder, and shortly after started presenting with symptoms that looked like NMS. We messed around with his meds for about 2 weeks, but nothing was working, and he was still having on and off symptoms.
Turns out, he was getting ecstacy from a visitor...apparently the effects of the drug almost exactly mimics NMS. Not to mention it's almost impossible to catch that on a urine tox due to the extremely short half-life.
at the store i trained, every psych guy was on anywhere between 4 to 8 meds...that 8th med would be benadryl 50 qid or something...i think the goal of the psych is to snow the patient completely
Even though I like psych, this isn't my forte.
Call Psych RX consult. That's what I would do.
Call Psych RX consult. That's what I would do.
Oh yeah? I thought your were specialty-less.
How come no one ever posts a question in my forté? 🙁😛
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For those not passing the buck, doses as I recall, nothing over the top. Not at max dose of Sinemet, but reasonable doses of everything else (Comtan 200 QID, Mirapex 1 TID, Effexor 150, Zyprexa 10). Pt has been on Zyprexa for years and is a poor historian, there's no telling what changed recently that might have provoked her symptoms now. She did get immediate relief with dantrolene IV.
She was a really interesting case finding the balance between dopamine and ACh, tremors and psychoses. Especially since a lot (a neurologist I heard speak said 100% if they live long enough) PD pts do progress to some sort of dementia.
This pt was taken off of the Zyprexa, Mirapex and the Effexor and the Sinemet was titrated up. This case made me rethink dopamine agonists and think about MAO-Bs a bit more for PD treatment. Clozaril is the best antipsychotic in PD (wonder if Seroquel is a lesser evil as well?) I don't know what the psychiatrist did when the pt was discharged. I have chart review next month, I'll see what has happened to her since.
So Spiriva, what is your forte?
She was a really interesting case finding the balance between dopamine and ACh, tremors and psychoses. Especially since a lot (a neurologist I heard speak said 100% if they live long enough) PD pts do progress to some sort of dementia.
This pt was taken off of the Zyprexa, Mirapex and the Effexor and the Sinemet was titrated up. This case made me rethink dopamine agonists and think about MAO-Bs a bit more for PD treatment. Clozaril is the best antipsychotic in PD (wonder if Seroquel is a lesser evil as well?) I don't know what the psychiatrist did when the pt was discharged. I have chart review next month, I'll see what has happened to her since.
So Spiriva, what is your forte?
tat was my other thought of putting him on seroquel, less monitoring than with clozaril
Welcome to your future.
WOW, that could be me?
Well, thanks for asking.
I actually oversee about 30 hospital pharmacies. I like to travel around and visit them and tell them what they're doing wrong. Kind of like a seagull; I swoop in, make a lot of noise and **** everywhere, then leave. They're usually pretty excited to see me go. I'm always sure to stop by and say hi to all of the pretty nurses and flash my fancy vendor bracelet at them. Usually makes for fun small talk in the elevators.
I sign up for as many charitable golf tournies that I can find. Oftentimes I'll wine and dine potential customers and show them an excel spreadsheet I've put together with 10 billion figures in it, showing them how I'll save their department 30 trillion dollars in the next fiscal year in type 2 and 3 savings. They think this sounds wonderful.
To make it look like I'm really being productive though, I'll have some of our residents put together a nice guideline that I'll send it to my director, claiming I did it from the comfort of my own home office.
It's tough work...but someone's got to do it!!!
Cowgirl...what setting are you practicing in? 😉
Well, thanks for asking.
I actually oversee about 30 hospital pharmacies. I like to travel around and visit them and tell them what they're doing wrong. Kind of like a seagull; I swoop in, make a lot of noise and **** everywhere, then leave. They're usually pretty excited to see me go. I'm always sure to stop by and say hi to all of the pretty nurses and flash my fancy vendor bracelet at them. Usually makes for fun small talk in the elevators.
I sign up for as many charitable golf tournies that I can find. Oftentimes I'll wine and dine potential customers and show them an excel spreadsheet I've put together with 10 billion figures in it, showing them how I'll save their department 30 trillion dollars in the next fiscal year in type 2 and 3 savings. They think this sounds wonderful.
To make it look like I'm really being productive though, I'll have some of our residents put together a nice guideline that I'll send it to my director, claiming I did it from the comfort of my own home office.
It's tough work...but someone's got to do it!!!
😱 You're my hero!!
Rural health system - amb and inpatient. We see a bit of everything, that's for sure.
As a psychiatrist, I would never place a Parkinson's patient on anti-psychotics. Almost certainly will make him worse. Valproic Acid or Lamotrigine would be my starting point and get rid of as much sedation as possible, Carbamazepine and derivatives as backup, Lithium as a reluctant 3rd option, but it would likely make him more withdrawn and anhedonic.
Plus, the current concerns about geriatrics and anti-psychotics may also translate to Parkinson's patients even younger than 65. Not to mention Olanzapine is terribly sedating, cognitively clouding and will likely give this guy weight gain and diabetes. Anti-psychotics are a bad idea and Olanzapine is a horrible idea. If nothing else, at least put him on Aripiprazole.
Plus, the current concerns about geriatrics and anti-psychotics may also translate to Parkinson's patients even younger than 65. Not to mention Olanzapine is terribly sedating, cognitively clouding and will likely give this guy weight gain and diabetes. Anti-psychotics are a bad idea and Olanzapine is a horrible idea. If nothing else, at least put him on Aripiprazole.
Well, thanks for asking.
I actually oversee about 30 hospital pharmacies. I like to travel around and visit them and tell them what they're doing wrong. Kind of like a seagull; I swoop in, make a lot of noise and **** everywhere, then leave. They're usually pretty excited to see me go. I'm always sure to stop by and say hi to all of the pretty nurses and flash my fancy vendor bracelet at them. Usually makes for fun small talk in the elevators.
I sign up for as many charitable golf tournies that I can find. Oftentimes I'll wine and dine potential customers and show them an excel spreadsheet I've put together with 10 billion figures in it, showing them how I'll save their department 30 trillion dollars in the next fiscal year in type 2 and 3 savings. They think this sounds wonderful.
To make it look like I'm really being productive though, I'll have some of our residents put together a nice guideline that I'll send it to my director, claiming I did it from the comfort of my own home office.
It's tough work...but someone's got to do it!!!
Wow, you really are a drug rep.
Doesn't that make your brain rot? It can lower IQ, if I remember correctly.
but it has my favorite brand name EVER!
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Wow, I'm sending my patients your way. I get complaints that it is 750-800/mth
8 of the 10 most expensive medicaid drugs here are psychiatric meds.
LOL. If you insist. I don't particularly find that chain of responsibility.
LOL i think its actually like 430 or something to be exact, unless they jacked the price up and i havent found out...the funny thing is if you ask a rep to justify the price they start bumbling
and yes, i also dont think public govt programs should pay for these kind of meds, especially since their benefits over other options hasnt been really shown...a lot of the medicaid patients are on a billion psych meds (they are always on combo of 4-8 meds, 'shotgun' therapy as its called), working in my pharmacy would make a hard core liberal reconsider his/her some their views
Well, it IS the only non-sedating antipsychotic.
all the more reason to not use it 🙂
it goes against the psych guys shotgun treatment plan whose goal is to just snow the patient
**** you Spiriva!Well, thanks for asking.
I actually oversee about 30 hospital pharmacies. I like to travel around and visit them and tell them what they're doing wrong. Kind of like a seagull; I swoop in, make a lot of noise and **** everywhere, then leave. They're usually pretty excited to see me go. I'm always sure to stop by and say hi to all of the pretty nurses and flash my fancy vendor bracelet at them. Usually makes for fun small talk in the elevators.
I sign up for as many charitable golf tournies that I can find. Oftentimes I'll wine and dine potential customers and show them an excel spreadsheet I've put together with 10 billion figures in it, showing them how I'll save their department 30 trillion dollars in the next fiscal year in type 2 and 3 savings. They think this sounds wonderful.
To make it look like I'm really being productive though, I'll have some of our residents put together a nice guideline that I'll send it to my director, claiming I did it from the comfort of my own home office.
It's tough work...but someone's got to do it!!!
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