Case for discussion - ADHD and tics

[PistolPete]

So I've begun seeing a 12 year old boy with MDD, ADHD as well as motor tic disorder (eye blinking as well as jerking head to the side, much more prominent when he's stressed). He's already seen neurology who put him on Intuniv 1mg at bedtime for the tics. He's also started in our DBT program because of impulsivity and a history of SI without attempt.

The DBT staff tell me that his ADHD is incredibly apparent and that if we don't get it under better control, he will likely fail out of the DBT program in the next month or two. Can't pay attention or sit still, distracts others, half-completes the homework or not at all, etc. When more stressed (i.e. when called upon in group), will have pronounced tics.

Currently he's on sertraline 75mg daily and Intuniv 1mg at bedtime, which is what prior outpatient psychiatrist had him on. The depression is well-controlled, but he's obviously still anxious.

Mother has her own personality psychopathology and is very anxious and with Cluster B traits.

He's had psych testing done form a well-respected psychologist in our area who confirmed the ADHD diagnosis. I don't remember the details other than FSIQ is 115 and that processing speed and working memory were low.

Questions for you all:
1. What would you treat first, the ADHD or the tics?
2. How would you treat him pharmacologically, given that stimulants can exacerbate his tics? I'm under the impression that his ADHD is so bad that maxing out the Intuniv is not likely to optimally control his ADHD symptoms. Would you start a stimulant? Which one?

Curious what you all would do.

---

Members don't see this ad.

 

[wolfvgang22]

Start low with a stimulant and see if tics worsen or not. It doesnt matter which. I like to start with methylphenidate or Concerta. Continue the intuniv. Once ADHD is better controlled consider atypical for the tics.

 

[Shikima]

Appears that there is some anxiety by being called out during group to discuss homework assignments as tics are more pronounced. Does anxiety play a role with the distractibility and tics?

 

[PistolPete]

Appears that there is some anxiety by being called out during group to discuss homework assignments as tics are more pronounced. Does anxiety play a role with the distractibility and tics?

Yes, some. But I've been told he tics even when he's not called upon. And mother confirms tics at home also, even before they started coming to our clinic this month.

 

[Information Underload]

Tics are something to be ignored until they cause clinical impairment. Granted, this kid is 12, so blinking a lot or grunting may well cause him some social impairment. You could start a stimulant and run the risk of worsening tics. Or you could start Strattera and ramp it up to 1.2mg/kg along with further titration of Intuniv over time. My experience with 12-year olds is that it is rare where Intuniv gets the job done on its own, though it is helpful. I would go the stimulant, as you will know rather quickly if this is 1) going to work or 2) worsen tics. Prepare parents and the patient for the possibility that this could worsen tics, and if it does, you could then switch to Strattera. If this kid's ADHD is going to get him kicked out of a program, address that first. He probably needs a stimulant if he can tolerate it if his symptoms are that bad.

Consider habit-reversal for the tics, too. He's of the age where he could do it.

 

[Jules A]

I have a similar age/presentation, odd but not meeting criteria for ASD, came to me from an excellent CAP so the heavy lifting was done. I was more concerned about the anxiety and ADHD than tics due to social and academic concerns. Patient was on Clonidine, which I tend to like better than Intuniv because in my experience its somewhat more sedating for the hyperactive kids and Zoloft 75mg. Over time I increased Zoloft to a max of 150mg which was well tolerated with improvement in depression but no reported improvement in anxiety. Added a low dose stimulant with positive effect on hyperactivity and inattention. No noted increase in tics, anxiety or sleep disturbance. I changed to Luvox started at 25 presently at 50mg with some improvement in anxiety, likely at or close to baseline as Mom also has anxiety and cluster B stuff going on. Separation anxiety is reduced, school and peer interactions are minimally improved. The child is in therapy, wish Mom would get her own therapist to but despite my best attempts to sell it as support for Mom's long list of unmet needs, falls flat every time.

 

[hamstergang]

1. What would you treat first, the ADHD or the tics?
2. How would you treat him pharmacologically, given that stimulants can exacerbate his tics? I'm under the impression that his ADHD is so bad that maxing out the Intuniv is not likely to optimally control his ADHD symptoms. Would you start a stimulant? Which one?

Just to add more support to a prior post, I 100% would treat the ADHD pharmacologically first and refer for HRT for tics if possible. Tics aren't generally anything to be scared of, so add on any stimulant. You can always switch quickly to Strattera if you need to.

My recollection of the literature is that it's not so clear if stimulants actually worsen anxiety or Tics.

What you may run into here, though, is that Zoloft possibly interacts with amphetamines (Zoloft inhibits amphetamine metabolism and both can contribute to serotonin syndrome), methylphenidates (methylphenidate inhibits Zoloft metabolism), and Strattera (Zoloft inhibits Strattera metabolism and may lengthen QTc). At least that's what some sources say. How significant these effects really are in real humans I'm not so sure. I still use them together all the time.

 

[MacDonaldTriad]

There have been case reports of Zoloft causing ticks. Compared to stimulants, Zoloft's weak dopamine reuptake inhibition is probably nothing, but I have seen adults with tick histories start ticking when Zoloft was added. Just try a different SSRI, who knows.

 

[PistolPete]

There have been case reports of Zoloft causing ticks. Compared to stimulants, Zoloft's weak dopamine reuptake inhibition is probably nothing, but I have seen adults with tick histories start ticking when Zoloft was added. Just try a different SSRI, who knows.

Hmm intersting. I thought about the Zoloft but I feel like the dopamine reuptake inhibition doesn't really start until doses are 150mg or higher, no? My gut is the 75mg hasn't caused the tics, and I'd have to confirm with mother.

 

[PistolPete]

Just to add more support to a prior post, I 100% would treat the ADHD pharmacologically first and refer for HRT for tics if possible. Tics aren't generally anything to be scared of, so add on any stimulant. You can always switch quickly to Strattera if you need to.

My recollection of the literature is that it's not so clear if stimulants actually worsen anxiety or Tics.

What you may run into here, though, is that Zoloft possibly interacts with amphetamines (Zoloft inhibits amphetamine metabolism and both can contribute to serotonin syndrome), methylphenidates (methylphenidate inhibits Zoloft metabolism), and Strattera (Zoloft inhibits Strattera metabolism and may lengthen QTc). At least that's what some sources say. How significant these effects really are in real humans I'm not so sure. I still use them together all the time.

Interesting. But I'm not worried about combining both zoloft and methylphenidate/mixed amphetamine salts since both would be at fairly low doses, at least to start.

 

[PistolPete]

Tics are something to be ignored until they cause clinical impairment. Granted, this kid is 12, so blinking a lot or grunting may well cause him some social impairment. You could start a stimulant and run the risk of worsening tics. Or you could start Strattera and ramp it up to 1.2mg/kg along with further titration of Intuniv over time. My experience with 12-year olds is that it is rare where Intuniv gets the job done on its own, though it is helpful. I would go the stimulant, as you will know rather quickly if this is 1) going to work or 2) worsen tics. Prepare parents and the patient for the possibility that this could worsen tics, and if it does, you could then switch to Strattera. If this kid's ADHD is going to get him kicked out of a program, address that first. He probably needs a stimulant if he can tolerate it if his symptoms are that bad.

Consider habit-reversal for the tics, too. He's of the age where he could do it.

Great idea but unfortunately I don't know anyone who does habit-reversal where we are. Plus he already goes to DBT twice per week and mother wouldn't go see yet another therapist (and I'd probably discourage that too, tbh, while he's in DBT, and they barely make it twice per week as far as I understand it).

 

[Wilf]

Definitely try a stimulant; I prefer Concerta first. Tics often improve when ADHD is treated. If tics continue, increase guanfacine.

 

[Ceke2002]

Hmm, I had motor tics (eye blinking and facial grimacing mainly) as a child, I still do to a degree just not as regularly and not as bad. I'm assuming the mother is participating in therapy either separately or alongside the child (or both)? Parental response to tics, at least in my experience, can either help, or make things worse. It would certainly behoove the mother to learn optimum response patterns to her child's ticks, preferably without her own psychopathology getting in the way. Excessive use of amphetamines in adulthood, for me at least, did tend to both re-trigger and worsen any motor tics (I've also seen it trigger motor tics in people who had no prior history of such); however, a normal prescribed dosage of stimulants (again, for me) didn't have the same effect. These days the tics only tend to occur when I'm excessively sleep deprived and/or under a higher than usual level of stress - oddly enough they're usually heralded by my eyes suddenly becoming excessively dry and gritty feeling, so using moisturising eyedrops is one way I head them off at the pass, so to speak (that and closing my eyes for a couple of seconds and taking a few controlled breaths until the urge passes). If they do occur when I'm in public, I usually pull out a tissue and grumble something about hayfever under my breath - these days though the likelihood of that happening more than a few times a year though is pretty remote.

 

[singasongofjoy]

Too bad you don't know anyone who does HRT/tic specific treatment in your area, as I've seen targeted behavioral treatments be quite effective in relatively few treatments (like ~12 +/- a few). Douglas Woods has some good manuals out there that combine HRT with relaxation training and function-specific approaches (e.g., would target anxiety if that's an important component). He does some excellent trainings on it and how to involve parents- if you ever happen upon an opportunity to hear him speak / attend a training, I def recommend it.

 

[PistolPete]

Too bad you don't know anyone who does HRT/tic specific treatment in your area, as I've seen targeted behavioral treatments be quite effective in relatively few treatments (like ~12 +/- a few). Douglas Woods has some good manuals out there that combine HRT with relaxation training and function-specific approaches (e.g., would target anxiety if that's an important component). He does some excellent trainings on it and how to involve parents- if you ever happen upon an opportunity to hear him speak / attend a training, I def recommend it.

Awesome, thanks for the tip. I've never heard of him before.

 

[Information Underload]

Great idea but unfortunately I don't know anyone who does habit-reversal where we are. Plus he already goes to DBT twice per week and mother wouldn't go see yet another therapist (and I'd probably discourage that too, tbh, while he's in DBT, and they barely make it twice per week as far as I understand it).

You could do it? I've had reasonable success working with kids even seeing them monthly for 40-minute sessions. You have to employ their parents and provide a lot of psychoeducation upfront, but it can be doable with older kids (10+). I'm not arguing that you're going to get the same results as seeing the kid weekly and really drawing out a detailed plan, but the concept itself isn't all that difficult.

 

[SmallBird]

So I've begun seeing a 12 year old boy with MDD, ADHD as well as motor tic disorder (eye blinking as well as jerking head to the side, much more prominent when he's stressed). He's already seen neurology who put him on Intuniv 1mg at bedtime for the tics. He's also started in our DBT program because of impulsivity and a history of SI without attempt.

The DBT staff tell me that his ADHD is incredibly apparent and that if we don't get it under better control, he will likely fail out of the DBT program in the next month or two. Can't pay attention or sit still, distracts others, half-completes the homework or not at all, etc. When more stressed (i.e. when called upon in group), will have pronounced tics.

Currently he's on sertraline 75mg daily and Intuniv 1mg at bedtime, which is what prior outpatient psychiatrist had him on. The depression is well-controlled, but he's obviously still anxious.

Mother has her own personality psychopathology and is very anxious and with Cluster B traits.

He's had psych testing done form a well-respected psychologist in our area who confirmed the ADHD diagnosis. I don't remember the details other than FSIQ is 115 and that processing speed and working memory were low.

Questions for you all:
1. What would you treat first, the ADHD or the tics?
2. How would you treat him pharmacologically, given that stimulants can exacerbate his tics? I'm under the impression that his ADHD is so bad that maxing out the Intuniv is not likely to optimally control his ADHD symptoms. Would you start a stimulant? Which one?

Curious what you all would do.

There was a meta-analysis in JAACAP that provides the clearest input on this issue:

http://www.sciencedirect.com/science/article/pii/S0890856715003949

There is no evidence that stimulants worsen tics or cause new tics. I'd start methylphenidate. Its not clear from this history how impairing the tics are but there are many options for treating these including a low dose of risperidone.

I don't know how things are structured in your area, but a case like this is likely best managed entirely by a psychiatrist or child psychiatrist - it could be more difficult to really optimize treatment of neurology is managing the tics.

 

[SmallBird]

You could do it? I've had reasonable success working with kids even seeing them monthly for 40-minute sessions. You have to employ their parents and provide a lot of psychoeducation upfront, but it can be doable with older kids (10+). I'm not arguing that you're going to get the same results as seeing the kid weekly and really drawing out a detailed plan, but the concept itself isn't all that difficult.

I agree it isn't difficult and good for you on having good outcomes! Just to offer a different perspective, this happens to be a treatment that can have adverse outcomes - it's not uncommon to hear that kids adopt their substitute behaviors as new tics which then become elaborated and distracting on their own. I've heard a case presentation from a smart but inexperienced therapist where things went worse for quite some time before there was slow improvement.

 

[PistolPete]

There was a meta-analysis in JAACAP that provides the clearest input on this issue:

http://www.sciencedirect.com/science/article/pii/S0890856715003949

There is no evidence that stimulants worsen tics or cause new tics. I'd start methylphenidate. Its not clear from this history how impairing the tics are but there are many options for treating these including a low dose of risperidone.

I don't know how things are structured in your area, but a case like this is likely best managed entirely by a psychiatrist or child psychiatrist - it could be more difficult to really optimize treatment of neurology is managing the tics.

I'm at a big medical center. A lot of patients we see have already been to neurology before they are eventually volun-forced to come to the psychiatry clinic... But usually once they're referred to us, neurology backs off and let's us handle anything psychiatry-related, including tics.

 

[singasongofjoy]

I agree it isn't difficult and good for you on having good outcomes! Just to offer a different perspective, this happens to be a treatment that can have adverse outcomes - it's not uncommon to hear that kids adopt their substitute behaviors as new tics which then become elaborated and distracting on their own. I've heard a case presentation from a smart but inexperienced therapist where things went worse for quite some time before there was slow improvement.

yes, that happens sometimes, and I think it is important to prepare patients/clients about that up front. but the point is that over time they learn the skills (and their parents learn the skills) that they can then implement with relative success on their own to target those tics. There will almost always be up and down recurrence of tics over time as development, environment, and stressors change, but I think developing some sense of control and "I can actually do something about this" is really empowering and gives a lot of hope back to kids even if things continue to be hard some of the time. They can always come back in for a few booster sessions in the future if needed. I think learning the skills is important even in the context of the inevitable waxing and waning of the tics. Even without behavioral therapy tics can change over time too- but things are a lot less stressful for most people, kids included, if they feel like they have some sort of skills they can employ- even if they continue to use meds in combination.

 

[smalltownpsych]

I didn't know about HRT so this was an extremely helpful thread for me. After reading up on it a bit, I think that this is something that should not be that difficult to implement for any professional with solid understanding of behavioral principles and it appears to be highly effective. I tried it with a long standing nail biter and it worked almost immediately which is consistent with what the research shows. Don't have any patients with tics so will have to wait to try that out and from the research, that is a little more difficult to extinguish.

 

[smalltownpsych]

Great idea but unfortunately I don't know anyone who does habit-reversal where we are. Plus he already goes to DBT twice per week and mother wouldn't go see yet another therapist (and I'd probably discourage that too, tbh, while he's in DBT, and they barely make it twice per week as far as I understand it).

DBT being a behavior therapy, they should be able to implement and integrate HRT. They probably just don't know about it although it is what they do with cutting...

 

[DD214_DOC]

1. The tics won't make him fail out of DBT, so start a stimulant for the presumed ADHD
2. It may "exacerbate" the tics or worsen anxiety, so you may end up titrating the intuniv simultaneously if it does. But, wait and see what happens.
3. Psych testing never confirms anything. It merely provides additional data to be interpreted in the context of your clinical evaluation. Slow processing speed and problems with working memory can be seen in several others things besides ADHD.
4. Strattera is almost always completely worthless, unless you like giving kids headaches.

 

[PistolPete]

1. The tics won't make him fail out of DBT, so start a stimulant for the presumed ADHD
2. It may "exacerbate" the tics or worsen anxiety, so you may end up titrating the intuniv simultaneously if it does. But, wait and see what happens.
3. Psych testing never confirms anything. It merely provides additional data to be interpreted in the context of your clinical evaluation. Slow processing speed and problems with working memory can be seen in several others things besides ADHD.
4. Strattera is almost always completely worthless, unless you like giving kids headaches.

1. True. I'm worried that he'll fail out of DBT and have bigger problems than tics. Mom is more worried about tics.
2. Mother pushing to limit meds and sounds like she wants to stop Intuniv if I start a stimulant.
3. Of course. I just meant I'm using the psych testing to confirm my clinical suspicion.
4. I have a few patients purely on Strattera who are doing well, so you never know!

I see him tomorrow so I'll let you guys know what happens.

 

[hamstergang]

4. Strattera is almost always completely worthless, unless you like giving kids headaches.

On what do you base this? I don't use it much but it seems alright when I do, and the literature does support it. I recall reading an effect size of 0.6 but don't remember where I got this from or how reliable it is.

 

[DD214_DOC]

On what do you base this? I don't use it much but it seems alright when I do, and the literature does support it. I recall reading an effect size of 0.6 but don't remember where I got this from or how reliable it is.

Anecdotal. I've had maybe 5-6 kids benefit from it out of I don't know how many tried.

 

[Merovinge]

On what do you base this? I don't use it much but it seems alright when I do, and the literature does support it. I recall reading an effect size of 0.6 but don't remember where I got this from or how reliable it is.

Literature for Strettera is pretty good. However, I almost never use it because it is essentially a stimulant in MOE that requires weeks to work and weeks to titrate. It can cause the same GI, HA, HTN problems that stimulants can so if those are why you are switching from a stimulant you are reasonably likely to have the same problem again. It's only real advantage is not being controlled sub/abusable, so in those cases it makes some sense. I have had decent luck with Wellbutrin (in depressed kids in particular) for ADHD. But all that said Stimulants + Alpha2's in various releases/formulations covers the overwhelming majority of patients.

 

[PistolPete]

Update: we ended up starting Adderall XR 5mg qam, to increase to 10mg qam in 1 week if no change in hyperactivity/inattention on the 5mg. Rest of the meds are the same. We'll see what happens with the tics, if anything.

 

[Merovinge]

Update: we ended up starting Adderall XR 5mg qam, to increase to 10mg qam in 1 week if no change in hyperactivity/inattention on the 5mg. Rest of the meds are the same. We'll see what happens with the tics, if anything.

Great job starting a long-acting and seeing how it goes! FWIW, I would lean towards a methylphenidate product here (Concerta if covered, otherwise Metadate CD (not ER)) as they involve more reuptake inhibition and less dumping of D and NE at the synapses compared to the amphetamines. It's a subtle point though and I certainly think Adderall XR is a much better choice than nothing.

 

[PistolPete]

Great job starting a long-acting and seeing how it goes! FWIW, I would lean towards a methylphenidate product here (Concerta if covered, otherwise Metadate CD (not ER)) as they involve more reuptake inhibition and less dumping of D and NE at the synapses compared to the amphetamines. It's a subtle point though and I certainly think Adderall XR is a much better choice than nothing.

Thought about that too, but mother had the Genesight testing done which showed the Adderall family of products with no interactions (green bar) and the methylphenidate products with some potential for interaction (yellow) bar and insisted that we do Adderall. If his tics worsen significantly on Adderall then we'll try Concerta.

 

[hamstergang]

Thought about that too, but mother had the Genesight testing done which showed the Adderall family of products with no interactions (green bar) and the methylphenidate products with some potential for interaction (yellow) bar and insisted that we do Adderall.

What reason did it give for the yellow on methylphenidate?

 

[Merovinge]

What reason did it give for the yellow on methylphenidate?

Garbage science don't need no reasons!

 

[DD214_DOC]

Never heard of Genesight....

 

[singasongofjoy]

Never heard of Genesight....

Me either. This was one of the first things that came up in my search: http://www.nbcnews.com/health/mental-health/new-psychiatric-dna-testing-unproven-ground-n437781

 

[DD214_DOC]

Great job starting a long-acting and seeing how it goes! FWIW, I would lean towards a methylphenidate product here (Concerta if covered, otherwise Metadate CD (not ER)) as they involve more reuptake inhibition and less dumping of D and NE at the synapses compared to the amphetamines. It's a subtle point though and I certainly think Adderall XR is a much better choice than nothing.

Why not Metadate ER? I have actually never prescribed either formulation of Metadate, and I have yet to read any reason why I would with Ritalin LA and Concerta both available. I encountered some, "odd" responses to Concerta in the past few months, which make sense after learning much more about how it's released. These few cases actually did quite well after switching them to Ritalin LA -- which is what I started using more often as first line MPH.

I triaged a referral this morning referencing a patient on, "Aptensio", which I never even heard of until this morning.

On this topic, any good sources you could recommend that serve as a really good, "one stop source" for the nitty-gritty details on these medications? I've managed to piece quite a bit together from different sources but realize there's still a lot I don't know.

 

[Merovinge]

Why not Metadate ER? I have actually never prescribed either formulation of Metadate, and I have yet to read any reason why I would with Ritalin LA and Concerta both available. I encountered some, "odd" responses to Concerta in the past few months, which make sense after learning much more about how it's released. These few cases actually did quite well after switching them to Ritalin LA -- which is what I started using more often as first line MPH.

I triaged a referral this morning referencing a patient on, "Aptensio", which I never even heard of until this morning.

On this topic, any good sources you could recommend that serve as a really good, "one stop source" for the nitty-gritty details on these medications? I've managed to piece quite a bit together from different sources but realize there's still a lot I don't know.

Metadate ER is a pretty crummy drug, it is just a monophasic extended release and should really never be used as the initial spike in stimulants seems to be part of the efficacy. Metadate CD is the same as Ritalin LA as far as I know, biphasic release with an IR spike to start and then a delayed burst later. Our formularies here just cover Metadate preferentially.

Curious what responses you had to Concerta that were odd. I tend to find it the best starting stimulant for kids unless there are specific concerns about appetite or sleep. Controlling sx all day at school only for the kid to fall apart at home/during homework time makes parents less happy (and is clearly worse for the pt).

 

[DD214_DOC]

Metadate ER is a pretty crummy drug, it is just a monophasic extended release and should really never be used as the initial spike in stimulants seems to be part of the efficacy. Metadate CD is the same as Ritalin LA as far as I know, biphasic release with an IR spike to start and then a delayed burst later. Our formularies here just cover Metadate preferentially.

Curious what responses you had to Concerta that were odd. I tend to find it the best starting stimulant for kids unless there are specific concerns about appetite or sleep. Controlling sx all day at school only for the kid to fall apart at home/during homework time makes parents less happy (and is clearly worse for the pt).

It has only been a handful of cases so far, but the 22% IR/78% SR mechanism of Concerta ended up with some kids having a gap between administration and noticeable therapeutic efficacy of 2-3 hours, with others (sometimes the same patient) experiencing residual side effects such as appetite suppression and insomnia well into the late evening.

 

[PistolPete]

What reason did it give for the yellow on methylphenidate?

I didn't look at it too closely, but basically he has heterozygous for whatever CYP enzyme is involved in metabolism of methylphenidate (so a slightly slower metabolizer) and he is homozygous (aka 'full normal') for metabolism of amohetamine. Clinically this of course probably will make no difference whatsoever but I wasn't gonna explain this to mother, who was initially still resistant to starting any stimulant whatsoever.

 

[PistolPete]

Me either. This was one of the first things that came up in my search: http://www.nbcnews.com/health/mental-health/new-psychiatric-dna-testing-unproven-ground-n437781

Yup, that's it!

 

[Jules A]

I didn't look at it too closely, but basically he has heterozygous for whatever CYP enzyme is involved in metabolism of methylphenidate (so a slightly slower metabolizer) and he is homozygous (aka 'full normal') for metabolism of amohetamine. Clinically this of course probably will make no difference whatsoever but I wasn't gonna explain this to mother, who was initially still resistant to starting any stimulant whatsoever.

There are a couple of clinics around here ordering it for everyone. My understanding is it only shows metabolism which doesn't equate to tolerability or efficacy. I've admitted a couple of patients to the acute unit after long term well tolerated meds were changed based solely on these tests and it was a disaster. Patients seem to love it and I've had difficulty swaying them from that mindset which is problematic because most of the meds that show as a better option are the newer, more expensive meds.

 

[hamstergang]

My understanding is it only shows metabolism which doesn't equate to tolerability or efficacy.

Genesight also looks at genes for serotonin receptors that have been linked to the chance an SSRI will be effective for depression in some studies. For ADHD, I believe it is just CYP stuff but I admittedly haven't looked at it in a while since I don't think it's very helpful.

 

[Jules A]

Genesight also looks at genes for serotonin receptors that have been linked to the chance an SSRI will be effective for depression in some studies. For ADHD, I believe it is just CYP stuff but I admittedly haven't looked at it in a while since I don't think it's very helpful.

Interesting I didn't realize there was actual correlation to efficacy. The patient's I've cared for were being typed for antipsychotics which is why it got dicey when they were changed from a long term regimen. I'm sure it is something that will be useful down the line but for now its been more problematic than helpful in my very limited experience.

 

[Merovinge]

Interesting I didn't realize there was actual correlation to efficacy. The patient's I've cared for were being typed for antipsychotics which is why it got dicey when they were changed from a long term regimen. I'm sure it is something that will be useful down the line but for now its been more problematic than helpful in my very limited experience.

The antipsychotic stuff is just CYP metabolism that's garbage in the overwhelming majority of cases. It can make sense to justify over max doses or something in cases where the response fits over metabolism (or less often under) but those cases are never what people seem to actually use them for.

 

[hamstergang]

The antipsychotic stuff is just CYP metabolism that's garbage in the overwhelming majority of cases. It can make sense to justify over max doses or something in cases where the response fits over metabolism (or less often under) but those cases are never what people seem to actually use them for.

Plus in these cases, you could just check a serum level to see if there's room to go up without being toxic.

 

[Merovinge]

Plus in these cases, you could just check a serum level to see if there's room to go up without being toxic.

Is there good data on what blood levels = toxicity? I use levels to check for non-compliance (rarely) but had always been told that levels don't really equate to clinical effect or toxicity. I'll admit I have never looked at the literature, any pointers would be great.

 

[hamstergang]

Is there good data on what blood levels = toxicity? I use levels to check for non-compliance (rarely) but had always been told that levels don't really equate to clinical effect or toxicity. I'll admit I have never looked at the literature, any pointers would be great.

I don't know. I've only actually done this with Zoloft a few times so far. I don't think serum levels correlate well with efficacy either, but I'd think there'd be more data on toxicity.