Cytomel

[futuredo32]

I hear it being talked about as an adjunct. How much can you impact a patients thyroid level with It? Do you prescribe for patients with Hashimotos?

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[wolfvgang22]

The September and and October issues of the Psychiatric Times newsletter have some good articles by Dr. James Phelps, MD about this. Part 2 in the September issue is particularly useful. It's free. You can view it online with free registration.

 

[randomdoc1]

I'm no scholar at it, but it can be a useful adjunct. My understanding is you dose it until the TSH is towards low end of normal or a little below normal range. However, I don't think much is known about long term use. There is some concern longitudinally about bone demineralization but I believe that may be currently still actively debated?

Also watch for s/s hyperthyroidism/too high a dose. In extreme cases you can get an iatrogenic thyrotoxicosis.

 

[Sushirolls]

My small sample size of use, has not yielded clinical response.

 

[futuredo32]

Thanks. I returned from a conference and many spoke about cytomel but couldn't answer when asked. I inherited a patient on 50 mg. Her t3 was 0.1 above normal her tsh and t4 almost 0 but she's having hypothroid symptoms. I sent her to her Pcp he sent her back to me. The wait for an endocrinologist is 6 months. She has a history of Hashimotos but never 9n thyroid meds.

 

[splik]

the main issue is you can cause hypothyroidism by suppressing endogenous production of thyroxine. which is why we monitor TSH levels. if they go low, the patient can be at risk of hypothyroidism. endocrinologists really dont like cytomel and dont normally use it for hashimoto's.

 

[futuredo32]

the main issue is you can cause hypothyroidism by suppressing endogenous production of thyroxine. which is why we monitor TSH levels. if they go low, the patient can be at risk of hypothyroidism. endocrinologists really dont like cytomel and dont normally use it for hashimoto's.

I didn't start her on this. It does look like she is making pretty much no t3. But her t3 is 0.1 high so wouldn't that mean she's a little hyperthyroid? Do I leave her be until she sees an endocrinologist? Do a taper and hope her body picks up and makes It? I don't prescribe it because I'm afraid of ruining someone's thyroid

 

[Sushirolls]

Instead of adjuncting with cytomel, consider reaching for TMS or ECT.

 

[futuredo32]

Instead of adjuncting with cytomel, consider reaching for TMS or ECT.

The problem is that shes,already on it.

 

[clausewitz2]

I didn't start her on this. It does look like she is making pretty much no t3. But her t3 is 0.1 high so wouldn't that mean she's a little hyperthyroid? Do I leave her be until she sees an endocrinologist? Do a taper and hope her body picks up and makes It? I don't prescribe it because I'm afraid of ruining someone's thyroid

I mean there is some animal work suggesting that T4 has some direct action on the brain independent of being converted into T3, so having minimal circulating levels of it might be a problem. Also the endocrinology literature on using high-dose thyroid supplementation for treating various thyroid cancers suggest that excess exogenous hormone just doesn't seem to cause classical symptoms of hyperthyroidism for the most part. Probably the mechanism for classical hyperthyroidism is more complicated than just "your T3 levels are too high".

I do find it a little weird that we get so antsy about thyroid supplementation when we routinely hand out neuroleptics. If you have prescribed a significant number of neuroleptics over the course of your career it is almost certain that you have caused someone to suffer a sudden cardiac death as a result. It is always and everywhere about risks v. benefits.

I think in your situation given that you are deeply uncomfortable with managing this medication there is literature out there on combining T3 and T4. how convincingly hypothyroid is she v. depressed? If she is hypothyroid it is clearly not for lack of T3, so as a temporizing measure lowering the dose and adding T4 could ameliorate things a bit. Is there an endocrinologist you can call to curbside while you wait to get her in?

 

[futuredo32]

I mean there is some animal work suggesting that T4 has some direct action on the brain independent of being converted into T3, so having minimal circulating levels of it might be a problem. Also the endocrinology literature on using high-dose thyroid supplementation for treating various thyroid cancers suggest that excess exogenous hormone just doesn't seem to cause classical symptoms of hyperthyroidism for the most part. Probably the mechanism for classical hyperthyroidism is more complicated than just "your T3 levels are too high".

I do find it a little weird that we get so antsy about thyroid supplementation when we routinely hand out neuroleptics. If you have prescribed a significant number of neuroleptics over the course of your career it is almost certain that you have caused someone to suffer a sudden cardiac death as a result. It is always and everywhere about risks v. benefits.

I think in your situation given that you are deeply uncomfortable with managing this medication there is literature out there on combining T3 and T4. how convincingly hypothyroid is she v. depressed? If she is hypothyroid it is clearly not for lack of T3, so as a temporizing measure lowering the dose and adding T4 could ameliorate things a bit. Is there an endocrinologist you can call to curbside while you wait to get her in?

From what I have read it isn't supposed to be as strong as syn5hroid. Per her labs it looks like her body is making little or no thyroid hormones on it's own but she has grossly dry skin and other self reported hypothyroidism symptoms. I don't know an endocrinologist. I'm going to try having her take 50 every other day and 25 the opposite days and check labs again in 2 weeks. I used other meds in residency and can't find a good solid source for cytomel.

 

[whopper]

I don't give it first, 2nd, or even 3rd line as an antidepressant adjunct. I'm not saying it's a bad choice. So why my approach? The data with other meds is more abundant (e.g. Buspirone) and other med choices are cheaper.
Here's the price of generic Cytomel:

• 5 mcg (30 ea): $32.30
• 25 mcg (30 ea): $49.99
• 50 mcg (30 ea): $47.49

Generic Buspirone can often-times be obtained for less than $10 depending on the pharmacy.

Now all this said, Cytomel is not a bad choice. In fact perhaps maybe it is a better choice but I don't see the data out there supporting this, nor have seen real-world cases large enough to change my current view on it. STAR*D did head to head studies on various antidepressant adjunct treatments and while it found some differences they were for the most part not of any type that would point out one as much more significant vs the other. (E.g. Lamotrigine, Buspirone, an SNRI added to an SSRI, it's been years since I read it so someone correct me if I'm wrong).

I have at at times added it to treatment-resistant patients c/o chronic fatigue but oddly, and I didn't expect this until I saw this, it can cause weight gain. I figured the opposite would happen cause their metabolism would go up. Also patients on this medication often times would wake up in the middle of the night sweating.

 

[whopper]

There's a lot of data showing Buspirone works for augmentation of antidepressants but it in and of itself is not an antidepressant. Hence why I termed it an "antidepressant adjunct" and not an antidepressant above.

 

[Attending1985]

I do find it a little weird that we get so antsy about thyroid supplementation when we routinely hand out neuroleptics. If you have prescribed a significant number of neuroleptics over the course of your career it is almost certain that you have caused someone to suffer a sudden cardiac death as a result. It is always and everywhere about risks v. benefits

Agreed and also disturbed by this.

 

[whopper]

Along the same lines I find it odd that so many psychiatrists intentionally are ignorant of the human body, "I'm not a doctor I'm a psychiatrist" and yet do some very harmful medication regimens.

The entire point of a psychiatrist having an MD is cause these meds can be dangerous, and a foundation in our training, and the training of all physicians is to have at least a basic understanding in medical knowledge and treatment.

I won't point out the institution (though some will readily know which one I'm talking about) but in this one city there's more than 1 psych program, and one is more heavily research-based. The other program, possibly in response, say "we're a psychodynamic-based program" yet oddly with except 1 of them none of them seem to know their psychodynamics.

It's as if they're really using that line as an excuse not to know their biological psychiatry. E.g. I talked to one guy who was a "psychodynamic" psychiatrist about some Freudian ideas such as self-objects, object-internalization, and if there was any data on Freudian psychodynamics with homosexuals. E.g. do Electra or Oedipus complexes happen just as much, more or less with homosexuals given that the drives are in different directions. I also brought up Jung, again the guy wasn't aware of him or his theories.

He had no idea what I was talking about, and I don't consider myself some Freud expert anymore than any psychiatrist. Yet when we talked meds, he kept deflecting the conversation saying he doesn't know meds becuase he's a "psychodynamic psychiatrist," but he doesn't seem to know that either.

I would've read at least several of Freud's and Jung's works before I could overcome the imposter syndrome related to stating I'm a "psychodynamic" psychiatrist.

 

[Attending1985]

I’ve applied for internal medicine this year after practicing for the past couple years. It’s not working with the mentally ill that’s pushing me away but all the harm caused by medications and a system that uses them without any restraint. I don’t want to be responsible for harm. I want to make people healthy not unhealthy. Knowing you caused someone to die is not something I want on my mind.

 

[wolfvgang22]

I’ve applied for internal medicine this year after practicing for the past couple years. It’s not working with the mentally ill that’s pushing me away but all the harm caused by medications and a system that uses them without any restraint. I don’t want to be responsible for harm. I want to make people healthy not unhealthy. Knowing you caused someone to die is not something I want on my mind.

You really think IM is better?

 

[Attending1985]

You really think IM is better?

Yes I do especially hospital medicine dealing with acute problems

 

[Merely]

Along the same lines I find it odd that so many psychiatrists intentionally are ignorant of the human body, "I'm not a doctor I'm a psychiatrist" and yet do some very harmful medication regimens.

The entire point of a psychiatrist having an MD is cause these meds can be dangerous, and a foundation in our training, and the training of all physicians is to have at least a basic understanding in medical knowledge and treatment.

I won't point out the institution (though some will readily know which one I'm talking about) but in this one city there's more than 1 psych program, and one is more heavily research-based. The other program, possibly in response, say "we're a psychodynamic-based program" yet oddly with except 1 of them none of them seem to know their psychodynamics.

It's as if they're really using that line as an excuse not to know their biological psychiatry. E.g. I talked to one guy who was a "psychodynamic" psychiatrist about some Freudian ideas such as self-objects, object-internalization, and if there was any data on Freudian psychodynamics with homosexuals. E.g. do Electra or Oedipus complexes happen just as much, more or less with homosexuals given that the drives are in different directions. I also brought up Jung, again the guy wasn't aware of him or his theories.

He had no idea what I was talking about, and I don't consider myself some Freud expert anymore than any psychiatrist. Yet when we talked meds, he kept deflecting the conversation saying he doesn't know meds becuase he's a "psychodynamic psychiatrist," but he doesn't seem to know that either.

I would've read at least several of Freud's and Jung's works before I could overcome the imposter syndrome related to stating I'm a "psychodynamic" psychiatrist.

Lol that’s so sad but funny, aren’t Freud and jung taught during residency didactics?

 

[futuredo32]

Yes I do especially hospital medicine dealing with acute problems

Me too.

 

[birchswing]

I do find it a little weird that we get so antsy about thyroid supplementation when we routinely hand out neuroleptics. If you have prescribed a significant number of neuroleptics over the course of your career it is almost certain that you have caused someone to suffer a sudden cardiac death as a result. It is always and everywhere about risks v. benefits.

Is that due specifically in QT prolongation and TdP or is it the etiology unknown?

 

[whopper]

aren’t Freud and jung taught during residency didactics?

To a very superficial level. Yes it's taught but most psychiatrist have only perfunctory knowledge of it and haven't learned about things like internalization of objects. There's a difference with someone whose read books hundreds of pages long on Jung or Freud vs someone who was given a PP outline with about 10 boxes of data on it....
Then declaring themselves a...
PSYCHODYNAMIC psychiatrist.

Especially when the self-declared biological psychiatrists have the same amount of training on the same stuff.

 

[Attending1985]

I’ve applied for internal medicine this year after practicing for the past couple years. It’s not working with the mentally ill that’s pushing me away but all the harm caused by medications and a system that uses them without any restraint. I don’t want to be responsible for harm. I want to make people healthy not unhealthy. Knowing you caused someone to die is not something I want on my mind.

Do others out there have the same feelings as me? Wondering if anyone else is planning an exit from the field?

 

[hamstergang]

Do others out there have the same feelings as me? Wondering if anyone else is planning an exit from the field?

I don't feel the same way and don't completely understand your feeling. But I'd like to understand.

Why does it matter if "the system" (what system, by the way) uses meds without restraint? Can't you, as an individual psychiatrist, use medications with restraint and only when benefits outweigh the harms? I certainly don't feel that I'm causing net harm to my patients, nor do I feel pressured to by anyone.

 

[Attending1985]

I don't feel the same way and don't completely understand your feeling. But I'd like to understand.

Why does it matter if "the system" (what system, by the way) uses meds without restraint? Can't you, as an individual psychiatrist, use medications with restraint and only when benefits outweigh the harms? I certainly don't feel that I'm causing net harm to my patients, nor do I feel pressured to by anyone.

By the system I mean the standard by which I see psychiatry currently being practiced. I constantly inherit patients with depression and anxiety on antipsychotics, chronic benzos and stimulants. You're right that it doesn't mean that I have to do so but I want to part of a system that is reasonable and promotes health. It's also really hard to get people off of the medications in a humane way.

Someone earlier said that statistically, in your career, if you are prescribing antipsychotics you are going to responsible for a sudden cardiac death. There's also the question if these medications are helpful or harmful long term.

Thanks for wanting to understand.

 

[Ironspy]

By the system I mean the standard by which I see psychiatry currently being practiced. I constantly inherit patients with depression and anxiety on antipsychotics, chronic benzos and stimulants. You're right that it doesn't mean that I have to do so but I want to part of a system that is reasonable and promotes health. It's also really hard to get people off of the medications in a humane way.

Someone earlier said that statistically, in your career, if you are prescribing antipsychotics you are going to responsible for a sudden cardiac death. There's also the question if these medications are helpful or harmful long term.

Thanks for wanting to understand.

I understand what you're saying and there is a ton of bad psychiatry out there. That said, there's a lot of bad medicine and surgery also that I have seen in both medical school and residency.

Cleaning up psychopharm messes is important work. Only you can weigh the risks and benefits for yourself in terms of whether that work is a good fit. I do believe that being a judicious, well-read and thoughtful psychiatrist means providing a net benefit for patients and there is a need for psychiatrists willing and able to do good work. Best of luck

 

[whopper]

Here's some of the more common bad psychiatry regimens I've seen.

1) Everyone gets a diagnosis of Bipolar Disorder. Doesn't matter that the patient doesn't meet the criteria of it. Doesn't matter that the meds aren't helping. Doesn't matter that they were on a few illicit substances when brought to the hospital.

2) A medication is tried. It doesn't work at all yet the doctor keeps it on and adds something else. Then a few weeks later same thing. Before you know it the patient is on 6 meds with none of them working.

3) Antidepressant tried at the starting dosage. Patient never gets better. The data shows at starting dosages antidepressants in general aren't expected to work better than placebo. Yet the doctor keeps the patient on it despite this and that the trial period should be 4-6 weeks. The patient's been on it for 6 months and edit-yes the doctor is still puzzling as to why the patient isn't getting better.

4) Zombification. The doctor's goal isn't to really get the patient better but to get the patient zonked. Throw a lot of sedating meds like Quetiapine.

5) Ambien long term and high dosages-despite that the data shows it's bad with long term use (over 1 month) and it's not FDA indicated for sleep maintenance. The doctor never explained this to the patient, explored things like sleep hygiene, or tried safer alternatives.

6) Medication given with weight gain heavily associated and yet the doctor never warned the patient about it. When the patient asks the edit-doctor for a different med they're give some idiot answer, "Well you ought to stay on that one because it's my favorite medication."

7) Antidepressants chosen because the drug-rep gives the most amount of freebies to the doctor. E.g. I'll see patients and every single med given to them are all the tradename ones that are still very expensive as first-line choices with no good reason to have chosen them over generics.

8) The oh so often idiot doctor that gives everyone every med of abuse they want.

9) Medicating Borderline PD with no success with several meds and never even telling the patient DBT is the preferred treatment.

 

[randomdoc1]

Do others out there have the same feelings as me? Wondering if anyone else is planning an exit from the field?

I don't think changing specialities will really necessarily be that much more fulfilling. At least in psychiatry, there is the option of 30 min visits if you do the psychotherapy add on and you still get paid very well. In PC, you are often doing 15 minute encounters and even more rushed. I think in the vast majority of specialties, you will be responsible for your share of bad outcomes, it's just how the statistics shake out. But at least in psychiatry, I really try to use that to address their health as well and discuss matters like diet and weight management in depth and many PCPs don't have the luxury of that amount of time. Heck, my mother is prediabetic and her FP just said "just be more active." That doesn't cut it for most patients. In my psychiatric follow-ups, I define to patients what "active" means and how to effectively dose their exercise. Also, in PC, there's probably a good chance at some point you'll encounter things like BP meds were dosed a little too high and that sweet little old lady falls and breaks her hip. Or you gave an antibiotic and someone gets c diff. etc. etc. It's the same principle, we'll all have our share of medical errors and even when meds are prescribed in good faith and good practice, you will still be responsible for your share of bad outcomes.

I love my PP. I get to practice medicine in an evidence based fashion and patients that are not on board can go elsewhere.

 

[clausewitz2]

By the system I mean the standard by which I see psychiatry currently being practiced. I constantly inherit patients with depression and anxiety on antipsychotics, chronic benzos and stimulants. You're right that it doesn't mean that I have to do so but I want to part of a system that is reasonable and promotes health. It's also really hard to get people off of the medications in a humane way.

Someone earlier said that statistically, in your career, if you are prescribing antipsychotics you are going to responsible for a sudden cardiac death. There's also the question if these medications are helpful or harmful long term.

Thanks for wanting to understand.

An important caveat to what I said about neuroleptics is that the best epidemiological data suggests they reduce all cause mortality in people diagnosed with schizophrenia. So even from the crude metric of years of life there is going to be a net benefit for a significant number of people.

I don't know that there is fantastic data out there for the other uses of neuroleptics that have mushroomed in the last couple decades so that risk:benefit calculation is less clear.

 

[clausewitz2]

Is that due specifically in QT prolongation and TdP or is it the etiology unknown?

It is -probably- an induced channelopathy of some kind but this is a conclusion from prescription registry data so it is hard to pin the exact mechanism down to a high degree of confidence. Dyslipidemia, diabetes and the CV event risk that comes along with them probably also plays a role.

 

[Attending1985]

I understand what you're saying and there is a ton of bad psychiatry out there. That said, there's a lot of bad medicine and surgery also that I have seen in both medical school and residency.

Cleaning up psychopharm messes is important work. Only you can weigh the risks and benefits for yourself in terms of whether that work is a good fit. I do believe that being a judicious, well-read and thoughtful psychiatrist means providing a net benefit for patients and there is a need for psychiatrists willing and able to do good work. Best of luck

Thanks for the perspective. For me it doesn’t feel right. I’ve tried to make it work but probably would’ve been better if I would’ve made the move after residency.

 

[michaelrack]

. Knowing you caused someone to die is not something I want on my mind.

As a board-certified internist and psychiatrist, I can assure you that you are more likely to kill or permanently disable someone as an internist. Even if you always make the "correct" evidence-based decision, bad out-comes are going to occur because of your decisions. Take the issue of perioperative anticoagulation (bridging)- too aggressive and the patient can suffer a serious bleed; not aggressive enough and they can stroke out. And sometimes your judgement, based on the best available evidence, will lead to a bad outcome.

 

[whopper]

. That said, there's a lot of bad medicine and surgery also that I have seen in both medical school and residency.

I agree, but IMHO the amount of bad psychiatrists pull a psychodynamic angle somtimes to defend their BS while in medicine and surgery it's more cut and dry. I think that's the frustration angle with the field in general. Further, due to the general shortage of psychiatrists, a lot of places keep ones that are bad.

I see bad IM all the time. E.g. i had a patient with temporal arteritis and her PCP did nothing about it. I MEAN NOTHING, and kept telling her it was in her head despite that she had classic symptoms. I had to tell her to go to the ER.

 

[Attending1985]

I agree, but IMHO the amount of bad psychiatrists pull a psychodynamic angle somtimes to defend their BS while in medicine and surgery it's more cut and dry. I think that's the frustration angle with the field in general. Further, due to the general shortage of psychiatrists, a lot of places keep ones that are bad.

I see bad IM all the time. E.g. i had a patient with temporal arteritis and her PCP did nothing about it. I MEAN NOTHING, and kept telling her it was in her head despite that she had classic symptoms. I had to tell her to go to the ER.

Also in psychiatry it seems no matter how terrible you are there are no consequences. From what I’m seeing out there someone needs to enforce some regulations on prescribing. There are some in nursing homes but need to be in general practice as well. Anything goes is not working

 

[WisNeuro]

Anything goes is not working

Well, it's working if you are a patient who just wants benzos or stims pretty easily.

 

[whopper]

I forgot to add this and this has happened quite a few times. It's a pet-peeve of mine when the patient has a non-psych problem, I notice it, tell the other physician about it and the other physician 1) Denies it, 2) Does something stupid like tell the patient it's all in their head and then do NOTHING, such as not even a physical exam or a cheap lab test to verify it, and then 3) When I try to discuss the issue with the other doctor they blow me off telling me I'm a psychiatrist so I know nothing about it and then 4) It turned out the patient had the problem to begin with and then the other doctor instead of working together still does some idiot narcissistic behavior such as making the "tfff" sound while turning their head as if to spurn the patient and I.

While I did inpatient psych this happened about once every 2 months. I had cases where the patient suffered bad outcomes because of the above. I had one particular case where the patient's bill went up to over $300K cause of something like this. The physician in the other fields refused to do their end and it cause serious complications. I had another where the patient had an infected spinal cord that lingered for days because the surgeon refused to show up to the psych unit when I ordered a consult, with the patient's surgery site emitting pus and the IM doctor even telling me it was out of his league and surgery needed to get involved.

One time I had a patient on an artificial respirator that could've gone kaput at any moment and the doctor in charge kept blowing everyone off. Every someone called him you could hear him eating popcorn and watching a football game on the phone while he found every excuse to blow everyone else off.

So when this type of thing happened something else that really ticked me off is if I documented it sometimes someone in the hospital would tell me not to do it cause it made the other doctor look bad. "There's one easy way to fix this!! Have that idiot show up and actually do his job!"

It's definitely one thing I don't miss about working in a hospital although I see it in outpatient, just not quite as confrontationally cause I usually don't see the other doctor face to face, and usually not as serious cause outpatient cases usually aren't as severe.

 

[Stagg737]

Someone earlier said that statistically, in your career, if you are prescribing antipsychotics you are going to responsible for a sudden cardiac death. There's also the question if these medications are helpful or harmful long term.

I think the same can be said for a lot of non-psych meds as well. Plenty of new meds out for diabetes or stroke prevention that have been around less than 10 years. Apixaban has only been around for 6-7 years and we use it all the times. That family of drugs has only been used in the US for 15ish years, so definitely not much long-term data to go on there (though you can argue that it's less necessary given the population using it).

Also in psychiatry it seems no matter how terrible you are there are no consequences. From what I’m seeing out there someone needs to enforce some regulations on prescribing. There are some in nursing homes but need to be in general practice as well. Anything goes is not working

I think part of this problem is that there is a genuine shortage of psychiatrists that still exists even with NPs and PCPs treating patients. It's hard to cut staff and hold people more accountable when they are literally the only ones in the town/area that can actually do that job.


Anecdotally, a question I like to ask my attendings (and did in med school) was that if they got sick which doctors would they want treating them? I've been surprised by how common it is for them to say they wouldn't trust any of them or that they would only trust 1 or 2 (who were usually the ones several people would mention). This was especially true in IM and inpt FM where docs felt like their partners did not spend enough time with patients or had treatment plans they didn't agree with. We like to think that medicine as a whole is largely evidence-based, but the fact is that most of us have preferences or deviate from that evidence in some way or another (which is sometimes a good thing). However, as Clause stated above, even following EBM sometimes leads to the worst outcomes. For people earlier in our careers, I think we like to feel like we're learning how to do things right and that as long as we're learning and using the guidelines things will be fine. Those I've talked to farther along in their careers who are well respected realize that even with all of the amazing developments and advancements, we're still treating patients in ways that frequently lead to less than optimal outcomes and sometimes make things worse. Basically we're forever infants in the medical field and how we treat patients even as masters, regardless of whether that field is psychiatry, IM, or whatever.