Good resource for tapering AED's and other meds?

[ryerica22]

I'm working to clean up some awful med regimens in a clinic where NP used to work. I routinely see folks on Trileptal, Topamax and Tegretol. I know we often can use epocrates for dosing but for how to taper these, do you guys have any suggestions or is there a good quick resource I can use?

It's quite disappointing some of the management I've seen at this clinic.

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[psychapp121]

Can’t you just stop them cold turkey if they don’t have history of seizure?

 

[dl2dp2]

I'm working to clean up some awful med regimens in a clinic where NP used to work. I routinely see folks on Trileptal, Topamax and Tegretol. I know we often can use epocrates for dosing but for how to taper these, do you guys have any suggestions or is there a good quick resource I can use?

It's quite disappointing some of the management I've seen at this clinic.

I also see this. Why is that?? WTF. What is with NPs and off label psych AEDs.

 

[PikminOC]

I also see this. Why is that?? WTF. What is with NPs and off label psych AEDs.

Lack of education and structured, properly supervised experience like we get in medical school and residency.

 

[clozareal]

Can’t you just stop them cold turkey if they don’t have history of seizure?

No definitely not. Depending on the half life of the medication, this can provoke a seizure even without a history of seizure. However, provoked seizures have very low risk of future seizures so it's not like they would develop a seizure disorder.

There are no guidelines or studies to inform safe withdrawal of AEDs when used as mood stabilizers unfortunately. Most of the literature comes from withdrawing from anticonvulsants after seizure-free periods for a certain number of years.

There's a recent book published a few months ago called Deprescribing in Psychiatry by Gupta, Cahill, and Miller. I've skimmed through the books and it looks promising, but there's so little literature out there on how to safely deprescribe so most of the book also reflects how uninformed this practice is.

Also, there's a free podcast called the psychopharmacology institute that has interesting discussions. One of the episode is on Deprescribing in Psychiatry. You can listen to it here: Psychopharmacology Institute

 

[psychapp121]

No definitely not. Depending on the half life of the medication, this can provoke a seizure even without a history of seizure. However, provoked seizures have very low risk of future seizures so it's not like they would develop a seizure disorder.

There are no guidelines or studies to inform safe withdrawal of AEDs when used as mood stabilizers unfortunately. Most of the literature comes from withdrawing from anticonvulsants after seizure-free periods for a certain number of years.

There's a recent book published a few months ago called Deprescribing in Psychiatry by Gupta, Cahill, and Miller. I've skimmed through the books and it looks promising, but there's so little literature out there on how to safely deprescribe so most of the book also reflects how uninformed this practice is.

Also, there's a free podcast called the psychopharmacology institute that has interesting discussions. One of the episode is on Deprescribing in Psychiatry. You can listen to it here: Psychopharmacology Institute

my attending is a ******* then..he said “why wouldn’t you be able to stop it? They don’t have a history of seizure and you’re not treating for seizures so stop it cold turkey” this was when I stopped it when we were admitting from the ED into the psych unit

 

[Mass Effect]

my attending is a ******* then..he said “why wouldn’t you be able to stop it? They don’t have a history of seizure and you’re not treating for seizures so stop it cold turkey” this was when I stopped it when we were admitting from the ED into the psych unit

There are very few meds in psychiatry that you can just stop cold turkey and not affect health risks or patient comfort. Even if they were on starter doses, I certainly wouldn't discontinue all three at once.

OP, what doses of the medications are we talking? I would get collateral as to why these meds were prescribed and then I would slowly withdraw one at a time.

As an aside, some may consider this obnoxious, but when I see a med regimen like that, I call the NP if possible and ask why and depending on answer, if it's ludicrous, I tell them we don't usually do that and explain the risks. I did this with one NP who was prescribing qid dosing of Xanax in a 65-year-old female. She thanked me. We had a 30-minute conversation about it. It won't always be received that way, but I find educating these NPs helps relieve my frustration with their prescribing patterns making it less likely that I'll come home and vent with my hair on fire to friends and family about it.

 

[clausewitz2]

There are very few meds in psychiatry that you can just stop cold turkey and not affect health risks or patient comfort. Even if they were on starter doses, I certainly wouldn't discontinue all three at once.

OP, what doses of the medications are we talking? I would get collateral as to why these meds were prescribed and then I would slowly withdraw one at a time.

As an aside, some may consider this obnoxious, but when I see a med regimen like that, I call the NP if possible and ask why and depending on answer, if it's ludicrous, I tell them we don't usually do that and explain the risks. I did this with one NP who was prescribing qid dosing of Xanax in a 65-year-old female. She thanked me. We had a 30-minute conversation about it. It won't always be received that way, but I find educating these NPs helps relieve my frustration with their prescribing patterns making it less likely that I'll come home and vent with my hair on fire to friends and family about it.

Yeah you really don't want to find out they have actually been taking them since they were a teenager for epilepsy and just didn't think to mention it because they haven't had a seizure in a decade.

 

[hallowmann]

Up to date recommends gradual reduction in both topiramate and carbemazepine, due primarily to risk of seizure, but also to risk of relapse of potential mood symptoms managed by those medications as well as potential withdrawal symptoms. I usually wean gradually for topiramate (weeks to months with regular visits). A little more aggressive for carbemazepine (probably safe over weeks to 1-2 mos). Oxcarbazepine I've titrated very quickly in the outpatient setting (1-2 wks) - honestly most people don't even notice anything after stopping it.

If there is an adverse side effect, I have no problem stopping oxcarbazepine and carbemazepine very quickly. Topiramate slows me down more, but depending on severity of adverse effect, risks of harm outweigh risks of withdrawal symptoms. This is ultimately how the majority of our staff taught us.

Yeah you really don't want to find out they have actually been taking them since they were a teenager for epilepsy and just didn't think to mention it because they haven't had a seizure in a decade.

Have seen this at least a handful of times (AEDs believed to be solely for mood and after months, finally find collateral that describes seizure disorder in young childhood/adolescence). Fortunately, those were found before any adjustments to AEDs were made. Especially difficult with patients where the majority of the history is based on the limited info that the group home they've been living have. Parents/guardians have either passed or moved away and you are stuck debating exactly why each of these medications are onboard.

 

[psychapp121]

Up to date recommends gradual reduction in both topiramate and carbemazepine, due primarily to risk of seizure, but also to risk of relapse of potential mood symptoms managed by those medications as well as potential withdrawal symptoms. I usually wean gradually for topiramate (weeks to months with regular visits). A little more aggressive for carbemazepine (probably safe over weeks to 1-2 mos). Oxcarbazepine I've titrated very quickly in the outpatient setting (1-2 wks) - honestly most people don't even notice anything after stopping it.

If there is an adverse side effect, I have no problem stopping oxcarbazepine and carbemazepine very quickly. Topiramate slows me down more, but depending on severity of adverse effect, risks of harm outweigh risks of withdrawal symptoms. This is ultimately how the majority of our staff taught us.



Have seen this at least a handful of times (AEDs believed to be solely for mood and after months, finally find collateral that describes seizure disorder in young childhood/adolescence). Fortunately, those were found before any adjustments to AEDs were made. Especially difficult with patients where the majority of the history is based on the limited info that the group home they've been living have. Parents/guardians have either passed or moved away and you are stuck debating exactly why each of these medications are onboard.

but why would stopping quickly anti seizure medication cause a seizure in someone with no seizure history?

 

[clausewitz2]

Up to date recommends gradual reduction in both topiramate and carbemazepine, due primarily to risk of seizure, but also to risk of relapse of potential mood symptoms managed by those medications as well as potential withdrawal symptoms. I usually wean gradually for topiramate (weeks to months with regular visits). A little more aggressive for carbemazepine (probably safe over weeks to 1-2 mos). Oxcarbazepine I've titrated very quickly in the outpatient setting (1-2 wks) - honestly most people don't even notice anything after stopping it.

If there is an adverse side effect, I have no problem stopping oxcarbazepine and carbemazepine very quickly. Topiramate slows me down more, but depending on severity of adverse effect, risks of harm outweigh risks of withdrawal symptoms. This is ultimately how the majority of our staff taught us.



Have seen this at least a handful of times (AEDs believed to be solely for mood and after months, finally find collateral that describes seizure disorder in young childhood/adolescence). Fortunately, those were found before any adjustments to AEDs were made. Especially difficult with patients where the majority of the history is based on the limited info that the group home they've been living have. Parents/guardians have either passed or moved away and you are stuck debating exactly why each of these medications are onboard.

My limited experience with these sort of group home/residential facility graduate folks is that by the time I see them they are also on four neuroleptics, lithium, two stimulants and buspirone QID for the kind of "anxiety" that involves punching people who steal their stuff. It's an easy mistake to assume all the meds they have are equally stupid.

 

[aim-agm]

but why would stopping quickly anti seizure medication cause a seizure in someone with no seizure history?

Think about what happens when you stop alcohol, barbiturates, or benzos suddenly. Not the same mechanism, but similar general principle.

 

[ryerica22]

Think about what happens when you stop alcohol, barbiturates, or benzos suddenly. Not the same mechanism, but similar general principle.

Sorry, why not the same mechanism? you are stopping a CNS depressant (in theory you could say the AED is one). Maybe I'm having a brain freeze, could you please elaborate.

 

[psychapp121]

Sorry, why not the same mechanism? you are stopping a CNS depressant (in theory you could say the AED is one). Maybe I'm having a brain freeze, could you please elaborate.

because the aed are not gaba agonists I guess

 

[ryerica22]

No definitely not. Depending on the half life of the medication, this can provoke a seizure even without a history of seizure. However, provoked seizures have very low risk of future seizures so it's not like they would develop a seizure disorder.

There are no guidelines or studies to inform safe withdrawal of AEDs when used as mood stabilizers unfortunately. Most of the literature comes from withdrawing from anticonvulsants after seizure-free periods for a certain number of years.

There's a recent book published a few months ago called Deprescribing in Psychiatry by Gupta, Cahill, and Miller. I've skimmed through the books and it looks promising, but there's so little literature out there on how to safely deprescribe so most of the book also reflects how uninformed this practice is.

Also, there's a free podcast called the psychopharmacology institute that has interesting discussions. One of the episode is on Deprescribing in Psychiatry. You can listen to it here: Psychopharmacology Institute

I will need to check this out. My brain is completely rattled with how much mess I'm cleaning up. Since when is Tegretol and Depakote appropriate treatment for ADHD.

 

[clausewitz2]

Sorry, why not the same mechanism? you are stopping a CNS depressant (in theory you could say the AED is one). Maybe I'm having a brain freeze, could you please elaborate.

"CNS depressant" is not a mechanism. Brains don't have a throttle. RAS is closest analogy but you still have to squint.