Medication Combination of the Day

[robellis]

No, there's a whole backstory. Tip of the iceberg is that when my colleague called the prescriber for collateral, they immediately began screaming that they were reporting my colleague to the hospital administrators and demanded contact info and license numbers. Just the tip of the iceberg.

Don’t use prescriber man..we’re not prescribers…we’re physicians

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[calvnandhobbs68]

Former residency classmate passed one along:

Effexor 225 mg, Prozac 80 mg, geodon 80 mg, remeron 45 mg, doxepin 10 mg qid, buspar 15 mg bid, atarax 25 mg bid.

Seen at a methadone clinic.



Also, I'm usually not super worried about serotonin syndrome compared to some of my colleagues, but I am worried about serotonin syndrome. Can't fathom the intent Effexor + prozac + geodon combo apart from inducing SS

Good god. Again, I don't get how some of this stuff even makes it through the pharmacy when I have pharmacists calling me to make sure I'm aware of the "risk of serotonin syndrome" from 40mg of Prozac and 15mg of Remeron....

 

[calvnandhobbs68]

Don’t use prescriber man..we’re not prescribers…we’re physicians

Idk someone who's "prescribing" that regimen...can just be a prescriber. Can't say I'm seeing that one using his/her "physician" knowledge base very well there.

 

[calvnandhobbs68]

Oh wow, I totally thought strattera was an SNRI, didn't realize it's norepinephrine only. Well, that makes more sense now!

This is a very common misperception that even I've had to correct child psych fellows on. Remember this and you'll be the smartest med student on your child psych rotation lol. This is why I hate when people call strattera an "SNRI". It is a SELECTIVE norepinephrine reuptake inhibitor not a SEROTONIN norepinephrine reuptake inhibitor.

 

[shotgunlagoon]

This is a very common misperception that even I've had to correct child psych fellows on. Remember this and you'll be the smartest med student on your child psych rotation lol. This is why I hate when people call strattera an "SNRI". It is a SELECTIVE norepinephrine reuptake inhibitor not a SEROTONIN norepinephrine reuptake inhibitor.

Yeah, I think I saw it abbreviated as "SNRI" somewhere and I was like "so.... serotonin and norepinephrine"

 

[nowaysanjose]

Idk someone who's "prescribing" that regimen...can just be a prescriber. Can't say I'm seeing that one using his/her "physician" knowledge base very well there.

This is the deal that really bugs me about the pharmacist thing, but why I guess they thought it could be done? I’m pretty sure they can’t make a diagnosis? Or interpret side effects? Or rule out medical conditions masquerading as psychiatric illness? How is this possible? I couldn’t see this ever happening in something like Neuro which we’re supposed to be so close to, or any other field for that matter

 

[calvnandhobbs68]

This is the deal that really bugs me about the pharmacist thing, but why I guess they thought it could be done? I’m pretty sure they can’t make a diagnosis? Or interpret side effects? Or rule out medical conditions masquerading as psychiatric illness? How is this possible? I couldn’t see this ever happening in something like Neuro which we’re supposed to be so close to, or any other field for that matter

That was about the guy who was prescribing
6mg Klonopin, 6mg Xanax, 24mg Suboxone, 90mg Adderall all to the same patient. Not the pharmacist thing.

In fact, it gets harder to argue against pharmacists prescribing when you have people out there throwing patients on regimens like that.

 

[hamstergang]

This is the deal that really bugs me about the pharmacist thing, but why I guess they thought it could be done? I’m pretty sure they can’t make a diagnosis? Or interpret side effects? Or rule out medical conditions masquerading as psychiatric illness? How is this possible? I couldn’t see this ever happening in something like Neuro which we’re supposed to be so close to, or any other field for that matter

The clinical pharmacists at the VA prescribe for a variety of conditions, not just for psych. When I was at a VA for residency, one ran a Coumadin clinic, for instance.

Here's an article: Clinical pharmacist prescribing activities in the Veterans Health Administration - PubMed
"During fiscal year 2015, VHA clinical pharmacists accounted for more than 5 million patient encounters and 1.9 million prescriptions for chronic disease-targeted medications, generating at least 20% of prescriptions for hepatitis C therapies, hypoglycemic agents, and erythropoiesis-stimulating agents and 69% of prescriptions for anticoagulants systemwide."

I don't know anything about their training, I don't know if this is good or bad, but I do know it's not just targeted at psychiatry.

 

[shotgunlagoon]

The clinical pharmacists at the VA prescribe for a variety of conditions, not just for psych. When I was at a VA for residency, one ran a Coumadin clinic, for instance.

Here's an article: Clinical pharmacist prescribing activities in the Veterans Health Administration - PubMed
"During fiscal year 2015, VHA clinical pharmacists accounted for more than 5 million patient encounters and 1.9 million prescriptions for chronic disease-targeted medications, generating at least 20% of prescriptions for hepatitis C therapies, hypoglycemic agents, and erythropoiesis-stimulating agents and 69% of prescriptions for anticoagulants systemwide."

I don't know anything about their training, I don't know if this is good or bad, but I do know it's not just targeted at psychiatry.

I can understand renewing prescriptions, say if a patient has been on metformin for diabetes for the past 2 years and needs their prescription renewed, in theory it could be fine. However, starting anticoag therapy sounds.... out of scope?

 

[nowaysanjose]

I can understand renewing prescriptions, say if a patient has been on metformin for diabetes for the past 2 years and needs their prescription renewed, in theory it could be fine. However, starting anticoag therapy sounds.... out of scope?

Agree. And I can’t really understand it with us. I mean granted I know their knowledge of pharmacology far outweighs NPs, however I can’t see where they get any training to diagnose? (NPs either but that’s another topic.) Unless they’re just going with whatever dx comes to them and rx based on that, which would be scary

 

[Styrene]

Don’t use prescriber man..we’re not prescribers…we’re physicians

I wrote that to specify that the person who was called was the person prescribing the medication. I don't use that term generally. I prescribe as few medications as possible anyway.

 

[Stagg737]

That is not an snri so no I wouldn’t worry about it

Oh wow, I totally thought strattera was an SNRI, didn't realize it's norepinephrine only. Well, that makes more sense now!

This is a very common misperception that even I've had to correct child psych fellows on. Remember this and you'll be the smartest med student on your child psych rotation lol. This is why I hate when people call strattera an "SNRI". It is a SELECTIVE norepinephrine reuptake inhibitor not a SEROTONIN norepinephrine reuptake inhibitor.

I mean, it technically is an SNRI and has some effects on the SERT receptors. Clinically it just mostly works through NRI action in humans. When considering if patient has SS though, I count it as serotonergic to remain on the conservative side.

 

[calvnandhobbs68]

I mean, it technically is an SNRI and has some effects on the SERT receptors. Clinically it just mostly works through NRI action in humans. When considering if patient has SS though, I count it as serotonergic to remain on the conservative side.

Its not clear that any effects on SERT receptors are actually clinically relevant in humans though. For classification purposes it’s classified as a selective NE reuptake inhibitor.

I’d be much more concerned about CYP interactions with atomoxetine causing SS with multiple agents rather than the atomoxetine itself.

 

[Stagg737]

Its not clear that any effects on SERT receptors are actually clinically relevant in humans though. For classification purposes it’s classified as a selective NE reuptake inhibitor.

I’d be much more concerned about CYP interactions with atomoxetine causing SS with multiple agents rather than the atomoxetine itself.

Right, that's basically why I include it as "serotonergic". It's Ki isn't irrelevant, but it's binding affinity is weak and it has minimal clinical serotonergic effects like you said. I'm just being "technically correct", lol.

 

[aim-agm]

@shotgunlagoon I've seen SNRI used both ways so understandable.

To add to the above, atomoxetine 20 mg BID had no significant effect on platelet serotonin (which is mediated by SERT).

Clinical pharmacology of tomoxetine, a potential antidepressant.

Tomoxetine (LY139603) selectively inhibits norepinephrine uptake in animals and has activity in animal models of depression. Tomoxetine was administered in single oral doses up to 90 mg to healthy normal volunteers. In addition, normal human subjects received either 20 or 40 mg of tomoxetine...

jpet.aspetjournals.org

I’d be much more concerned about CYP interactions with atomoxetine causing SS with multiple agents rather than the atomoxetine itself.

Can you elaborate?

 

[calvnandhobbs68]

@shotgunlagoon I've seen SNRI used both ways so understandable.

To add to the above, atomoxetine 20 mg BID had no significant effect on platelet serotonin (which is mediated by SERT).

Clinical pharmacology of tomoxetine, a potential antidepressant.

Tomoxetine (LY139603) selectively inhibits norepinephrine uptake in animals and has activity in animal models of depression. Tomoxetine was administered in single oral doses up to 90 mg to healthy normal volunteers. In addition, normal human subjects received either 20 or 40 mg of tomoxetine...

jpet.aspetjournals.org

Can you elaborate?

I probably should have phrased that better.
Strattera is primarily metabolized through CYP2D6 so one could imagine that pairing higher doses of strattera with a serotonergic/non serotonergic CYP2D6 inhibitor could result in supraphysiologic levels of strattera which could then theoretically contribute to serotonin syndrome. Poor metabolizers see about 5x the Cmax of normal metabolizers. But this doesn’t make sense unless you understand the CYP interaction.

So if for instance you have someone on 100mg strattera a day and then get put on Wellbutrin (in my opinion probably would need to be on other serotonergic meds to develop SS), and develop SS, it’s probably that the Wellbutrin was causing them to see strattera max concentrations which were much higher than they’d usually ever see. So the right long term move would be to get rid of the inhibitor and put them back on the strattera if it was helpful rather than drop all the meds because you’re worried strattera by itself possibly caused SS.

 

[Ceke2002]

“Ritalin 160mg daily”

Was re-referred a guy who I saw years ago who left my rooms unhappy as I wouldn’t prescribe him dexamphetamine. He’d given a history of ongoing recreational drug use, concerns about potential trafficking and couldn’t provide anything close to resembling ADHD symptoms through to poor engagement. He’d also only wanted something like MDMA and refused everything else that might have potentially been of benefit.

After this the patient had then seen another psychiatrist who initially prescribed him Ritalin, and then refused to prescribe him dexamphetamine after disagreements over dose escalations. He later saw another psych notorious for prescribing megadoses, and even he refused to prescribe – and this is after prescribing 160mg of Ritalin and then apparently switched him to an equivalent dose of dexamphetamine. My only guess is that he was using more than this amount.

Even his previous referring doctor who had a go at me when I initially declined to treat him with a stimulant also had enough of him, with comments on the letter about getting valium scripts different doctors and going to different pharmacies in order to self-medicate on 50mg a day. Looking back over his record I could also see that he’d been getting morphine ampoules from yet another doctor which also seemed very unusual.

Naturally, I declined the referral - this was exactly the kind of outcome that I had feared would occur all those years ago, and not a mess of my creation that I felt obliged to try and sort out.

Of course he wanted dexies, they have a higher street value than ritalin. I doubt he was using 160mgs worth himself, or the equivalent amount for dexamphetamine. Going by 90s prices dexamphetamine sold for $250-300 a bottle, or $5 per tablet; ritalin went around $3 a tablet, you could valium for $2 a tablet. Add that all up and that buys a decent amount of meth or smack. Access to morphine vials if you're heavily immersed in the drug scene isn't that unusual either. When I was on the streets one of the first few things a new comer learnt was which of the regular clients were Doctors, and who out of those paid cash and who paid in scripts or vials of narcotics for services rendered. That's not including the Doctors who accepted cash, and/or or sexual favours, in exchange for a 'write your own script' policy and/or provided vials of narcotics within their actual clinical practice. And then you had the few who were actually supplying the pill runners themselves in exchange for a cut of the profits. If you knew where to go you could pretty much get anything you wanted.

Honestly the best policy, imho, for drugs of potential addiction is a zero scripts policy for the majority of patients. Back in the day if we knew that a Doctor was an absolute, definite 'no, not under any circumstances' in terms of getting any sort of pills out of them, we just wouldn't go to that Doctor. If we knew a Doctor who was more on the fence about it, we'd be much more likely to try our luck with them.

 

[aim-agm]

I probably should have phrased that better.
Strattera is primarily metabolized through CYP2D6 so one could imagine that pairing higher doses of strattera with a serotonergic/non serotonergic CYP2D6 inhibitor could result in supraphysiologic levels of strattera which could then theoretically contribute to serotonin syndrome. Poor metabolizers see about 5x the Cmax of normal metabolizers. But this doesn’t make sense unless you understand the CYP interaction.

So if for instance you have someone on 100mg strattera a day and then get put on Wellbutrin (in my opinion probably would need to be on other serotonergic meds to develop SS), and develop SS, it’s probably that the Wellbutrin was causing them to see strattera max concentrations which were much higher than they’d usually ever see. So the right long term move would be to get rid of the inhibitor and put them back on the strattera if it was helpful rather than drop all the meds because you’re worried strattera by itself possibly caused SS.

That's what I thought, but the toxidrome of atomoxetine doesn't seem to be mediated by serotonin (e.g. no hyperthermia)

 

[Liquid8]

Of course he wanted dexies, they have a higher street value than ritalin. I doubt he was using 160mgs worth himself, or the equivalent amount for dexamphetamine. Going by 90s prices dexamphetamine sold for $250-300 a bottle, or $5 per tablet; ritalin went around $3 a tablet, you could valium for $2 a tablet. Add that all up and that buys a decent amount of meth or smack. Access to morphine vials if you're heavily immersed in the drug scene isn't that unusual either. When I was on the streets one of the first few things a new comer learnt was which of the regular clients were Doctors, and who out of those paid cash and who paid in scripts or vials of narcotics for services rendered. That's not including the Doctors who accepted cash, and/or or sexual favours, in exchange for a 'write your own script' policy and/or provided vials of narcotics within their actual clinical practice. And then you had the few who were actually supplying the pill runners themselves in exchange for a cut of the profits. If you knew where to go you could pretty much get anything you wanted.

Honestly the best policy, imho, for drugs of potential addiction is a zero scripts policy for the majority of patients. Back in the day if we knew that a Doctor was an absolute, definite 'no, not under any circumstances' in terms of getting any sort of pills out of them, we just wouldn't go to that Doctor. If we knew a Doctor who was more on the fence about it, we'd be much more likely to try our luck with them.

That’s very interesting. From what patients tell me the going rate for drugs on the street is probably about double, although trying out different psychiatrists may not be the most profitable exercise as there are very few who bulk bill or even prescribe stimulants. Given waiting lists are exceeding 6 months for private services, I figure that anyone seeking a drug high has cheaper and more accessible alternatives if that’s what they are after.

Outside of antidepressants, GPs prescribing of psychotropic is probably on the decline too especially given limitations on Xanax and a culture of more risk adverse prescribing behaviour. That being said I wouldn’t be surprised if some doctors were engaged in unethical activity, as I was recently made aware of a GP who was allegedly dealing S8s on the side. However, the risk to professional reputation and career likely outweighs any benefits so I doubt this is as common.

These days I think with current script checking and monitoring systems inappropriate behaviour becomes apparent especially when scripts consistently run out early or are “lost.” I also suspect that anyone engaging in dealing to fund a habit may not necessarily have the best impulse control in terms keeping to rules leading to repeat instances and raised suspicion. Pharmacists are quite good in this regard too, not being afraid to call and confirm things with prescribers.

What does bother me are when colleagues starting patients on 6-10 tablets in one go or rapidly increasing the dose to that kind of level. While this isn’t inherently wrong, from my experience patients often do well at lower doses and if needing to take a medication more frequently during the day, discussions on switching to long acting options are often well received.