Medication high scores

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Celexa

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Let's have some fun. What are the highest prescribed doses of medication you've ever seen, both indicated and not indicated? Let's keep to outpatient and also things you know a pharmacy actually filled. I've had catatonic and manic inpatients on elephant doses of benzos but that's different.

Here are some of mine:

Risperidone 8mg bid. An antipsychotic was indicated, but... Not that much.

Adderall IR 30mg qid. Suspect pt was diverting, shocked someone was filling it.

Xanax 2mg qid. Pt was also prescribed a second benzo [emoji854]
 
1000mg seroquel, but was sort of worth trying for the patient.

8mg Requip for RLS.

Been years since seeing, but recently saw 60mg Celexa.
 
Celexa said:
Let's have some fun. What are the highest prescribed doses of medication you've ever seen, both indicated and not indicated? Let's keep to outpatient and also things you know a pharmacy actually filled. I've had catatonic and manic inpatients on elephant doses of benzos but that's different.

Here are some of mine:

Risperidone 8mg bid. An antipsychotic was indicated, but... Not that much.

Adderall IR 30mg qid. Suspect pt was diverting, shocked someone was filling it.

Xanax 2mg qid. Pt was also prescribed a second benzo [emoji854]
Click to expand...

I'll see that in my geri patients at least a few times a year.
 
Sushirolls said:
1000mg seroquel, but was sort of worth trying for the patient.

8mg Requip for RLS.

Been years since seeing, but recently saw 60mg Celexa.
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That's a super reasonable dose of citalopram, was the previously approved dosage prior to old folks with QTc issues raising some alarms. I would wager most teens to middle aged adults I would be shooting for a 60mg dosage if treating OCD. Or am I falling a joke here?
 
From residency days I recall they dropped FDA limit, but also clinical results showed most people don't respond beyond 40mg. I saw some people back in residency days at 60mg or 80mg. But was more surprise to see again after such a long time. Not really a big deal, but been a long time.
 
What’s the highest Wellbutrin XL can go up to? I had a patient at my pharmacy who was prescribed 600 mg per day. When I called to verify the dose, disgruntled psychiatrist comes on the phone and starts yelling “that’s the dose patient has been on for years”

I mean seriously dude? This is your explanation?
 
Chrish said:
What’s the highest Wellbutrin XL can go up to? I had a patient at my pharmacy who was prescribed 600 mg per day. When I called to verify the dose, disgruntled psychiatrist comes on the phone and starts yelling “that’s the dose patient has been on for years”

I mean seriously dude? This is your explanation?
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I think the benefits of even 450XL are pretty meager compared to 300 in the lion's share of cases and the SE profile absolutely ramps up. 600mg I have seen once and it feels like trying to get ECT on the cheap at that range.
 
Chrish said:
What’s the highest Wellbutrin XL can go up to? I had a patient at my pharmacy who was prescribed 600 mg per day. When I called to verify the dose, disgruntled psychiatrist comes on the phone and starts yelling “that’s the dose patient has been on for years”

I mean seriously dude? This is your explanation?
Click to expand...

Eh I mean it's not a wild explanation, biggest side effect to worry about is seizure risk and unlikely that's gonna happen unless something drastically changed so if the patient hadn't responded to other options before and responded to pushing up to 600mg XL and has been stable for years, I could see it. Stahl's recommends getting a blood level if considering pushing past 450mg but lays it out as a possible option.

I personally don't go above 450mg myself though.
 
Little rusty, think I had Vyvanse 90mg in a drinking middle aged male, who also picked up a Bipolar diagnosis at some point, and possibly no OSA workup. Didn't like my 'no bipolar' and reducing vyvanse to 70mg, and requiring Sleep Med consult. Patient elected to continue with previous non-local Psychiatrist.
 
Chrish said:
What’s the highest Wellbutrin XL can go up to? I had a patient at my pharmacy who was prescribed 600 mg per day. When I called to verify the dose, disgruntled psychiatrist comes on the phone and starts yelling “that’s the dose patient has been on for years”

I mean seriously dude? This is your explanation?
Click to expand...
That’s a pretty solid explanation..lol
 
calvnandhobbs68 said:
Eh I mean it's not a wild explanation, biggest side effect to worry about is seizure risk and unlikely that's gonna happen unless something drastically changed so if the patient hadn't responded to other options before and responded to pushing up to 600mg XL and has been stable for years, I could see it. Stahl's recommends getting a blood level if considering pushing past 450mg but lays it out as a possible option.

I personally don't go above 450mg myself though.
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I rotated with toxicology at one point and it gave me a whole new appreciation of the risks of wellbutrin. That therapeutic index is NARROW compared to a lot of our other meds. There's absolutely no way I would go above 450mg.
 
Celexa said:
I rotated with toxicology at one point and it gave me a whole new appreciation of the risks of wellbutrin. That therapeutic index is NARROW compared to a lot of our other meds. There's absolutely no way I would go above 450mg.
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I mean a person comes to you on it for many years and is very stable with the story that when he goes down to 450 his symptoms recur, he has no history of any medical problems/seizures and no contraindications, you’re going to taper him?
 
forchinet121 said:
I mean a person comes to you on it for many years and is very stable with the story that when he goes down to 450 his symptoms recur, he has no history of any medical problems/seizures and no contraindications, you’re going to taper him?
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Right I mean I don't do it but if a patient transferred to me like that, I'd probably document a thorough risk/benefit discussion and continue, especially if this is a verified history from whoever did that in the first place. Probably also make them draw serum levels. Haven't had it happen though lol.

Celexa said:
I rotated with toxicology at one point and it gave me a whole new appreciation of the risks of wellbutrin. That therapeutic index is NARROW compared to a lot of our other meds. There's absolutely no way I would go above 450mg.
Click to expand...

Toxicology is often taking a look at overdoses, so yeah risk of seizure is high with bupropion in an overdose, but TCAs are also really toxic in overdose. Lithium also has a really narrow therapeutic index, that doesn't mean a ton it just means you need to be careful with it. I agree I myself wouldn't go above 450mg.
 
Lol, those are rookie numbers. Actual doses of outpatients I inherited in clinics during PGY-3:

lamotrigine 300mg qam + 400mg qhs (prescribed by psych, not neuro)
seroquel 1200mg QHS
alprazolam 4mg QID (not on it when I inherited her, but PCP had previously pushed her to that dose to treat "mania")
alprazolam 2mg QID that she was taking as 2mg QAM and 6-8mg QHS
alprazolam 2mg QID that was being taken as 1mg Q3H (would literally wake up to take it every 3 hours)
risperidone 10mg QHS

I've personally titrated a person up to lexapro 50mg and another to prozac 120mg for OCD, both improved and tolerated fine

Doses I've heard of from attendings where I did residency:
Olanzapine 50mg daily total
Haldol 20mg TID
Thorazine 1000mg QHS (Shockingly, I actually encountered this patient in my ER recently and found he had been as high as 1,200mg)
Zoloft 450mg daily

In the national psych group on FB there was a guy saying he had no problem putting patients on venlafaxine 600mg

The most impressive dosing I saw was on a 60-something year old guy I treated inpatient at the VA (I know, thread is outpt only) who we had on total daily dosing of depakote 3,500mg, Lithium 2,400mg, haldol 10mg TID, and I'm sure some PRNs. Labs were within therapeutic range. Guy was literally still skipping up and down the halls and took weeks to stabilize.
 
forchinet121 said:
That’s a pretty solid explanation..lol
Click to expand...

It’s fine but if you are gonna do something out of ordinary and if I call to verify, provide me with brief explanation/ rationale behind the said decision rather than acting all high and mighty.

I am just trying to do my job of documenting any anomaly. And plenty of times when I call on high doses, it turned out to an error on prescriber’s part and then it was corrected.
 
forchinet121 said:
I mean a person comes to you on it for many years and is very stable with the story that when he goes down to 450 his symptoms recur, he has no history of any medical problems/seizures and no contraindications, you’re going to taper him?
Click to expand...
I would have a very long conversation about risk/benefit. I would have to be EXTREMELY convinced of the story (which is hard to imagine). And then I would also tell the patient that it's not my recommendation but I am willing to continue as long as they are also medically stable. Which will not be forever. All stability is temporary. Everyone gets old. Everyone accumulates new physical vulnerabilities. These medication regimens that look fine in a healthy 20 year old look very different in a 60 yo with CKD or a new cirrhosis diagnosis. Prescribing is always easier than deprescribing and patients are usually not given enough chances to be on fewer meds.
 
Celexa said:
I would have a very long conversation about risk/benefit. I would have to be EXTREMELY convinced of the story (which is hard to imagine). And then I would also tell the patient that it's not my recommendation but I am willing to continue as long as they are also medically stable. Which will not be forever. All stability is temporary. Everyone gets old. Everyone accumulates new physical vulnerabilities. These medication regimens that look fine in a healthy 20 year old look very different in a 60 yo with CKD or a new cirrhosis diagnosis. Prescribing is always easier than deprescribing and patients are usually not given enough chances to be on fewer meds.
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I agree with all of that, it’s just I’ve found in this field it’s so hard to say “I will never do this” because the next week someone shows up and reminds you it might just be reasonable
 
Sushirolls said:
Little rusty, think I had Vyvanse 90mg in a drinking middle aged male, who also picked up a Bipolar diagnosis at some point, and possibly no OSA workup. Didn't like my 'no bipolar' and reducing vyvanse to 70mg, and requiring Sleep Med consult. Patient elected to continue with previous non-local Psychiatrist.
Click to expand...

Excluding that there is more going on here, Vyvanse 90 = about Adderall XR 40 so not unusual in the grand scheme of things.
 
Sushirolls said:
Little rusty, think I had Vyvanse 90mg in a drinking middle aged male, who also picked up a Bipolar diagnosis at some point, and possibly no OSA workup. Didn't like my 'no bipolar' and reducing vyvanse to 70mg, and requiring Sleep Med consult. Patient elected to continue with previous non-local Psychiatrist.
Click to expand...
Little Rusty is an awesome rapper name.
 
TexasPhysician said:
Lorazepam 34mg/day
Lexapro 80mg/day
Click to expand...
Oh wow, 80mg of lexapro is pretty impressive. Only way I can imagine dosing that much is for someone with OCD who's an ultra-rapid metabolizer and had gastric bypass.

Was the lorazepam patient on that dose for catatonia? That's the only time I've heard of a patient being prescribed more than 16mg in a day on an outpatient basis.
 
Stagg737 said:
Oh wow, 80mg of lexapro is pretty impressive. Only way I can imagine dosing that much is for someone with OCD who's an ultra-rapid metabolizer and had gastric bypass.

Was the lorazepam patient on that dose for catatonia? That's the only time I've heard of a patient being prescribed more than 16mg in a day on an outpatient basis.
Click to expand...
Anxiety in someone older than 70
 
In the other direction, prozac 1.25mg in a 20 year old college student... I guess if one truly hopes to be fascinating by virtue of having idiosyncratic medication responses, this is on the more benign end of the spectrum.
 
SmallBird said:
In the other direction, prozac 1.25mg in a 20 year old college student... I guess if one truly hopes to be fascinating by virtue of having idiosyncratic medication responses, this is on the more benign end of the spectrum.
Click to expand...

How do you even get to 1.25mg? Some weird calculation with the liquid dose? Cause 1ml = 4mg, so 0.25ml = 1mg. Unless it was 1.25ml which would be 5mg.
 
Celexa said:
Xanax 2mg qid. Pt was also prescribed a second benzo [emoji854]
Click to expand...

I just had an Adderall 30mg BID and Xanax 2g 5x/day combo (I don't even know the abbreviation for 5 times per day). Diagnosed with "Panic disorder and ADHD," apparently.
 
I more commonly see lots of meds with same mechanism together none at therapeutic dose than meds at high doses
 
xanax 9mg with ambien 10mg and valium 5mg bid stands out as one. Ive seen a lot of elderly people on high doses of adderall xr dosed BID as well. Recently i had a woman on doxepin 250mg, lexapro 10mg, and cymbalta 30mg. She stated she didnt feel depressed anymore but also had memory issues and felt like a robot. Consolidated her meds to lexapro 10mg and doxepin 10mg and she was very appreciative.

I get a lot of elderly so over half of my intakes are on inappropriate doses of benzos or stimulants typically
 
Forgot about Ambien. Also had a guy in residency who was taken 20mg of Ambien QHS. Most surprising part was this was at a VA and they had been filling it for at least a couple of years (through a PTSD clinic).
 
My patient experiences....

Xanax 16mgs a day, with offers from Doctor to increase dose if I wanted to. At that point I needed about 8mgs to prevent withdrawals; I was taking around 10-12mgs a day. Nearly every appointment it would be, "So how are you on the Xanax, we can increase the dose if you want". Dude was my methadone prescribing Doctor, had this really odd idea that if he just pilled his patients out they'd be less likely to want to to score. I mean I suppose if you pill your patients into semi consciousness this could work? 😒🙄

Seroquel 1200mgs, off label, prescribed by a GP for anxiety and sleep problems. One of these 'saviour complex' situations, where when I didn't immediately respond to medication they just decided to keep upping the dose hoping something would work. Spoiler: it didn't. :smack:

400mgs Tramadol + 75mgs Effexor = Hello serotonin syndrome. Okay that one's not that extreme dose wise, but being rushed into the ER and ending up as a priority 1 emergency was not fun. 0/10 do not recommend. :grumpy:

Had a very close friend who was on about 7 different antidepressants at one stage (not sure what doses). Severe clinical depression + alcoholism. Didn't like it when his Psychiatrist would brooch the subject of giving up drinking, so he'd shaft one and move onto the next. Trouble was he kept taking the different antidepressants prescribed to him, and didn't inform future Doctors what he'd been previously been prescribed. This was in the 90s when they didn't have script tracking to counter stuff like Doctor shopping, or Psychiatrist shopping in this case. I sometimes wonder if he was attempting to passively commit suicide. He died from alcohol related liver failure a couple of years ago.

I get stupid medication doses if patients were prescribed like back in the 90s or earlier, but how are some of these other patients ending up on these sorts of doses you guys are talking about with stuff like computerised script checking in place now? Doesn't over prescribing like this send off some sort of electronic alarm bells or something?
 
There’s a few that come to mind…

Concerta 216mg/d (4 x 54mg)
Vyvanse 210mg/d (3 x 70mg)
Seroquel 2000mg/d
Venlafaxine 600mg/d

Just found out that one of the guys writing our national ADHD guidelines figures it’s ok to go up to Ritalin LA 160mg before getting a second opinion! Colleagues have mentioned that he titrates from 0 to 140mg Vyvanse in 2 weeks telling them to “increase it every day by 10mg until you feel something.”

One of my ED colleagues mentioned he saw someone on Vyvanse 210mg and Dex 40mg (8 x 5 mg) – but this patient had recently come out of jail and someone else had been filling the scripts each month when they were incarcerated!

Had a patient who came to me on Ritalin 100mg/d, first appointment wanted to increase which was an immediate warning sign. Switched them to Concerta, which they self-increased to 4x/day. Sent them for a second opinion who agreed it was too much, then they decided to go see someone else which was fine by me.
 
TheRightMedication said:
A hot take for ya -

1200 mg of seroquel isn't too much, and here's the spicy part -

There's a more solid rational to treat schizophrenia with 1200 mg than to treat insomnia with 25 or 50 mg.
Click to expand...
Well for insomnia there's multiple randomized controlled trials and a meta-analysis published in 2023 showing it works. That seems solid to me.
 
I am interested in those trials, if you could give me a name to google.

I've attached what I've got - the first article is a very nice, tight review of seroquel. The second one is a bit more of a polemic, but it is supports-my-hot-take quality of evidence which is the best kind. The last is some guidelines if anyone is reading this and realizing they could use a little sharpening up on their sleep meds.

My biggest takeaway from the literature as I read it is seroquel causes considerable weight gain even at low doses.
 

Attachments

Stagg737 said:
risperidone 10mg QHS
Click to expand...
I ended up having someone on this regimen. Had been for years deemed “noncompliant” prior to me seeing them, with long term psychosis. They had “trialed” many meds, olanzapine 20, quetiapine 800, haldol 20…

I had them get on risperidone up to 8mg nightly with bimonthly appointments and still did not have any cogwheeling. I was scratching my head because the patient swore up and down they were taking it, and had not had seizures in weeks so had clearly been taking the seizure med they were on.

I bumped to 10mg and lo and behold at next visit, mild cogwheeling and improvement in psychosis. Turned out the “noncompliant” patient for years was actually a hypermetabolizer, and had just been having pharmacokinetic failure across the board with many docs. They assumed the pt was not taking it and would switch meds.
 
TheRightMedication said:
A hot take for ya -

1200 mg of seroquel isn't too much, and here's the spicy part -

There's a more solid rational to treat schizophrenia with 1200 mg than to treat insomnia with 25 or 50 mg.
Click to expand...
I don't disagree, I've seen plenty of patients who had been in the 800mg+ range of quetiapine for psychosis. I think it's just less common to see it used in schizophrenic patients now and 1200mg is a very solid dose.

SmallBird said:
Well for insomnia there's multiple randomized controlled trials and a meta-analysis published in 2023 showing it works. That seems solid to me.
Click to expand...
You talking about the paper out of Taiwan? Not a bad review, but their conclusions don't line up with the data they actually presented. They concluded it is helpful for sleep (mostly in old men with anxiety or depression), but at the same time found it's ineffective for primary insomnia. They also stated it has a fairly high level of AEs but then just gave the generic "more studies are needed". So not exactly convincing when the group they say it's most effective for is also the group at greater risk for the AEs. Link to paper below:

www.sciencedirect.com

Effects of quetiapine on sleep: A systematic review and meta-analysis of clinical trials

Quetiapine is a common off-label antipsychotic drug for treating insomnia. Its effects in different disease conditions and dosages remain unclear. We …
www.sciencedirect.com www.sciencedirect.com


TheRightMedication said:
I am interested in those trials, if you could give me a name to google.

I've attached what I've got - the first article is a very nice, tight review of seroquel. The second one is a bit more of a polemic, but it is supports-my-hot-take quality of evidence which is the best kind. The last is some guidelines if anyone is reading this and realizing they could use a little sharpening up on their sleep meds.

My biggest takeaway from the literature as I read it is seroquel causes considerable weight gain even at low doses.
Click to expand...
Lol, the third link was one of the 3 primary sources of my QI project in residency. I will say there is some (fairly weak) evidence for it's use in sleep problems in PTSD and there is some data for it's use with PTSD-related nightmares.

mistafab said:
I ended up having someone on this regimen. Had been for years deemed “noncompliant” prior to me seeing them, with long term psychosis. They had “trialed” many meds, olanzapine 20, quetiapine 800, haldol 20…

I had them get on risperidone up to 8mg nightly with bimonthly appointments and still did not have any cogwheeling. I was scratching my head because the patient swore up and down they were taking it, and had not had seizures in weeks so had clearly been taking the seizure med they were on.

I bumped to 10mg and lo and behold at next visit, mild cogwheeling and improvement in psychosis. Turned out the “noncompliant” patient for years was actually a hypermetabolizer, and had just been having pharmacokinetic failure across the board with many docs. They assumed the pt was not taking it and would switch meds.
Click to expand...
These are the rare cases where imo genetic testing can be justified. If solid doses of multiple meds across the board seem like placebo, it's worth finding out if they're an ultra-rapid metabolizer or if there's issues with free vs bound levels of certain meds (turned out to be the case for depakote with the inpatient guy I referenced earlier).
 
Venlafaxine 900 mg qD

Granted, this was because of a filling error (was supposed to be 100 TID, got filled as 300 TID) and was corrected immediately upon discovery. Very interestingly the patient denied any side effects and noted some additional efficacy in the 2-3 weeks before the error was caught.
 
I have seen plenty of Seroquel at 2400 or even 3200 mg daily. Same with Thorazine.

Haldol 60 mg per day not unheard of where I trained. When you factor in the decanoate they were also taking, I have seen equivalents to 100 mg per day oral somewhat more often than I would expect.

The thing I find weirdest is when people insist on things like Depakote ER 500 bid or other weird BID dosing or low doses for the 24-hour formulation.
 
aim-agm said:
Venlafaxine 900 mg qD

Granted, this was because of a filling error (was supposed to be 100 TID, got filled as 300 TID) and was corrected immediately upon discovery. Very interestingly the patient denied any side effects and noted some additional efficacy in the 2-3 weeks before the error was caught.
Click to expand...
The genetic testing we have is nearly always useless, meanwhile I would do some fairly dramatic things for a generic test which let us know someone's underlying vulnerability to serotonin syndrome. I've seen true serotonin syndrome from standard dosed SSRIs and meanwhile that patient calmly ingested 3-4x the high end range of venlafaxine for weeks? wow.
 
ObsequiousAplomb said:
I have seen plenty of Seroquel at 2400 or even 3200 mg daily. Same with Thorazine.

Haldol 60 mg per day not unheard of where I trained. When you factor in the decanoate they were also taking, I have seen equivalents to 100 mg per day oral somewhat more often than I would expect.
Click to expand...
You'll see some crazy stuff at state/forensic hospitals. I've never seen quetiapine that high, but co-residents who did moonlighting at our state hospital encountered people on equivalents of 50-60mg of Olanzapine or 80mg of Haldol. I saw a guy in the ED who had previously been on Aristada LAI 1,064mg + Invega LAI 234mg + 6mg daily of Invega PO.

ObsequiousAplomb said:
The thing I find weirdest is when people insist on things like Depakote ER 500 bid or other weird BID dosing or low doses for the 24-hour formulation.
Click to expand...
BID for ER formulations is usually d/t either evidence of a (ultra) rapid metabolizer or symptom exacerbation several hours before daily dose. I've seen plenty of people on BID dosing of ER meds for that reason. It's also not that uncommon to see the opposite where people who are poor metabolizers do fine on very low doses. I saw a lady last month whose trough level for depakote ER 250mg BID was almost 50, and she wasn't a tiny person.
 
Stagg737 said:
You'll see some crazy stuff at state/forensic hospitals. I've never seen quetiapine that high, but co-residents who did moonlighting at our state hospital encountered people on equivalents of 50-60mg of Olanzapine or 80mg of Haldol. I saw a guy in the ED who had previously been on Aristada LAI 1,064mg + Invega LAI 234mg + 6mg daily of Invega PO.


BID for ER formulations is usually d/t either evidence of a (ultra) rapid metabolizer or symptom exacerbation several hours before daily dose. I've seen plenty of people on BID dosing of ER meds for that reason. It's also not that uncommon to see the opposite where people who are poor metabolizers do fine on very low doses. I saw a lady last month whose trough level for depakote ER 250mg BID was almost 50, and she wasn't a tiny person.
Click to expand...
Yeah, I know there are specific use cases for bid of depakote ER. I'm talking about people who exclusively prescribe depakote ER as either 250 or 500 bid. If they get a level ever, it's less than 12 hours after the last ER dose.

Sadly, my high score for Zyprexa is 80 per day (in addition to absurd doses of two other things).
 
TheRightMedication said:
A hot take for ya -

1200 mg of seroquel isn't too much, and here's the spicy part -

There's a more solid rational to treat schizophrenia with 1200 mg than to treat insomnia with 25 or 50 mg.
Click to expand...

Agreed, and this is why I think Psychiatrists should be managing medications like this, and not General Practitioners. You guys have specialised training that GPs don't have. No offense to GPs, my own GP is a deadset legend, but he still doesn't have specialist training in the whole range of psych meds. I might be a bit too hardline on this (as a former patient), but I don't think GPs should be prescribing stuff like Seroquel without a proper psychiatric consult in place. I could be wrong on this, I'm not a healthcare professional so always willing to concede if I have the wrong idea about anything.
 
I had an intake for anxiety sent to me on Adderall 60 BID and 10 TID prn bc they did not improve when Sertraline 25 was added for 2 months
 
Highest I've ever seen was Haloperidol several dozen mg a day plus a 10 mg IM Q hour that was given about once every 1-3 hours.

What happened with this poor person was he suffered a TBI and since then nothing, I mean nothing except Haloperidol reduced the symptoms. Due to impulse he'd try to bash his head into the wall, and I don't mean while sitting down. I'm talking running into a cement wall at full force while running.

Even with the above dosage, which only reduced his symptoms, he was still out of control. Every atypical and mood stabilizer was used. He was sent to the long-term facility where I suspect he'd probably be there the rest of his life.

Only thing that might've helped in hindsight (and I saw this case as a resident) was maybe an ADHD med. I suspect an ADHD med would've reduced the impulsivity but no one was willing to give this guy a stimulant.
 
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