Medication Regimen

[Keesee78]

Need some advice. I have this new patient with an interesting medication regimen. This patient takes Effexor Xr (75 mgs), Lamictal (75 mgs), Klonopin (1-2 mgs daily prn), Propranolol (10 mgs prn for anxiety attacks). Had Dx of GAD, MDD, ADD.
The patient has a rather large history of switching up antidepressants. After looking at patient files, Pt's been on every SSRI, and SRNI. Has anyone seen a patient that could possibly have some form of OCD and obsess about the antidepressants? Pt emailed me and asked if we could try Prozac, however I see in my records pt was already on it at one point, but only a week. Should I just prescribe it and d/c Effexor? Pt asked me to fax it. So, if you were in my shoes, would you prescribe it? Would you fax it in? I also read somewhere that Prozac interferes with Adderall XR. Literature I've came upon explains that Prozac and Paxil significantly block the pathway for the metabolism of Adderall and all of the amphetamine products. So, in theory, would that even work?

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[heysexylady]

Need some advice. I have this new patient with an interesting medication regimen. This patient takes Effexor Xr (75 mgs), Lamictal (75 mgs), Klonopin (1-2 mgs daily prn), Propranolol (10 mgs prn for anxiety attacks). Had Dx of GAD, MDD, ADD.
The patient has a rather large history of switching up antidepressants. After looking at patient files, Pt's been on every SSRI, and SRNI. Has anyone seen a patient that could possibly have some form of OCD and obsess about the antidepressants? Pt emailed me and asked if we could try Prozac, however I see in my records pt was already on it at one point, but only a week. Should I just prescribe it and d/c Effexor? Pt asked me to fax it. So, if you were in my shoes, would you prescribe it? Would you fax it in? I also read somewhere that Prozac interferes with Adderall XR. Literature I've came upon explains that Prozac and Paxil significantly block the pathway for the metabolism of Adderall and all of the amphetamine products. So, in theory, would that even work?

What is his current symptoms that would make you consider switching? How long has he been in good current regimen and is he having any side effects? Why does he all of a sudden want to change it and has he tried any type of therapy consistentl.?

I really wouldn't change it and just try to optimize his current regimen. Sit down and explain to him that it takes a while for Ned's to kick in and that he needs to give this current regimen a try if he isn't haven't any intolerable side effects. If he hasn't had any therapy... Recommended cbt or something but playing musical chair with his meds will cause more harm than Good long term. If he is resistant, he is always free to get a second opinion.

 

[st2205]

Who is providing supervision for you and what has their response been?

 

[Jules A]

"interesting medication regimen" is a generous description. I'm unclear, are they on Adderall also? Does their medical record indicate trials and doses? I prefer not to allow patients to grab the reins and change meds willy nilly because sans a true adverse reaction or acute danger in which case hospitalization would probably be the best course of action it doesn't make sense not to require a decent trial. If they truly have tried and failed SSRIs and SNRIs without SUD or personality disorder I'd also consider r/o Bipad.

I tend to do nothing via phone, email etc. except in the rare case that we clearly discussed it as a possibility during the face to face assessment. Neither the Effexor or Lamictal is maximized which would be where I would probably head first before I started reducing with a plan to likely d/c the benzo.

 

[hamstergang]

Anyone else feel that this reads more like it's coming from a patient than a psychiatrist?

 

[NickNaylor]

Anyone else feel that this reads more like it's coming from a patient than a psychiatrist?

This was my thought as well - just the way the post is written is somewhat odd and comes across as coming from someone with limited clinical training.

My other thought is that this regimen is one antipsychotic away from the borderline PD psychopharm special with multiple agents from various classes all at minimal doses. "Medications just don't work for me!"

 

[Liquid8]

The medication regime isn’t that interesting.

Effexor and Lamictal are at relatively low doses for treating depression, so a change to an alternative would only be justified if the patient was not tolerating the current regime or there was evidence that they coming down from a higher dose that was ineffective.

As this patient has previously tried and stopped Prozac, you should explore with the patient why this happened before making a decision as to whether this is appropriate to retrial.

As a rule of thumb, if you aren't able to justify an action like stopping or starting a medication then you should be questioning yourself whether this is a necessary action to take, and be prepared to have that discussion with the patient.

 

[Jules A]

Pt's been on every SSRI, and SRNI. Has anyone seen a patient that could possibly have some form of OCD and obsess about the antidepressants?

Anyone else feel that this reads more like it's coming from a patient than a psychiatrist?

Yeah. I was seriously hoping not a NP.

 

[thoffen]

What clinician doesn't have ample experience with patients who have been on such rapidly switching polypharmacy? But I guess there are plenty who still think the problem is that they haven't found the right combo of meds for the patient.