off-label use of meds

Virtually all antipsychotics given to children are 'off label.' The only antipsychotics FDA approved for children are:
Haloperidol: 3 and older
Orap: 12 and older (Tourette's)
Thioridazine: 2 and older

Three off the top of my head in free association fashion:

Topamax: Adjunct to antipsychotic to prevent weight gain or help with weight loss

Gabapentin: Off label use in anxiety and bipolar

Chlorpromazine: Intractable hiccups

Hundreds more...but i need to go play some Oblivion (X-box 360) and do laundry.

 

IV Haldol for delirium. Haldol is not approved for intravenous use, or for the treatment of delirium - but is still the gold standard and used daily in hospitals around the world.

 

Topiramate is a good drug to look up all the random off label use that occurs including for etoh, binge eating, cocaine (that is still in the experimental phase), bipolar/impulse dyscontrol, etc. I don't think its overwhelmingly effective, but it is interesting to learn about and the big reason people like it is the side effect profile of weight loss. in fact, its a drug of abuse for vanity dieting but not recommended for that purpose.

best,
worriedwell

 

also regarding adjuctive depression use, probably the best studied addition to antidepressants in refractory cases is the use of lithium, especially with TCAs.

 

Basically 98% of Neurontin scripts are written for off-label uses.
(Really---have any of you ever actually seen it written for seizures????)

 

Periactin to reduce sexual s/e with SSRIs.

Neurontin, Provigil, Topamax... Guess I must be tired. I'm not coming up with the others, but they're there... Florinef to support BP with TCAs and MAOIs. (<<Anyone here done this?) Inderal for anxiety. Verapamil for anxiety and mood stabilization?

Nope. Need to sleep to remember anything else. (Hell, I can't even spell their names tonight. Cognitive decline of middle age, I guess.)

 

Doxepin (Sinequan) for pruritis and neuro-dermatitis.

 

And IIRC pfizer got in trouble because the neurontin reps were pushing the off-label use. Might be an interesting angle for a paper... that and how they never did the pain studies for FDA approval because it was going generic soon, but got the indications immediately for its successor (lyrica).

 

Ritalin/Dexedrine for depression in the medically ill.

Buprenorphine for depression.

Sodium Amytal (yes, "truth serum") for conversion DO.

 

Have you ever done an amytal interview?
I came very close to doing one myself, but it fell through. Had the meds in hand and everything. I've seen them done, but never did one myself. It's a big project...need anesthesia, O2, etc....

 

Hey Doc, what's the thinking out there about IM Zyprexa for delirium, speaking from the perspective of grandiose Northeastern teaching hospitals with psychosomatic fellowships ?

I've been on call this weekend and have been getting my gluteoids whomped by our consult service for some reason. Guess I'm a bit rusty! Anyhow, had a 90 y/o failure to thrive lady with delirium (age in years>wt in lbs!) and the service was looking for a parenteral antidepressant. She's on remeron already, and I just wondered if 2.5 mg of olanzapine might help.

 

There are at least a few studies claiming efficacy both in open label and head-to-head vs. haldol for delirium in the inpatient setting.

I've used it a few times (IM, Zydis and tab) on the consult service. It seemed to work about as well as other treatments. Of course, it can be quite sedating, so (I don't have to tell you this), be sure that an iatrogenic hypoactive delirium is not mistaken for 'improvement.'

We don't get called for the hypoactive cases. Only the ones that cause the nurses grief.

 

Funny you should ask... just wrote a very grandiose textbook chapter on this.

Our best understanding of the mechanism of delirium is based on the relative susceptibility of various neurons to oxidative stress. It seems that the most susceptible neurons are cholinergic and dopaminergic.
Dopaminergic neurons store dopamine in granules, so damage here leads to release of endogenous dopamine. Cholinergic neurons can produce Ach "on demand", so damage here leads to a deficiency of Ach. Thus, we have the hyperdopaminergic/hypocholinergic hypothesis of delirium. Since Ach mediates attention via the reticular activiating system, we see inattention. Excess dopamine produces hallucinations, and also facilitates glutamate - producing agitation.

Whew! So... the name of the game in treating delirium is enhancing cholinergic activity and blocking dopaminergic activity. In terms of boosting Ach, studies looking at cholinesterase inhibitors have not shown benefit in acute delirium b/c they take so long to reach effective plasma levels, so the best intervention we can make here is minimizing anticholinergic medications. Fortunately, we can block dopamine like nobody's business with neuroleptics, so bring on the IV Haldol.

Now, getting back to your question... Atypicals like zyprexa were developed to minimize EPS (by - among other things - including their own anticholinergic mechanism), and to treat the negative symptoms of schizophrenia (by mixing up the dopamine receptor profile). In delirium, the first can be harmful, and we don't care about the second - so Haldol remains the first choice, by a long shot (basically only if there's a listed Haldol allergy). Would also eliminate any other psychotropic on board (especially an antihistamine like Remeron) as it can only confuse the picture in the treatment of her delirium.

Sorry for the long-windedness, but this is probably my favorite hobby-horse.

 

JCAHO now requires you to be certified for conscious sedation to do it, so until I find an anesthesiologist interested in psychiatry, it's on the back-burner. My fellowship director is still bullsh!t that "the bureaucrats" did this.

 

Seroquel in low doses as prn for anxiety in pts w/hx sub abuse...

 

How about super-low dose remeron for insomnia?

 

What about Zofran for OCD? (Anyone else heard of this?)

 

Effexor: decrease of chronic pain.

Works via the norephinephrine reuptake mechanism.
Cymbalta & Elavil, which are approved for pain (neuropathic pain in the case of cymbalta) work off of the same mechanism. However effexor never got the approval.

There are studies which back up Effexor's use to relieve pain.

Fibromyalgia patients will also benefit from the above meds.

"Seroquel in low doses as prn for anxiety in pts w/hx sub abuse..."

No offense fiatslug, I bring up a professional counter opinion- I would not give Seroquel for this reason. (Forgive any frustration you may detect in the following rant)

Why does Seroquel work as an antianxiety med? Its antihistaminic property.

So then, why give Seroquel (cost: $113.31-$353.85: 25 mg-60 tab supply-$113.31, 100mg 60 tab supply 188.35, 200 mg 60 tab supply 353.85)
---WHEN BENADRYL 50MG 60 TABS COSTS $8.99?

Hmm--2 meds, work off the same mechanism--one is over $100 (in some cases over $350.00) per month, the other, $8.99.

Benadryl is considered a safer med & has an FDA approval for sedation.

Another problem with seroquel---several drug abusers want it for abuse purposes. That's why so many drug abusers "love it". They do not want it for legitimate reasons.

There are some that want it for valid reasons, who happen to be drug abusers. It seems to work well with opioid addicts.

Think about why--how do you treat opioid withdrawal? Well 2 of the well established meds are an antihistamine and an alpha agonist. Seroquel has both an antihistaminic and alpha agonist property. Why then give Seroquel when benadryl & clonidine are available?

If you give seroquel to a drug abuser on an outpatient basis, you are seriously running the risk of providing this person with a med they will use for abuse purposes or will be used to be sold on the street. Seroquel does have a high street value.

Seroquel is not addictive, but when mixed with other meds does potentiate the the level of the "high" and length of duration of the "high". I'd advise you consider giving out seroquel to drug abusers in a highly scrutinized manner if at all.

Forgive this rant--It seems to be the popular thing now for doctors to give out Seroquel as a sleep aid. It does work for that, for the same reason benadryl works. Again--we have the problem of giving a med with a cost that's over 1000% higher than a OTC that does the same thing (benadryl), and is not approved for that purpose, while the OTC is approved.

Several docs are giving seroquel to help their patients sleep. I then see the patient for whatever reason--and tell them they're on an antipsychotic, and they flip out. "WHAT, HE PUT ME ON A DRUG FOR SCHIZOPHRENICS?!?!?!?!?"?.

The patient gets ticked off, and understandably so. The doctor didn't explain to them what the drug is for. Then the patient, who has no DSM dx is now worrying that perhaps they have mental illness when in fact they do not.

Another problem is as with several sleep meds, a sleep tolerance develops. So when this happens, the doctor simply ups the dosage of Seroquel. Fine, (and we won't get into the perils of simply upping the med when its only going to be a short term solution).

The antihistaminic benefit of seroquel tops off at 200mg. BUt the doctor goes above 200mg. So now you got a patient on 600mg of Seroquel just to go to sleep. Its ridiculous. So then I see the patient for whatever reason (e.g. consult), and I'm suspecting that the patient has mental illness (when the patient doesn't) because their idiot outpatient doctor put them on a dose of Seroquel effective for schizophrenia, and for sleep--well it tops off at 200mg, and I'm actually giving the outpatient doctor the benefit of the doubt, hoping this doc actually knows what he's doing (which he doesn't).

So I bring up mental illness to the patient, and the patient blows up at me. I end up calling the doctor, and the doctor doesn't know what the heck he's doing with the seroquel, but since I'm a resident, he won't listen to me.

Part of my post is pure rant...but you get the point?"