Pharmacological dilemma

[Piaget]

Advertisement - Members don't see this ad

I saw a new patient in outpatient clinic yesterday because his previous psychiatrist retired. patient was diagnosed with generalized anxiety disorder and his current treatment regimen is as following :-

Venlafaxine extended release 300 mg in the morning and 150 mg at bedtime - has been on this since 1986
Proxetine 30 mg 3 times a day ( total 90 mg ) - has been on this since one year
Doxepin 50 mg 3 times a day ( total of 150 mg daily ) -has been on this for more than a year
Mirtazapine 30 mg 3 times a day ( total of 90 mg daily ) - has been on this since 5 years

Patient reports improvement in his anxiety symptoms ( not complete remission ) but expects me to continue his current medications 😕

I am still trying to figure out the rational for the above-mentioned pharmacological management of this patient especially the bizarre dosing ???


What would you do in such situations when you get this kind of new patient ?

 

[nitemagi]

Um, question the veracity and accuracy -- Venlafaxine wasn't on the market in 1986.

http://en.wikipedia.org/wiki/Venlafaxine

After that make the argument that the reason he's having problems is he's on too much.

 

[whopper]

First off, I've seen plenty of (idiot) doctors prescribe like the above. The fact that this patient may have been on this regimen may have been the creation of a doctor who doesn't understand the concepts of psychopharm well.

(In fact one of the doctors rated one of the best in the area by a local magazine prescribes like this, and most of her patients and colleagues think she's terrible, so WTF she got this honor....who knows?)

A doctor should always document why they are doing what they are doing, and what benefits and problems the patient is experiencing with a medication. Unfortunately, it's been my experience that several do not. In fact, at one location I work at, less than 50% of the psychiatrists do this. They usually write down something to the effect of...

"Patient seen. Psychotic. Will continue current medication"
(With no explanantion what the medicaiton was at the time).

What to do? Try to get the old records. Ask the patient, if they can remember, what benefit each medication had. Try to see if there was any merit with this medication regimen. It's rare but sometimes a patient can only get success with some type of polypharmacy regimen that seems it's from Hell, but if that's the case, the doctor should've documented, but like I said, many do not.

I'd explain to the patient the dangers of polypharmacy, and that in general, if we use psychotropics, we should try to shoot for the least amount needed. Mix in that the dosages are way over the manufacturer's recommended dosage. I would not continue the meds mentioned above the manufacturer's recommended dosage unless the person was extremely overweight.

Also try to figure out why the patient is having these problems despite polypharmacy. It could be bona-fide treatment resistance. It could also be misdiagnosis (maybe it's ADHD?), an Axis II DO, a medical problem causing psychiatric problems (e.g. a thyroid problem).

I would definitely try to get the patient on less medication, but try to figure out what's going on for real before you go in a specific direction.

I've been in your situation several times. The doctor I mentioned who was rated a top local doctor stopped taking Anthem, and now I got a bunch of her patients. All of them were on polypharmacy, there's poor documentation, and after I get the patient on a simpler regimen, they usually actually feel better. They told me this doctor never really actually talked to them. They'd step into her office, she's listen for literally 30 seconds, and then wrote them a script.

When you hear it from one patient, that's one thing. When you've heard it from over 20, those 20 don't know each other, and they all say the same thing, theyr'e all on some crazy polypharm regimen, I think there's most likely something foul going on with that doctor.

 

[Chimed]

Yeah, that's a pretty strange combo. The only way this dosing would make any remote sense is if your patient is 4 years old with a super fast metabolism (I'm pointing toward the tid dosing here). Otherwise, I would just explain something like "I have good news, you can get the same benefit from taking some of the medications once a day!" There have been many days when I've had patients coming in on funky medication polypharm from other docs where I had to give my frontal lobe an extreme workout.

 

[Chimed]

I've been in your situation several times. The doctor I mentioned who was rated a top local doctor stopped taking Anthem, and now I got a bunch of her patients. All of them were on polypharmacy, there's poor documentation, and after I get the patient on a simpler regimen, they usually actually feel better. They told me this doctor never really actually talked to them. They'd step into her office, she's listen for literally 30 seconds, and then wrote them a script.

When you hear it from one patient, that's one thing. When you've heard it from over 20, those 20 don't know each other, and they all say the same thing, theyr'e all on some crazy polypharm regimen, I think there's most likely something foul going on with that doctor.

Maybe there is a placebo effect for the patient as the doctor was constantly "tinkering" to make things "just right" for that patient? The more you "do something" the happier the patient? Or....The patients were narc seeking and the doctor just wrote a script without asking too many questions?

 

[billypilgrim37]

Start tapering something (pick whatever - Effexor seems like a good place to start) and watch your pt leave to find some other incompetent "psychopharmacologist" who will give him what he wants. There are plenty of other patients who will happy to work with you to formulate a non-ridiculous treatment plan.

Or you could just add Seroquel 😀

 

[OldPsychDoc]

Start tapering something (pick whatever - Effexor seems like a good place to start) and watch your pt leave to find some other incompetent "psychopharmacologist" who will give him what he wants. There are plenty of other patients who will happy to work with you to formulate a non-ridiculous treatment plan.

Or you could just add Seroquel 😀

Homer Simpson, MD: "To Seroquel--the cause of, and solution to, all of life's little problems."

 

[kugel]

A) As already stated, get the records from the clinic. Don't just try - this is essential for you to safely treat the patient.

B) Get the records from the pharmacy. This will tell you what the patient actually picked up - not just what was prescribed. And it may reveal other things prescribed that the pt didn't disclose.

C) Collateral information. Make appts to have key people come in to provide you with additional information. If key people who might have historical information are out of the area, get contact numbers.

D) Coordination with PCP. Get consents to trade information back and forth - and DO it. Including basic labs, TSH, pregnancy, and discussion about birth control.

E) Drug testing. It's part of your diagnostic information. "I'll be asking you for drug screens at various appts. You'd be astounded at how many people use illicit drugs to change their brain chemistry at the same time they're asking me to do it - and you can imagine how rarely that works out."

F) As already stated, make a goal (e.g. "as few medications as possible") and a plan for how to get there in a reasonable time (e.g. "three years") by beginning to taper one after another.

G) THERAPY
Again, don't just try. You can make this a contingency of continued treatment. Get consents to trade information and DO IT - regularly.

 

[Piaget]

Thank you all for great inputs !!

This is what I did
- Did lot of psychoeducation
- Getting prior records
- Getting TSH ( to rule out overlap of sxs )
- Considering that he had risks for metabolic syndrome , I picked up mirtazapine and have started tapering gradually. Furthermore streamlined his dosing schedule and recommended him HS dosing for mirtazapine .
This guy is a driver , I wonder how he was able to do his job with taking daytime dose all these sedating medications ...

Good thing is that he is willing to work with me ( to clean this mess )
Seriously, his previous provider surprised me 😕

I didnt even think about effexor availability year huh

Anyways guys thanks for nice comments

 

[firedoor]

Worth mentioning: Paxil is a strong 2D6 inhibitor and Doxepin is primarily metabolized via 2D6. Hence, concomitant use of these drugs creates a risk of TCA toxicity.

 

[whopper]

Yes, of course check for interactions with other meds!

Maybe there is a placebo effect for the patient as the doctor was constantly "tinkering" to make things "just right" for that patient? The more you "do something" the happier the patient? Or....The patients were narc seeking and the doctor just wrote a script without asking too many questions?

They weren't when I got them. In fact many of them told me they told this doc they felt they were overmedicated but she did nothing to reduce their meds, including a lady i just saw two weeks ago put on Xanax 8 mg a day for several months. She told me she told the doc she felt drunk all the time and felt it wasn't safe. She eventually got another doctor who weaned her off the Xanax but said she felt permanently worse off the Xanax than she ever was even before it.

Believe me this "best doctor" rating is not some type of academic thing. Most of the doctors I know in the area that are highly ranked for a real reason (e.g. they advanced the field) who know of this doc tell me they don't think she's much of a doctor at all.