Polypharmacy or Good Practice?

[TS1979]

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Hello--I am a med student rotating on psych. My attending and resident seem to have a disagreement on prescribing practices and I was curious what other's opinions are. I was wondering if I could post a few hypothetical cases for your thoughts? Might not have a lot of information, but I was just wondering if this was common or bad...

1. 50 y/o male, diagnosis MDD, Recurrent (seems moderate to mild and unsure if enough symptom criteria was actually met); also DM type 2 on insulin and metformin. Has been seen by psych since 2006 and tried on different SSRIs/Benzos, but current regime is as follows:
-Klonopin 1mg qam and 2mg q 2000
-Trazodone 150mg PO q 2000
-Wellbutrin SR 200mg qam
-Concerta 54mg q am

2. 26 y/o female with diagnosis of Dysthymic Disorder in some notes and Depressive Disorder, NOS in others. Also obese and the psychiatrist is using Topamax for Obesity by itself. Is this something often done?

3. There are a bunch of patients who take regimes similar to this for depression (most young 20s):
-Prozac 10mg
-Wellbutrin 75mg BID
-Adderall XR 10mg daily
-Trazodone 50mg qhs
-Melatonin 3mg

Resident feels this should be simplified and doses maximized, attending feels all receptors should be hit

4. There are also combinations of sleep aids used and FDA doses exceeded...is this done often?

5. Somewhat unrelated, but is there a limit to how much Elivil a patient should be given at once? I asked around a little and no one seemed to give a minimal toxic dose or a threshold of how many tabs/mg should be given per monthly prescription.

Thanks, sorry if this is basic or dumb.

 

[wholeheartedly]

but I was just wondering if this was common or bad...
.

It's worth noting that even if it is common, it doesn't mean it's not bad.

 

[Doctor Bagel]

I agree with your resident. Also, what's up with all the stimulants for depression? Regarding Topamax for weight -- I think that was done but is no longer commonly done (of course I can only speak for my neck of the woods). It does help people lose weight, but it also makes you kinda stupid.

 

[OldPsychDoc]

regimen (plural regimens or regimina)

1. Orderly government; system of order; administration.
2. Any regulation or remedy which is intended to produce beneficial effects by gradual operation.

regime (plural regimes)

1. Mode of rule or management.
2. A form of government, or the government in power (as in a socialist regime).

The former is more correct in typical English in a medical context.
Sorry, I just can't stand it. And don't you DARE call it a "regiment", or I might have a stroke.

 

[birchswing]

regimen (plural regimens or regimina)

1. Orderly government; system of order; administration.
2. Any regulation or remedy which is intended to produce beneficial effects by gradual operation.

regime (plural regimes)

1. Mode of rule or management.
2. A form of government, or the government in power (as in a socialist regime).

The former is more correct in typical English in a medical context.
Sorry, I just can't stand it. And don't you DARE call it a "regiment", or I might have a stroke.

Have you ever studied linguistics? It can cure a person of what ails you.

 

[Shikima]

I agree with your resident. Also, what's up with all the stimulants for depression? Regarding Topamax for weight -- I think that was done but is no longer commonly done (of course I can only speak for my neck of the woods). It does help people lose weight, but it also makes you kinda stupid.

Good 'ol Dopamax. Kinda ranks up there with Buspar in controlling depression/anxiety symptoms.

 

[notdeadyet]

Regarding Topamax for weight -- I think that was done but is no longer commonly done (of course I can only speak for my neck of the woods). It does help people lose weight, but it also makes you kinda stupid.

That's overstated, though. It has a high side effect rate of cognitive dulling, but that rate is still only 15-20%. Again, that's high for a side effect, but it means that for every patient that gets it, 4 do not.

 

[Bartelby]

Points 1, 2, and 3: It's tough to really weigh in without the full clinical story. Taking what you say at face value (that these patients have mild depression and are typically on three antidepressant medications (counting the trazodone for sleep), a stimulant, and other sleep aids) I would tend to agree with your resident. A good starting resource for examining the evidence behind a stepwise approach to antidepressant trials is STAR*D. A typical practice for depression without other comorbidities would be to start one antidepressant chosen based on its side effect profile, increase the dose weighing response and side effects, and give an adequate trial (at least a month, if safe to do so giving two months or more would be ideal especially with partial response). If this is inadequate at that point you might switch to another antidepressant or add one adjunctive treatment such as thyroid hormone, lithium, a second antidepressant such as wellbutrin (or a combo like effexor/remeron), or a second generation antipsychotic. Again you would try to invidualize based on the patient's presentation and side effect profile. Psychotherapy is helpful pretty much anywhere throughout this algorithm.

The catch to all that I have written above is that (1) the person needs to actually take the medications as prescribed for an adequate time period if you want to fairly assess response (which may not have happened in the past) and (2) if the person has already worked through such an algorithm you may be dealing with other issues like substance abuse or personality disorder for which additional treatment including psychotherapy is likely indicated; in some of these scenarios symptom control medications that do not follow an exact algorithm may be helpful on a case by case basis. Obviously stimulants and benzodiazepines should be used with caution because they are addictive, have street value, and can come with their own side effects that may worsen the patient's presentation.

Point 4: I have seen FDA recommendations exceeded. Check the literature and check sources like UpToDate to get a sense of what is common and accepted practice. You should not typically "go it alone" in cooking up untested dosing and regimens but if the literature supports an approach it may still be useful.

Point 5: Think hard about whether you want to give out only enough medication to not be fatal in overdose. Many medications such as tricyclics, MAOIs, lithium, etc can be lethal in overdose. You do need some faith that the individual does not currently intend to overdose on those medications when you prescribe them. However, if you are documenting that the patient is at such high risk that they cannot be safely given enough medication to overdose the question arises whether you are taking other steps to secure their safety which could include inpatient hospitalization, having a family member or visiting nurse administer the medications, more frequent check ins with you or other providers, etc. Patients can still stash their medications and overdose (or kill themselves in a multitude of other ways) and documenting that you are too afraid to give them more than seven days of elavil at a time (for example) without documenting a sound risk assessment and safety plan could potentially come back to bite you in the case of an adverse outcome.

Hopefully the above is helpful, it's nice to see medical students thinking critically about these things!

 

[hamstergang]

Resident feels this should be simplified and doses maximized, attending feels all receptors should be hit

Well, since it seems to me that using multiple medications vs fewer medications costs more money, increases risk of drug interactions, increases risk of having an adverse effect, and increases risk of noncompliance (due to forgetting with a more complicated regimen), I would want this attending to provide some evidence that 'hitting all the receptors' is a more effective strategy so it could at least have a chance to be worthwhile.

 

[Doctor Bagel]

That's overstated, though. It has a high side effect rate of cognitive dulling, but that rate is still only 15-20%. Again, that's high for a side effect, but it means that for every patient that gets it, 4 do not.

Well, one, that's still pretty high, and two, it's a medication of very limited benefit for psychiatric conditions.

More thoughts about stimulants. I've seen a few patients recently who were started on stimulants by other psychiatrists for mood complaints, and man, no one wants to stop those. I'm not sure it's a road I want to go down.

 

[notdeadyet]

Well, one, that's still pretty high, and two, it's a medication of very limited benefit for psychiatric conditions.

I agree, I just think we need to be careful about phrasing. When we say drug x "causes ______," it implies an expectation. Even a high rate of side effect like cognitive dulling with Topamax still only happens to a minority of patients. It's important because if we are not precise, we stereotype and when a drug is needed, patients, PMDs, or other psychiatrists avoid it because we've in accurately characterized it.

 

[whopper]

A problem with making statements on specific patients is that I've seen some patients, however rare, that need to be on a polypharm regimen. In such cases the clinician should document why they put the patient on such a far out and weird list.

I got a patient now on Remeron 15 mg Q HS, Ultram (max dose), Lunesta 3 mg Q HS, Gabapentin 400 mg Q TID for PTSD, OCD, and Panic Disorder and Major Depressive Disorder.

Yes he really has all of those disorders. All SSRIs have been tried and failed. All SNRIs have been tried and failed. Several TCAs have been tried and failed. Cannot tolerate even low dosages of Seroquel without getting bed EPS. All mood stabilizers have been tried and failed. BP meds are off the table because he has POTS syndrome and his other doctors bent-over backwards getting a BP regimen that works for this guy. Only medication class I haven't tried that might have some reason to believe it'll help is MAO-Is, and the problem there is he has extreme difficulty sleeping, and one of the only meds that puts a dent in that problem is Remeron. If we take him off of it, he won't sleep for the weeks of time he'll have to be off of it before an MAO-I could be started.

I've also discussed the case with some of the top people in our field and still have had problems getting him better than I have.

Yeah this guy's a real fluke. MMPI testing already done, several other psychological tests have been done. I'm thinking Deep Brain Stimulation or cingulotomy may be needed but the guy is too scared (understandibly) to get it done.

The only victory I could claim was before he had me, he was literally hospitalized about 8x a year. Since I've been treating him it's been about 2x a year. The last meeting I told him that unless DBS or a cingulotomy was done, I don't know if there was anything else that could be done to get him better other than ECT, though given his disorders, we wouldn't expect it to do much for the OCD/PTSD/Panic Disorder and those are the main things hurting him now.

Point is the regimen he's on now has been the product of about 1.5 years of hit and miss attempts and only keeping him on the stuff that worked, and then trying other things hoping other meds would add to the overall effect while getting rid of meds that didn't work at all.

Bear in mind, however, that of all the patients I've had, less than 5% end up being cases like this. I'd even say less than 2%. When there is polypharmacy, it begs the question if it was necessary, and from my own clinical experience, often times it's not, especially when it doesn't sound like it makes sense from a superficial examination.

 

[michaelrack]

regimen (plural regimens or regimina)

1. Orderly government; system of order; administration.
2. Any regulation or remedy which is intended to produce beneficial effects by gradual operation.

regime (plural regimes)

1. Mode of rule or management.
2. A form of government, or the government in power (as in a socialist regime).

The former is more correct in typical English in a medical context.
Sorry, I just can't stand it. And don't you DARE call it a "regiment", or I might have a stroke.

I hate it when docs use the term "diplomat" instead of the correct "diplomate"

 

[vistaril]

I agree with your resident. Also, what's up with all the stimulants for depression? Regarding Topamax for weight -- I think that was done but is no longer commonly done (of course I can only speak for my neck of the woods). It does help people lose weight, but it also makes you kinda stupid.

Stimulants in the outpt non community mental health world are used a ton by psychiatrists. The criteria for use in most cases seems to be that a pt complains of low energy and wants to be on a stimulant. Most other medical providers(pcps, neurologists, primary care nps and pas) are aware that if they refer their pt to a psychiatrist, especially a private practice psychiatrist, they will wind up on a stimulant. It makes us look very bad as a group.

 

[Doctor Bagel]

Stimulants in the outpt non community mental health world are used a ton by psychiatrists. The criteria for use in most cases seems to be that a pt complains of low energy and wants to be on a stimulant. Most other medical providers(pcps, neurologists, primary care nps and pas) are aware that if they refer their pt to a psychiatrist, especially a private practice psychiatrist, they will wind up on a stimulant. It makes us look very bad as a group.

I've been seeing it more and more recently and find it discouraging. Sure, it's an easy fix, and I'm guessing it makes most people feel better. It also makes our work easier because we wind up with a satisfied patient, although we're probably not giving them the best care. I've also been struck by how easy it is to get an ADHD diagnosis out in the world. I'd have no problem getting a stimulant from some of the providers I've seen in spite of my ability to complete medical school and another graduate program and all my schooling before that without any impairment. I do think I'd be more organized on Vyvanse, though -- maybe I should go get a prescription.

 

[vistaril]

I've been seeing it more and more recently and find it discouraging. Sure, it's an easy fix, and I'm guessing it makes most people feel better. It also makes our work easier because we wind up with a satisfied patient, although we're probably not giving them the best care. I've also been struck by how easy it is to get an ADHD diagnosis out in the world. I'd have no problem getting a stimulant from some of the providers I've seen in spite of my ability to complete medical school and another graduate program and all my schooling before that without any impairment. I do think I'd be more organized on Vyvanse, though -- maybe I should go get a prescription.

well maybe....why wouldn't you?

 

[Doctor Bagel]

well maybe....why wouldn't you?

Then I could get some benzos to counteract some of the anxiety produced by the stimulant.

 

[notdeadyet]

Then I could get some benzos to counteract some of the anxiety produced by the stimulant.

Exactly. You'd sleep better on Ambien. And lose weight better with Topomax. Might have some cognitive dulling there, so bump up the amphetamines. If you get more jittery from that, you can bump up the benzos.

It's interesting seeing the changing trend in willingness to reach for a pill to solve one's problems. It tracks pretty nicely to changes in different generations.

 

[Shikima]

Ah polypharmacy... It's pretty fun taking it all away.

 

[vistaril]

Then I could get some benzos to counteract some of the anxiety produced by the stimulant.

But a lot of 'soft' adhd cases(for whatever that means) don't find stimulants anxiogenic. I don't disagree that the potential is there, but that's not what most patients experience imo.

 

[vistaril]

Ah polypharmacy... It's pretty fun taking it all away.

yes, but that creates a problem for our profession(in individual pt's eyes) as a whole. think about it:

women with irritability, mild dysthymia, low energy frequently and occasional mood swings and emotional reactivity goes to a pcp and is put on Lexapro 10 or 20. It doesn't do much and eventually she is sent to an outpt psychiatrist. Over the next 18 months with two different psychiatrists her med regimen becomes Cymbalta, Lamictal, Vyvance, and Klonopin. Throw in a little Abilify or Seroquel just because if you like. She still has the same issues, and she goes to a new psychiatrist who says "whoa, I don't know what to make of this nonsense". And they feel pretty comfortable that she doesn't have a bipolar spectrum disorder and takes everything away eventually, and eventually restarts................Lexapro(or something very similar).

Think about how the pt experiences that- she's been seeing us for 18 months, has spent thousands of dollars on copays and meds, and is now back on basically the same medication as her pcp started 18 months ago. I'm not saying it's bad to simplify massive polypharm and take stuff away, but when you do you have to think about how the patient may percieve it.

 

[Shikima]

yes, but that creates a problem for our profession(in individual pt's eyes) as a whole. think about it:

women with irritability, mild dysthymia, low energy frequently and occasional mood swings and emotional reactivity goes to a pcp and is put on Lexapro 10 or 20. It doesn't do much and eventually she is sent to an outpt psychiatrist. Over the next 18 months with two different psychiatrists her med regimen becomes Cymbalta, Lamictal, Vyvance, and Klonopin. Throw in a little Abilify or Seroquel just because if you like. She still has the same issues, and she goes to a new psychiatrist who says "whoa, I don't know what to make of this nonsense". And they feel pretty comfortable that she doesn't have a bipolar spectrum disorder and takes everything away eventually, and eventually restarts................Lexapro(or something very similar).

Think about how the pt experiences that- she's been seeing us for 18 months, has spent thousands of dollars on copays and meds, and is now back on basically the same medication as her pcp started 18 months ago. I'm not saying it's bad to simplify massive polypharm and take stuff away, but when you do you have to think about how the patient may percieve it.

First, do no harm.

 

[vistaril]

First, do no harm.

well of course, but(again, looking at things from the patient's perspective) they aren't paying us just to do no harm. Heck she could have gotten 'no harm' for free.

 

[moonshined]

.

 

[Shikima]

well of course, but(again, looking at things from the patient's perspective) they aren't paying us just to do no harm. Heck she could have gotten 'no harm' for free.

Second, provide education and rationale with their consent in the decision making process.

Those that do not agree self-select out of my clinic and find a different person to refill xanax or whatever they want, plenty of those out there to do that.

I choose not to.

 

[vistaril]

Second, provide education and rationale with their consent in the decision making process.

Those that do not agree self-select out of my clinic and find a different person to refill xanax or whatever they want, plenty of those out there to do that.

I choose not to.

yes me to. But it's a lot easier to make a decent salary that way when you have those 'easy' patients. That's not to say all of those patients are easy(some are pure hell and the most demanding of all).