Prescribing Propanolol for anxiety/insomnia with stimulants?

[shahseh22]

I have a teenage patient with a history of ADHD that I'm seeing who was prescribed low dose of Propanolol (20 mg) and Adderall XR 20 mg by his previous provider. He says he is only taking the Propanolol as needed for sleep but I worry about him getting unopposed Beta Blockade blockade if he takes the Adderall and Propanolol together. I know he is on a low dose of Propanolol but I wish to avoid any type of blood pressure fluctuations if possible especially with him taking it as needed. I discussed Clonidine and Tenex but he says they caused dizziness in the past. He doesn't want to try Trazodone or any other medications. He is pretty irritated that I am not willing to continue both the Propanolol and Adderall due to drug interactions so I am only giving him Adderall and Benadryl. Is there any alternative I can offer besides sleep hygiene techniques? I am not keen on trying Seroquel or Mirtazapine (he doesn't really have any depressive symptoms) and his anxiety is very mild.

If we were to continue the Adderall and Propanolol combination, should I obtain an EKG in the absence of any CV complaints? I'm very OCD about not using meds that are FDA approved and venturing into medical meds (Prazosin, Clonidine, Beta blockers etc).

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[wolfvgang22]

I've had a patient on both these meds occasionally. It's never been a problem.
I get an EKG on every patient before I prescribe stimulants for ADHD.

 

[shahseh22]

I've had a patient on both these meds occasionally. It's never been a problem.
I get an EKG on every patient before I prescribe stimulants for ADHD.

I almost never get an EKG before starting a stimulant unless there is a history of structural heart deformity. It is not required.

 

[tr]

How often and when does he take the propranolol? If it's rare/occasional (1x/month or less often, and taken at night, so 12 or so hours after the Adderall) I wouldn't worry about it, although an EKG would be a reasonable and safe precaution.

If he needs it every night to sleep I'd be opposed to that. You could consider a trial of the regular-release Adderall to see if the insomnia is just that the XR is still hanging around at bedtime. After that, CBTi. Personally I don't provide sleeping medication for chronic nightly use at all. Anyone who is on a nightly sleeper is either in an active mood episode with the expectation that they will wean off the sleeper when the mood episode resolves, or in concurrent CBTi while working to wean off the sleeper.

 

[wolfvgang22]

I almost never get an EKG before starting a stimulant unless there is a history of structural heart deformity. It is not required.

True, I do it out of an abundance of caution.
I'm curious, though, why the heck you ask advice about getting an EKG if you know that? It is off putting.
Ciao.

 

[shahseh22]

True, I do it out of an abundance of caution.
I'm curious, though, why the heck you ask advice about getting an EKG if you know that? It is off putting.
Ciao.

Only because he is taking Propanolol and the stimulant.

 

[shahseh22]

How often and when does he take the propranolol? If it's rare/occasional (1x/month or less often, and taken at night, so 12 or so hours after the Adderall) I wouldn't worry about it, although an EKG would be a reasonable and safe precaution.

If he needs it every night to sleep I'd be opposed to that. You could consider a trial of the regular-release Adderall to see if the insomnia is just that the XR is still hanging around at bedtime. After that, CBTi. Personally I don't provide sleeping medication for chronic nightly use at all. Anyone who is on a nightly sleeper is either in an active mood episode with the expectation that they will wean off the sleeper when the mood episode resolves, or in concurrent CBTi while working to wean off the sleeper.

I agree with you. I think he is taking it more than that (like 4-5 times a week). But I did mention the Adderall IR which may be better but did not want to make too many changes at once. I think I will order an EKG next time I see him.

 

[hamstergang]

I worry about him getting unopposed Beta Blockade blockade if he takes the Adderall and Propanolol together.

He's not taking them together, but many hours apart. Even if taken at the same time, is there any evidence (even case reports) of adverse effects from this combination at typical doses?

What would you be looking for with an EKG here?

 

[VA Hopeful Dr]

Have you thought about clonidine? The psychiatrists where I trained used that a good bit for this.

 

[whopper]

I discussed Clonidine and Tenex but he says they caused dizziness in the past.

The Propranolol is a low dose so I wouldn't worry about it too much.

An EKG is not required but not a bad idea to get one.

Something I've seen in several psychiatrists, many of them don't get vital signs, even when prescribing a med known to possibly dramatically increase BP and HR. E.g. I've seen Atomoxetine cause HR to skyrocket within days of use. I've had patients on Venlafaxine with very high BPs and were already started on it before I saw them and I would warn them I had no idea if the Venlafaxine caused the high BP cause they were on it before they saw me from another psychiatrist that didn't take the VS.

I had a police officer patient who had bad ADHD and Methylphenidate worked well on him but while on it his BP went to over HTN crisis levels and he did have crisis sx (e.g. confusion, visual changes) while on it. Despite that I warned him this could happen and if so to stop the med he didn't for over a month. He told me his other police offers played pranks on him all the time and would play some pranks on him even while he was in HTN crisis. I was kind of ticked when I heard that and told him he could've literally had a stroke and he just laughed and didn't seem to care. Oh well. He didn't have a stroke, and didn't seem to care about the risk. I changed his meds.

 

[wolfvgang22]

he just laughed and didn't seem to care. Oh well.

It boggles my mind how many patients are so cavalier. Of course, I believe these same patients are probably the ones who are the first to be litigious if they do experience an ADR with severe consequences.

 

[Eernie]

He's not taking them together, but many hours apart. Even if taken at the same time, is there any evidence (even case reports) of adverse effects from this combination at typical doses?

What would you be looking for with an EKG here?

Exactly: what the heck would you be looking for on EKG here???

 

[whopper]

Exactly: what the heck would you be looking for on EKG here???

I can't answer for the guy who brought this up but I can answer why I'd want an EKG. You want a baseline. You also want to r/o any cardiac problems you might've not known about before the treatment begins.

E.g. a patient might not knowing have cardiomyopathy or other cardiac pathologies they didn't know about. A common USMLE question is that of a kid on his first day of high school sports keels over and dies because of Sudden Death Syndrome. Turned out the kid had cardiomyopathy that was never diagnosed because EKGs aren't required to enter high school sports, but had one been done ahead of time it could've been identified before the death happened.

Of course such a thing is very rare and to the degree where prior EKGs are not required, but IMHO it's not a bad idea to have them especially if the person needs a high dose of a stimulant.

On the adult side I've had patients who didn't exactly take good care of themselves have ADHD. E.g. high cholesterol, smoker, overweight, and they have ADHD. I even had a guy with 3 prior MIs with pretty bad ADHD to the degree where if it wasn't treated he wouldn't be able to work. I told the guy I wouldn't prescribe a stimulant unless his cardiologist and I worked together on his case.

As I mentioned before, don't think that just because you might not give a stimulant you don't have to worry about it. Atomoxetine is 5-10% linked to significant changes in BP and HR and as I've mentioned I've seen that first hand, and has been linked to significant QT prolongation. In fact the first 3 out of 3 times I prescribed it the patients had bad cardiac reactions. I sometimes wonder if Atomoxetine might even be more cardiac-risky than a stimulant.

Also for stimulants and Atomoxetine the safety guidelines are "baseline cardiac eval. in pts w/ risk factors; BP, HR at baseline, after dose incr, then periodically;"

I would hardly say a psychiatrist that just gives out a stimulant without checking VS would be accomplishing the above, but would say someone who got the VS before treatment started, during treatment and got an EKG did follow the above guidelines.

 

[hamstergang]

I can't answer for the guy who brought this up but I can answer why I'd want an EKG. You want a baseline.

This patient is already on meds so we've missed the opportunity for a baseline. What would you be trying to screen for with an EKG in this patient?

 

[watto]

Any sense that he has delayed circadian phase? Google the Auto-MEQ from the Center for Environmental Therapeutics and see how he scores. So many ADHD teens are working with a delayed circadian rhythm + stimulant that you may need to consider alternative methods for phase shifting (dark / light exposure, melatonin, meal timing, prolonged wind down at hs).

 

[whopper]

This patient is already on meds so we've missed the opportunity for a baseline.

If it's a stimulant than you likely already know they can skip the med 1-2 days then get an EKG. Stimulants unlike many other psych meds don't have to be taken daily unless the ADHD just happens to be so so so so bad they're dangerous without them. That's not written with sarcasm. I've seen cases like this although it's very rare.

 

[dassie]

What time is he taking the stimulant in the morning? Could he move it up to first thing in the morning? Or you could switch to methylphenidate SR/ER.

 

[Ironspy]

I don’t see kids but to me stimulant+propranolol >>>>>stimulant+benzo

 

[birchswing]

I don’t see kids but to me stimulant+propranolol >>>>>stimulant+benzo

The issue in this case is the unopposed alpha stimulation.

Even the small amounts of epinephrine in a dental anesthetic can cause a person on a non-selective beta blocker to experience paroxsymal hypertension, which is why they are contraindicated in certain patients. EMTs don't treat caffeine overdose with beta blockers (you can carefully in a hospital setting though), and you would never treat a cocaine overdose with just a beta blocker, so it makes sense to be cautious about combining an ADHD drug with a non-selective beta blocker.