Rant about Seroquel

[whopper]

I posted this in another thread, but I think its worth its own.

I've noticed several doctors giving out Seroquel for non FDA approved uses. That in and of itself it not worrisome to me. There are several meds that are not FDA approved that are standard of care concerning specific uses and have plentiful data to back up a non FDA approved use.

But here's where I get ticked off with Seroquel usage.----

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?"
Seroquel--no reason to give it as an antihistamine, Benadryl costs less than 10% of the amount.
No reason to give it as an alpha agonist --give clonidine
Consider not giving it to drug abusers.

I would though give Seroquel to a patient with bipolar mania, schizophrenia or schizoaffective, where the antihistaminic property and the alpha agonism did fit their profile---e.g. a schizophrenic with several allergies who needs to gain weight, or a bipolar manic patient who needed to gain weight.

---

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[Anasazi23]

I posted this in another thread, but I think its worth its own.

I've noticed several doctors giving out Seroquel for non FDA approved uses. That in and of itself it not worrisome to me. There are several meds that are not FDA approved that are standard of care concerning specific uses and have plentiful data to back up a non FDA approved use.

[clip........]

You sound like me ranting in the hospital. That's probably a bad thing.

I agree with you for the most part, though remember that some psychiatrists see severe anxiety (not drug abusers) on a thought disorder spectrum that could straddle a psychotic spectrum disorder. I know that you're not really referring to these patients.

I try hard to prevent myself from giving into the constant stream of drug-abusers asking for Seroquel. I feel your pain.

 

[OldPsychDoc]

Basically, I'm guilty of this crime, but hear me out on a couple of things. (BTW--I'm a major proponent of using the cheaper med where possible! The Forest rep HATES me because I never start anyone on Lexapro.)

1) As Sazi said, I see severe, "racing thoughts" anxiety as kind of on a continuum with psychosis. My clinical experience is that benedryl, vistaril, trazodone and the like just don't cut it the way quetiapine does.

2) Seroquel snorting and potentiation hasn't quite caught on here the way it has in Sazi's hometown, so I really don't buy the diversion issue right now. I deal with a lot of addicted folks. My #1 problem is meth--folks who can't sit still, can't sleep, can't turn off their brains b/c of all of the DA receptor sensitization (assuming they still have a couple of functioning cells left in their basal ganglia). That's where I find quetiapine most helpful.

3) I always tell the patient "I'm prescribing an antipsychotic medication. This does not mean I think you are psychotic." I'm sorry that you run into patients who haven't gotten good education from their MDs before they reach you.

 

[Anasazi23]

I again saw this phenomena this morning in rounds. Seroquel was prescribed by one of our MD/Ph.Ds no less (PhD in pharmacology) to a drug addict.

I think what we didn't mention, that at least plagues us to a large degree, is that these people are complaining of psychotic symptoms (as bogus as they often are). In order to get paid by the hospital/insurance, etc, one must prescribe a medication that treats (presumably) the presenting complaint. I think many attendings see seroquel as a relatively benign psychotropic, dose it in subtherapeutic doses (<400mg) to provide a sort of mini-high/sedating effect, while having on paper that they are treating the "voices."

 

[whopper]

Ok....

Thanks for reading my long post and not holding the negative tone against me. Yeah it was a rant. Yes I could've written it down in a more objective manner.

Anasazi--thanks for the empathic response. I sound like you in the hospital? Ouch! 🙂

Oldpsychedoc--no need to apologize to me. I'm sure I haven't gotten any of your patients, and you didn't do anything wrong (At least as far as I know! 😉 )
I'm not against Seroquel. I'm against it being used inappropriately. When there's $10 for benadryl and $300 for Seroquel--just to go to sleep (and nothing else), and they work by the same mechanism-with no FDA approval for Seroquel for sleep--it really ticks me off, and it seems like most the docs in my parts are doing it.

We're our own enemy when it comes to medical waste.

 

[Anuwolf]

Whooper, benadryl doesn't work for everyone, It certainly don't help me.. If I take too much of benadryl it dries me out. I admit of not being overly of a big fan of Seroquel because It's waaaaaaaaaaaay tooo strong for me and that I feel that the psychiatrist that gave me this gave me it for all of the wrong reasons, which is what you're complaining about.

 

[worriedwell]

great post...agree about big pharma jamming down doctors throats that seroquel is good for xyz, then we all prescribe these meds that cost hundreds further feeding the pharma mafia when some other meds work just as well.

couple thoughts though...

1. I believe in the literature, Benadryl starts to become less and less effective after prolonged use for insomnia...something like after about 10 days of use.

2. While in vitro, Seroquel is strongly antihistamine at low doses, its hard to fully extrapolate in vivo what is going on and to compare doses of seroquel and benadryl. I think clinically it is apparent that seroquel is a "stronger" sleeping pill.

3. The more I read and see patients, the more I believe that in 20 years everybody will be ripping all these "atypicals" whatever that phrase even means, to shreds based on their side effect profile which is a devastating long term public health concern in terms of metabolic syndrome side effects.

4. Drug addicts are just an entirely different breed than other "pure psych" patients, and we have such a paradoxical way of treating them that defeats the purpose half the time (being dual diagnosed). On one hand the most effective treatment is AA/NA abstinence and directed therapy, but then in the next breath we are giving them all these drugs that have the potential for abuse or even regardless of that, the philosophy is that they need to take this substance to get well. It is a mess.

 

[whopper]

great post...agree about big pharma jamming down doctors throats that seroquel is good for xyz, then we all prescribe these meds that cost hundreds further feeding the pharma mafia when some other meds work just as well.

couple thoughts though...

1. I believe in the literature, Benadryl starts to become less and less effective after prolonged use for insomnia...something like after about 10 days of use.
As I mentioned in my first post, some docs don't know that sleep tolerance occurs, and when their patient mentions that Seroquel was working great--but it later stopped (due to sleep tolerance), the doc just ups the med. They eventually pass the 200mg mark--and that's where the antihistamine value plateaus. Then the idiot doctor just keeps on upping it more and more and more and more....

2. While in vitro, Seroquel is strongly antihistamine at low doses, its hard to fully extrapolate in vivo what is going on and to compare doses of seroquel and benadryl. I think clinically it is apparent that seroquel is a "stronger" sleeping pill.

3. The more I read and see patients, the more I believe that in 20 years everybody will be ripping all these "atypicals" whatever that phrase even means, to shreds based on their side effect profile which is a devastating long term public health concern in terms of metabolic syndrome side effects.

4. Drug addicts are just an entirely different breed than other "pure psych" patients, and we have such a paradoxical way of treating them that defeats the purpose half the time (being dual diagnosed). On one hand the most effective treatment is AA/NA abstinence and directed therapy, but then in the next breath we are giving them all these drugs that have the potential for abuse or even regardless of that, the philosophy is that they need to take this substance to get well. It is a mess.

1) yes--this is the dreaded sleep tolerance that happens with most medications that help with sleep. (A selling point for some of the newer sleep meds which claim to avoid sleep tolerance)

2) This is true--however studies indicate its antihistaminic effect tops off at 200mg. Also throw in that some people will respond perhaps better to it than benadryl in terms of the antihistaminic effect. Still the botttom line I argue still applies. $8.99 vs over $300?

3) well atypicals, as bad (or good) as they are are pretty much the best we got for psychosis. It still though ticks me off about Seroquel just being out like its candy---$300 candy, and the state & insurance companies shelve out the money, and everyone complains about why medical bills are so high.

4) Don't agree with this statement. Let me clarify. The following is not really generally known information although it is widely documented and in fact even tested on quite frequently on PRITE exams.
Antihistamines, when mixed with opioids (and arguably other drugs, but opioids are the ones well documented) enhance the high & duration of the high.

For this reason, some opioid abusers mix their drug of abuse with an antihistamine.

Several drug abusers don't know its really an antihistamine that does it. They just know that Seroquel does it, not knowing its an antihistamine. That's why Seroquel has a street value. IMHO this occured because of the high number of drug abusers with a dual dx. Also, and if you hang out with drug abusers who were your friends in high school--they'll try anything. You give them prozac--you'll find some pothead type who crushed it up and snorted it just to see what happened.

Drug abusers when given any med are very quick to memorize and narcotic benefit that med may give.

There is no FDA indication for treating drug abusers with Seroquel. There is no reason as far as I know to give it to a drug abuser as a treatment for drug abuse or dependence.

Further, if the patient has a dual dx: e.g. opioid dependence and psychosis (especially if they are repeat relapsers with drug dependence) there are several other meds to choose from---risperdal, geodon, zyprexa, abilify, with more on the way just a few months from now. Why give Seroquel as a first line given that several use it for abuse purposes?

A very small dose--something as little as 25mg has strong antihistaminic effect. Imagine giving a drug abusing pt a 600 mg (the manufacturer's reccomended dosage) PO QD? Wow---that's 24 sales right there a day the patient can shell out on the street.

Given the culture of the area where I live--all the patients know about Seroquel's abuse potential. The patients from the Rescue mission who are frequent flyers talk to each other about it all the time. They give each other lessons on it.

This makes Seroquel's value as a true treatment very little. You got patients who don't want to abuse drugs--going back to the mission getting their Seroquel stolen, you got ones wanting to do the right thing but the prospect of being able to sell it for needed money hangs over their heads.

I don't know how much this street knowledge has permeated the country--but I can tell you this knowledge as far as I know is prevalent in the drug abusing communities in Atlantic City, Camden & Philadelphia.

I will give a medication to a drug abuser if I believe it will help them gain control of their drug problem. E.g. Campral for alcoholics, Wellbutrin for cocaine abusers, there is data to support a theory that mood stabilizers may also help to reduce drug abuse, but more study IMHO needs to be done in that area.

 

[Anasazi23]

Good points.

Seroquel is underdosed nationwide. CATIE showed this clearly. I think the reason for this was that the manufacturer had the initial starting dosing too low (commonly happens i.e. Abilify, Geodon, Risperdal, Zyprexa).

I didn't have much faith in Seroquel in an inpatient setting until I attended the conferences and started pushing the doses much higher. Now I use it quite often (daily) and find that, paradoxical as it may seem, it is protective against dystonia and akathesia, like the literature asserts.

I agree that these bull&^%$ dosages of 100mg BID to drug addicts does nothing but put out a stronger street value.

I had a "catatonic" dual diagnoser in telemetry the other day who wouldn't talk at all....except when I told him I was walking out and if he had a preference for a medication, he'd better tell me. The poor soul managed to squeek out the words (Seroquel and Xanax) before I hit the door.
🙄

 

[Hurricane]

1) yes--this is the dreaded sleep tolerance that happens with most medications that help with sleep. (A selling point for some of the newer sleep meds which claim to avoid sleep tolerance)

Doesn't prolonged benadryl use mess with sleep architecture as well? I went to a Seroquel dinner (yeah, I'm a sucker for a good meal) and the speaker said there was a recent poster that showed normal polysomnograms when Seroquel was used at the lower doses purely as a sleep aid, but of course it had a very small n.

 

[whopper]

Doesn't prolonged benadryl use mess with sleep architecture as well? I went to a Seroquel dinner (yeah, I'm a sucker for a good meal) and the speaker said there was a recent poster that showed normal polysomnograms when Seroquel was used at the lower doses purely as a sleep aid, but of course it had a very small n.

benadryl does mess up sleep architecture.

"speaker said there was a recent poster that showed normal polysomnograms when Seroquel was used at the lower doses purely as a sleep aid, but of course it had a very small n."

Well this is somewhat questionable practice to cite this at a dinner since its supposedly policy (at least in NJ) that drug reps and those they pay to speak cannot advocate nonFDA prescribed uses for meds. Yeah we know it happens a lot anyways.

But to answer your question, I don't know if Seroquel does interfere with sleep architecture. I would assume it does,though assumption is nonscientific practure. However this is based on the fact that Seroquel's primary activity is as an antihistamine, and therefore--it should work in a parallel manner to benadryl.

Also, take into consideration that the medication's sedative effects--when taken for some time diminish. In fact the company's reps say to tell this to patients who complain of drowsiness 2ndary to Seroquel.

I can say from personal experience that I've seen several patients on Seroquel develop sleep tolerance to it--which is why the dosage was upped by their primary care doctor.

I actually did a pubmed search to see what it would yield on the manner, but didn't find much. I don't like giving anecdotal data concerning medical treatment. I like to stick to studies, but I can't find any relevant ones online concerning Seroquel and sleep architecture.

Unfortunately, since I'm doing outpatient now, I won't be at the Cooper University Hospital mega medical library to check it out in further detail for at least another 5 days.

 

[Hurricane]

Well this is somewhat questionable practice to cite this at a dinner since its supposedly policy (at least in NJ) that drug reps and those they pay to speak cannot advocate nonFDA prescribed uses for meds. Yeah we know it happens a lot anyways.

Well, he was directly asked...

 

[nortomaso]

Whooper, benadryl doesn't work for everyone, It certainly don't help me.. If I take too much of benadryl it dries me out. I admit of not being overly of a big fan of Seroquel because It's waaaaaaaaaaaay tooo strong for me and that I feel that the psychiatrist that gave me this gave me it for all of the wrong reasons, which is what you're complaining about.

Anyone know how benadryl, seroquel, vistaril differ in terms of their respective anticholinergic actions?

 

[PopoZao]

If you read in Kaplan and Saddok they discuss vistaril and benadryl and the onset of action. The vistaril has a quicker onset than benadryl and this apparently helps to increase the high on opiods. If you've ever seen chronic pain patients you know they love their vistaril.

 

[chagall]

Bringing a thread back from the dead...

This is probably just a variant of one of the questions already asked...but would you (anyone) consider Seroquel for severe nighttime agitation/anxiety in an otherwise depressed patient? No obvious psychotic symptoms otherwise.

Thanks!

 

[OldPsychDoc]

Bringing a thread back from the dead...

This is probably just a variant of one of the questions already asked...but would you (anyone) consider Seroquel for severe nighttime agitation/anxiety in an otherwise depressed patient? No obvious psychotic symptoms otherwise.

Thanks!

Absolutely.

 

[michaelrack]

I agree that much of the sleep-promoting effect of quetiapine comes from its antihistaminergic activity, but one shouldn't discount the effect of alpha-1 and 5HT-2 blockage. I don't prescribe it for primary/psychophysiological insomnia, but have found it quite useful for insomnia associated with MDD or bipolar disorder. In these cases, I will typically use it at a doseage of 25-300 mg qhs. There is a fair amount of research supporting the use of seroquel for insomnia associated with various psychiatric illnesses:

http://www.ncbi.nlm.nih.gov/pubmed/...ez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSum

I do have one patient with opioid dependence/bipolar disorder on both seroquel and suboxone.

 

[Solideliquid]

Absolutely.

Even if you aren't treating a psychotic depression? Wouldn't a BZ be more appropriate?

In other words, what would be your answer in court when asked what psychotic illness you were treating with quetiapine when the patient comes at you with new onset diabetes/hyperlipidemia/etc (purely hypothetical, btw)?

 

[michaelrack]

In other words, what would be your answer in court when asked what psychotic illness you were treating with quetiapine when the patient comes at you with new onset diabetes/hyperlipidemia/etc (purely hypothetical, btw)?

It would be important to demonstrate to the court that you had been following standard guidelines for monitoring for metabolic side effects, and that you had informed the patient of the risks involved. If I was involved in such a lawsuit, I would present the research evidence that atypical antipsychotics are effective agents in bipolar disorder, and effective augmenting agents in unipolar depression. I would emphasize to the court that I was using Seroquel for both its mood and sleep effects.

Most of the atypicals have indications for bipolar, and abilify just got an indication as an augmenting agent in MDD.

If you were using an atypical for insomnia associated with a pure anxiety disorder, you would be on more shaky legal/clinical grounds, but I think you could still prevail in court.

 

[MBK2003]

This is probably just a variant of one of the questions already asked...but would you (anyone) consider Seroquel for severe nighttime agitation/anxiety in an otherwise depressed patient? No obvious psychotic symptoms otherwise.

Maybe, but not first line. I've had good luck with Remeron, Clonidine, or Ativan for these symptoms, which I've then been able to wean off once the depression was improved.

Seroquel is a big hammer that nonspecifically improves many symptoms, but outside of a psychotic or bipolar disorder it often doesn't target the underlying etiology. Case example: I had an adolescent with Asperger's and severe separation & social anxiety, who under the stress of returning to school was so anxious he looked thought disordered (not a far cry from his usual Asperger's thought process). Started on Seroquel by another clinician and yes, he was able to sleep and he was less anxious overall (or sedated), but still bizarre, tangential thought process. I switched him to low dose fluoxetine after parents stopped the Seroquel and 2 months later he's a new kid, looking forward to school, sleeping, making friends, and no more bizarre perseverations. I hesitate to use Seroquel to target non-psychotic anxiety sxs, because I don't think I am hitting the underlying process.

Just my two cents.

 

[whopper]

but have found it quite useful for insomnia associated with MDD or bipolar disorder.

It should be useful for bipolar--think about it. If a person has insomnia, it could be from the manic, or depressive component. Both of which are effectively treated by Seroquel.

As for MDD, I'd be on the fence on that one. MDD often presents with decreased sleep. Seroquel does help sleep, but I question the use on that area (already wrote why above).

 

[michaelrack]

As for MDD, I'd be on the fence on that one. MDD often presents with decreased sleep. Seroquel does help sleep, but I question the use on that area (already wrote why above).

I agree that Seroquel should not be a first line agent for MDD-associated insomnia; I would consider it a 3rd line agent.
There is some limited research that it is useful for MDD:
http://www.ncbi.nlm.nih.gov/pubmed/...ez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSum

http://www.ncbi.nlm.nih.gov/pubmed/...ez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSum

It looks like there soon will be some info on quetiapine and sleep architecture:

J Clin Psychopharmacol. 2007 Dec;27(6):703-5. Links
Sleep quality and architecture in quetiapine, risperidone, or never-treated schizophrenia patients.

Keshavan MS, Prasad KM, Montrose DM, Miewald JM, Kupfer DJ.

 

[chagall]

Thanks for the opinions. I guess if there is a question that these agitated/anxious episodes may be more related to a bipolar type II than to a pure unipolar depression, Seroquel might make more sense.

 

[whopper]

It looks like there soon will be some info on quetiapine and sleep architecture:

Thanks for the info. I would not have known what you wrote had you not mentioned it. Depending on the upcoming data, should it provide evidence to support possible superiority of Seroquel over Benadryl for sleep --> I would be open to giving out Seroquel for that reason. Until then.....(don't want to repeat myself).

Thanks Mike!

 

[hippiedoc13]

The following is not really generally known information although it is widely documented and in fact even tested on quite frequently on PRITE exams.
Antihistamines, when mixed with opioids (and arguably other drugs, but opioids are the ones well documented) enhance the high & duration of the high.

For this reason, some opioid abusers mix their drug of abuse with an antihistamine.

Several drug abusers don't know its really an antihistamine that does it. They just know that Seroquel does it, not knowing its an antihistamine. That's why Seroquel has a street value. IMHO this occured because of the high number of drug abusers with a dual dx. Also, and if you hang out with drug abusers who were your friends in high school--they'll try anything. You give them prozac--you'll find some pothead type who crushed it up and snorted it just to see what happened.

Bringing an old thread back to life.

Whopper, can you point me toward where these facts are well-documented, specifically the one about antihistamines enhancing an opioid high? A very similar discussion about Seroquel came up recently in during one of our didactic sessions and the antihistamine/opiate thing was raised, but it was news to most of the residents and to the faculty member giving the lecture. I have been looking for evidence to back me up, but haven't found anything to specifically support this in the literature. Would love it if you know of some references. thanks.

 

[hippiedoc13]

Ack, never mind that last post. Should have scoured my Kaplan & Sadock more carefully before giving up:

"The coadministration of antihistamines and opioids can increase the euphoria experienced by persons with substance dependence."

When the lit search fails you, consider (gasp!) opening the textbook, lol.

 

[Solideliquid]

Here's the thing about benadryl. Most of the patient's with insomnia on the inpatient ward don't will refuse benadryl and demand something stronger (read - "something that starts with X[anax]).

Folks I encounter in clinic that are on seroquel for insomnia (for years) will look at you like an idiot if you mention benadryl. The usual response is something like "BENADRYL? I am paying you to tell me to take a common household over the counter medication? I have serious problems and an over the counter medicine isn't going to help me. Are you sure you graduated from medical school?"

 

[atsai3]

2. While in vitro, Seroquel is strongly antihistamine at low doses, its hard to fully extrapolate in vivo what is going on and to compare doses of seroquel and benadryl. I think clinically it is apparent that seroquel is a "stronger" sleeping pill.

Can someone point me to these papers? I've heard this said once or twice before but have not managed to find the original citations.

Thanks
-AT.

 

[Hurricane]

Ack, never mind that last post. Should have scoured my Kaplan & Sadock more carefully before giving up:

"The coadministration of antihistamines and opioids can increase the euphoria experienced by persons with substance dependence."

When the lit search fails you, consider (gasp!) opening the textbook, lol.

Yeah, here in Dallas, the kids are mixing heroin and Tylenol PM for this reason. (They call it cheese) I don't know why they just don't make it with straight benadryl. Last year when I was on consults, there were a couple of kids with toxic livers because of the tylenol.

Regarding the Seroquel, soon it will have an FDA indication for everything, and we won't have to worry about off-label use 😉

 

[OldPsychDoc]

...
Regarding the Seroquel, soon it will have an FDA indication for everything, and we won't have to worry about off-label use 😉

Oooh--an excuse to post a link to my second-favorite Onion article*!

(My favorite is the one about the FDA approving prescription placebo. 😀)

*For those of you new to this game--back before sertraline went generic, Pfizer was notorious for rolling out "new indications"...whoever wrote this article had CLEARLY experienced their detailing! 🙄

 

[whopper]

"The coadministration of antihistamines and opioids can increase the euphoria experienced by persons with substance dependence."

Thing that bugs me about K&S is they often don't cite the source of the information. I haven't seen studies backing this, though I do see it clinically & yes, K&S documents it in their text. (Hence my rant, by the way its been documented in several journals as well, though in case studies or in letters to the editor on new trends doctors are noticing among their patients), and repeating what I mentioned above--I've seen it put on a few PRITE exams.

I had a conversation with an ER doctor & he told me that patients with sickle cell anemia know how to treat their pain because several of them get acute bouts of pain 2ndary to their sickle cell anemia. He tells me almost all of them know ask the ER doc for a benadryl when that ER doc refuses to give more pain meds.

The mechanism? I've looked into & can't find it myself. There are some studies I'm aware of that histamiines reduce the anti-anxiety effects of opioids.

http://www.ncbi.nlm.nih.gov/pubmed/...ez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSum

Though this was observed through behavior with no explanation as to the mechanism of what is going on in the brain.

Anyways, still feel the same about Seroquel. For psychosis CATIE ranked it as the least efficacious & its level of harmful metabolic side effects were right behind zyprexa. For that reason, it doesn't make sense to me to give it as a first line for psychosis. As for weight gain, zyprexa's weight gain effects are more predictable--it all tends to happen in the first few weeks in those patients that gain weight from it, so if I see that happen, I can either stop it right then & there (at only a few pounds of weight gain, before the patient balloons up), or continue it if the patient wants to be on it despite the weight gain. While Seroquel--the weight can still add on months after they're on it. I would only consider it first line if the patient was having some serious EPS/Parkinson's symptoms. As for an augmentation agent for depression, there are several other augmentation agents that have more studies such as lamictal, buspirone or lithium backing their use. Abilify's gotten FDA approval for that.

Given its low efficacy & abuse potential, Seroquel's one of the meds I'd consider last.

 

[Faebinder]

At first, Zoloft was only used to treat depression," Pugh said. "But what is depression, really? Who died and gave doctors the authority to dictate who is and isn't depressed?

Idiots. 😡

 

[fang]

Interesting thread; I never knew seroquel had a street value.

I'm an IM resident just browsing your forum looking for some good stories, but this caught my attention because seroquel is my second-favorite sleep aid for insomnia in the hospital. Let me illustrate why:

Scenario 1: I have just admitted Mr. Jones, an 87 y/o man with CAD, PAD, and mild vascular dementia here with PNA. At 1:15 the nurse pages to tell me he can't sleep. I give him 25 mg of benadryl, and an hour later he's a) ripping out his IV's, b) running naked down the hall, or perhaps c) urinating on his roommate's bed.

Scenario 2: I give him seroquel instead. It may not work and he may be up all night bothering the nurses and need to be reminded 8 times why he's in the hospital, but at least he's not engaged in the activities above.

You can't just use benadryl as a replacement for the anticholinergic effects and expect the same results in elderly people. Obviously, antipsychotics are the better choice in delerium, but sometimes pt's are not yet delerius, but will be after benadryl/ambien/benzo's. I usually give 25 mg and check the QTc before/after.

 

[OldPsychDoc]

Interesting thread; I never knew seroquel had a street value.

I'm an IM resident just browsing your forum looking for some good stories, but this caught my attention because seroquel is my second-favorite sleep aid for insomnia in the hospital. Let me illustrate why:

Scenario 1: I have just admitted Mr. Jones, an 87 y/o man with CAD, PAD, and mild vascular dementia here with PNA. At 1:15 the nurse pages to tell me he can't sleep. I give him 25 mg of benadryl, and an hour later he's a) ripping out his IV's, b) running naked down the hall, or perhaps c) urinating on his roommate's bed.

Scenario 2: I give him seroquel instead. It may not work and he may be up all night bothering the nurses and need to be reminded 8 times why he's in the hospital, but at least he's not engaged in the activities above.

You can't just use benadryl as a replacement for the anticholinergic effects and expect the same results in elderly people. Obviously, antipsychotics are the better choice in delerium, but sometimes pt's are not yet delerius, but will be after benadryl/ambien/benzo's. I usually give 25 mg and check the QTc before/after.

Sounds like you could be depriving our service of a potential consult! 😉

 

[187502]

Anyone know how benadryl, seroquel, vistaril differ in terms of their respective anticholinergic actions?

I had the same question in mind while reading this thread.

 

[Doc Samson]

Interesting thread; I never knew seroquel had a street value.

I'm an IM resident just browsing your forum looking for some good stories, but this caught my attention because seroquel is my second-favorite sleep aid for insomnia in the hospital. Let me illustrate why:

Scenario 1: I have just admitted Mr. Jones, an 87 y/o man with CAD, PAD, and mild vascular dementia here with PNA. At 1:15 the nurse pages to tell me he can't sleep. I give him 25 mg of benadryl, and an hour later he's a) ripping out his IV's, b) running naked down the hall, or perhaps c) urinating on his roommate's bed.

Scenario 2: I give him seroquel instead. It may not work and he may be up all night bothering the nurses and need to be reminded 8 times why he's in the hospital, but at least he's not engaged in the activities above.

You can't just use benadryl as a replacement for the anticholinergic effects and expect the same results in elderly people. Obviously, antipsychotics are the better choice in delerium, but sometimes pt's are not yet delerius, but will be after benadryl/ambien/benzo's. I usually give 25 mg and check the QTc before/after.

Good Lord - if more IM docs were as thoughtful as this I'd be out of a job.

 

[DebDynamite]

I just came off an addictions month where I had an IM attending and a psych attending. My IM attending frequently gave the patients seroquel for sleep. (I'm post-call, so I won't elaborate on the controversy/debate that went on about his practice of giving seroquel for sleep at my institution, but it was much like this thread).

One interesting thing to note was that he commented on the fact that in patients with hepC virus, seroquel seemed to zonk them for about 24 hours +. I witnessed it in one patient myself, who was literally nodding off all day after receiving it for sleep. Hard to tell if the methadone is therapeutic....so, he always shyed away from giving it to these patients.

 

[whopper]

Scenario 2: I give him seroquel instead. It may not work and he may be up all night bothering the nurses and need to be reminded 8 times why he's in the hospital, but at least he's not engaged in the activities above.

Well seems then you're not simply giving it just to induce sleep but to also control some agitated behaviors.

In which case Seroquel's being used for its intended antipsychotic properties, not so much because its being used purely as a sleep med (which I shun becuase of the reasons I mentioned above) and not giving it to drug abusers who may be trying to heighten the effect of their drug of abuse or sell it.

I don't see a problem with that other than that there is a blackbox warning against using an atypical to do so. While I think the BB warning causes more problems that solutions (then it pushes docs to give haldol instead--which isn't really safer but doesn't have a BB warning), be wary of what I mentioned for your own protection.

I didn't have much faith in Seroquel in an inpatient setting until I attended the conferences and started pushing the doses much higher. Now I use it quite often (daily) and find that, paradoxical as it may seem, it is protective against dystonia and akathesia, like the literature asserts.

Just got a guy transferred to my unit today. Seroquel 1200mg a day. Only at that dosage did it get rid of his hallucinations. Personally I want the guy off of it. He's obese, hyperlipidemia & HTN. I'd rather put him on a metabolically neutral med, gave him my reasoning & told him his risk of metabolic disease. The guy though doesn't want to switch, and being that he's not going to be dishcharged for years, fine, I got no worry with the drug abuse potential here.

 

[OldPsychDoc]

...Just got a guy transferred to my unit today. Seroquel 1200mg a day. Only at that dosage did it get rid of his hallucinations. Personally I want the guy off of it. He's obese, hyperlipidemia & HTN. I'd rather put him on a metabolically neutral med, gave him my reasoning & told him his risk of metabolic disease. The guy though doesn't want to switch, and being that he's not going to be dishcharged for years, fine, I got no worry with the drug abuse potential here.

Good luck--but there I days when I think the drugs should be renamed GEEitDON't-get-rid-of-psychosis, and ABILIWHY-is-this-patient-still-manic-and-hallucinating!

 

[whopper]

GEEitDON't-get-rid-of-psychosis

Yeah well Abilify don't work so well as an antipsychotic. Yes it works, but studies show it tends to take more time. Its head to head efficacy vs the other atpyicals has yet to be judged by a CATIE like trial.

For that reason, and because it has shown efficacy in treating bipolar & bipolar maintenance, I've been giving it to bipolar patients (not schizoaffective BP patients), in addition to a mood stabilizer or using it for MDD with psychotic features in addition to an antidepressant.

As for Geodon, several studies show that the higher the dosage, the more the efficacy. Yeah, Geodon didn't fare so well in CATIE but its metabolically neutral claims were valid. Also, its dosages were not near their max in CATIE....to the point where from my own extrapolation, it can stand on par with risperdal & zyprexa, but only if the dosages are at the manufacturer's max or above. So for anyone on Geodon with schizophrenia--I try to get to the max and reinforce the need to take it with meals which increases the absorption. I'm currently in an institution that highly encourages going above the max and the their committees have gotten the data in studies to back it up due to danger often experienced with forensic patients. These guys don't just get psychotic--some of them kill when psychotic.

 

[Doc Samson]

I don't see a problem with that other than that there is a blackbox warning against using an atypical to do so. While I think the BB warning causes more problems that solutions (then it pushes docs to give haldol instead--which isn't really safer but doesn't have a BB warning), be wary of what I mentioned for your own protection.

Nope - the first generation neuroleptics now have the same blackbox. The FDA continues it's crusade to liberate the demented from the evils of psychotropics.

 

[subtle1epiphany]

Thought I'd chime in on Seroquel (XR).

It's been mentioned that it's being increasingly prescribed off-label for MDD and anxiety. Fear not! It may soon be FDA-approved for monotherapy in both depression and generalized anxiety.

An AstraZeneca rep recently noted that NDAs have been submitted for these indications and the Phase III study (I should be receiving the paper soon) supports the use in these disorders.

Not sure how everyone else feels about this, but I took the issue to task regarding the receptor affinity and doses employed in treatment and the cost-efficacy issues that were brought up above. No real comment as the study isn't published yet...

I'm sure that this will happen in the future, there's no real stopping the push by pharma (and other parties, not just pharma) to move atypicals into these diagnoses. The SSRI patents have dried up and these meds likely do show efficacy, but I absolutely agree that they are truly a sledgehammer searching for a whole mess of thumbtacks.

While I'm not looking towards psychiatry as a career, it impacts all specialties in that it's medicine and pharmacology, and that psychiatry is so integral to medical practice. I'm sure that it's clear that I don't support this indication (pending reading more on the subject, and I'm just a student), but things should be more interesting as issues like this crop up in all fields.

What are your reactions to this? I'm not practicing medicine yet, so feedback from those prescribing and working with patients who are on these meds is what interests me.

 

[whopper]

I remember a drug rep telling it pretty much works for everything

OK yeah, well ahem....Let's look at that. Seroquel is not a clean med. It hits several receptors, so yes, I wouldn't be surprised if it did work on "Everything" given the right dosage. Hey it has no antipsychotic effect up until 400mg because its very not a strong potency D2 blocker.

So at doses of hundreds of mgs, I'm sure it does hit "everything"--ok well not everything but a lot of stuff that other meds don't hit. I.E. causing benefits across the board psychopharm wise.

But that can also cause problems. Since it hits several receptors--it also causes a lot of side effects. Its not exactly the best choice med in each area it treats, and if it does get several non-antipsychotic approvals, it could become the lazy psychiatrist's med of choice.

 

[atsai3]

Hey it has no antipsychotic effect up until 400mg because its very not a strong potency D2 blocker.

I've seen this mentioned several times on SDN but have never been able to find any original literature supporting this statement. Can someone point me to some of the key papers? Thanks,

-AT.

 

[OldPsychDoc]

I remember a drug rep telling it pretty much works for everything

OK yeah, well ahem....Let's look at that. Seroquel is not a clean med. It hits several receptors, so yes, I wouldn't be surprised if it did work on "Everything" given the right dosage. Hey it has no antipsychotic effect up until 400mg because its very not a strong potency D2 blocker.

So at doses of hundreds of mgs, I'm sure it does hit "everything"--ok well not everything but a lot of stuff that other meds don't hit. I.E. causing benefits across the board psychopharm wise.

But that can also cause problems. Since it hits several receptors--it also causes a lot of side effects. Its not exactly the best choice med in each area it treats, and if it does get several non-antipsychotic approvals, it could become the lazy psychiatrist's med of choice.

This is the second thread this week that you've implied (perhaps unintentionally, but still a point worth challenging a bit) that meds which are are "clean"--more pharmacologically specific--are in someway better than those which are more "dirty" (=non-specific). It's actually fairly rare that compounds developed as highly specific ligands are very clinically useful. Thorazine, TCAs, clozapine--all very "dirty" by your assessment, yet also revolutionary in their time and immensely useful still.

Since we unfortunately do not yet have a pathophysiology of disease that indicates that patient A needs a pure D2 blocade as opposed to patient B needing 5HT transporter blockade with possibly a little alpha antagonism thrown in, we're stuck with using the meds we have empirically to alleviate the suffering of our patients, and often a "dirtier" med does the trick.

 

[whopper]

that meds which are are "clean"--more pharmacologically specific--are in someway better than those which are more "dirty" (=non-specific).

Well there are more ways to rate meds besides their "cleanliness", and aside from clozaril, of the meds you have cited, there are superior meds in terms of efficacy (or equal efficacy) with less side effects. Why not give the med with equal or superior efficacy with less side effects?

Whether or not its "clean", I'm also interested in its efficacy vs the side effects (and I'm not talking about non FDA approved effects that are wanted--those aren't side effects). Cleanliness often correlates well with less side effects.

But in the case of Clozaril, its efficacy is so significantly higher than the other atypicals, regardless of the side effects, you got to respect that.

often a "dirtier" med does the trick.

Does Seroquel work? Of course it does--but per CATIE its not very efficacious vs the other meds of its class (it ranked last in terms of efficacy). Dirty does not mean better here. As for Clozaril, dirty yes--but more efficacious than anyone else in its class. Its "dirtiness" in this case may hold some benefit in terms to its benefit, but you also got to warn the patient of its side effects and use it 3rd line.

TCAs? Useful--of course--given the right situation. I wouldn't though use it first, second or even 3rd line. They, as any med, though still have their place in use.

 

[whopper]

I've seen this mentioned several times on SDN but have never been able to find any original literature supporting this statement. Can someone point me to some of the key papers? Thanks,

My own sources for this info were various speakers at grand rounds presentations, who did cite their sources during grand rounds but unfortunately, during my own pubmed search to show you some studies, I'm having problems finding some myself.

But nuts--I don't remember those sources offhand.

http://www.ncbi.nlm.nih.gov/pubmed/...ez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSum

I haven't read this study, but this one critically examines how efficacious it is and at specific doses. Haven't read it yet myself.

 

[Hurricane]

Since it hits several receptors--it also causes a lot of side effects. Its not exactly the best choice med in each area it treats, and if it does get several non-antipsychotic approvals, it could become the lazy psychiatrist's med of choice.

Yeah, I had a drug rep ask a table full of residents if we thought that diagnosis wouldn't be important anymore after Seroquel had all these new indications, since it would work for everything. And she was totally serious.

 

[TheWowEffect]

Yeah, I had a drug rep ask a table full of residents if we thought that diagnosis wouldn't be important anymore after Seroquel had all these new indications, since it would work for everything. And she was totally serious.

I just hope someone in the group had a good enough retort for her.

 

[whopper]

Yeah, I had a drug rep ask a table full of residents if we thought that diagnosis wouldn't be important anymore after Seroquel had all these new indications, since it would work for everything. And she was totally serious.

The Astra Zeneca rep in the previous place I was at said the same exact thing. Coincidence or maybe AZ is telling their reps to say this bull.

If Seroquel truly worked as an antidepressant--ok fine, then why not give it? Well aside from the fact that there's plenty of generics available for $4/month, would the side effects be worth the benefit vs the other ones out there? I mean really--if the side effect profile for Seroquel truly is what the patient needs (sedation, hypotension, weight gain, increase in appetite)--then fine by me.

Any idiot can simply give out an antidepressant for depression, an antipsychotic for psychosis yada yada yada. A real psychiatrist is going to have some reasoning as to why they chose the one they did vs the plenty of other ones out there (efficacy vs side effects, price, convenience etc), and that reason had better not be laziness, or because the drug rep gave a dinner.

I knew an attending that threw geodon at everything, and lo & behold the Pfizer rep & him had a relationship that IMHO showed a conflict of interest. Depressed? Geodon, Bipolar? Geodon, Schizophrenia? Geodon, Anxiety DO-Geodon. We all understand it works on bipolar & schizophrenic patients, but its highly serotinergic--so shouldn't it work as an antidepressant & anti-anxiety? (that seemed to be his reasoning)