seroquel prn racing thoughts?

[storyhill]

I am a night shift pharmacist and am the only one on duty. Could you give me a little input? I just received an order from a day shift physician on our behavioral health unit for seroquel 100 mg po q4h prn for racing thoughts/mania. I am aware of using it prn for sleep but not q4hprn for thoughts/mania? Is this a normal off label practice? I've only been out of school a few years and this is my first job at a hospital with a psych unit. I've never had anyone order this before. Thanks for any help.

---

Members don't see this ad.

 

[whopper]

Seroquel is indicated in the treatment of bipolar disorder. It is not indicated for sleep though it does help people do that.

That said, it first binds onto antihistamine receptors first, and doesn't start actual D2 blockage until around 150-250 mg per person of normal weight. So to give 100 mg PRN, the first dosage wouldn't really do anything (in theory). I would only find this rational prescribing if the person was already on a dosage of Seroquel to begin with and the extra 100 mg was added to it or was already on an antihistamine.

I would only continue such a regimen if the patient actually mentioned it helped. If not, I would adjust the dosage after the patient's given it some time (about a few days tops).

An issue with someone still being stabilized is usually in the first few days of treatment, the starting dosages aren't enough, so in addition to the daily med, the patient may need more medication. A problem with adding PRN of an existing med they're already on is if it goes higher than the manufacturer's recommended rate of increase, the patient could have problems. Give a patient nothing daily to Seroquel > 200 mg a day and that patient could faint due to the alpha receptor interaction of Seroquel.

While I was a resident, another resident gave a patient Risperdal 2 mg QBID the first day of hosptialization. The recommended dosage guideline is no more than 2 mg per day an increase. That patient fainted and hit his head against a toilet during the fall. It turned out the attending wasn't going over the daily dosages with her and about once every 2-3 weeks she had someone coding due to her over-prescribing. I noticed this problem told the attending and had to double-check everything she did. Fine, until my rotation was over and the next senior resident didn't do a thing and patients starting coding again and the attending only reacted to it, and didn't prevent it.

 

[TexasPhysician]

Racing thoughts to the patient may mean anxiety provoked thoughts. Patients often dont understand our language. Seroquel is FDA approved for Bipolar, and if someone wanted to make it look like it was being used for an FDA indication while simultaneously making more sense to the patient on when to take the med, racing thoughts as an indication could be rational.

 

[vistaril]

I am a night shift pharmacist and am the only one on duty. Could you give me a little input? I just received an order from a day shift physician on our behavioral health unit for seroquel 100 mg po q4h prn for racing thoughts/mania. I am aware of using it prn for sleep but not q4hprn for thoughts/mania? Is this a normal off label practice? I've only been out of school a few years and this is my first job at a hospital with a psych unit. I've never had anyone order this before. Thanks for any help.

seems like another psych is practicing in a substandard way......you wouldnt use 100mg of Seroquel prn for that.

Quite frankly, the literature on using small doses(25-200mg) of seroquel for anything is very limited and crappy, but that doesnt stop people from doing it left and right......

 

[whopper]

Patients often dont understand our language.

Tell someone with ADHD or an anxiety disorder if they got racing thoughts and they often times will say yes. That doesn't mean they have bipolar disorder.

What I ask instead, is if the person say yes, ask them what the racing thoughts are like. I sometimes will also ask "is it as if your thoughts are so fast they're actually uncomfortable?" I also impress upon them that psychiatric diagnosis can be at times not precise so they had to be very clear with me on what was going on with them and that not telling me what was going could lead to misdiagnosis.

"Racing thoughts" does not mean bipolar disorder.

Mentioned this before but a senior resident of mine during training asked patients if they "heard voices." When they said "yeah I hear your voice" he immediately put them on Risperdal even though they weren't psychotic.

 

[nitemagi]

I don't use seroquel much, but during a titration period, particularly while manic, prn doses could be used to gauge the amount required as a scheduled amount, which is a dosing strategy used with many other medications (such as benzo's in catatonia). I think using indications of "racing thoughts" and "mania" are vague parameters though and prone to overuse by nursing or someone med seeking, so I'd aim to narrow down the prn parameters.

 

[whopper]

Agree but with PRN dosing, with Seroquel, you're not supposed to raise the dose over 150 mg a day and with good reason. The resulting hypotension could knock out the patient causing them to fall and hit their head, crash their car, what have you.

So if someone was on a dosage of Seroquel, still had symptoms and only got 100 mg extra Seroquel via PRN usage, okay that's fine, but beyond that no, and this is only if the patient is already on Seroquel. To give it PRN when there's no standard daily dosage of it is only giving the patient expensive antihistamine up until about 200 mg, then beyond that you're just opening yourself up to liability.

A counter argument I've heard is, well what if the patient is agitated. If that's the case I don't think Seroquel at an extra 100 should be a first option...more like Zyprexa Zydis, IM, Haldol, etc.

 

[nitemagi]

Agree but with PRN dosing, with Seroquel, you're not supposed to raise the dose over 150 mg a day and with good reason. The resulting hypotension could knock out the patient causing them to fall and hit their head, crash their car, what have you.

So if someone was on a dosage of Seroquel, still had symptoms and only got 100 mg extra Seroquel via PRN usage, okay that's fine, but beyond that no, and this is only if the patient is already on Seroquel. To give it PRN when there's no standard daily dosage of it is only giving the patient expensive antihistamine up until about 200 mg, then beyond that you're just opening yourself up to liability.

A counter argument I've heard is, well what if the patient is agitated. If that's the case I don't think Seroquel at an extra 100 should be a first option...more like Zyprexa Zydis, IM, Haldol, etc.

The benefit on an inpt. basis could be checking regular VS, including orthostats if too concerned.

 

[whopper]

We'll have to agree to disagree. A problem with going over the manufacturer's guidelines, IMHO, aside that I've seen bad outcomes such as the resident whose patients coded every few weeks, is that a patient could have fine orthostatics at 1PM on this type of dosing but not at 3 PM. Meds can be tricky like this causing hypotension at one time but not another depending on the patient. I think for the sake of the staff, the patient, and your own piece of mind, you won't want to do orthostatic VS every hour to make sure the patient won't faint.

If that patient wasn't that bad, I'd simply tell the patient to just wait a few days for the med to be titrated up appropriately. If they were bad (e.g. agitation), I'd be thinking of something like Haldol or Zyprexa before raising the Seroquel just 100 mg.

 

[nitemagi]

In general I think seroquel is grossly overused, and I tend to use it only as a 3rd or 4th line medication, for a variety of reasons including the risk of abuse and diversion.

 

[whopper]

I've spent a few rants against Seroquel. I still stand by them (did worst in the CATIE trial, high likelihood of worse side effects, low efficacy, high price, zonks patients out.)

I have, however seen some data suggesting that it may be a better choice antipsychotic to try in psychosis related to dementia. The data is sparse, but when I thought about it, perhaps the psychosis related to dementia is a different beast to the degree where the CATIE rules may not apply quite as much.

I've had a few patients on the geriatric unit that responded well to Seroquel for psychotic dementia, but not others with higher efficacy. I've hardly ever seen that younger patients that just had a plain psychotic disorder unrelated to dementia.

I'm still looking into this. I ought to ask one of my bosses-one who is the PD of the geriatric psychiatry program, the other a top 100 ranked doctor.

 

[splik]

I have, however seen some data suggesting that it may be a better choice antipsychotic to try in psychosis related to dementia. The data is sparse, but when I thought about it, perhaps the psychosis related to dementia is a different beast to the degree where the CATIE rules may not apply quite as much.

Yes this is pretty much the only time I use it, oh and in Parkinson's disease psychosis (because of low likelihood of worsening parkinson's and easier to use than clozapine for which there is better evidence). Even then only if it causes distress or impairment. Most Parkinson's patients with a few delusions and hallucinations don't need treatment for it.

 

[storyhill]

I guess off-label wasn't the best word to use in my question as that usually is referring to the indication. The dosing schedule was what threw me off. Things like this are kind of tough as pharmacists because I can catch mistakes that happen such as therapeutic duplications or "off the wall" doses. These are easy enough to correct when contacting physicians because they realize the mistake right away but if it's something like this where it may just not be a best practice but it is what they want there isn't much chance of changing therapy. Thank you all very much for your input.

 

[OldPsychDoc]

Sorry I didn't chime in this morning, but I will say that I have written orders like this for inpts who might be highly reactive and agitated, need something fairly rapidly calming as a prn, and for whom I'm trying to avoid benzos at all costs. I will say that I'd be unlikely to be starting this at 100 mg, however--but many patients I've encountered in this situation are already habituated to the acute sedative effects.

 

[vistaril]

Sorry I didn't chime in this morning, but I will say that I have written orders like this for inpts who might be highly reactive and agitated, need something fairly rapidly calming as a prn, and for whom I'm trying to avoid benzos at all costs. I will say that I'd be unlikely to be starting this at 100 mg, however--but many patients I've encountered in this situation are already habituated to the acute sedative effects.

as whopper said, if that's the case(highly reactive/agitated inpatients) then there are better options.....

 

[OldPsychDoc]

as whopper said, if that's the case (highly reactive/agitated inpatients) then there are better options.....

Yes I'm quite aware of that -- I'm not advocating it as a gold-plated standard of care. It is an effective temporizing measure in my patients who are typically young, voluntary (i.e. not someone qualifying for a forced B52, and having the right to say "hell no" to haldol), and with considerable chemical dependency comorbidities. If it gets them through the day without punching a wall or a nurse, I consider it justifiable.

 

[vistaril]

Yes I'm quite aware of that -- I'm not advocating it as a gold-plated standard of care. It is an effective temporizing measure in my patients who are typically young, voluntary (i.e. not someone qualifying for a forced B52, and having the right to say "hell no" to haldol), and with considerable chemical dependency comorbidities. If it gets them through the day without punching a wall or a nurse, I consider it justifiable.

why not just give them a high dose antihistamine in that case then? a lot cheaper, cleaner, etc.....

at 100mg D2 blockade is negligible.

when there is good data that shows low dose seroquel works for....anything(except sedation secondary to anti-serot and hist effects)....then I'll start using it. either that data doesn't exist, or I'm just not aware of it.

 

[OldPsychDoc]

why not just give them a high dose antihistamine in that case then? a lot cheaper, cleaner, etc.....

at 100mg D2 blockade is negligible.

when there is good data that shows low dose seroquel works for....anything(except sedation secondary to anti-serot and hist effects)....then I'll start using it. either that data doesn't exist, or I'm just not aware of it.

Yes, yes I know... I've usually tried generous dosings of your namesake med before upping the ante to quetiapine. I'll just point out that I'm not running a clinical trials unit with nice clean diagnoses--more of a M*A*S*H unit with lots of co-morbidities and messy psychosocial situations. Get 'em stable enough to more on to a PHP or residential program or whatever...

Just attempting to reassure the OP that the particular order in question is not *that* unusual in the inpatient world.

 

[whopper]

I've gotten into discussion about Seroquel's benefits at low dosages.

I've had patients swear that it really is different than just an antihistamine that was therapeutic. The problem here, and they may be telling the truth, is that this med has a street value, and it's the same population, a substance abusing one that often demands it from me.

Seroquel's first metabolite, norquietapine is an SNRI, so it may have antidepressant benefit. It works on the alpha receptors so it may have ADHD benefits.

 

[TexasPhysician]

Tell someone with ADHD or an anxiety disorder if they got racing thoughts and they often times will say yes. That doesn't mean they have bipolar disorder.

What I ask instead, is if the person say yes, ask them what the racing thoughts are like. I sometimes will also ask "is it as if your thoughts are so fast they're actually uncomfortable?" I also impress upon them that psychiatric diagnosis can be at times not precise so they had to be very clear with me on what was going on with them and that not telling me what was going could lead to misdiagnosis.

"Racing thoughts" does not mean bipolar disorder.

Mentioned this before but a senior resident of mine during training asked patients if they "heard voices." When they said "yeah I hear your voice" he immediately put them on Risperdal even though they weren't psychotic.

I think you misunderstood me. If the patient perceives "racing thoughts" as a symptom of anxiety, agitation, or whatever, it may make more legal sense to list that symptom with "bipolar" assuming bipolar is already part of the diagnosis. It gives the perception that you are treating for an FDA indication and adding antipsychotics on very slowly to minimize side effects - rather than using Seroquel to treat something without FDA approval. Just a thought.