TCA Question

[sunlioness]

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I feel totally stupid asking this question, but to be honest I don't prescribe a lot of TCAs. I am considering clomiprimine in a patient with pretty bad OCD. I have been trying to find (and failing) if the current recommendation is a screening ECG in everyone prior to initiating a TCA or just for those with a h/o cardiac dz? This is for a woman in her 50s.

 

[whopper]

have been trying to find (and failing) if the current recommendation is a screening ECG in everyone prior to initiating a TCA or just for those with a h/o cardiac dz? This is for a woman in her 50s.

I would order an EKG on any person given an TCA with history of cardiac disease.

With full acknowledgment that you perhaps tried this, and it didn't work...
I'd try to avoid the use of a TCA if possible. Antidepressants can be augmented with several agents such as lamictal, buspirone, an atypical, etc. I'd rather use that than a TCA on a person with a history of a cardiac disorder.

But if you are stuck, and want to consider a TCA, get the EKG. That's my recommendation. I don't know if you are going to find a specific text recommending this. As you likely know, several texts do not specify several things we do in medicine. For example, diabetes, few sources I've seen give the order of diet & excercise first, then try metformin, then glitazone, then insulin. The sources will mention what can be done, but not give a protocol, and protocol is often clinically taught, but not found in a book.

As a once new attending (hey I'm a fellow now), I recommend you be in a position where you can ask colleagues for support if you are stuck. That was one of the things I enjoyed about working in a hospital, and not private practice first thing out. This site can help.

 

[prominence]

With full acknowledgment that you perhaps tried this, and it didn't work... I'd try to avoid the use of a TCA if possible. Antidepressants can be augmented with several agents such as lamictal, buspirone, an atypical, etc. I'd rather use that than a TCA on a person with a history of a cardiac disorder.

Does augmentation with Lamictal work for OCD?

 

[sunlioness]

Thanks, Whopper. Yeah, I knew that with a h/o cardiac disease and would try to avoid it at all costs in that population. This was with someone without such a history and I seemed to vaguely recall reading somewhere that now they were recommending ECGs for everyone regardless. Only I couldn't remember where I read that and I couldn't find it anywhere. In any case, I did ultimately decide to go a different way. She'd really only been on one other SSRI for her OCD (it was prozac and it made her agitated) and even that at a non-therapeutic dose for OCD. So even though she claimed to be dead set against trying another SSRI and was really wanting Anafranil, after we really talked about the various risks/benefits, she was amenable to trying a different SSRI.

I definitely miss having people within shouting distance to bounce things off of. I still have people in the community who are more experienced than I am and who are happy to help me that way, but now I have to pick up the phone or write an email instead of walk across the hall. Glad to have you guys too. 🙂

 

[snarfer]

Does augmentation with Lamictal work for OCD?

Usually the first line is a SSRI, as we all know. If there's partial response at an adequate dose, then adding clomipramine is a good idea. Monotherapy with an atypical, ie. olanzapine, is a another option given the thought content disturbances of OCD patiets.

To answer your question, there hasn't been much evidence for this medicine in OCD. Maybe third line if all else fails.

There seems to be high incidents of sinus tach, prolonged qrs/pr/qt interval, flat t wave with the TCAs so a baseline ECG is a must in my opinion. If an atypical is considered, getting a baseline ecg along with the fasting labs would be good ideas as well.

 

[whopper]

Snarfer answered the question, though I need to clarify that the augmentation I spoke of was specifically for depression.

There was a great article in a journal about 2 years ago where there was a recommended protocol on treating OCD, even if it got to the point of recommending guidelines for the treatment-resistant.

I keep apologizing for this. I normally gladly look through my old articles I've collected that actually made a difference in the way I practice, or find the source online. I'm currently in a state where every free moment I have is used catching up on sleep, and reassuring my wife that this hell-year where I'm doing fellowship and moonlighting till I drop to keep my mortgage payments on-time will be over soon.

She'd really only been on one other SSRI for her OCD (it was prozac and it made her agitated)

I avoid Prozac in the treatment of anxiety disorders as a first line treatment. Prozac is known to have mild stimulant properties which can actually set off anxiety a bit more in many patients.

Considering that Prozac is not the only $4 generic SSRI out there, and it is a "dirty" SSRI, I generally try to go with Celexa first. Of course, every medication has a place depending on the patient, and the circumstances. I generally consider Prozac only if other choices did not work (Celexa, Zoloft were tried), the patient has a known history of Prozac working for them and they were happy on it, and if they are known to miss dosages often (Prozac has a long half-life).

 

[billypilgrim37]

Zoloft 400mg daily. Because anything less would be uncivilized. 🙄

 

[st2205]

Zoloft 400mg daily. Because anything less would be uncivilized. 🙄

 

[sunlioness]

I avoid Prozac in the treatment of anxiety disorders as a first line treatment. Prozac is known to have mild stimulant properties which can actually set off anxiety a bit more in many patients.

Yeah, I tend not to use it in anxiety d/o patients for the very same reasons. I think this woman's brief experience with it was several years ago. She'd been dealing with her sx on her own for years, scared to try meds again, until she started seeing a new therapist who over time talked to her about it and ultimately sent her to me. I think she was asking about clomipramine because she knew it wasn't an SSRI and had the idea from her experience that SSRIs were "bad". Citalopram is what I ended up prescribing for her. 🙂

 

[masterofmonkeys]

I dunno that I'd get an ECG before any anti-psychotic, not unless there was a history of cardiac dz (including arrhythmia).

High potency anti-psychotics whether typical or atypical, have pretty darn low amounts of QT prolongation. Less than many commonly prescribed drugs. As a side note, call me weird, but I still find it useful to distinguish between low and high potency antipsychotics when dealing with atypical agents as well.

ECG is not a prerequisite to starting a patient on fluoroquinolong abx even though they have much greater QT prolongation than higher potency antipsychotics.

 

[HMSPSYCH]

I dunno that I'd get an ECG before any anti-psychotic, not unless there was a history of cardiac dz (including arrhythmia).

High potency anti-psychotics whether typical or atypical, have pretty darn low amounts of QT prolongation. Less than many commonly prescribed drugs. As a side note, call me weird, but I still find it useful to distinguish between low and high potency antipsychotics when dealing with atypical agents as well.

ECG is not a prerequisite to starting a patient on fluoroquinolong abx even though they have much greater QT prolongation than higher potency antipsychotics.

good thought but Fluoquinolone is used short term. the atypicals are used long term.