Titrating Anti-Psychotics?

[Solideliquid]

Is there any evidence that antipsychotics, for example let's use Risperidone, need to be slowly uptitrated (Clozapine, and typicals aside).


Example: you have a psychotic patient on the ward (with past psych hx) but not on meds for six months. You decide to give Risperidone, do you start at 1mg QHS or BID? Anyone just go straight to 4mg QHS? Discuss.

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[OldPsychDoc]

Is there any evidence that antipsychotics, for example let's use Risperidone, need to be slowly uptitrated (Clozapine, and typicals aside).


Example: you have a psychotic patient on the ward (with past psych hx) but not on meds for six months. You decide to give Risperidone, do you start at 1mg QHS or BID? Anyone just go straight to 4mg QHS? Discuss.

If they're grossly psychotic, then I think risperdal's a great "go for it" med--2 mg bid. Zyprexa is also good to go in at a mid-to-high dose, 10-15 mg qhs or 10 bid. The others it seems like you need to start lower and titrate.
Just my experience so far...

 

[Anasazi23]

I'm a big fan of the Zyprexa 20-30mg loading dose with later cross taper or outright switch to another SGA.

If they're not neuroleptically naive, you can hit them with 2 BID of risperdal if you want. Just monitor and deal with side effects if they happen.

 

[whopper]

Is there any evidence that antipsychotics, for example let's use Risperidone, need to be slowly uptitrated

Yes.

Several atypicals have very strong alpha adrenergic effect ---> they'll drop blood pressure.

Seroquel for example cannot simply be started on its therapeutic dosage for this reason.

I had an idiot resident who was later kicked out of my program who just started patients on therapeutic dosages without uptitrating as reccomended by the manufacturer.

This resulted in 3 codes in 1 month on the inpatient psyche unit. We'd normally get 1 code maybe every few years.

One example: 1 patient was put on Risperdal 4mg PO Q BID from nothing. She experienced significant hypotension, then when she defecated, the valsalva maneuver futher dropped her BP and she fainted. When she fell down, he head hit the toilet. She was found on the ground unconcious with blood coming from her head.

Anytime you deviate from the manufacturer's reccomended guidelines (and most atypicals have specific guidelines on uptitrating), you better justify your actions on the documentation. Following the guidelines to some degree will protect you from a bad outcome should it go to court. I almost always followed the guidelines. That one resident didn't and 3 codes in 1 month.

If you want quicker results, you're better off using a typical than an atypical. (E.g. agitated pt punching holes in the wall). Or using an atypical as augmentation therapy in addition to an atypical. If you want to disregard the guidelines and play guinea pig on your patient, you're not exactly playing responsibly medicine.

Several of the guidelines put in by the manufacturer are there for reasons. Of course some of them are bad reasons such as the cataract check up for Seroquel. However for the safety of your patient as well as just to cover your butt, you need to know the reasons for the guidelines if you're going to choose to disregard them, and document why you did so.

 

[Solideliquid]

Whopper, that's all well and good, and I agree with what you are saying. Now, what if my attending is ordering these dosages (telling me to)?

 

[whopper]

If your attending is telling you to do this, document that your attending directed you to do this and you are following his/her orders on the chart. For added coverage, also state you discussed with him/her this dosing strategy.

Some meds can be titrated up a bit faster than the guidelines. These are usually newer meds that have been found to be a bit safer than once previous thought such as Geodon.

However, again, if you're a bit skeptical about the attending, document, and do so in a way that is factual, & will cover your butt, but also neutral sounding so your attending won't get ticked off at you.

HEre's what I would write.

"I discussed with the titration schedule with Dr. x and he/she stated that this dosage schedule was safe."

There--doesn't make the attending look out to be a bad person and you wrote down that you talked about it with the attending.

 

[Anasazi23]

"I discussed with the titration schedule with Dr. x and he/she stated that this dosage schedule was safe."

I think that if I were an attending and I read that in my resident's note, I'd be a little pissed. But, I think there are ways around this, like Whopper said.

In a couple of rare cases, I've actually told an attending to write a crazy order themselves...but did so in a joking way while I hand the chart to them. When I was jokingly questioned back, I simply told them that I'd feel more comfortable if they simply wrote that order themselves.

If they insist you write the order, I have my standard. "Case discussed with attending, who formulated above treatment plan."

The point of covering your behind is to pretend that everything you write will be read in a court of law at some point. As the resident, you already are absolved of most responsibility. If an attending tries to rat you out by saying that you were cavalier and wrote the order without their knowledge, they're still responsible since it is their responsibility to review charts and take charge of patient care (See "Captain of the ship" clause).

If in some extreme circumstance the case does wind up in court, that sentence will be read once, and all liability will again be shifted away from you...even though you had very little, if any, responsibility to begin with.

I remember a case where I was adamently against the course of care. A very elderly woman who had a parasuicidal attempt, and was admitted, which I disagreed with to begin with. She had multiple somatic complaints, and they forced me to call a pain management consult for chronic back pain....also something I disagreed with. The consult recommended lidocaine patch, which I was adamently in disagreement with.

She got the patch, and subsequently became delirious, fell, fractured her left elbow, both hips, and pelvis. Two weeks in the ICU later, she barely survived. As we know, a hip fracture in an 80 year old carries something like a 75% mortality. Needless to say, the case went to M&M, and I was called in for my versio of what happened. I never ratted in the chart, but I did write the above statements, and made my disagreement with the plan evident in rounds. I told administration that some attendings seem to blindly follow consults, and that I was in public disagreement with the plan. This is an extreme example, and I rarely make my dissenting opinion so known, but never was the onus on me to explain my course of care.