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It happens if they were well controlled on stimulants and they stopped them bc they got pregnant or are planning to do so....
Topiramate
- Thread starter medhead1990
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Correct. The times I see someone know something better than I do I'm a mosquito to a flame. We only get better by sharpening steel with steel.
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So we're entering the primary care realm now...Just to give an example of stuff I'm seeing as majority problems-I don't see physicians recommending prevention of C difficile infections when prescribing antibiotics, significant amounts simply medicating with Zolpidem when a patient has a sleep issue with no warning of addiction, doctors providing benzos with no addiction warnings or warnings to not mix with alcohol, prescribing birth control to women who still smoke and above age 35 with no warning, doctors prescribing stimulants to women of child-bearing age with no warning it's teratogenic, psychiatrists not take vitals, weight, and patient's placed on Venlafaxine who already has bad Hypertension, psychiatrists who place patients on several meds and don't document what effects that med had on the patient, PCPs who give out antibiotics to anyone who asks even when it's clear the patient has a viral infection....
I'm sure you read the following thread...
Tired of this
Here’s the med list for my consult today: Diazepam 10 mg daily Xanax 0.5 mg qid Hydrocodone 7.5 mg qid Ambien 10 mg at hs So sick of dealing with thisforums.studentdoctor.net
The point being that this is not some bad 1% of doctors that hardly happens. This is the normal reality. IF you're not seeing this you're very lucky and likely at a top institution where the overwhelming majority are very good-which in your case is what is going on. (I've met Mistafab in-person).
Outside of reducing antibiotic use, there's nothing currently supported by any evidence to prevent c diff in the vast majority of cases.
Speaking to overuse of antibiotics: yes this is 100% an issue. But this will not change until several things happen:
First, get rid of patient satisfaction scores. Until that stops being a factor in both my income and my employment I will keep giving antibiotics to people with colds.
Second, you must get 100% of doctors on board. It's useless if I practice by the guidelines while Dr. Jackass at urgent care keeps giving them out for colds.
Third, better ways to tell what needs treatment and what doesn't. Every PCP has had more than a few cases where we didn't give antibiotics per guidelines and it bit us in the ass when that patient ends up hospitalized.
Fourth, you have to get buy in from patients. We're talking a huge public information campaign type thing.
Until all of that happens, this will not change.
There's not good evidence that stimulants are teratogenic. And you know as well as I do that untreated mental illness is a big risk factor for bad pregnancy outcomes.
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Our leadership is trying to make a big push to stop treating UTI’s that don’t need to be treated. Our altered old people without sepsis and with pyuria are suppose to be watched first. They are going to annoy us with queries for documenting dysuria ect. . . . The ED continues to tell any of person that stumbles they are being admitted for a UTI. Our sub specilists make stupid recommendations. I had a neurologist put in multiple notes to get a UA and CXR for a guy who came in with breakthrough seizures. Sure he hasn’t been sleeping for 24 hours prior his seizures because he is so concerned about his wife’s sleep apnea with a new mask that isn’t working, he is drinking some beer on and off, and no one actually got a level of his Keppra before he got loaded. Sure, it is the asymptomatic UTI.
Never saw such **** Neuro exam. Remember when neurologist were good? Sorry, vent off.
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I have never witnessed this
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They're out there, just have to do some digging. I only work with a handful of neurologists as referral sources at this point in my career. And they're ones who have already done the good up front work to rule out the obvious before sending them my way.
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The plague of our neuro service is that there's no consistency, they haul in the outpatient subspecialists for two weeks a year. Got a patient with complicated neuropsychiatric symptoms? Oops it's a neuromuscular guy this week. Your consult is exactly as good as whatever he bothered not to forget an area of neurology he doesn't care about. Weird movement symptoms in a psych patient that aren't consistent with tardive? So sorry the attending this week is headache and the only thing they're gonna contribute is giving you one.
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The hospital I work for is building up it's neuro-hospitalist program to help with this and stroke call
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Interesting, all but one neurologist I’ve worked with have been fantastic. We do have a very robust neuro department (like 5 or 6 different specialty clinics) and we work pretty closely with them on consults. I can imagine PP being more of a disaster as PP tends to be much more hit or miss with quality of any doc, so maybe I’m just spoiled in my little ivory tower where I’m at.
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There’s no standard of care that they all must know?
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I mean, they all completed a general neuro residency but if you're 5, 10, 15, 20 years out and working entirely in an outpatient subspecialty clinic, you aren't exactly going to be up on the latest in inpatient presentations of things not in your specialty.
I technically completed the required child and adolescent rotations for a general psych residency but if you put a 10 year old in front of me and asked me to do an autism evaluation I would be near useless as a subspecialist adult consult-liaison psychiatrist. But Im not required to abandon my area of expertise two weeks a year and go do assessments in a completely different field, and that's essentially what is being asked of these faculty.
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I'm jealous. It sounds like you are somewhere with a right-sized neuro department--big enough to have a good array of specialists, but not big enough to have fragmented down into comically narrow areas of expertise.
I do have a friend in an outpatient employed position who has basically given up on getting neuro consults because theyre so consistently awful (and frequently done only by NPs).
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Yeah but isn’t that a recipe for malpractice? I mean if someone asked me to see kids I wouldn’t do it I wouldn’t agree to do it 2 weeks a year
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The metaphor works for the knowledge level but doesn't translate to the legal level. Also, as much as I'm maligning my neurology colleagues when they are on consults, they aren't delivering a lower quality of care than average in the community. They work with residents who fill in gaps and rely on them heavily. But as a consulting psychiatrist the cases where we intersect as consulting specialties are by definition usually particularly difficult, confusing, and challenging. Instead of getting a fresh set of eyes and useful expertise, we get the brush off. Not every single time but frequently enough it's a running theme.
When there IS match between the covering attending and the consult questions things usually go great. Had lucky timing on a parkisnons case a few months ago where the covering neuro consult attending just happened to be a movement guy. Jackpot! Actually useful input. But that stood out bc it was atypical.
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As an intern I remember rotating on our neuro consult service. One of the attendings that month was a neuro-otologist, legit a big deal who had authored a fair amount of UptoDate's content on vertigo at the time, but that was all this man did. We could do a hell of a vertigo work-up; the "is strange, has neurons" consult that made up their bread and butter, not so much.
What's worse, he made it pretty obvious he didn't care, in the sense that he would literally walk away from residents trying to present to him after 60-120 seconds and just decide to do whatever after talking to the patient for a few minutes.
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Topiramate is rarely my first choice, but is definitely something I use for a variety of conditions.
For one, its an effective migraine medication for someone with comorbid migraines that for whatever reason no one has bothered to offer prophylactic meds ("I've only been given NSAIDs and triptans before... what's a prophylactic med?").
Second it was well established in weight loss prior to GLP-1s, and I'll usually use it after failure of metformin for the antipsychotic induced metabolic effects. Most patients describe it as changing the taste of things (like soda doesn't take sweet anymore). Also helpful for BED.
Third, I often use it after intolerance/failure of prazosin for PTSD associated nightmares.
Fourth, its a reasonable nth line option for AUD, after the typical trials of naltrexone or acamprosate fail or aren't tolerated. Also use in combination with some first line items. I group it, baclofen, gabapentin, etc. together as a "they kind of work for some people" group.
I will also rarely use it for bad BPD, but can maybe think of only a handful of times, where maybe 2 found it helpful.
It was often used where I trained, and where I am now, tends to be used mostly just for weight loss.
I would agree with regards to the cognitive dulling. It usually is not significant until above 100 mg in my experience, but it happens regularly enough that I always mention it as a potential adverse effect.
Its funny, I stumbled upon that article like a week ago when I was looking for something else.
To be completely honest, my goals for the >75 population is almost always "less is more" and deprescribing. Its very rare that I see someone in that age group that truly needs "more" meds, unless we are dealing with dementia related behavioral disturbance.
Yes, this is definitely a concern, especially in the cHTN (aka just HTN...) and at risk cHTN population.
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tbh ive always felt like topamax is a medication where you dont exactly what the intended result is youre trying to get with it, but "why the hell not". I personally dont use it, and havent found it effective for cocaine use, binge eating, etc. People always feel loopy on it.
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When dealing with dementia behavioral disturbance do you go to antipsychotics as your first line medication?
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Funny, where I'm at new patients I'm seeing on lamotrigine that's often the reason they're on it. Almost 100% of the time if the referral is from an NP.
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also lamictal 25-50mg but i know we all already had our lamictal vs sga debate a while ago on here
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Yea, either patients are on homeopathic doses or neuro dosing (300+mg per day). I almost never get consulted on patients on doses in the 100-200mg/day range.
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Not to derail the thread - but is there any clinical utility in lamotrigine extended release compared to just standard formulation? The half life on standard is already so long that I think I must be missing something as to why they have an extended release.
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You use XR if you want to do above 200mg otherwise you have to use the regular lamotrigine BID dosing.
With that being said, neurologists use XR BID to get smoother steady state concentration curves for seizure control. I don't think it's the same for psychiatric conditions. There's also no evidence to use it above 200mg for psychiatric conditions. If the patient has bad side effects to peak serum levels of lamotrigine, an extended-release might help.
EDIT: If patients are taking carbamazepine, phenytoin, primidone, or phenobarb and NOT taking Depakote, you are supposed to use a higher dose of lamotrigine and that's when you'd probably go to a higher dose and use it XR.
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Its depends on the behavioral disturbance. I will often use low-dose trazodone or SRI first, unless we're really talking violence, and then unfortunately often the antipsychotics are what's needed. None of its ideal though. First line in general should always be redirection/behavioral interventions.
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I just had legal case where I testified. In this case the patient, elderly, did not have dementia, was misdiagnosed as having dementia, and did poorly on a MOCA test likely cause the treating doctor in the facility put him on Olanzapine and the patient was over-sedated while being administered the MOCA.
So legally this presented in a pretty much, this other doctor boxed himself in real-good, situation.
It was completely and strongly provable the patient was misdiagnosed. To which the doctor was defensive because he misdiagnosed, but any argument that the patient had dementia then brought up the clear argument was "if you thought he had dementia why did you put him on Olanzapine, a med where there's a black box warning against it's use in dementia?"
So either way he had no clear path to exonerate him. Point is if you give an antipsychotic in a demented patient you should have very rock solid and documentable reasoning. In the above case the patient was not physically dangerous, so why give him the PRN agitation med? Seriously the patient, aside from being misdiagnosed, didn't need it. At worst he was cantankerous and not easy-going but this was understandable given the patient's situation.
A clear situation where a PRN antipsychotic is needed is the patient is physically dangerous even with the black-box warning. The difficult situation is the grey-zone where you have reason to believe they are so but aren't sure if they're going to be dangerous in the near future.
So legally this presented in a pretty much, this other doctor boxed himself in real-good, situation.
It was completely and strongly provable the patient was misdiagnosed. To which the doctor was defensive because he misdiagnosed, but any argument that the patient had dementia then brought up the clear argument was "if you thought he had dementia why did you put him on Olanzapine, a med where there's a black box warning against it's use in dementia?"
So either way he had no clear path to exonerate him. Point is if you give an antipsychotic in a demented patient you should have very rock solid and documentable reasoning. In the above case the patient was not physically dangerous, so why give him the PRN agitation med? Seriously the patient, aside from being misdiagnosed, didn't need it. At worst he was cantankerous and not easy-going but this was understandable given the patient's situation.
A clear situation where a PRN antipsychotic is needed is the patient is physically dangerous even with the black-box warning. The difficult situation is the grey-zone where you have reason to believe they are so but aren't sure if they're going to be dangerous in the near future.
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same, i often start zoloft or a different SSRI. I generally only do antipsychotics when the quality of life is significantly impaired. Intermittent yelling i would not do an antipsychotic.
