What is your policy on missed doses? Continue? Restart?

[Blitz2006]

So in outpatient, there are always patients that say they have missed 1,2,3...6 days, etc. What is your move if a patient comes in, say on 200 mg zoloft, and says he has missed last 3 days? Do you go right back to starting dose?

Do you use pharmacokinetics (as in half lives, so your approach is different if they missed 2 days of Prozac vs. 2 days of Paxil)?

Different Psychiatrists have given me different answers, so I'm wondering if there is an objective/standardized approach, or is it subjective?

Obviously the main goal is to avoid an serious adverse effects in patient. Don't want to go from 0 to 200 mg...

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[OldPsychDoc]

It's not "objective vs subjective" as much as it is individual. The only policy is "It depends"--on the patient, the reasons for the misses, the medication... You'll treat someone on clozapine differently than olanzapine, lamotrigine differently than valproate. In your sertraline example I'm sure I've had patients who have skipped and resumed full doses without noticing anything, and patients who thought it was the "worst thing ever". Very patient-dependent. This is where you get to put on your doctor thinking cap and figure out what works for that patient in that situation.

 

[Merovinge]

I usually go with the half-life and figure out how much is left in their system but certainly SSRIs different than anti-epileptics different than antipsychotics. Nothing wrong with doing an abbreviated titration to get them back up if they have been non-compliant for a while.

 

[whopper]

Lock and Key Theory: some meds don't work as much as others based on shape of the receptor vs molecule.
Some people are faster metabolizers. Some are slower.

I just had a guy that was off of opioids for 4 days and in very strong withdrawal. By all conventional guidelines he was in the free and clear to try Buprenorphine but still got precipitated withdrawal from it, a phenomenon that almost occurs to no one past 24 hours of being off of an opioid and suffering withdrawal.

Not everyone's the same. The FDA guidelines are mere guidelines for the majority but remember the majority only means over 50%. They give us a good starting point and vantage point on what to estimate what will happen but from there on things could deviate quite a bit from them.

 

[DisorderedDoc417]

Basically the literature would indicate that..... it depends.

 

[Bartelby]

In some cases, the answer is widely agreed upon. For example, if someone has been off of lamictal or clozapine for week, then starting them back at full dose would be a clear medication error.

Aside from those clear cases, as others have mentioned you can go by half life and the whole clinical picture (other meds they are on, risk for interactions, worst-case side effect profiles, etc.).

 

[whopper]

I use the prescription FDA guidelines. E.g. Sertrline you can go up and down by 50 mg/day per week. So if someone's on 150 mg daily, missed for a few days, I just tell them to go back on 150 mg daily. If they were off for 1 week I tell them to 100 mg daily, then go back up to 150 mg daily.

But this is all things being equal/FDA guidelines. Like I said above everyone's different, and I always warn patients about this. I tell patients whenever we try something new that despite the studies they could have a reaction that most people don't get. Again the FDA applies to the majority but in many cases this is not the overwhelming majority. I tell patients whatever their experience was with the medication that's going to be their best indicator and not the studies that only apply to populations and not individuals.