What PRN medication would you prescribe for agitation in outpatient setting?

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The patient is a young adult with unspecified mental handicap who comes with mom. He has been on the following regimen for years:

clonidine 0.3mg per day
depakote DR 1000mg per day
geodon 200mg per day
valium 20mg per day

(Most of the above medications are split into two dosings a day.)

He has been on the regimen for years and is tolerating medications. Mother does not want to change the treatment. The above combination was from much trial and error and patient used to be much worse.

However, he has history of uncontrollable outbursts, even with optimized pharmacology. Since the last visit, he was hospitalized twice. Police was involved and had to restrain him. Inpatient treatment consists of increasing clonidine and depakote by a bit. Then he was discharged after a few days without prescriptions. Inpatient physician's rationale was that outpatient psychiatrist will manage medication.

Patient never remembers his outbursts. He cannot specific a trigger.

Since mom and patient wanted to keep the current medications, we agreed to add PRN medications for agitation. Mom is a nurse and know how to give injections.

1. What would be your PRN medication and why?

2. Would you have done something differently than prescribe PRN medication for agitation? If so, what would you have done?

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The patient is a young adult with unspecified mental handicap who comes with mom. He has been on the following regimen for years:

clonidine 0.3mg per day
depakote DR 1000mg per day
geodon 200mg per day
valium 20mg per day

(Most of the above medications are split into two dosings a day.)

He has been on the regimen for years and is tolerating medications. Mother does not want to change the treatment. The above combination was from much trial and error and patient used to be much worse.

However, he has history of uncontrollable outbursts, even with optimized pharmacology. Since the last visit, he was hospitalized twice. Police was involved and had to restrain him. Inpatient treatment consists of increasing clonidine and depakote by a bit. Then he was discharged after a few days without prescriptions. Inpatient physician's rationale was that outpatient psychiatrist will manage medication.

Patient never remembers his outbursts. He cannot specific a trigger.

Since mom and patient wanted to keep the current medications, we agreed to add PRN medications for agitation. Mom is a nurse and know how to give injections.

1. What would be your PRN medication and why?

2. Would you have done something differently than prescribe PRN medication for agitation? If so, what would you have done?

A Functional behavior analysis with subsequent development of a positive behavior support plan that mom can be trained in.

If he's DD and/or IDD, does he not qualify for wrap around support services, including ABA services/consultation?
 
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A Functional behavior analysis with subsequent development of a positive behavior support plan that mom can be trained in.

If he's DD and/or IDD, does he not qualify for wrap around support services, including ABA services/consultation?

This will be very state dependent! In some states medicaid and commercial insurance will cover in-home behavioral services, but there is a massive provider shortage. In other states this isn't really available at all. Of course in principle I agree fully.

In Connecticut, Maryland, Rhode Island (and no doubt some other places) there are DD units that would admit the patient for a month and try and increase stability, develop a behavioral plan, and adjust medications in a more comprehensive way.

I think that going the PRN route is not a good idea. And in terms of the regimen overall, risperidone and aripiprazole have orders of magnitude more evidence for this indication than any other antipsychotic and even though he may have been trailed on these before, I'd return to them unless there was a major tolerability issue, or some really convincing evidence that the current regimen is more helpful. Aggression is predictably unpredictable in ID and it can be very difficult to know if a medication is helping or not. He may have had other environmental determinants at the time it was trialled and it may be worth trying again now.

Unpublished data from trials at emory suggests that alpha agonists may worsen irritability at higher doses (stick to < 2mg for guanfacine and < 0.2mg daily for clonidine).

You could also try transdermal nicotine - some case reports and a study in both dementia and schizophrenia. Extremely low risk intervention, I've had some great results.

Finally, again this is state dependent but I wouldn't typically be comfortable with a patient needing to get IM's at home. At this point they would likely be eligible for a group home in most northeastern states but again that might not be available in some places.
 
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The patient is a young adult with unspecified mental handicap who comes with mom. He has been on the following regimen for years:

clonidine 0.3mg per day
depakote DR 1000mg per day
geodon 200mg per day
valium 20mg per day

(Most of the above medications are split into two dosings a day.)

He has been on the regimen for years and is tolerating medications. Mother does not want to change the treatment. The above combination was from much trial and error and patient used to be much worse.

However, he has history of uncontrollable outbursts, even with optimized pharmacology. Since the last visit, he was hospitalized twice. Police was involved and had to restrain him. Inpatient treatment consists of increasing clonidine and depakote by a bit. Then he was discharged after a few days without prescriptions. Inpatient physician's rationale was that outpatient psychiatrist will manage medication.

Patient never remembers his outbursts. He cannot specific a trigger.

Since mom and patient wanted to keep the current medications, we agreed to add PRN medications for agitation. Mom is a nurse and know how to give injections.

1. What would be your PRN medication and why?

2. Would you have done something differently than prescribe PRN medication for agitation? If so, what would you have done?

What do you mean, "mom doesn't want to change"? She only wants to add a PRN on top of what he already has? If so, there really isn't anything you could offer, as any PO med likely won't start to have any effect until well after the incident. If she's not open to changing his standard regimen or non-pharmacologic interventions, I guess you really have nothing to offer and she's free to go elsewhere.
 
The patient is a young adult with unspecified mental handicap who comes with mom. He has been on the following regimen for years:

clonidine 0.3mg per day
depakote DR 1000mg per day
geodon 200mg per day
valium 20mg per day

(Most of the above medications are split into two dosings a day.)

He has been on the regimen for years and is tolerating medications. Mother does not want to change the treatment. The above combination was from much trial and error and patient used to be much worse.

However, he has history of uncontrollable outbursts, even with optimized pharmacology. Since the last visit, he was hospitalized twice. Police was involved and had to restrain him. Inpatient treatment consists of increasing clonidine and depakote by a bit. Then he was discharged after a few days without prescriptions. Inpatient physician's rationale was that outpatient psychiatrist will manage medication.

Patient never remembers his outbursts. He cannot specific a trigger.

Since mom and patient wanted to keep the current medications, we agreed to add PRN medications for agitation. Mom is a nurse and know how to give injections.

1. What would be your PRN medication and why?

2. Would you have done something differently than prescribe PRN medication for agitation? If so, what would you have done?

Why add a PRN? Why not address it on the front end and prevent agitation. Explain to the mother that there have been many medication trials but there must be something better as his behavior is not well controlled.
I'd start adding SSRI/SNRI to see what efficacy they have on his behavior using 5-HT to feed back to the frontal lobe. Check labs on VPA including NH4 - elevated NH4 could be contributory. There is little efficacy, in general, in using Geodon, consider multi-dosing Risperdal - again, no clear picture on what has been attempted, to what dosage and what the impact/problems were with previous medications. Consider Anticholinesterases - sometimes they can be effective anecdotally.

You'll need to spend a lot of time educating her.
 
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Suggest to her that you add a paralytic agent to just keep him in a medically induced coma. Pretty much the best way to keep the outbursts from happening in the first place. I agree with others, a good behavioral shaping/training program is the best bet. On units where we've had a good geropsychologist (LTC units) or a psychologist with good behavioral training background (long term behavioral units), the behavior programs work so much better than meds. Unless of course, meds are just used to keep someone gorked out 24/7. Consult with OT/SW to see if they know of any community resources on this front, if not, bring on the gorking.
 
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Recommending treatment for an "unspecified mental handicap" over the internet seems like a bad idea. Agree with the recommendation to do a behavioral analysis.
 
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One potential problem with using medications to manage ID population is the potential effect on an already diminished mental capacity. I did a quick search but couldn't find any data on this.
 
One potential problem with using medications to manage ID population is the potential effect on an already diminished mental capacity. I did a quick search but couldn't find any data on this.

You can just extrapolate the general research of certain meds (sedatives, opiates, etc) effects on cognitive domains. Most people are appreciably affected, although some more so (e.g., elderly). So, the meds will have an effect.
 
That sounds like a puny dose of valproate; I always prefer to push the meds they're already on rather than adding new and exciting agents. The evidence base is lousy if I recall correctly, so it is largely empirical. Getting the analysis and getting some kind of symptom diary will be really helpful too.

The PRN IM shots seem like a really bad idea, is the mom really going to chase after her kid with a syringe full of meds when he's raging out of control?
 
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In doing a lot of research on benzodiazepines, I come across some interesting things.

There were recently two new orphan drug status approved formulations of Ativan, one is an intranasal mist called Truveta. The approval was for a rare type of seizure; although, the company in their press releases also refers to panic disorder. Valium has been available for a long time as a rectal gel.

(As an aside, if you look at orphan drug approvals, most are for new uses of existing compounds, which was not the point of the program.)

I mention this because of the conversation regarding trying to use an IM injection during whatever type of episode is being discussed.

Versed is also available as an intranasal agent.

Not advocating for these. Actually I came across this info while doing research for the Massachusetts benzo bill (which attempts to curtail benzo usage). Benzo prescriptions continue to increase--since around 2000.

Anyhow, I thought I would mention it in case there are other drugs available intranasally.
 
You can just extrapolate the general research of certain meds (sedatives, opiates, etc) effects on cognitive domains. Most people are appreciably affected, although some more so (e.g., elderly). So, the meds will have an effect.

Or you could rely on the multiple clinical trials and subsequent meta-analyses. Behavioral interventions are the best, no question. But meds aren't just about inducing coma. They have moderate effect sizes, and large effect sizes in ASD. Risperidone and Aripiprazole are not particularly sedating and are extremely helpful in these cases.
 
Or you could rely on the multiple clinical trials and subsequent meta-analyses. Behavioral interventions are the best, no question. But meds aren't just about inducing coma. They have moderate effect sizes, and large effect sizes in ASD. Risperidone and Aripiprazole are not particularly sedating and are extremely helpful in these cases.

I am referring to clinical trials and meta-analyses. Most of the work with risperidone is with schizophrenics, in which there are "improvements" in cognition, but they are largely due to controlling of symptoms which leads to better task engagement and functional outcomes. This beneficial cognitive effect reverses trend at higher doses. Less data with a gero and peds population, but some similar findings, better management of aggression and some functional improvement, but neg cog effects at higher doses. No way to tell about the synergstic effects of this particular patient's polypharmacy considering many of the studies referenced generally look at the medications in isolation. As for the meds inducing coma/stupor/gorkness, really depends on the institution. At places with fewer functional supports (behavioral health/ot/SW) I have definitely seen med management used to pretty much put chemically manage pts at the expense of QOL. All a matter of available resources.
 
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More information is needed, quite obviously. But also quite obviously (I would think), is that the idea of simply medicating maladative behavior, even in someone is profoundly disabled, is not really good care since it doesn't not really utilize all of what the behavioral sciences/behavioral heath profession has to offer. If its rejected, so be it, but it still needs to but on on the menu and encouraged.

Rats can learn. So to thus can humans. All behavior has a function, you might need to really explore to find it, though.

None of this is to suggests that this is easy. Its not.
 
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I would exercise a little "paternalism" (using the word a little glibly). First, does he meet criteria for autism spectrum disorder? If so, that strengthens the case 1000x for retrying risperdal/abilify. Even if he doesn't meet criteria these are still good go tos. Everything else is going to be anecdotal (though one of my attendings swears by lithium when his confirmation bias tells him there are bipolarish symptoms--- another reason why I can't wait to be done with residency-- no more having to answer to attending nonsense!).

Also, the clonidine is probably contributing to rebound agitation
 
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A lot of good answers. More information regarding the patient would have been great, but it is not always possible to get, especially when mother is not sure about specifics and attending limits the time with patient.

Unpublished data from trials at emory suggests that alpha agonists may worsen irritability at higher doses (stick to < 2mg for guanfacine and < 0.2mg daily for clonidine).

You could also try transdermal nicotine - some case reports and a study in both dementia and schizophrenia. Extremely low risk intervention, I've had some great results.

Also, the clonidine is probably contributing to rebound agitation

I did not consider clonidine contributing to outbursts. Is it related to rebound hypertension. Any good sources on clonidine causing irritability / agitation?

Switching the regimen is a popular option, but the patient and mom has to be on board. They like what they have because it works well overall, save once a month or so. Considering that mom lives under the same roof as the patient while I don't, I'll honor her request as long as it is not outrageous.

It would be detrimental to the physician - patient / mom relationship to disregard what she says, switch up the medications, and have him become even worse. "I told the doctor this was going to happen, but he didn't listen."

Anyways, this is what I did (which I did not include in the beginning so your input won't be affected):

I added zyprexa zydis PRN. As some of you pointed out, a needle and an out-of-control man would potentially be disastrous. Zydis would be the easiest to administer without harm and has history of being used as PRN (which I learned from SDN, so thanks guys). Mom was happy. Attending was happy. Let's see how it turns out.

Next time I see them, I'll ask about behavioral interventions.
 
A lot of good answers. More information regarding the patient would have been great, but it is not always possible to get, especially when mother is not sure about specifics and attending limits the time with patient.





I did not consider clonidine contributing to outbursts. Is it related to rebound hypertension. Any good sources on clonidine causing irritability / agitation?

Switching the regimen is a popular option, but the patient and mom has to be on board. They like what they have because it works well overall, save once a month or so. Considering that mom lives under the same roof as the patient while I don't, I'll honor her request as long as it is not outrageous.

It would be detrimental to the physician - patient / mom relationship to disregard what she says, switch up the medications, and have him become even worse. "I told the doctor this was going to happen, but he didn't listen."

Anyways, this is what I did (which I did not include in the beginning so your input won't be affected):

I added zyprexa zydis PRN. As some of you pointed out, a needle and an out-of-control man would potentially be disastrous. Zydis would be the easiest to administer without harm and has history of being used as PRN (which I learned from SDN, so thanks guys). Mom was happy. Attending was happy. Let's see how it turns out.

Next time I see them, I'll ask about behavioral interventions.

I sympathize with what you are saying, I really do, by you are prioritizing avoiding negative affect from the mother over pursuing the most rational treatment plan. I do this too sometimes, but it's important to be aware of it, and ensure it doesn't drive your practice.
 
And, according to every patient ever who has had them "It's the OOONNNNLLLLYYYY thing that works!"

Yeah. It's an especially strong argument when they are in the hospital for intractable panic attacks following steady escalation of benzodiazepine dosage. More is clearly the answer.
 
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Yeah. It's an especially strong argument when they are in the hospital for intractable panic attacks following steady escalation of benzodiazepine dosage. More is clearly the answer.

Might as well change that .5 mg 2x/day to 1 mg 3/day at this point. I changed jobs a few months back and I've found our system's local candyperson. Every single patient this PCP has sent to me for an eval has been prescribed Xanax from her. Every single report I send back contains language that their medications are likely influencing subjective cognitive deficits and that they should discuss alternative anxiety management solutions with their PCP. I want to just put "Stop prescribing benzos to every person you see! Especially my geriatric patients!"
 
should discuss alternative anxiety management solutions

It's more complicated than this, but I would phrase it as going off the benzos improves anxiety--that itself is the alternative management. And the benzo itself is the disease. I say it's more complicated because I believe benzos, long-term, are anxiogenic but create manifestations of anxiety that don't precisely overlap with the symptoms of an anxiety disorder. I'm not sure that you could even tell what symptoms of the original anxiety disorder are still present when a person has taken benzos long-term. The original anxiety to me is a lesser disorder than the benzo disease.
 
People need to start learning to become comfortable with uncomfortable emotions. Stop trying to suppress them!
 
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People need to start learning to become comfortable with uncomfortable emotions. Stop trying to suppress them!
That's true. I also think that some of the release valves family structure used to provide for people with their emotions and development have disappeared.
 
Or you could rely on the multiple clinical trials and subsequent meta-analyses. Behavioral interventions are the best, no question. But meds aren't just about inducing coma. They have moderate effect sizes, and large effect sizes in ASD. Risperidone and Aripiprazole are not particularly sedating and are extremely helpful in these cases.
The problem occurs when "doc, the risperidone really helped for a while, but now it's not working and he is still having aggressive outbursts!" and then irrational polypharmacy ensues. I don't think anyone is saying that medications are never helpful in treating the developmentally disabled, just that there are more effective options that are often not implemented or are even hindered by the fruitless search for a pill that will make him or her behave.
 
It's more complicated than this, but I would phrase it as going off the benzos improves anxiety--that itself is the alternative management. And the benzo itself is the disease. I say it's more complicated because I believe benzos, long-term, are anxiogenic but create manifestations of anxiety that don't precisely overlap with the symptoms of an anxiety disorder. I'm not sure that you could even tell what symptoms of the original anxiety disorder are still present when a person has taken benzos long-term. The original anxiety to me is a lesser disorder than the benzo disease.

This highlights what I struggle with most in approaching anxiety with patients. It's not that I don't want to give them relief and don't recognize that giving a benzo can do that. Mostly, though, I see the anxiety disorder which is not the same as the symptom. Unfortunately, treating the disorder effectively might mean making sacrifices in treating the symptom. What really irks me is that the healthcare system and society have made the symptom functional, allying with the power of the distress and the powerlessness of the person against the distress, providing both an external hope of a solution to the distress and an absolving from the shame of failing to overcome it.
 
Might as well change that .5 mg 2x/day to 1 mg 3/day at this point. I changed jobs a few months back and I've found our system's local candyperson. Every single patient this PCP has sent to me for an eval has been prescribed Xanax from her. Every single report I send back contains language that their medications are likely influencing subjective cognitive deficits and that they should discuss alternative anxiety management solutions with their PCP. I want to just put "Stop prescribing benzos to every person you see! Especially my geriatric patients!"

Nobody reads consult notes. You gotta call the other doctor if you want to change their behavior.
 
Resident chiming in. Isn't scheduled propranolol indicated for aggression, and particularly as they get older, clonidine works less well, while propranolol continues to show efficacy into adulthood.

People at my facility agree that though geodon is indicated for aggression, we haven't had much luck with it in severe cases vs say risperdal or zyprexa or haldol (my personal pet theory about this is that geodon structure bears more similarity to abilify and latuda (strong affinity but weak antagonism) than say zyprexa or clozaril (strong affinity strong antagonism)). That's also quite a high level of geodon he's on right now. Cardiac symptoms may be misinterpreted by the patient as anxiety and result in more acting out... But you're saying that he has been on strong D2/S2 blockers before and those didn't work?

Agree with above that if pt is on this many medications and has repeat hospitalizations, then would need wrap around services.
 
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