What’s your upper limit for number of medications?

[nowaysanjose]

I’ve seen plenty of NP regimens having greater than 10 or more meds for very questionable diagnoses. While rare, I’ve also seen MDs do this as well. What is your upper limit for starting medications at a time? 3, 4, 5 or more? How many medications are you comfortable managing at once before starting to discontinue some?

---

Members don't see this ad.

 

[Stagg737]

I’ve seen plenty of NP regimens having greater than 10 or more meds for very questionable diagnoses. While rare, I’ve also seen MDs do this as well. What is your upper limit for starting medications at a time? 3, 4, 5 or more? How many medications are you comfortable managing at once before starting to discontinue some?

Depends. In the outpatient setting I typically don't start more than 2 scheduled and will consider 1-2 prns. Inpatient I'm more likely to start more (especially PRNs) because we can monitor them. It obviously also depends on the diagnoses. How many at once is really dependent on the patient. I don't like patients on more than 3-4 scheduled meds, but sometimes more are warranted. I've seen patients where I legitimately felt like 8+ meds could be justified. I want patients on as few meds as possible, but I'm also fine with someone being on 5+ if they're tolerating them and receiving benefit from each one.

 

[J ROD]

As many as it takes......nothing more.

 

[nowaysanjose]

Depends. In the outpatient setting I typically don't start more than 2 scheduled and will consider 1-2 prns. Inpatient I'm more likely to start more (especially PRNs) because we can monitor them. It obviously also depends on the diagnoses. How many at once is really dependent on the patient. I don't like patients on more than 3-4 scheduled meds, but sometimes more are warranted. I've seen patients where I legitimately felt like 8+ meds could be justified. I want patients on as few meds as possible, but I'm also fine with someone being on 5+ if they're tolerating them and receiving benefit from each one.

Thank you, this is very helpful

 

[Liquid8]

No issue with managing patients on multiple meds, but usually will draw a hard line at prescribing more than 2 of any one class. Where possible, my standard process is to introduce one regular medication at a time to account for side effects and avoid any confusion.

There are different prescribing styles however. My mentors will try and maximise a single agent, pushing doses above PI limits if there were no side effects before adding additional agents. In other countries, I am aware of psychiatrists sticking solidly to the PI recommendations, but adding up to 3, 4 or even 5 other drugs of the same class.

 

[nowaysanjose]

No issue with managing patients on multiple meds, but usually will draw a hard line at prescribing more than 2 of any one class. Where possible, my standard process is to introduce one regular medication at a time to account for side effects and avoid any confusion.

There are different prescribing styles however. My mentors will try and maximise a single agent, pushing doses above PI limits if there were no side effects before adding additional agents. In other countries, I am aware of psychiatrists sticking solidly to the PI recommendations, but adding up to 3, 4 or even 5 other drugs of the same class.

This is what I was wondering as well, teasing out side effects if starting multiple agents at once.

 

[FlowRate]

Rare for me to start or dose change more than one at a time in outpatients unless there's an obvious reason to do so. E.g. pt reliably has activation when starting an SSRI so I'll do a simultaneous short course of BID clonazepam to get them through that. Or a pt with pretty bad hypomania/mania that you want to get on top of.

As a general rule it becomes suspect when someone is on more than 3 standing meds at the same time. At that point it's likely a failure to discontinue meds that were having little or no effect.

 

[clausewitz2]

Rare for me to start or dose change more than one at a time in outpatients unless there's an obvious reason to do so. E.g. pt reliably has activation when starting an SSRI so I'll do a simultaneous short course of BID clonazepam to get them through that. Or a pt with pretty bad hypomania/mania that you want to get on top of.

As a general rule it becomes suspect when someone is on more than 3 standing meds at the same time. At that point it's likely a failure to discontinue meds that were having little or no effect.

This generally mirrors my practice. The one exception is people who may be on 3 standing meds with fairly well-documented efficacy who also happen to be on naltrexone or acamprosate for AUD. It's all connected obviously but the utility of the naltrexone v. most other medications is clear and specific enough that it doesn't strike me as strictly redundant.

 

[Stagg737]

Depends. In the outpatient setting I typically don't start more than 2 scheduled and will consider 1-2 prns. Inpatient I'm more likely to start more (especially PRNs) because we can monitor them. It obviously also depends on the diagnoses. How many at once is really dependent on the patient. I don't like patients on more than 3-4 scheduled meds, but sometimes more are warranted. I've seen patients where I legitimately felt like 8+ meds could be justified. I want patients on as few meds as possible, but I'm also fine with someone being on 5+ if they're tolerating them and receiving benefit from each one.

I should clarify the bolded, this is for an initial encounter with a patient or a new eval. For f/up visits I try to only change 1 med at once and typically don't change more than 2 unless a patient just isn't really using a prn anymore. In that case though I'm not really discontinuing it since they self-discontinued it. I won't change more than 2 meds a patient is consistently taking in one appointment and typically only change 2 if I'm doing a cross-titration.

 

[mmms85]

For starting medications at one time? Depends on inpatient or outpatient.

Inpatient it's not rare for me to start several drugs at once, like starting Zyprexa + PRN IM Haldol/Ativan for acute psychosis or Lithium + Seroquel + PRN Klonopin for mania, where outpatient I generally don't do that. In the hospital these patients are generally doing much worse and require more aggressive treatment, plus we can monitor them very closely. Outpatient, I rarely touch more than one med at a time, with some exceptions. An example of an exception is starting Inderal alongside Abilify in someone who is psychotic but does not require inpatient treatment and has had problems with akathisia in the past.

So I'd say my very upper limit for meds to start at one time inpatient is 4, outpatient is 2, but there may be situations that challenge this and I don't like to be too rigid.

 

[allantois]

I've seen garbage regimens from all sorts of providers. Psychiatrists past retirement seem to particularly not care about having patients on 3 controlled meds if not more