Your favorite "off label" use of prescription medications

[scharnhorst]

Can list as many as you like , only key is has to be "off label" use

thanks

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[scharnhorst]

my apologies is was supposed to be in the FM /primary care forum
mods please move it
thanks

 

[heyjack70]

I like using Prozac for generalized anxiety disorder and seroquel XR for bipolar II disorder hypomania

 

[deleted87716]

There are lots.

Gabapentin for neuropathic pain.
Amitriptyline for post-herpetic neuralgia.
Paroxetine for premature ejaculation.
Metformin for impaired fasting glucose/"pre-diabetes" (if HgbA1c >6.0 but <6.5%).
Bupropion SR for smoking cessation.

 

[deleted87716]

I like using Prozac for generalized anxiety disorder

Prozac is indicated for panic disorder, so not strictly off-label.

 

[heyjack70]

Prozac is indicated for panic disorder, so not strictly off-label.

As a psychiatrist, I can tell you that panic disorder is not generalized anxiety disorder. I'm highlighting the absurdity of some of our FDA approvals in psych, when we know there is a class effect (e.g. SSRIs are good for panic, anxiety, depression, ocd, ptsd, etc....even if a specific drug didn't get FDA approval specifically).

 

[deleted87716]

As a psychiatrist, I can tell you that panic disorder is not generalized anxiety disorder. I'm highlighting the absurdity of some of our FDA approvals in psych, when we know there is a class effect (e.g. SSRIs are good for panic, anxiety, depression, ocd, ptsd, etc....even if a specific drug didn't get FDA approval specifically).

Yeah, I get that. But, there's definitely overlap between GAD and panic d/o, so (at least IMO), it's not entirely illogical to use Prozac for GAD (although it's not my first choice due to it generally being more activating than other SSRIs, like Lexapro - which is typically my go-to for GAD).

But, I concede if you're talking strict indications.

 

[heyjack70]

Yeah, I get that. But, there's definitely overlap between GAD and panic d/o, so (at least IMO), it's not entirely illogical to use Prozac for GAD (although it's not my first choice due to it generally being more activating than other SSRIs, like Lexapro - which is typically my go-to for GAD).

But, I concede if you're talking strict indications.

maybe I'm just still upset from the time insurance denied my patient's abilify for bipolar 2 disorder, because it isn't approved for bipolar 2 disorder. But when you look, nothing is specifically approved for bipolar 2 disorder. Sheesh.

 

[hallowmann]

There are lots.

Gabapentin for neuropathic pain.
Amitriptyline for post-herpetic neuralgia.
Paroxetine for premature ejaculation.
Metformin for impaired fasting glucose/"pre-diabetes" (if HgbA1c >6.0 but <6.5%).
Bupropion SR for smoking cessation.

Why Paxil as opposed to literally any SSRI? And on that note is any med FDA approved for premature ejaculation? I don't remember one.

Some other psych ones (of which there seem to be endless examples):
Prazosin and topiramate in the Nightmare/PTSD world comes to mind.
Wellbutrin+Naltrexone for amphetamine use disorders.
Propranolol for performance anxiety and akathisia (and I guess panic attacks).
Gabapentin for mild alcohol withdrawal.
Bupropion for ADHD.

Non-psych uses:
Topiramate for appetite suppression.
Wellbutrin for appetite suppression.
Mirtazapine for appetite promotion in elderly.
Gabapentin for neuropathic pain.
GLP-1s for weight loss/NAFLD.
Metformin for PCOS or GODM.

The lists really can go on. I think I need to start asking myself what meds I use for their FDA approved indications...

 

[deleted87716]

Why Paxil as opposed to literally any SSRI? And on that note is any med FDA approved for premature ejaculation? I don't remember one.

The useful (in this case) SE seems to be more pronounced w/Paxil. Nothing's FDA approved for that indication as far as I know.

 

[betamale]

Flomax, lidocaine iv for kidney stone
Lidocaine neb for cough
TXA for hemoptysis and nosebleed
Ativan for nausea and vertigo
Alcohol pads for nausea
Benadryl for headache, pain, agitation/anxiety
Haldol for pain, insomnia
Compazine for migraine
Morphine or ketamine for panicked resp distress
Nitro for pulmonary edema
Sugar for rectal prolapse

 

[Sardonix]

Not that it's non-FDA, but I still enjoy the history of how Viagra was discovered.

"Well Doc, my blood pressure is still the same... but while you're here, let me tell ya something about my sex life..."

 

[Postictal Raiden]

Not that it's non-FDA, but I still enjoy the history of how Viagra was discovered.

"Well Doc, my blood pressure is still the same... but while you're here, let me tell ya something about my sex life..."

Yeah, many drugs have been repurposed to treat conditions other than they were initially intended to treat. From my field, amantadine (resting tremors), primidone (essential tremors), gabapentin (neuropathy) as mentioned above, propranolol (migraine and ET), TCAs (neuropathy, migraine, and even vertigo), and don’t get me started on Depakote (mood instability, headache, myoclonus, etc).

 

[Sardonix]

Yeah, many drugs have been repurposed to treat conditions other than they were initially intended to treat. From my field, amantadine (resting tremors), primidone (essential tremors), gabapentin (neuropathy) as mentioned above, propranolol (migraine and ET), TCAs (neuropathy, migraine, and even vertigo), and don’t get me started on Depakote (mood instability, headache, myoclonus, etc).

I had a psych attending where if I didn't want to be pimped I'd just write "mood stabilizer" instead of a seizure medication like levitoracitam or valproic acid and then sit back for the inevitable 30min rant about the term being clinically disingenuous.

 

[Postictal Raiden]

I had a psych attending where if I didn't want to be pimped I'd just write "mood stabilizer" instead of a seizure medication like levitoracitam or valproic acid and then sit back for the inevitable 30min rant about the term being clinically disingenuous.

Funny. Yeah every attending has a pet peeve. One of mine would lose his **** if someone referred to TIA as a “mini stroke”.

 

[robellis]

Flomax, lidocaine iv for kidney stone
Lidocaine neb for cough
TXA for hemoptysis and nosebleed
Ativan for nausea and vertigo
Alcohol pads for nausea
Benadryl for headache, pain, agitation/anxiety
Haldol for pain, insomnia
Compazine for migraine
Morphine or ketamine for panicked resp distress
Nitro for pulmonary edema
Sugar for rectal prolapse

Haldol for insomnia...?

 

[hallowmann]

The useful (in this case) SE seems to be more pronounced w/Paxil. Nothing's FDA approved for that indication as far as I know.

My go-to is usually sertraline or fluoxetine, because I rarely see other adverse effects with them, but paroxetine is certainly also effective.

Funny. Yeah every attending has a pet peeve. One of mine would lose his **** if someone referred to TIA as a “mini stroke”.

AEDs are quite nice, and I mean technically "mini stroke" isn't the most accurate description... (inhales deeply in preparation for rant)...

Haldol for insomnia...?

Certainly used it for migraines/migraine prophylaxis especially prior to ECT, but I can't say I've used it for insomnia. I hate even using quetiapine for insomnia.

 

[robellis]

My go-to is usually sertraline or fluoxetine, because I rarely see other adverse effects with them, but paroxetine is certainly also effective.


AEDs are quite nice, and I mean technically "mini stroke" isn't the most accurate description... (inhales deeply in preparation for rant)...

Certainly used it for migraines/migraine prophylaxis especially prior to ECT, but I can't say I've used it for insomnia. I hate even using quetiapine for insomnia.

Agreed antipsychotics shouldn’t really be used for insomnia

 

[FrustratedFamDoc]

I've actually had success in 3 patients for Lamictal and fibromyalgia
Gabapentin: mood stabilizer when everything else has failed

 

[galactus]

My fav is nitroglycerin patches for tennis elbow. When I started doing that years ago, i would get calls from pharmacies asking me "are you sure? it's not indicated for that" or "you can't cut it into quarters!". Now I do it so much I haven't received a single inquiry from any pharmacist in a while lol.

 

[AFMD]

I do a lot of mental health, pain, and addiction where the patient has tried a lot of things and been through a lot of physicians.

So many options for prn anxiety or sleep treatment that aren't benzos: prn buspirone or TCAs, gabapentinoids, beta/alpha blockers, antihistamines, muscle relaxers, antipsychotics. I never use benzos, there are so many alternatives.

I've tried memantine a few times for fibro, migraine, pain, or augment for depression. Only when after trying everything else. Also modafinil or liothyronine as augment for depression.

I swear nortriptyline works just as well for smoking cessation as bupropion (although Chantix is king in my opinion). Speaking of which, I used to be nervous using bupropion with anxiety, but I think it actually works just fine now that I've used it with more patients. Use it for ADHD and weight loss.

Baclofen works great for as needed use for alcohol cravings in my experience, with or without Vivitrol or naltrexone for example. Gabapentin is preferred though, but with bad liver disease baclofen is probably the only option. Works for some bad GERD cases too. Surprising drug.

Tizanidine for those that don't respond to triptans for as needed migraine I've found works well.

I'm not really super comfortable with Medical Cannabis, but those that report it really helped them a lot I have used Marinol with good success.

Singular, doxepin, or famotadine as add ons for chronic rhinitis/allergies.

Echo the above, Topomax or bupropion for weight loss. I don't use stimulants for this.

Of course, like everyone else I use antidepressants for pain, some of which don't have the fda label.

Of course, buprenophine for pain with or without addiction history. Doesn't work any worse than full agonist opioids. I almost never start full agonist opioids, there's just no reason.

These are all after doing all the conventional and conservative treatments. I've been back into a lot of corners and had to get creative a few times.

 

[robellis]

I do a lot of mental health, pain, and addiction where the patient has tried a lot of things and been through a lot of physicians.

So many options for prn anxiety or sleep treatment that aren't benzos: prn buspirone or TCAs, gabapentinoids, beta/alpha blockers, antihistamines, muscle relaxers, antipsychotics. I never use benzos, there are so many alternatives.

I've tried memantine a few times for fibro, migraine, pain, or augment for depression. Only when after trying everything else. Also modafinil or liothyronine as augment for depression.

I swear nortriptyline works just as well for smoking cessation as bupropion (although Chantix is king in my opinion). Speaking of which, I used to be nervous using bupropion with anxiety, but I think it actually works just fine now that I've used it with more patients. Use it for ADHD and weight loss.

Baclofen works great for as needed use for alcohol cravings in my experience, with or without Vivitrol or naltrexone for example. Gabapentin is preferred though, but with bad liver disease baclofen is probably the only option. Works for some bad GERD cases too. Surprising drug.

Tizanidine for those that don't respond to triptans for as needed migraine I've found works well.

I'm not really super comfortable with Medical Cannabis, but those that report it really helped them a lot I have used Marinol with good success.

Singular, doxepin, or famotadine as add ons for chronic rhinitis/allergies.

Echo the above, Topomax or bupropion for weight loss. I don't use stimulants for this.

Of course, like everyone else I use antidepressants for pain, some of which don't have the fda label.

Of course, buprenophine for pain with or without addiction history. Doesn't work any worse than full agonist opioids. I almost never start full agonist opioids, there's just no reason.

These are all after doing all the conventional and conservative treatments. I've been back into a lot of corners and had to get creative a few times.

If the patient has been through a lot of physicians for mental health treatment they should probably be seeing a psychiatrist..also no offense but a lot of what you mention is absolutely not recommended so please do your patients a favor and recommend them to a specialist if possible

 

[AFMD]

If the patient has been through a lot of physicians for mental health treatment they should probably be seeing a psychiatrist..also no offense but a lot of what you mention is absolutely not recommended so please do your patients a favor and recommend them to a specialist if possible

I'm not a psychiatrist, but in the outpatient setting any family doctor should really be able to do at least 75% what a psychiatrist can do. These issues are just to common in Primary Care. Having said that, I actually do refer to Psychiatry all the time.

I didn't come up with these at all. All the treatments above are just reading the up-to-date article far enough down and just trying everything in order per the article. None of these are actually very original or creative on my part.

 

[robellis]

I'm not a psychiatrist, but in the outpatient setting any family doctor should really be able to do at least 75% what a psychiatrist can do. These issues are just to common in Primary Care. Having said that, I actually do refer to Psychiatry all the time.

I didn't come up with these at all. All the treatments above are just reading the up-to-date article far enough down and just trying everything in order per the article. None of these are actually very original or creative on my part.

If you are using prn buspar/TCAs, antipsychotics for sleep, and never using benzodiazepines, again it’s a matter of “you don’t know what you don’t know” and thinking you can do 75 percent of a specialists job is part of the problem

 

[AFMD]

If you are using prn buspar/TCAs, antipsychotics for sleep, and never using benzodiazepines, again it’s a matter of “you don’t know what you don’t know” and thinking you can do 75 percent of a specialists job is part of the problem

Sorry, I probably mix everything up by putting sleep/anxiety together.

I’ve used buspirone, as have many I work with, as needed for anxiety. In my environment, it is not uncommon. The evidence is for scheduled used though. I think PRN use is very reasonable in the right situation.

PRN TCAs for sleep? This is very mainstream. I believe doxepin has an FDA label for insomnia. I'd be very surprised if you have never used a TCA for insomnia.

I don’t recall a specific person I’ve used antipsychotics for insomnia, and I’d use Ambien first, after other alternatives. You could consider it in someone with another issue that could be treated with it as well? I’ve used it for PRN anxiety though, after other alternatives. Those with PTSD treated with benzos are more likely to kill themselves, I’ll use Seroquel is a heartbeat instead of a benzo. I’d try others first though. Too many physicians are using benzos inappropriately, and this probably plays a role in the deaths of some PTSD patients.

And no, I almost never use benzos. I don’t work in an ER or a hospital. If someone is in a crisis that needs them, they likely need a higher level of care. I know my limits.



Just a review of the rest of my list above:



Memantine is listed as a medication with limited data on uptodate, and there is a positive RCT. I’ve probably used this once or twice on fibromyalgia patients that tried TCAs, SNRIs, gabapentin, Lyrica, and exercise/PT (to the best of my memory), and for quite a while. I really think this is reasonable, and my alternative was a pain consult and likely opioids, so I really think this was reasonable.

UpToDate

It is also listed as a third line medication for chronic migraine. I’ve used it once that I remember, and it worked very well in this one patient. They had tried most of the first- and second-line medications from what I remember.

UpToDate

I don’t remember specifically using memantine for depression, but I did look it up, and there is not good evidence for this. I want to make sure this is clear. It is listed on uptodate as a treatment with little to no benefit for depression.

UpToDate

Thyroid hormone is very reasonable for truly treatment resistant depression. There is an AAFP article as well. I’d encourage everyone to consider it, it is probably an underutilized treatment, and I think family doctors are especially equipped to use it given our broad training including both mental health and endocrinology expertise.

UpToDate

Modafinil as an augment for depression is more unorthodox, but very reasonable per UpToDate. I find it is useful for depression (as augment only) with continued fatigue/hypersomnia despite good CPAP treatment in OSA, and for depression/apathy with dementia as well. I usually try bupropion as an augment first, and I actually use modafinil very uncommonly.

UpToDate

Nortriptyline is very commonly used for smoking cessation. It is a second line medication. If you haven't used it, you have not treated smoking cessation enough, one of the biggest killers of our patients.

UpToDate

I think a lot of family doctors really shy away from addiction medicine, but it’s so common, we should all be experts. Baclofen is used all the time for alcohol use disorder in those with bad cirrhosis. The data is not amazing, but there are precious few options with a really bad liver. Any good GI doc will be familiar with this as well.

UpToDate

UpToDate

Tizanidine has some evidence for headache prevention, so it’s my first muscle relaxer for headache. I don’t think there is good evidence for PRN use, but I think this is reasonable. I’ve seen a lot of crazy headache cocktails out there, mine are pretty mainstream.

UpToDate

I don’t know what to say about Marinol. I believe there is a clinical trial underway for depression. Whatever the trials say, if something worked in a particular patient, that is difficult to argue with. I’ve never used it on anyone who wasn’t on Medical Cannabis previously. There is some harm reduction argument to be made here as well. I recognize this is well out of the mainstream, but this is well within a “reasonable physician” standard.

Singular was more popular for allergies before the new mental health warnings. I try to push Flonase now more, and it is the better treatment all things being equal. Flonase works really well in my experience.

UpToDate

Famotidine is an extrapolation from ER use in allergic reactions. Admittedly, not the best evidence. I think I've tried it once or twice.

Doxepin, similarly, is an extrapolation from use for other allergy related conditions, but man does it work. In my experience, this works better than any 2nd gen antihistamine most of the time. Give this drug a chance!

Topamax and bupropion are used for weight loss all the time. Similarly for antidepressants for pain, some with FDA labels.

Buprenorphine actually does have an FDA label for pain, so doesn’t belong here. I strongly think that many of my peers using full agonist opioids when they could be using opioids are exposing their patients to higher risk than necessary, and I also believe that this sentiment is very quickly growing in the mainstream of medicine.


BTW: I do not think I can do 75% or what any specialist can do, that would be insane. I can't do what a psychiatrist does in the hospital or the ER at all. I think you are selling the Psychiatrist short here! Outpatient psychiatric care is only one part of what they do. Being able to do the easiest 75% of psychiatric management outpatient is a very reasonable goal in primary care. Especially where most of us work in areas with Psychiatrist shortage. I doubt many of us send more than 25% of our mental health diagnoses to a psychiatrist? If you live in a place where that is even possible, please let me know about it!

 

[scharnhorst]

thanks I love this aspect about primary care

 

[TableMD]

Note sure it counts as a "favorite" since I used it ONCE, but it worked so well I am grateful.

I had a poor woman who was very jammed up after a post surgical infection, worsening pain became a chronic focal hotspot of pain and misery that after a very, very, very exhaustive work up/imaging/interventions/consultations, I eventually diagnosed her as suffering from complex regional pain syndrome, type II, and as a matter of last resort tried her on Alendronate at it worked. Crazy.

 

[FamilymedMD]

SL buprenorphine naloxone for pain (only the patch is FDA approved for pain)

 

[scharnhorst]

how safe is clonidine qhs for sleep , does it not cause rebound HTN/tachy if only once a day dosing ?

 

[AFMD]

SL buprenorphine naloxone for pain (only the patch is FDA approved for pain)

There is a buccal form that is FDA labeled for pain as well.

I think the issue with rebound in clonidine is typically when it is used chronically and discontinued. Using half or a whole tablet of 0.1mg HS is pretty common in mental health circles here, but definitely not the most common.

 

[Ironspy]

Sorry, I probably mix everything up by putting sleep/anxiety together.

I’ve used buspirone, as have many I work with, as needed for anxiety. In my environment, it is not uncommon. The evidence is for scheduled used though. I think PRN use is very reasonable in the right situation.

PRN TCAs for sleep? This is very mainstream. I believe doxepin has an FDA label for insomnia. I'd be very surprised if you have never used a TCA for insomnia.

I don’t recall a specific person I’ve used antipsychotics for insomnia, and I’d use Ambien first, after other alternatives. You could consider it in someone with another issue that could be treated with it as well? I’ve used it for PRN anxiety though, after other alternatives. Those with PTSD treated with benzos are more likely to kill themselves, I’ll use Seroquel is a heartbeat instead of a benzo. I’d try others first though. Too many physicians are using benzos inappropriately, and this probably plays a role in the deaths of some PTSD patients.

And no, I almost never use benzos. I don’t work in an ER or a hospital. If someone is in a crisis that needs them, they likely need a higher level of care. I know my limits.



Just a review of the rest of my list above:



Memantine is listed as a medication with limited data on uptodate, and there is a positive RCT. I’ve probably used this once or twice on fibromyalgia patients that tried TCAs, SNRIs, gabapentin, Lyrica, and exercise/PT (to the best of my memory), and for quite a while. I really think this is reasonable, and my alternative was a pain consult and likely opioids, so I really think this was reasonable.

UpToDate

It is also listed as a third line medication for chronic migraine. I’ve used it once that I remember, and it worked very well in this one patient. They had tried most of the first- and second-line medications from what I remember.

UpToDate

I don’t remember specifically using memantine for depression, but I did look it up, and there is not good evidence for this. I want to make sure this is clear. It is listed on uptodate as a treatment with little to no benefit for depression.

UpToDate

Thyroid hormone is very reasonable for truly treatment resistant depression. There is an AAFP article as well. I’d encourage everyone to consider it, it is probably an underutilized treatment, and I think family doctors are especially equipped to use it given our broad training including both mental health and endocrinology expertise.

UpToDate

Modafinil as an augment for depression is more unorthodox, but very reasonable per UpToDate. I find it is useful for depression (as augment only) with continued fatigue/hypersomnia despite good CPAP treatment in OSA, and for depression/apathy with dementia as well. I usually try bupropion as an augment first, and I actually use modafinil very uncommonly.

UpToDate

Nortriptyline is very commonly used for smoking cessation. It is a second line medication. If you haven't used it, you have not treated smoking cessation enough, one of the biggest killers of our patients.

UpToDate

I think a lot of family doctors really shy away from addiction medicine, but it’s so common, we should all be experts. Baclofen is used all the time for alcohol use disorder in those with bad cirrhosis. The data is not amazing, but there are precious few options with a really bad liver. Any good GI doc will be familiar with this as well.

UpToDate

UpToDate

Tizanidine has some evidence for headache prevention, so it’s my first muscle relaxer for headache. I don’t think there is good evidence for PRN use, but I think this is reasonable. I’ve seen a lot of crazy headache cocktails out there, mine are pretty mainstream.

UpToDate

I don’t know what to say about Marinol. I believe there is a clinical trial underway for depression. Whatever the trials say, if something worked in a particular patient, that is difficult to argue with. I’ve never used it on anyone who wasn’t on Medical Cannabis previously. There is some harm reduction argument to be made here as well. I recognize this is well out of the mainstream, but this is well within a “reasonable physician” standard.

Singular was more popular for allergies before the new mental health warnings. I try to push Flonase now more, and it is the better treatment all things being equal. Flonase works really well in my experience.

UpToDate

Famotidine is an extrapolation from ER use in allergic reactions. Admittedly, not the best evidence. I think I've tried it once or twice.

Doxepin, similarly, is an extrapolation from use for other allergy related conditions, but man does it work. In my experience, this works better than any 2nd gen antihistamine most of the time. Give this drug a chance!

Topamax and bupropion are used for weight loss all the time. Similarly for antidepressants for pain, some with FDA labels.

Buprenorphine actually does have an FDA label for pain, so doesn’t belong here. I strongly think that many of my peers using full agonist opioids when they could be using opioids are exposing their patients to higher risk than necessary, and I also believe that this sentiment is very quickly growing in the mainstream of medicine.


BTW: I do not think I can do 75% or what any specialist can do, that would be insane. I can't do what a psychiatrist does in the hospital or the ER at all. I think you are selling the Psychiatrist short here! Outpatient psychiatric care is only one part of what they do. Being able to do the easiest 75% of psychiatric management outpatient is a very reasonable goal in primary care. Especially where most of us work in areas with Psychiatrist shortage. I doubt many of us send more than 25% of our mental health diagnoses to a psychiatrist? If you live in a place where that is even possible, please let me know about it!

I"m a psychiatrist and all of these seem reasonable FWIW. I rarely prescribe benzos and never start chronic benzos as I don't think the risk/benefit is favorable. I don't use antipsychotics for sleep unless I'm dealing with mania/psychosis given the metabolic AEs but I see plenty of psychiatrists doing this.