Auvelity

[annoyedpsychiatrist]

has insurance coverage gotten better with this or does insurance coverage still restrict its use significantly? For the people using it, have you guys been using adjunct medicaitons with auvelity like SGAs, SSRIs or just using it as a primary therapy?

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[whopper]

It's an ongoing process. I've had over 50% success rate with coverage. All new meds go through a phase where there's little coverage, then coverage gets better. Tradename meds that have been out for years like Rexulti and Vraylar now have overwhelming majority coverage.

I've found Auvelity + Vraylar (and unfortunately both are very expensive) as EXTREMELY efficacious. In the last year I've been able to get some patients off of ECT and put treatment resistant depression into literally complete remission thanks to these meds where several SSRIs, Bupriopion, SNRIs, Mirtazpine + several augmentations didn't work.

I've even noticed some psychiatrists who were profiting quite nicely with Ketamine treatments, and trying the patient on Auvelity with success to the degree where the antisocial psychiatrist now no longer offers Auvelity because it caused the patient, improved with Auvelity, no longer wants Ketamine.

 

[ObsequiousAplomb]

It's interesting that you're finding the combination of Auvelity and Vraylar helpful in TRD. Wasn't there that big study that showed that Vraylar was well-tolerated but not effective in depression?

 

[calvnandhobbs68]

It's interesting that you're finding the combination of Auvelity and Vraylar helpful in TRD. Wasn't there that big study that showed that Vraylar was well-tolerated but not effective in depression?

Vraylar has an FDA approval as an adjunct for MDD.

 

[whopper]

Wasn't there that big study that showed that Vraylar was well-tolerated but not effective in depression?

I've heard of one study, but haven't seen it. Despite this I've seen Vraylar work better than several stand-alone antidepressants. I've had patients where SSRI or SNRI partially worked, Vraylar addition they felt much better, then on their own, without talking to me about it they stopped the SSRI, and they told me they maintained the improvement without the SSRI or SNRI.

Also, although the data for Vraylar were done over a month, I've seen patients get better with Vraylar within days of used instead of the weeks with an SSRI or SNRI.

So WTF does this all mean? Seriously I'm not sure myself. It could be that Vraylar does work well as a standalone antidepressant, but this one study might've not captured it. (Almost all meds have several studies showing they didn't work such as statins, SSRIs, etc. As we should all know the publication standards are 95% accurate, not 100%, and that a study, even if well done might've not captured what is really going on). It's possible the patient, already in remission from depression, might've no longer needed the antidepressant, although all of them say they never felt as improved until the Vraylar was added. It could be that the Vraylar is hitting a nice receptor that wasn't being targeted by the SSRI or SNRI, but it's not approved for MDD (but it is approved as an MDD adjunct only treatment). Maybe that patient truly had Bipolar Depression, although the same patients were never manic even on an antidepressant for years.

In any case, however, I can say, and the science and math backs this up, when SSRIs, SNRIs, DNRI, Mirtazapine, have been tried and failed or only partial success you're going to have patients where the novel mechanisms such as Auvelity, Ketamine, TMS, or ECT (or Vraylar) should be tried. Unfortunately this slice of our patients will not be small. You got to try a new approach, and given that we had a drought where no new meds with novel mechanisms had come out for over a decade, all psychiatrists with a practice will have at least dozens of treatment resistant depression (TRD) patients where these novel mechanisms should be tried if they already haven't been.

I've had patients for over 5 years, TRD, and with the introduction of one of these newer options got better where before there was no or only partial improvement. My list of TRD patients literally was cut down to less than half in the last year because of these newer options. The list for me now is significantly dwindled, but unfortunately still present.

 

[psycho-matic]

I've heard of one study, but haven't seen it. Despite this I've seen Vraylar work better than several stand-alone antidepressants. I've had patients where SSRI or SNRI partially worked, Vraylar addition they felt much better, then on their own, without talking to me about it they stopped the SSRI, and they told me they maintained the improvement without the SSRI or SNRI.

Also, although the data for Vraylar were done over a month, I've seen patients get better with Vraylar within days of used instead of the weeks with an SSRI or SNRI.

So WTF does this all mean? Seriously I'm not sure myself. It could be that Vraylar does work well as a standalone antidepressant, but this one study might've not captured it. (Almost all meds have several studies showing they didn't work such as statins, SSRIs, etc. As we should all know the publication standards are 95% accurate, not 100%, and that a study, even if well done might've not captured what is really going on). It's possible the patient, already in remission from depression, might've no longer needed the antidepressant, although all of them say they never felt as improved until the Vraylar was added. It could be that the Vraylar is hitting a nice receptor that wasn't being targeted by the SSRI or SNRI, but it's not approved for MDD (but it is approved as an MDD adjunct only treatment). Maybe that patient truly had Bipolar Depression, although the same patients were never manic even on an antidepressant for years.

In any case, however, I can say, and the science and math backs this up, when SSRIs, SNRIs, DNRI, Mirtazapine, have been tried and failed or only partial success you're going to have patients where the novel mechanisms such as Auvelity, Ketamine, TMS, or ECT (or Vraylar) should be tried. Unfortunately this slice of our patients will not be small. You got to try a new approach, and given that we had a drought where no new meds with novel mechanisms had come out for over a decade, all psychiatrists with a practice will have at least dozens of treatment resistant depression (TRD) patients where these novel mechanisms should be tried if they already haven't been.

I've had patients for over 5 years, TRD, and with the introduction of one of these newer options got better where before there was no or only partial improvement. My list of TRD patients literally was cut down to less than half in the last year because of these newer options. The list for me now is significantly dwindled, but unfortunately still present.

Have you seen much discontinuance of Auvelity due to nausea?

 

[allantois]

Auvelity seems to work pretty well; probably could use adjuncts with it, although I've never done that

Auvelity + Vraylar is a 2k+ combo..

 

[great_expectations]

I've heard of one study, but haven't seen it. Despite this I've seen Vraylar work better than several stand-alone antidepressants. I've had patients where SSRI or SNRI partially worked, Vraylar addition they felt much better, then on their own, without talking to me about it they stopped the SSRI, and they told me they maintained the improvement without the SSRI or SNRI.

Also, although the data for Vraylar were done over a month, I've seen patients get better with Vraylar within days of used instead of the weeks with an SSRI or SNRI.

So WTF does this all mean? Seriously I'm not sure myself. It could be that Vraylar does work well as a standalone antidepressant, but this one study might've not captured it. (Almost all meds have several studies showing they didn't work such as statins, SSRIs, etc. As we should all know the publication standards are 95% accurate, not 100%, and that a study, even if well done might've not captured what is really going on). It's possible the patient, already in remission from depression, might've no longer needed the antidepressant, although all of them say they never felt as improved until the Vraylar was added. It could be that the Vraylar is hitting a nice receptor that wasn't being targeted by the SSRI or SNRI, but it's not approved for MDD (but it is approved as an MDD adjunct only treatment). Maybe that patient truly had Bipolar Depression, although the same patients were never manic even on an antidepressant for years.

In any case, however, I can say, and the science and math backs this up, when SSRIs, SNRIs, DNRI, Mirtazapine, have been tried and failed or only partial success you're going to have patients where the novel mechanisms such as Auvelity, Ketamine, TMS, or ECT (or Vraylar) should be tried. Unfortunately this slice of our patients will not be small. You got to try a new approach, and given that we had a drought where no new meds with novel mechanisms had come out for over a decade, all psychiatrists with a practice will have at least dozens of treatment resistant depression (TRD) patients where these novel mechanisms should be tried if they already haven't been.

I've had patients for over 5 years, TRD, and with the introduction of one of these newer options got better where before there was no or only partial improvement. My list of TRD patients literally was cut down to less than half in the last year because of these newer options. The list for me now is significantly dwindled, but unfortunately still present.

This isn't hard. Here are the two studies looking at cariprazine in treatment resistant depression:

1. S Durgam et al. Efficacy and safety of adjunctive cariprazine in inadequate responders to antidepressants: a randomized, double-blind, placebo-controlled study in adult patients with major depressive disorder. J Clin Psychiatry 2016; 77:371. doi:10.4088/jcp.15m10070
2. GS Sachs et al. Adjunctive cariprazine for the treatment of patients with major depressive disorder: a randomized, double-blind, placebo-controlled phase 3 study. Am J Psychiatry 2023; 180:241. doi:10.1176/appi.ajp.20220504

Only one of them showed statistical benefit. Additionally, aripiprazole has much clearer benefit in this population. I swear psychiatrists would rather die by antecdata rather than look up high-quality primary research.

 

[calvnandhobbs68]

This isn't hard. Here are the two studies looking at cariprazine in treatment resistant depression:

1. S Durgam et al. Efficacy and safety of adjunctive cariprazine in inadequate responders to antidepressants: a randomized, double-blind, placebo-controlled study in adult patients with major depressive disorder. J Clin Psychiatry 2016; 77:371. doi:10.4088/jcp.15m10070
2. GS Sachs et al. Adjunctive cariprazine for the treatment of patients with major depressive disorder: a randomized, double-blind, placebo-controlled phase 3 study. Am J Psychiatry 2023; 180:241. doi:10.1176/appi.ajp.20220504

Only one of them showed statistical benefit. Additionally, aripiprazole has much clearer benefit in this population. I swear psychiatrists would rather die by antecdata rather than look up high-quality primary research.

Right those are the two pharma sponsored trials that led to the FDA approval.

 

[SmallBird]

I've heard of one study, but haven't seen it. Despite this I've seen Vraylar work better than several stand-alone antidepressants. I've had patients where SSRI or SNRI partially worked, Vraylar addition they felt much better, then on their own, without talking to me about it they stopped the SSRI, and they told me they maintained the improvement without the SSRI or SNRI.

Also, although the data for Vraylar were done over a month, I've seen patients get better with Vraylar within days of used instead of the weeks with an SSRI or SNRI.

So WTF does this all mean? Seriously I'm not sure myself. It could be that Vraylar does work well as a standalone antidepressant, but this one study might've not captured it. (Almost all meds have several studies showing they didn't work such as statins, SSRIs, etc. As we should all know the publication standards are 95% accurate, not 100%, and that a study, even if well done might've not captured what is really going on). It's possible the patient, already in remission from depression, might've no longer needed the antidepressant, although all of them say they never felt as improved until the Vraylar was added. It could be that the Vraylar is hitting a nice receptor that wasn't being targeted by the SSRI or SNRI, but it's not approved for MDD (but it is approved as an MDD adjunct only treatment). Maybe that patient truly had Bipolar Depression, although the same patients were never manic even on an antidepressant for years.

In any case, however, I can say, and the science and math backs this up, when SSRIs, SNRIs, DNRI, Mirtazapine, have been tried and failed or only partial success you're going to have patients where the novel mechanisms such as Auvelity, Ketamine, TMS, or ECT (or Vraylar) should be tried. Unfortunately this slice of our patients will not be small. You got to try a new approach, and given that we had a drought where no new meds with novel mechanisms had come out for over a decade, all psychiatrists with a practice will have at least dozens of treatment resistant depression (TRD) patients where these novel mechanisms should be tried if they already haven't been.

I've had patients for over 5 years, TRD, and with the introduction of one of these newer options got better where before there was no or only partial improvement. My list of TRD patients literally was cut down to less than half in the last year because of these newer options. The list for me now is significantly dwindled, but unfortunately still present.

Do you feel more confident in your uncontrolled unblinded single-case designs than available RCT data?

 

[splik]

Right those are the two pharma sponsored trials that led to the FDA approval.

not only sponsored by pharma, the papers were co-authored by pharma too. many papers are ghost written but they shamelessly put their names to it!

 

[annoyedpsychiatrist]

Interesting, ive tried vraylar for depression augmentation and never had any luck with it. Ive had much better luck for bipolar depression and schizophrenia. Ive found older and younger people have issues tolerating it. I actually prefer abilify as an SGA for augmentation. I rexulti is hit or miss for me as well.

Do you take people off SSRis and go with auvelity then? Assuming theyre majorly depressed and on an SSRI, do you just switch them?

 

[Merovinge]

not only sponsored by pharma, the papers were co-authored by pharma too. many papers are ghost written but they shamelessly put their names to it!

Can they sign with $$ in their names? It's already a thing in hip-hop, so there is precedent.

 

[Merovinge]

I've heard of one study, but haven't seen it. Despite this I've seen Vraylar work better than several stand-alone antidepressants. I've had patients where SSRI or SNRI partially worked, Vraylar addition they felt much better, then on their own, without talking to me about it they stopped the SSRI, and they told me they maintained the improvement without the SSRI or SNRI.

Also, although the data for Vraylar were done over a month, I've seen patients get better with Vraylar within days of used instead of the weeks with an SSRI or SNRI.

So WTF does this all mean? Seriously I'm not sure myself. It could be that Vraylar does work well as a standalone antidepressant, but this one study might've not captured it. (Almost all meds have several studies showing they didn't work such as statins, SSRIs, etc. As we should all know the publication standards are 95% accurate, not 100%, and that a study, even if well done might've not captured what is really going on). It's possible the patient, already in remission from depression, might've no longer needed the antidepressant, although all of them say they never felt as improved until the Vraylar was added. It could be that the Vraylar is hitting a nice receptor that wasn't being targeted by the SSRI or SNRI, but it's not approved for MDD (but it is approved as an MDD adjunct only treatment). Maybe that patient truly had Bipolar Depression, although the same patients were never manic even on an antidepressant for years.

In any case, however, I can say, and the science and math backs this up, when SSRIs, SNRIs, DNRI, Mirtazapine, have been tried and failed or only partial success you're going to have patients where the novel mechanisms such as Auvelity, Ketamine, TMS, or ECT (or Vraylar) should be tried. Unfortunately this slice of our patients will not be small. You got to try a new approach, and given that we had a drought where no new meds with novel mechanisms had come out for over a decade, all psychiatrists with a practice will have at least dozens of treatment resistant depression (TRD) patients where these novel mechanisms should be tried if they already haven't been.

I've had patients for over 5 years, TRD, and with the introduction of one of these newer options got better where before there was no or only partial improvement. My list of TRD patients literally was cut down to less than half in the last year because of these newer options. The list for me now is significantly dwindled, but unfortunately still present.

Not commenting on anything about the Vrylar, but I really agree that if people have had solid trials of several of the more classic antidepressants that it makes sense to use novel mechanism medications. It's already so defeating to have TRD, having seen patient's were the psychiatrists appear to have given up must be soul crushing. Sure they need better sleep, diet, exercise but I still like the idea of having someone working to help with novel interventions in their corner, always pushing to help.

 

[Stagg737]

This isn't hard. Here are the two studies looking at cariprazine in treatment resistant depression:

1. S Durgam et al. Efficacy and safety of adjunctive cariprazine in inadequate responders to antidepressants: a randomized, double-blind, placebo-controlled study in adult patients with major depressive disorder. J Clin Psychiatry 2016; 77:371. doi:10.4088/jcp.15m10070
2. GS Sachs et al. Adjunctive cariprazine for the treatment of patients with major depressive disorder: a randomized, double-blind, placebo-controlled phase 3 study. Am J Psychiatry 2023; 180:241. doi:10.1176/appi.ajp.20220504

Only one of them showed statistical benefit. Additionally, aripiprazole has much clearer benefit in this population. I swear psychiatrists would rather die by antecdata rather than look up high-quality primary research.

Do you feel more confident in your uncontrolled unblinded single-case designs than available RCT data?

I've talked about it before, but there's unfortunately a lot of problems with EBM in psych, not least of which being the problem with EBM for any medical field that data on large groups in RCTs and meta-analyses may not be applicable to the individual. Studies like this are great as guidelines and for general practices, but on an individual level everyone is going to be different. I can give plenty of examples where going off-label or using a med that's "not indicated" for something but can be efficacious is the "right med" for that patient (buspar for depression for example).

Yes, we need to follow the basics and EBM for most patients. However, there's also plenty of patients in psych where the standard recommendations just don't work or are inadequate. Being specialists partially means knowing when to stray from the typical treatment path for individual patients for whatever reason. If that weren't the case, they could just create algorithms that PCPs and mid-levels could follow and we wouldn't be necessary.

 

[whopper]

Do you take people off SSRis and go with auvelity then? Assuming theyre majorly depressed and on an SSRI, do you just switch them?

At most I tell people they could lessen the dosage of the SSRI, but then we run the risk of the current regimen that is currently working now not working.

I got this from prior experience with Buspirone. I've had several patients where an SSRI or SNRI worked but caused sexual side effects, but with Buspirone augmentation, we were able to keep the success with a lesser dose of an SSRI or SNRI where there were no sexual side effect or much less and more tolerable effects.

Further, I tell patients that they could just keep the dosage the way it is as SSRIs and SNRIs are very safe (unless there's a serious side effect) and there's also the effect that longer remission may correlate to need for lesser dosage, so why risk now if they can risk later with less risk.

One more factor I tell patients is if they're currently happy with their current regimen, do not risk changing the regimen unless things for the next several weeks will be smooth sailing. I give the example of, "if your Bar exam is 3 weeks from now, no way do you change your regimen if it's working."

Also it's not just about Vraylar. I've seen Busiprone, Rexulti, and Lamotrigine work very well as augmentation meds. Just that with Rexulti and Vraylar I do see benefits very quickly where Buspirone usually takes 2-3 weeks, and Lamotrigine over 1 month before we usually see any significant benefit. To save the patient money, I also tell them even if successful on Vraylar, now that they're stable we could try to switch them to something else while the Vraylar acts as a bridge med. Most patients don't want to get off unless their insurance already stated they will not pay for it.

 

[great_expectations]

Right those are the two pharma sponsored trials that led to the FDA approval.

not only sponsored by pharma, the papers were co-authored by pharma too. many papers are ghost written but they shamelessly put their names to it!

I've talked about it before, but there's unfortunately a lot of problems with EBM in psych, not least of which being the problem with EBM for any medical field that data on large groups in RCTs and meta-analyses may not be applicable to the individual. Studies like this are great as guidelines and for general practices, but on an individual level everyone is going to be different. I can give plenty of examples where going off-label or using a med that's "not indicated" for something but can be efficacious is the "right med" for that patient (buspar for depression for example).

Yes, we need to follow the basics and EBM for most patients. However, there's also plenty of patients in psych where the standard recommendations just don't work or are inadequate. Being specialists partially means knowing when to stray from the typical treatment path for individual patients for whatever reason. If that weren't the case, they could just create algorithms that PCPs and mid-levels could follow and we wouldn't be necessary.

My point is this: Even the industry sponsored trials barely supported cariprazine for treatment resistant depression. Even if you hate EBM, why would you choose an agent that a pharmaceutical company could barely justify?

The tone of this sub is incomprehensible. Half the posts crap on NPs for ignoring best practices, the other half rail against the very literature we're supposed to utilize in practice.

 

[Stagg737]

My point is this: Even the industry sponsored trials barely supported cariprazine for treatment resistant depression. Even if you hate EBM, why would you choose an agent that a pharmaceutical company could barely justify?

To be clear, I don't hate EBM at all. I almost never start patients on Vraylar for plenty of reasons, and that would be true if considering Vraylar for TRD as well unless augmenting with Abilify was really helpful but there was some other problem with using it, then a different med with similar MOA would be logical. I agree that it would be way down the line of medication choices.

My point was just that individual patients will have very different outcomes with different meds, and we should be aware of and consider all options when patients have had numerous prior therapeutic failures or inadequate responses as evidence for a population may be poor but for the individual may be a lifesaver.

 

[great_expectations]

To be clear, I don't hate EBM at all. I almost never start patients on Vraylar for plenty of reasons, and that would be true if considering Vraylar for TRD as well unless augmenting with Abilify was really helpful but there was some other problem with using it, then a different med with similar MOA would be logical. I agree that it would be way down the line of medication choices.

My point was just that individual patients will have very different outcomes with different meds, and we should be aware of and consider all options when patients have had numerous prior therapeutic failures or inadequate responses as evidence for a population may be poor but for the individual may be a lifesaver.

I completely agree that it’s difficult to extrapolate population level data to individuals. I also diverge from best practices at times. As someone who used this forum during medical school and residency, i just want people to be aware of the actual evidence.

Getting back to Auvelity, I have a few concerns. The original study looked promising, but left questions about how it compared to bupropion alone. In the green journal, bupropion alone actually appeared to perform worse than the placebo arm in the original study. Obviously you can’t compare the two directly. It’s just highly suspicious that a true placebo seemed equivalent to a medication with previously demonstrated benefits in depression.

 

[whopper]

I completely agree that it’s difficult to extrapolate population level data to individuals.

Someone once told me. "if a med works 99%, if it didn't work on the patient it didn't work on them 100%."

 

[psycho-matic]

I completely agree that it’s difficult to extrapolate population level data to individuals. I also diverge from best practices at times. As someone who used this forum during medical school and residency, i just want people to be aware of the actual evidence.

Getting back to Auvelity, I have a few concerns. The original study looked promising, but left questions about how it compared to bupropion alone. In the green journal, bupropion alone actually appeared to perform worse than the placebo arm in the original study. Obviously you can’t compare the two directly. It’s just highly suspicious that a true placebo seemed equivalent to a medication with previously demonstrated benefits in depression.

Are you comparing Auvelity to bupropion alone because it contains bupropion? Bupropion isn't the therapeutic ingredient in Auvelity, and if you notice, the bupropion dose is actually quite low. Bupropion is there to slow down the metabolism of dextromethorphan, which is providing the antidepressant action via glutamate modulation (hypothetically, at least).

 

[splik]

Are you comparing Auvelity to bupropion alone because it contains bupropion? Bupropion isn't the therapeutic ingredient in Auvelity, and if you notice, the bupropion dose is actually quite low. Bupropion is there to slow down the metabolism of dextromethorphan, which is providing the antidepressant action via glutamate modulation (hypothetically, at least).

This is not quite correct. While bupropion is acting as the CYP2D6 inhibitor, Auvelity is also marketed as a dopamine and norepinephrine reuptake inhibitor. It is also known to interact with dopaminergic drugs (which is not true for Nuedexta). And the dosing contains 210mg of bupropion which is above the minimum therapeutic dose of bupropion. So yes, it would make sense to compare Auvelity to WBT alone.

 

[psycho-matic]

This is not quite correct. While bupropion is acting as the CYP2D6 inhibitor, Auvelity is also marketed as a dopamine and norepinephrine reuptake inhibitor. It is also known to interact with dopaminergic drugs (which is not true for Nuedexta). And the dosing contains 210mg of bupropion which is above the minimum therapeutic dose of bupropion. So yes, it would make sense to compare Auvelity to WBT alone.

105 mg per tablet but yes that's correct at 210 mg per day. I was repeating what I've heard other psychiatrists say as far as the MOA and the reason bupropion was added.

 

[allantois]

I've talked to a psychiatrist who was involved in development, he did in-fact state that bupropion was used due to its anti-depressant effects; if they did not want that; they would have used something like quinidine

 

[ObsequiousAplomb]

I've talked to a psychiatrist who was involved in development, he did in-fact state that bupropion was used due to its anti-depressant effects; if they did not want that; they would have used something like quinidine

you mean like the drug that already did that? They probably didn't copy that and try to patent it for a reason entirely unrelated to bupropion's efficacy.

 

[Merovinge]

105 mg per tablet but yes that's correct at 210 mg per day. I was repeating what I've heard other psychiatrists say as far as the MOA and the reason bupropion was added.

I don't even know where to begin, but thank you for being honest.

 

[aim-agm]

you mean like the drug that already did that? They probably didn't copy that and try to patent it for a reason entirely unrelated to bupropion's efficacy.

Interestingly, at least per the Flockhart table, the only "strong" 2d6 inhibitors other than quinidine are all antidepressants: bupropion, fluoxetine, and paroxetine. I would guess they favored bupropion for its milder side effect profile compared to the SRIs.

 

[Merovinge]

Interestingly, at least per the Flockhart table, the only "strong" 2d6 inhibitors other than quinidine are all antidepressants: bupropion, fluoxetine, and paroxetine. I would guess they favored bupropion for its milder side effect profile compared to the SRIs.

Nope, they preferred bupropion due to the risk of 5-HT syndrome with SSRIs and DXM.

 

[calvnandhobbs68]

Nope, they preferred bupropion due to the risk of 5-HT syndrome with SSRIs and DXM.

Right I think the risk is quite low but yes that’s why they did this combo.

 

[clausewitz2]

DXM as a side note is one of the few drugs that really can't be combined safely with MAOIs that isn't just an SSRI/SNRI/clomipramine/methadone/demerol.

 

[Stagg737]

DXM as a side note is one of the few drugs that really can't be combined safely with MAOIs that isn't just an SSRI/SNRI/clomipramine/methadone/demerol.

As another side note, every time I see someone write "DXM" I think of DMX and X Gon' Give it to Ya pops into my head. /tangential thought

 

[Merovinge]

DXM as a side note is one of the few drugs that really can't be combined safely with MAOIs that isn't just an SSRI/SNRI/clomipramine/methadone/demerol.

How is fentenyl with MAOI's (like rxed by a doc, not street fent)? I have lost some of my understanding of the real 5HT risk being out of adult psychiatry for so many years.

 

[mistafab]

How is fentenyl with MAOI's (like rxed by a doc, not street fent)? I have lost some of my understanding of the real 5HT risk being out of adult psychiatry for so many years.

I can't say specifically about MAOI's, but the serotonin syndrome cases I've had in hospital tend to be either fentanyl patches or linezolid as the straw that broke the camel's back. Tends to be a fentanyl patch on a fluoxetine user.

MAOIs are just prescribed so rarely these days that those pts on MAOIs are so attuned to the risks of those drugs that serotonin syndrome cases just dont happen with them - not that they cant.

 

[ObsequiousAplomb]

I think that the Fentanyl serotonin syndrome risk is most prominent in surgery, when patients are receiving large amounts of it intravenously along with other medications that may temporarily limit monoamine oxidase function. Of course, as psychiatrists we don't see that, the anesthesiologist does, and the patients is unconscious and paralyzed for it anyway.

As mistafab said, we psychiatrists would see them usually as those really high dose Fentanyl patches in someone who's getting an SSRI or SNRI. I don't know if anyone is doing Emsam + Fentanyl patch, but that would be a way to possibly get serotonin syndrome from Fentanyl and an MAOi, I guess. I imagine the patients getting serotonin syndrome from illicit use are probably recovering on their own, miserably, without talking to doctors about it much.