Medication Combination of the Day

[Sushirolls]

Several bottles a day intake; AUD severe. First go of it. No real quit attempts so no knowledge of withdrawal intensity. Gastric bypass history, too. Recommended inpatient detox. Patient resistant, wants outpatient detox. Exploring all options for possible outpatient.

Consult at one Big Box chain, focuses on opioids. Chain is one of the places all the non-psych specialists with an X number sideline at, cardiology, EM, OB, etc. ARNP told patient doesn't need nor warrant inpatient detox, nor benzos, go home and sweat it out.

Patient mounted symptoms 48-72 hours in and resumed drinking.

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[calvnandhobbs68]

Some people do manage to do okay with propranolol TID for somatic symptoms of anxiety and obviously with acamprosate you're meant to do TID but outside of rare instances frequent dosing like this is attempting to harness, um, non-specific effects of treatment, let's say.

You're also supposed to dose short acting clonidine TID (even clonidine ER is BID), so I have to have people do that at times.

 

[calvnandhobbs68]

Several bottles a day intake; AUD severe. First go of it. No real quit attempts so no knowledge of withdrawal intensity. Gastric bypass history, too. Recommended inpatient detox. Patient resistant, wants outpatient detox. Exploring all options for possible outpatient.

Consult at one Big Box chain, focuses on opioids. Chain is one of the places all the non-psych specialists with an X number sideline at, cardiology, EM, OB, etc. ARNP told patient doesn't need nor warrant inpatient detox, nor benzos, go home and sweat it out.

Patient mounted symptoms 48-72 hours in and resumed drinking.

Maybe he'll want to do inpatient this time.

Severe AUD detox is pretty dangerous outpatient though... I wouldn't feel comfortable handling that outpatient detox myself. ARNP is gonna have a lawsuit when the dude seizes/aspirates after she tells him to quit cold turkey and he dies.

 

[FatherPsychiatry]

Psychotic patient admitted to a crappy private hospital (only one his insurance covered). They d/c his Haldol (which he was non-compliant with, which probably led to his decompensation), gave him some Abilify, and discharged him after giving a shot of 400mg Maintena. Total admission was 3-4 days. Mom calls a few days later, says her son is very "anxious" and pacing around the house non-stop. She takes him to a psych urgent care, where an NP diagnosed him with "anxiety" and prescribed him Prozac. Days later he jumped out of a moving car.

 

[calvnandhobbs68]

Psychotic patient admitted to a crappy private hospital (only one his insurance covered). They d/c his Haldol (which he was non-compliant with, which probably led to his decompensation), gave him some Abilify, and discharged him after giving a shot of 400mg Maintena. Total admission was 3-4 days. Mom calls a few days later, says her son is very "anxious" and pacing around the house non-stop. She takes him to a psych urgent care, where an NP diagnosed him with "anxiety" and prescribed him Prozac. Days later he jumped out of a moving car.

Yeahhh that's another lawsuit waiting to happen

 

[robellis]

Psychotic patient admitted to a crappy private hospital (only one his insurance covered). They d/c his Haldol (which he was non-compliant with, which probably led to his decompensation), gave him some Abilify, and discharged him after giving a shot of 400mg Maintena. Total admission was 3-4 days. Mom calls a few days later, says her son is very "anxious" and pacing around the house non-stop. She takes him to a psych urgent care, where an NP diagnosed him with "anxiety" and prescribed him Prozac. Days later he jumped out of a moving car.

That’s actually standard practice on the part of the psych hospital..obviously a problem with the NP

 

[Mass Effect]

Recently had an ARNP tell patient they had bipolar and started trileptal. Oh, and the patient is Asian, and they didn't discuss, nor order the HLA-B lab before starting.

Thankfully this patient knew better to discuss with me before starting - not bipolar and definitely doesn't need it.

I don't use Oxcarb and haven't since residency, but do people actually get the HLA lab on Asian patients? I mean, you can, but that isn't standard, is it?

 

[Mass Effect]

Is trileptal for "bipolar" something they teach in all NP schools? Where do they all get this idea...

Trileptal is often used for bipolar disorder by MDs as well. It's FDA approved for seizures, but it is used regularly in psychiatry. We had an attending in residency who always used it. I don't use it because there are better meds, but it isn't unheard of for MDs to use it

 

[calvnandhobbs68]

That’s actually standard practice on the part of the psych hospital..obviously a problem with the NP

Yeah I mean a lawsuit for the NP. Not that hard to give someone some propranolol for the akathisia and come back in a few days even if they have Abilify Maintena in their system.

 

[robellis]

I don't use Oxcarb and haven't since residency, but do people actually get the HLA lab on Asian patients? I mean, you can, but that isn't standard, is it?

I believe the standard is to get the lab, if you don’t and there’s a serious issue I would imagine you would be liable

 

[Mass Effect]

I believe the standard is to get the lab, if you don’t and there’s a serious issue I would imagine you would be liable

I looked it up because I don't remember getting it in residency. For oxcarb, Stahl's makes no mention of getting the lab. For carbamazepine, it says you should consider getting it. Interesting.

 

[robellis]

I looked it up because I don't remember getting it in residency. For oxcarb, Stahl's makes no mention of getting the lab. For carbamazepine, it says you should consider getting it. Interesting.

Yeah and manufacturers label for both suggests to check it

 

[clausewitz2]

Yeah I mean a lawsuit for the NP. Not that hard to give someone some propranolol for the akathisia and come back in a few days even if they have Abilify Maintena in their system.

Honestly for someone ill enough to need Maintena if the akathisia is that bad I might just go straight for a benzo for the short term

 

[Liquid8]

“Ritalin 160mg daily”

Was re-referred a guy who I saw years ago who left my rooms unhappy as I wouldn’t prescribe him dexamphetamine. He’d given a history of ongoing recreational drug use, concerns about potential trafficking and couldn’t provide anything close to resembling ADHD symptoms through to poor engagement. He’d also only wanted something like MDMA and refused everything else that might have potentially been of benefit.

After this the patient had then seen another psychiatrist who initially prescribed him Ritalin, and then refused to prescribe him dexamphetamine after disagreements over dose escalations. He later saw another psych notorious for prescribing megadoses, and even he refused to prescribe – and this is after prescribing 160mg of Ritalin and then apparently switched him to an equivalent dose of dexamphetamine. My only guess is that he was using more than this amount.

Even his previous referring doctor who had a go at me when I initially declined to treat him with a stimulant also had enough of him, with comments on the letter about getting valium scripts different doctors and going to different pharmacies in order to self-medicate on 50mg a day. Looking back over his record I could also see that he’d been getting morphine ampoules from yet another doctor which also seemed very unusual.

Naturally, I declined the referral - this was exactly the kind of outcome that I had feared would occur all those years ago, and not a mess of my creation that I felt obliged to try and sort out.

 

[PsyDr]

Gero male, referred for behavioral tx of "insomnia".

Current medications: 70mg vyvanse; 20mg adderall IR BID , and 30mg temazepam HS.

I wonder why he can't sleep.

 

[Sushirolls]

Gero male, referred for behavioral tx of "insomnia".

Current medications: 70mg vyvanse; 20mg adderall IR BID , and 30mg temazepam HS.

I wonder why he can't sleep.

ADHD not adequately treated and racing thoughts at night warrant my stimulant? /sarcasm

 

[Sushirolls]

AUD, Severe +/- cluster B
Relapse with OD, hospitalization

Discharged on Depakote and Zyprexa

Can't wait to get the hospital records and discharge summary...

 

[FlowRate]

AUD, Severe +/- cluster B
Relapse with OD, hospitalization

Discharged on Depakote and Zyprexa

Can't wait to get the hospital records and discharge summary...

Everyone has mania until proven otherwise. Cranky? Mania. Anxious? Mania. Insomnia? Mania. Can't pay attention? Mania and ADHD, add a stimulant to the above regimen to "stable them out."

 

[clausewitz2]

Not a whole regimen but inherited a recent autistic young person who was on fluvoxamine ER 150 mg BID. I really don't understand the thought process.

 

[Sushirolls]

I'm hoping that was just explained away by a med error that some one wrote for it wrong from IR to ER...

 

[DJKitty]

I've had two recent patients with pretty severe polypharmacy:
1) geriatric patient with AUD and chronic pain on Klonopin 1 TID, Seroquel 50 QHS, Trazodone 400 QHS (patient increased dose from 300 to 400), Prazosin 2 mg QHS (no history of PTSD), Sertraline 100 mg daily, Armodafinil 250 mg q AM, Testosterone (prescribed by a psychiatrist) as well as chronic opioids

2) geriatric patient with delirium/agitation: Hospice RN started the following (all at the same time): Haldol 2 mg po TID, Thorazine 50 mg TID, Zyprexa 2.5 mg BID, Ativan 1 mg TID, Ativan 1 mg q 6 hours prn, Tessalon pearls TID scheduled, and opioids (however, these were indicated for air hunger/dyspnea in hospice). In the ED, the psychiatrist stopped all medications and started the patient on Gabapentin 300 TID for benzo withdrawal. We put him back on opioids and a 25% dose decrease on Ativan with planned quick taper and he is doing much better.

 

[robellis]

I've had two recent patients with pretty severe polypharmacy:
1) geriatric patient with AUD and chronic pain on Klonopin 1 TID, Seroquel 50 QHS, Trazodone 400 QHS (patient increased dose from 300 to 400), Prazosin 2 mg QHS (no history of PTSD), Sertraline 100 mg daily, Armodafinil 250 mg q AM, Testosterone (prescribed by a psychiatrist) as well as chronic opioids

2) geriatric patient with delirium/agitation: Hospice RN started the following (all at the same time): Haldol 2 mg po TID, Thorazine 50 mg TID, Zyprexa 2.5 mg BID, Ativan 1 mg TID, Ativan 1 mg q 6 hours prn, Tessalon pearls TID scheduled, and opioids (however, these were indicated for air hunger/dyspnea in hospice). In the ED, the psychiatrist stopped all medications and started the patient on Gabapentin 300 TID for benzo withdrawal. We put him back on opioids and a 25% dose decrease on Ativan with planned quick taper and he is doing much better.

Hospice RN started 3 antipsychotics at the same time…

 

[DJKitty]

Hospice RN started 3 antipsychotics at the same time…

Within several days of each other. First the Zyprexa (which was reasonable), then 2 days later they added the Haldol, but also kept the Zyprexa. And 2 days after that added Thorazine while keeping the other two scheduled as well.

 

[deleted1100659]

1. 24 year old female, saw her in clinic for a short crisis eval. Clear cut MDD with acute suicidality and multiple stressors. No prior psych hx. Admitted to the CSU here, she leaves after four days on prozac, lithium, remeron, lamictal.

2. Peds patient i took over on concerta BID dosing (two hours apart), ritalin IR TID, tenex, clonidine, and risperdal, and a little ativan.

 

[clausewitz2]

1. 24 year old female, saw her in clinic for a short crisis eval. Clear cut MDD with acute suicidality and multiple stressors. No prior psych hx. Admitted to the CSU here, she leaves after four days on prozac, lithium, remeron, lamictal.

Out of curiosity, what was the lamictal dose? I want this story to be perfectly horrible and have it be like 200 mg or something wildly inappropriate for a four day stay.

2. Peds patient i took over on concerta BID dosing (two hours apart), ritalin IR TID, tenex, clonidine, and risperdal, and a little ativan.

Ahh, the "Timmy can't act right and I have no idea what to do" combo.

 

[deleted1100659]

Out of curiosity, what was the lamictal dose? I want this story to be perfectly horrible and have it be like 200 mg or something wildly inappropriate for a four day stay.



Ahh, the "Timmy can't act right and I have no idea what to do" combo.

actually it was 25mg, you know, basically the dose where its like "hey why not add some lamictal sprinkles and just hope it does something??" Not sure what their intention was with the 25mg or how they planned on titrating that in 4 days, or how in four days it was determined the patient was bipolar and needed lithium but also lamictal too, you know, in case the lithium didnt work. I see 25mg lamictal here as such a popular thing, especially on inpatient units. Also lots of trileptal....

Yep, I suppose if a kid is given enough medications hell become "well behaved"

 

[robellis]

actually it was 25mg, you know, basically the dose where its like "hey why not add some lamictal sprinkles and just hope it does something??" Not sure what their intention was with the 25mg or how they planned on titrating that in 4 days, or how in four days it was determined the patient was bipolar and needed lithium but also lamictal too, you know, in case the lithium didnt work. I see 25mg lamictal here as such a popular thing, especially on inpatient units. Also lots of trileptal....

Yep, I suppose if a kid is given enough medications hell become "well behaved"

25mg of lamictal would be the only dose that would make sense in the context of your story

 

[deleted1100659]

25mg of lamictal would be the only dose that would make sense in the context of your story

I generally do not like lamictal to be prescribed on our CSU. Starting someone on 25mg then discharging them with a 30 day supply and telling them to f/u, asap. when our patient population here is very, very noncompliant and you don't know how theyll take the lamictal upon discharge. Maybe with a close f/u and patient with a great history of compliance, and the history clearly points towards bipolar.

 

[tr]

actually it was 25mg, you know, basically the dose where its like "hey why not add some lamictal sprinkles and just hope it does something??" Not sure what their intention was with the 25mg or how they planned on titrating that in 4 days, or how in four days it was determined the patient was bipolar and needed lithium but also lamictal too, you know, in case the lithium didnt work. I see 25mg lamictal here as such a popular thing, especially on inpatient units. Also lots of trileptal....

Yep, I suppose if a kid is given enough medications hell become "well behaved"

Not excusing the nutty story but I will say that low dose lamictal (25-50 mg) often seems to be helpful for irritability and emotional lability regardless of bipolar dx. Not that it makes sense to throw on top of everything else in the short time period you described though.

 

[deleted1100659]

Not excusing the nutty story but I will say that low dose lamictal (25-50 mg) often seems to be helpful for irritability and emotional lability regardless of bipolar dx. Not that it makes sense to throw on top of everything else in the short time period you described though.

I do see that and Trileptal used a lot for irritability. Especially the older attendings, I see them prescribe quite a bit of trileptal.

 

[Styrene]

Male in his 30s with severe substance use disorders (Rx by IM addiction specialist):

Klonopin 2 mg TID
Xanax 2 mg TID PRN
Suboxone 8/2 TID
Adderall XR 30 mg qday
Adderall IR 30 mg BID

 

[shotgunlagoon]

Male in his 30s with severe substance use disorders (Rx by IM addiction specialist):

Klonopin 2 mg TID
Xanax 2 mg TID PRN
Suboxone 8/2 TID
Adderall XR 30 mg qday
Adderall IR 30 mg BID

You'd think an addiction specialist would try to treat addiction, not cause it, but the English language is funny like that.

 

[calvnandhobbs68]

Not an “insane” med combination but just did an intake with 20 something yo woman recently with PTSD and GAD whose PCP started her on Buspar…wait for it…7.5mg QHS. Since like Feb. Never been on even an SSRI ever.

 

[nowaysanjose]

Another one that sticks out for me was on my inpatient substance rotation. Patient was there for alcohol treatment. Was having panic attacks multiple times per but hadn't had alcohol for several weeks PTA. Patient was seeing a pharmacist through the VA for meds and was initially started on Paxil and trazodone. Patient was still anxious so buspar was added. Then patient was more depressed so Bupropion was added and titrated to 450mg. Then patient was having panic attacks and problems sleeping so PRN seroquel was added. Was still anxious/depressed so for some reason Venlafaxine was added...all of which occurred while the patient was drinking something like a fifth per day.

The med list (Paxil, Effexor, Buspar, Trazodone, bupropion, Seroquel) wasn't the worst on it's own, but the progression of that treatment plan just made me cringe, especially since it was coming from a pharmacist. Stopped the Paxil, Trazodone, and buropion and left the rest. Within a week he said his "panic attacks" were completely gone, no depression, mild anxiety. When he left was only on the Venla + Buspar with a prn for sleep (can't remember what, but I think Hydroxyzine?).

Pharmacist starting meds? Did I miss something or is this a thing now?

 

[calvnandhobbs68]

Pharmacist starting meds? Did I miss something or is this a thing now?

Yes, it is a thing at the VA.

 

[Stagg737]

Pharmacist starting meds? Did I miss something or is this a thing now?

NPs and pharmacists have been prescribing independently in the VA system for at least 5 years now.

 

[nowaysanjose]

Yes, it is a thing at the VA.

Wow. I wonder how this came to be--VAs started the psychologist rx thing too, right?

edit

 

[Styrene]

You'd think an addiction specialist would try to treat addiction, not cause it, but the English language is funny like that.

Yea the guys life was destroyed by the benzos. Horrible. We see this ALL the time in my area. Severe iatrogenic benzodiazepine dependence. Even up to 8-12 mg Xanax per day.

 

[Ceke2002]

You'd think an addiction specialist would try to treat addiction, not cause it, but the English language is funny like that.

The methadone prescribing Doctor I was seeing, almost 20 years ago now, had this odd belief that if his patients were all just pilled out then they'd have less motivation to go and score heroin. So most of us eventually ended up being prescribed stupidly high levels of benzos. At one point he was writing scripts for 16mgs Xanax daily for me alone. Coming off that was worse than coming off the heroin & methadone put together.

 

[deleted1100659]

The methadone prescribing Doctor I was seeing, almost 20 years ago now, had this odd belief that if his patients were all just pilled out then they'd have less motivation to go and score heroin. So most of us eventually ended up being prescribed stupidly high levels of benzos. At one point he was writing scripts for 16mgs Xanax daily for me alone. Coming off that was worse than coming off the heroin & methadone put together.

An addiction psychiatrist was giving you xanax with methadone while you were on heroin? Am I reading this correctly..?

And the whole pharmacist prescribing thing was bizare to me as well, but yep totally happens at the VA. They have their own clinic. I don't even think they're taught anything about psychiatric assessment/symptoms.

 

[tr]

Male in his 30s with severe substance use disorders (Rx by IM addiction specialist):

Klonopin 2 mg TID
Xanax 2 mg TID PRN
Suboxone 8/2 TID
Adderall XR 30 mg qday
Adderall IR 30 mg BID

Looks horrible, but how long has this person been in tx? Possible the addiction specialist got him with all that stuff on board already plus an opiate addiction, decided to tackle the opiates first with Suboxone, and is just holding steady on the rest of the regimen until he completes Suboxone taper?

 

[clausewitz2]

Former residency classmate passed one along:

Effexor 225 mg, Prozac 80 mg, geodon 80 mg, remeron 45 mg, doxepin 10 mg qid, buspar 15 mg bid, atarax 25 mg bid.

Seen at a methadone clinic.



Also, I'm usually not super worried about serotonin syndrome compared to some of my colleagues, but I am worried about serotonin syndrome. Can't fathom the intent Effexor + prozac + geodon combo apart from inducing SS

 

[deleted1100659]

Former residency classmate passed one along:

Effexor 225 mg, Prozac 80 mg, geodon 80 mg, remeron 45 mg, doxepin 10 mg qid, buspar 15 mg bid, atarax 25 mg bid.

Seen at a methadone clinic.



Also, I'm usually not super worried about serotonin syndrome compared to some of my colleagues, but I am worried about serotonin syndrome. Can't fathom the intent Effexor + prozac + geodon combo apart from inducing SS

I hate when I see SSRI+SNRI. I saw a patient as a consult one time who had serotonin syndrome and he was on an SSRI/SNRI combo so since then i always peel one off when I see it.

 

[shotgunlagoon]

I hate when I see SSRI+SNRI. I saw a patient as a consult one time who had serotonin syndrome and he was on an SSRI/SNRI combo so since then i always peel one off when I see it.

What about two SNRIs...?

 

[robellis]

What about two SNRIs...?

No..

 

[Ceke2002]

An addiction psychiatrist was giving you xanax with methadone while you were on heroin? Am I reading this correctly..?

And the whole pharmacist prescribing thing was bizare to me as well, but yep totally happens at the VA. They have their own clinic. I don't even think they're taught anything about psychiatric assessment/symptoms.

That is correct, although I wasn't on heroin at the same time. I was already physically dependent on Xanax when I saw him for Methadone treatment (for heroin addiction), but instead of stabilising my dose of Xanax, or working towards tapering me off of it, he just kept increasing the dose I was on.

I undertook 6 months of therapy during this time, which gave me some much needed insights into the fact that I wasn't just a heroin addict, I was a drug addict (plural) & therefore any drug of addiction and/or abuse was an issue I needed to deal with. I actually began tapering off the Xanax myself, and insisting that the dosage amount prescribed be consistent with what was required to prevent withdrawal symptoms, and not what was going to just get me **** faced (so to speak).

 

[shotgunlagoon]

No..

i have a friend who's on strattera for ADHD and effexor for MDD, you think i should tell them to talk to their doctor about it then? they did tell me they might be trying a stimulant in the future because the strattera isn't helping as much as they had hoped, but for now the combo has definitely helped them a lot more than the effexor alone did. I can tell there's a huge improvement. to my (admittedly basic) knowledge, while effexor is an SNRI, it's much more selective for serotonin with a pretty minor noradrenergic effect, while strattera has a stronger noradrenergic effect.

 

[robellis]

i have a friend who's on strattera for ADHD and effexor for MDD, you think i should tell them to talk to their doctor about it then? they did tell me they might be trying a stimulant in the future because the strattera isn't helping as much as they had hoped, but for now the combo has definitely helped them a lot more than the effexor alone did. I can tell there's a huge improvement. to my (admittedly basic) knowledge, while effexor is an SNRI, it's much more selective for serotonin with a pretty minor noradrenergic effect, while strattera has a stronger noradrenergic effect.

That is not an snri so no I wouldn’t worry about it

 

[shotgunlagoon]

That is not an snri so no I wouldn’t worry about it

Oh wow, I totally thought strattera was an SNRI, didn't realize it's norepinephrine only. Well, that makes more sense now!

 

[Styrene]

Looks horrible, but how long has this person been in tx? Possible the addiction specialist got him with all that stuff on board already plus an opiate addiction, decided to tackle the opiates first with Suboxone, and is just holding steady on the rest of the regimen until he completes Suboxone taper?

No, there's a whole backstory. Tip of the iceberg is that when my colleague called the prescriber for collateral, they immediately began screaming that they were reporting my colleague to the hospital administrators and demanded contact info and license numbers. Just the tip of the iceberg.