6 replies to this topic

[meatwad]

I am noticing many people saying not to mix one medication with another.
Here is a dosing schedule for a 50yo male, 6'2", 250 pounds, CVA with no use
of left arm. Left leg in a whole cast due to fall while being helped from his bed to wheelchair.


0800
---------
500mg depakote sprinkles
1mg resperidone
Sertraline 150mg

1200
-------
0.5mg resperidone

1600
------
500mg depakote sprinkles
1mg resperidone

2000
-----
trazadone 150mg
clomipramine 100mg

Person also receives several other non neuro medications,
including vitamin D 400iu/calcium 500mg 0800/1600, vicodin 10/325mg 0800/1600/2000,
premarin 0.625mg 2000, multivitamin/multimineral 0800, diet order is pureed/thickened water
so all his pills must be crushed.

What are your first thoughts? I am not going for a 'trick' question.

[bran319]

Is he a sex offender?

[meatwad]

Is he a sex offender?

Why certainly all those dopamine and serotonin affecting medications are leaping out of the page,
and your brain is telling you "omg that is too much!"

And no, he is not a sex offender.

Edited by meatwad, 20 November 2008 - 03:37 AM.

[bran319]

Why is he on the estrogen (premarin)?

[niner]

I am noticing many people saying not to mix one medication with another.
Here is a dosing schedule for a 50yo male, 6'2", 250 pounds, CVA with no use
of left arm. Left leg in a whole cast due to fall while being helped from his bed to wheelchair.


0800
---------
500mg depakote sprinkles
1mg resperidone
Sertraline 150mg

1200
-------
0.5mg resperidone

1600
------
500mg depakote sprinkles
1mg resperidone

2000
-----
trazadone 150mg
clomipramine 100mg

Person also receives several other non neuro medications,
including vitamin D 400iu/calcium 500mg 0800/1600, vicodin 10/325mg 0800/1600/2000,
premarin 0.625mg 2000, multivitamin/multimineral 0800, diet order is pureed/thickened water
so all his pills must be crushed.

What are your first thoughts? I am not going for a 'trick' question.

CVA = CerebroVascular Aneurism? What's the history there? Left arm is out of commision, what else? Can't swallow? A broken leg from that kind of fall suggests osteoporosis, or something along those lines. In that case, 400 IU of vitamin D isn't enough. There is a LOT more that he could be doing for bone health. Why all the psych meds? Was that a long standing condition, or secondary to the CVA? What's the vicodin for, his leg? How long since the break?

[StrangeAeons]

Somebody is clearly trying to sedate this person, and keep them in a nice, pliable state.
Here's a nifty little table about the oft-overlooked P450 system. It appears that Zoloft (sertraline) is an inhibitor of CYP2D6, and risperdone is a substrate of that enzyme. Therefore elimination of risperdone is hindered, and the drug will remain active in the system in higher doses for longer. The dose should be lowered, to avoid some of the many nasty side effects associated with chronic high doses of antipsychotics. It also appears the risperdone and trazodone are both substrates of the 3A4,5, and 6 enzymes. This competition will result in further impaired elimination of both.

Hmm... Looks like clomipramine is both a substrate and an inhibitor for 2D6. All in all it's fair to say this guy is getting a far higher dose of risperdone than the docs might initially think; and with a history of CVA and impaired mobility it's possible motor distrubances associated with EPS, TD or other nigrostriatal depletion might go unnoticed for a while. I'm afraid your patient is being screwed.

EDIT: if his stroke was embolic and he's stuck in a cast, I would seriously consider taking an anticoagulant as a prophylaxis; especially because he's probably not moving around much being loaded up with meds this way. At least 81mg enteric-coated aspirin, if not warfarin or heparin.

Edited by PetaKiaRose, 20 November 2008 - 05:23 AM.

[edward]

P450 system will be inhibited along with other liver enzymes, increased levels of multiple drugs. Multiple serotonin agents direct and indirect, with increased blood levels due to liver enzyme inhibition there is even more risk of serotonin syndrome.

Also I look at that cocktail and it just screams yuck in the way of side effects...but whatever gets you through the day. I did a psych rotation and I swear the amount of stuff some of those patients are on is insane. Makes me thankful I am not a schizophrenic. I mean who wants across the board dopamine inhibition thrown in with the general blahness of an antiepileptic mood stabilizer, but such things are the best we have for positive symptoms.

edit:

One more thing (other than as others mentioned that it is odd for a 50 yr old male to be on Premarin...though its not unheard of as estrogens are used to treat or rather mistreat prostate issues)

If you couple CYP450 inhibition with a dose of premarin you not only get impaired metabolism of endogenous estrogen and other hormones but impaired metabolism of the premarin so your combined endogenous and exogenous estrogen levels should be through the roof. Combine that with the Prolactin increasing effects of Risperidone (dopamine antagonism) and the Prolactin increasing effects of Trazadone (in particular its major metabolite) and the Prolactin increasing effects of the other serotonin drugs......and you have 0 sex drive and will very quickly be growing Man Boobs

Edited by edward, 20 November 2008 - 10:00 PM.