I’m taking a class just for fun right now — psychopharmacology — and the discussions that crop up are quite excellent. Many of the students are prescribers in my area, and I fill their scripts on a regular basis. It makes for an interesting, voyeuristic look into their thought processes given some of the case studies. That is, I know who they are, but they don’t know who I am…

This week’s topic is panic disorder and relapse in patients with and without a history of substance abuse. Fun topic, really, and one close to my heart.

Case study:

[You are] working with a 32 year old man who comes to you for an evaluation of panic in August in Lowell. He meets the diagnostic criteria for panic disorder and has been experiencing untriggered episodes for the last 2 months. Name three factors that would guide your selection of medication and then discuss your pharmacologic plan for this unfortunate man.

One of the responses — by a prescriber in my area — was to encourage deep breathing, progressive relaxation, identifying triggers and avoiding the situation, CBT, and starting an SSRI. If panic continues, start a benzo.

This strikes me as fairly typical approach for a primary care provider in dealing with someone who presents during an acute panic attack, but I think that it’s doing the patient a disservice. Perhaps it’s also a typical response for a psychiatrist who is afraid to use benzodiazepines.

I’ll post my response here, verbatim, because I think there’s a deep (and common) misunderstanding of what panic is, and what having a panic attack is like.

It seems like you’re thinking of panic as something that can be gotten out of, as though it’s a normal fight-or-flight type response where removal from a stressful stimulus means no more panic.

This is dangerous thinking, and forgive me if I’ve read you wrong.

It can be harder than perhaps some practitioners think to identify a trigger. While triggers can often be identified, I think it’s important to note that when a patient first presents, and you make a diagnosis of panic disorder, discovering these triggers will be more complex than simply avoiding a stressful situation, or simplifying and eliminating stressors from one’s life. (Which is a very time-consuming process.)

You can’t turn the ship on a dime.

Please don’t fall victim to the idea that because you’ve been scared out of your wits a few times and your heartrate went up and your BP went through the roof that that is a panic attack. It’s not. Panic attacks usually appear in a completely idiopathic manner, particularly the first time they hit. It’s not an “Oh Gee, you scared me,” type of thing, it’s more of a “DEAR GOD I’M DYING, SOMEONE PLEASE DIAL 911” type of thing.* (The caps are appropriate there. ;) )

Panic attacks can, and do hit without any warning in an otherwise comfortable, relaxed setting. Watching a movie in your living room, for example.

It’s not like [situation] -> panic attack a few minutes or an hour later with a clear antagonist. It can come days after the stressors. It can also take a few weeks and lots of practice to build up an arsenal of effective coping mechanisms to return oneself to a calming state in the middle of an active attack.

Re: Deep breathing. This can also be problematic as at the point where one’s lungs are fully inflated one can experience a PVC or PAC, which is VERY disconcerting to someone who’s already acutely aware of what their heart is doing. I can actually trigger PVCs in myself by doing this.

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I don’t mean to lecture. I’m not the professor, and perhaps I’ve read too much between the lines of what you’ve written. As someone who didn’t get out of bed for 3 weeks the first time I had a panic attack, I feel very strongly about the issue, and combatting it aggressively rather than taking a more laid back, it’ll-fix-itself approach. Particularly this: “deep breathing, progressive relaxation, identifying triggers and avoiding the situation, CBT, [etc.]”

Those are all great long-term approaches, but the short-term is what someone with panic disorder in an active phase cares about most. Long term stuff can come after, just get me through right now.

And I am keenly aware that my personal experience should never cloud my clinical judgement inasmuch as that is humanly possible.

* I tried to dial 911 my first time, in the middle of a biochemistry lecture, no less. But I couldn’t see well enough to dial the number. In retrospect, knowing what I know now, I’m glad I couldn’t because that would have been a misuse of medical resources. :p

Early in panic, people are usually not capable of accessing the skills to use behavioral coping mechanisms. You usually need to halt the panic quickly and this is where BZDs are needed. Panic is such an uncomfortable and painful experience, the BZD’s are in a way like pain medications in the early stages of treatment.

Something I’ve noticed for years: the more a patient talks at you, the more likely they are to be lying. They talk and talk and talk, and nothing of substance comes out. It’s a smokescreen for something else they want. They tell you their life story, and then ask for an early fill on their Vicodin as though the two are somehow related.

Do they think I’m stupid? I can’t count the number of times I’ve put the phone down with the person still talking at me (without having said more than “May I help you?”) done something, and then come back with them still blowing hot air.

The more words someone uses, the greater the chances are that they’re full of shit.

This is in contrast to someone with a legitimate issue who will tell you their story in as few words as possible, and then ask what they need to do. Even people who typically blow smoke talk less when they’re actually telling the truth and they have, for instance, a police report to back it up.

Every retail pharmacist in the world knows exactly what I’m talking about, and I’m sure most ED types do too. Remarkable that the bottom-feeders on the planet haven’t figured out that if they just kept their mouths shut, I’d be 2-3x more likely to believe them. I would have thought such a skill would be accidentally uncovered and remembered. But perhaps idle chatter is the verbal form of a nervous twitch, and many of these folks are halfway decent candidates for the Darwin Awards anyway, so I shouldn’t be surprised that they haven’t learned from past successes.

In any event, they’d all be shitty poker players.

This is going to be quick and dirty because I’ve got some other things to do, but I’ve been putting it off far longer than I’ve meant to. (No time like the present, right?) In the January 2008 issue, CR ran a feature on how people could save money on prescriptions meds. Generally speaking, I am in favor of this kind of thing. I like people to know the alternatives, and how they can save money.

Generally-speaking, it’s not a good idea to have word-choice errors in a piece that’s supposed to be professional. (See image.) Maybe they should get a medically-trained copy editor and add them to the list of peer-reviewers. Ridiculous.

I’ve re-created the table they have:

I’ll go through it quickly:

Zyrtec is now available OTC, and is comparable to the cost of Claritin. Claritin doesn’t work for a goodly number of folks, so Zyrtec is a better option. Zyrtec went OTC the month after this was published — and it wasn’t a big secret that it was going to happen.

For ADHD, Strattera is not a popular option. It doesn’t work for many people, and ADHD people have a hard time remembering to take their meds consistently, which makes this option less desirable, particularly where it takes a little while for Strattera to begin working. I’m surprised this drug was listed at all, as it’s rarely a first-line choice for ADHD spectrum disorders. Even comparing atomoxetine (an NRI) to methylphenidate (a stimulant) is a bit… off, and IMO, does the consumer no favors. Strattera is usually used where someone is at risk for drug abuse or has comorbidities like hypertension or anxiety (iatrogenic or otherwise) and so cannot tolerate stimulants.

Depression… don’t have much to say there. Fluoxetine tends to be more stimulating than Lexapro, and there are other subtle differences (half-life, solubility, etc.), but for most people, switching from one to the other is probably not impossible.

As for Diabetes… well. Using a biguanide is usually the first step in treating metabolic syndrome, and then you add other meds on top of that. I’d be skeptical of any doctor who used Actos before using metformin without a given reason. Diabetes treatment tends to go in stepwise fashion like most other chronic illnesses. Removing a TZD from a pre-existing diabetic regimen can be done, but it’s not as simple (or desirable) as this little blurb makes it seem. And a TZD isn’t normally used as monotherapy. Frankly, I think suggesting Glucotrol rather than metformin would have made more therapeutic sense. And in terms of good use of space, I think think they would have been better going after the ARBs and hypertension in general here.

Heartburn and GERD? Nexium 20mg? Who even uses the 20mg strength Nexium? I see it maybe 3 times a year. They should have done 40mg Nexium and suggested 40mg of Prilosec. (Hilarious sidenote: 40mg Prilosec caps (the one without a generic) cost ~$60 more than 40mg Nexium caps.) Generally, though, this one wasn’t too bad.

Insomnia: Eh, probably okay I guess. Insomnia is a poorly-treated condition in this country, and frankly, I’d rather see other methods explored before reaching for the BZRAs at all. But the BZRAs are the easiest, and they keep patients happy. Unfortunately, not enough time is spent diagnosing the underlying causes of insomnia, resulting in a poorly quality of life. There are differences in the polysomnograms of patients on eszopiclone and zolpidem, too, which are not talked about. I’d rather see ramelteon tried before any BZRA, and also see a psychologist about diagnosing an underlying cause for the insomnia in the first place, if a primary care provider cannot take the time (due to financial considerations) to do it themselves. And 5mg of Ambien might help with sleep induction, but the relatively short half-life will do next to nothing for those with sleep maintenance problems.

I’d rather have seen trazodone suggested, since insomnia is usually secondary to some kind of other psychiatric disturbance — a type of uni- or bipolar depression.

Not much to say about arthritis, but I hardly ever see Celebrex used anymore. Now that it stands alone as a COX-2 inhibitor, it’s also the most expensive anti-inflammatory in the book and insurers are loathe to use it. I’d rather see diclofenac recommended over ibuprofen, and suggesting that 400mg of ibuprofen daily is anywhere near equivalent to 200mg of celecoxib is laughable.

Schizophrenia. SCHIZO-FREAKIN-PHRENIA? CR is going to tackle SCHIZOPHRENIA in an article about how to save money?!?! I am having difficulty wrapping my brain around that one.

But okay, here goes. Schizophreniform disorders should be managed by a psychiatrist or psychiatric NP, IMNSHO. Diagnosis is tricky, and management is always tricky. All that said… while first generation antipsychotics are often as effective as their second gen counterparts, I am extremely leery of merely saying that Y could be substituted for X. At least CR has the good grace to state “The antipsychotics have major side effects and response to them is highly variable” — AKA “Take our advice with a monster grain of salt.” Not the least of the worries are akathisia, tardive dyskinesia, other extrapyramidal symptoms, weight gain, and about a bazillion other possible side effects. My mind is still boggled that they even went there.

Curiously, however, discontinuation rates of perphenazine in schizophrenic patients are lower than with any second gen antipsychotic save olanzapine (Zyprexa) — though people tended to d/c Zyprexa due to its metabolic effects and weight gain, and perphenazine for its extrapyramidal symptoms. Something to consider, I suppose.

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All things considered, it’s nice to see the mainstream media promoting saving money on drugs, but it bugs me that they did it in the way that they did.

Absolutely perfect timing with Dr Dino’s Oops Meter.

Got a phonecall from an FP’s office across the street from the pharmacy. Medicaid patient had brought in his Risperdal Consta injection for his bi-weekly shot. The nurse dropped the injection in the office, which broke it, resulting in some non-emergent, but non-trivial lacerations to herself in the process.

Could we get another one? Of course, it’s 4pm on a Friday, and MassHealth doesn’t do lost/damaged precription overrides — if they did, their budget would probably double (TAP doesn’t make this shit up, you know) — but could we pleeeeeeease try. And they would, of course, call MassHealth themselves.

Risperdal Consta is about $650 per dose.

Of course the answer was no, but with both of us on the phone, MassHealth said they could do it tomorrow (that would be today, I guess) as a once-in-a-lifetime early-fill don’t-ever-ask-again override.

I’m so glad it worked out, and I feel terrible for this nurse. She’s probably wishing she had dropped some cyanocobalamin instead. We’d have just given it to them for nothing had it been something like that.

Based on Dino’s examples on the oops meter, I’d give this a solid 8. Right next to breaking wind in front of your boss. On the elevator.

Got an Rx from a dentist today:

Onymnomycin 300mg
1 qid until finished
#40
0 refills

I love it when prescribers make shit up.

Spotted in the wild:

:ninja:

One of my people — we’ll call her Jane — takes two drugs. A generic SSRI, and Nexium. While sorting through the options available to her, and running two scenarios, I discovered just how much Nexium costs her per year. More specifically, how much money she will save by switching from 40mg of Nexium to 2x20mg omeprazole capsules.

$594 per year.

I asked Jane if she’d ever taken anything before the Nexium, because it looked to me like she started it in early 2006, and she told me that she hadn’t. The doctor had given her samples, and then a prescription, and she’d been taking it ever since.

Here’s the thing: Nexium isn’t better than Prilosec. Yes, we all know it’s the isolated, active enantiomer of omeprazole, and its time to acid drop is a bit better, and “studies” (paid for by AstraZeneca) have shown that Nexium beats Prilosec in squashing acid production.

Except that it doesn’t, because if you look at the fine print, you’ll see that those glossy, purty brochures that the big-titted drug reps bring you compare 40mg Nexium to 20mg Prilosec. In fact, when AZ did studies comparing 40mg to 40mg, they discovered that the difference was inconsequential, so they didn’t include those results in their marketing materials. (My source for this is a former sales manager for AZ who used to have Nexium as a drug, and then went on to be a regional drug rep manager. He’s with Forest now.)

Pretty slick. And underhanded.

Oh, and time to acid drop isn’t a particularly important metric, by the way, because PPIs are maintenance meds, not Tums. And Nexium was only something like 2% better than Prilosec for the 8% of the study participants that even showed a difference. Whoopty-do. Clinically significant? Not especially.

Back to saving money. By changing from Nexium to Prilosec, Jane is able to pick a different Part D plan that has a lower premium, not to mention that when she comes to the pharmacy, her copayment will be lower, too. So Jane will be switching. And she could probably eke out a few more dollars in savings if she tried just 20mg omeprazole daily, but I thought I’d be generous by allowing for a non-standard dose in my calculations so her doctor would feel better about switching.

There is a tiny, tiny percentage of people — less than 1 in 100 — that do not respond to omeprazole that do respond to esomeprazole. No one knows why this is, and simply changing from one to the other results in marked improvement. That is no excuse for reaching right for the Nexium over the omeprazole, because sometimes the reverse is true: omeprazole works when esomeprazole does not. Sometimes neither of them work and you need to pick a different drug altogether. This phenomenon is true across all drug classes, and is another reason that having an inflexible, national formulary is a BAD idea.

[tags]healthcare, inefficiency[/tags]