Tuesday, March 13, 2007

Why I Still Prescribe Seroquel

In my post below, Things I Wish I Knew, I talked about how I'm uncomfortable with uncertainty, in particular when I'm the one to make decisions for other people and don't really have any way to know the full consequences of the decisions I make for them.

I mentioned a number of things I wish I knew, most didn't draw much attention, but two topics did: The consequences of allowing children to watch video games, and the issue of prescribing novel antipsychotic medications off-label, as opposed to Xanax.

Enough about VideoKid--Spring sports have begun and he'll have gobs of homework as the school year ends, he's looking for a job, thinking about college, learning to drive, it's soon to be a moot point. We're doing our best here and it's an imperfect world, what can I say.

Instead, I'll tell you why I'm more comfortable prescribing a very low dose of a second generation anti-psychotic (usually either 25mg of seroquel or 2.5 my of zyprexa) off label when someone is subjectively distressed---let me call it agitated, it's hard for me to say because I'm not inside their skin. Often these are folks who have bipolar disorder or have an agitated major depression, and the dose of the antipsychotic is given on an as needed basis (determined by the patient) until something else kicks in. I don't think I've ever given this as the sole agent unless the patient has simply refused other medications.

To put it simply, I give these medications instead of Xanax because they are easy to stop. No one gets stuck on them, no one makes me uncomfortable by demanding that I continue to prescribe something that is no longer needed. People take them When Needed (usually a handful of times, or a few times a week). Xanax helps, and people take it a few times a day, maybe it helps so much they take it a few times every day, maybe it helps so much they take it a more than I suggested, and they don't want to stop, and if I refuse to continue to write for it they become demanding, or call repeatedly in distress insisting I MUST give them something, and I'm faced with the issue of refusing to write for it and risking that they'll withdraw and possibly seize, or writing for a medication on on-going basis that I'm not comfortable with, sometimes after it's been escalated to doses where I wonder if the FDA will hunt me down. This just doesn't happen with low-dose anti-psychotics.

Okay, in reality, I never use Xanax, so this has only been an issue when seeing patients that other docs have started and maintained someone on (up to 8mg a day, chronically, ouch!). But if the same patient as above shows up and there is no reason not to, I may use Ativan (lorezepam) or Klonopin (clonazepam) in the same way. I agree, if they can be used in the short term, and if someone doesn't become addicted to them or physically dependent or tolerant, the risks are less. So, I weigh it in my head: Is there a history of addiction? (yes-- no benzos). Is there a history of or current alcohol abuse (punt). Does the patient get distressed when I tell them they can't drink on this medicine? If there is no history of alcohol or benzodiazepine abuse or dependence (they are cross reactive), if the patient has been on a benzodiazepine before and had no trouble coming off, if they drink sometimes but have no history of alcohol abuse, then I feel comfortable prescribing a benzodiazapine. I give a small amount, and I tell them it's a crisis medication, not for regular use. I warn that it can be sedating, that it can be addicting. Most people worry about that: it's a good sign. It's the person who assures me that he won't get addicted that I worry about.

When I use a novel anti-psychotic, I tell the patient that it is a low dose and that the medication is associated with precipitating/fast-forwarding the onset of diabetes, lipid dysregulation, and weight gain. I suggest they take it only when needed and that they stop as soon as possible (there is no withdrawal to low doses). One of our commenters said that even low doses cause difficulties, even "kill" (I assume this means weight gain, diabetes, dyslipidemia)-- this may be, but in my personal experience, I have not seen problems with periodic low dose medication. Maybe I've simply been lucky to date.

I don't insist that anyone take any medication they don't want to take. Nor do I recruit patients, I'm an outpatient doc, people come to me, often asking for medication. I have never said to a patient "If you won't take this medication, I won't treat you." I tell them what the studies show, I tell them what I think they should do, if they don't want meds and they still feel helped by coming to see me, I see them.

We live in a society that values the right to make choices, even bad choices. We allow people to smoke and to drink alcohol, despite the fact that the risks they expose themselves (and others) to are both huge and certain, the cost to society exorbitant. It is unfortunate, perhaps even tragic, that we don't have medications with no side effects or ugly adverse effects and I wish that weren't so, it would make my job so much easier. But given the options we have, when I see someone in distress, I'm faced with what I know-- and that is full of uncertainty . Will this medicine make you sick? Will you have a recurrence of your illness without it? Will you have a recurrence anyway AND get sick if you take it? Given that there is no free ride, the other option is to refuse to prescribe, and that carries with it lots of other risks, the denial of something that often helps, and the message of there is no hope if you can't be patient-- and honestly, therapy alone, even great therapy, doesn't always do it. Mostly, I'm left to share what I know with the patient-- including statistics if I have them and if it's appropriate-- but ultimately the decision belongs to the patient, and when they leave it to me, I cross my fingers and do my best.

So no one wanted to comment on the rise in teenage suicide following the black box warning?