Posted by JohnL on February 26, 2000, at 5:09:06
In reply to To JohnL, posted by medlib on February 25, 2000, at 20:57:43
> JohnL-
> I really like the idea of your "bang-bang-bang" approach to new Rx initiation and would like very much to take some documentation to my pdoc next week that might convince him to try it with me. Waiting a month between mistakes is the PITS! Do you have any citations you could share with me? I would search Medline myself, but I can't think what to call such an approach. It doesn't correspond to any MeSH term, that's for sure. Any help would be much appreciated.
> Thanks!
> medlib
This is a copy of what my pdoc wrote to my family doc. It is a real life realtime example of probing for the magic molecule. Since pdocs are merely using educated guesses anyway in choosing medication, this approach organizes trials into a logical step by step probing exploration for superior matches. Superior matches are characterized by quick positive response. Inferior matches are charcterized by negative reactions, excessive side effects, and longer time to achieve results. The underlying philosophy is that medication reactions will guide treatment with more weight than the actual diagnosis. This is because any one of a number of different chemical imbalances can all cause the same exact symptoms. For example, just because someone has depression doesn't mean it is caused by serotonin/NE malfunction or that it will be normalized with an antidepressant. There are other causes that deserve probing.Keep in mind other drugs such as Paxil or Zoloft or tricyclics have already been weeded out, and that's why they aren't mentioned. It's already clear I benefit from SSRIs somewhat, but the pdoc wants to make sure I'm on the best match SSRI for my chemistry. And then he wants to explore uncharted territory to see if other chemical imbalances and/or instabilities are involved. Probing for the magic molecule in an organized manner. I am guessing, but my prediction is he will guide me to the right blend of medications in about 5 visits. To be continued...:)
Dear Dr. Libenson,
Concerning John L...The 43 year old father has suffered from apathy and periodically severe depression since childhood. He meets criteria for major depression. Numerous antidepressants (11) have worsened his condition, yet Prozac 20mg helps moderately. Zyprexa 5mg at bedtime has been markedly helpful for depression and insomnia. He still takes 7.5mg Remeron at bedtime.
Diagnostically he has major depression. Yet underlying slightly manic depressive or psychotic chemistry may be present. The efficacy of Zyprexa proves this. Lithium did not help, while Lamictal in contrast helped mental stability.
Ideas: find out what is his best antidepressant match.
1. He should continue for two weeks Prozac 20mg daily, combined with Zyprexa 5mg at bedtime. Remeron 7.5mg at bedtime should be discontinued.
2. After two weeks, Prozac should be discontinued, and switched to Celexa 20mg 1 to 2 in AM for depression for two weeks.
Celexa did not worsen psychosis, and helped aggression in a study involving 15 schizophrenicss.
Citalopram, a selective serotonin reuptake inhibitor, in the treatment of aggression in schizophrenia. Vartiainen H, et al. Acta Psychiatr Scand. 1995: 91 (5): 348-51, Finland.Celexa is excellent for perfectionists, and is similar to Prozac, but may be a better match for John. It should be given two weeks since Prozac has a 9 day half-life.
3. After Celexa has been tried, it should be switched to Luvox 50mg in AM for one week to make sure he is on the best matching antidepressant for his system.
He could then pick Prozac, Celexa, or Luvox to continue .
Other projects in the future should include briefly testing the following ideas:
1. Compare children's doses of stimulants such as Adderall 5mg: 1-2 in a.m. and at noon (#15) vs. Dexedrine 5mg tablets: 1-2 in a.m. and at noon (#15) for refractory depression.
2. Compare antipsychotics to optimize matching, such as Stelazine 2mg in AM vs. Risperdal 1mg: 1-2 in AM vs. Zyprexa 5mg at bedtime.
3. Compare anticonvulsants such as Depakote 250mg three times daily (#15) vs. Neurontin 300mg three times daily (#15) vs. Lamictal 100mg twice daily (#15).
poster:JohnL
thread:23875
URL: http://www.dr-bob.org/babble/20000220/msgs/23980.html