From: RogerPeele@...
Date: June 20, 2008 4:27:35 AM PDT
To: roger.peele@...
Subject: County Update -- 20June08

 

Folks,

 

At last month's Annual meeting, a talk on traumatic brain injury suggested the following three [in order of preference of the neurologist] for hyper-arousal: 1] trazodone; 2] carbamazepine; 3] haloperidol. He said donepezil makes the hyper-arousal worse.  If the manifestations are hypo-arousal, he suggested a check on hormone levels, but was not specific on which hormones he suggested be the focus.

 

Many of us have been using duloxetine off label for fibromyalgia. Now it is on label.

 

The FDA has expanded its warning on use of second generation antipsychotics in pts with dementia to first generation. This decision was more rational than empirical [they don't have the data].  I see about ten records/month of doc's use of antipsychotics with pts with dementia, and the average is near 1/pt, down from about 2 antipsychotics/pt when I first joined the County 7 years ago.  Much less olanzapine being prescribed now, and the trend is toward other second generation, not first generation.

 

In this month's A J Clin Psychiatry, another suggested off-label for naltrexone: gambling addiction, 50-150 mg/d for 18 weeks reduced gambling in some pts.

 

This week, another FDA warning about medication causing more suicidal thoughts and behaviors than placebo.  It is unclear if there were any suicides.  The following is quoted from the FDA: "The increased risk of suicidal behavior and suicidal ideation was observed as early as one week after starting the antiepileptic drug and continued through 24 weeks. The results were generally consistent among the eleven drugs.  Patients who were treated for epilepsy, psychiatric disorders, and other conditions were all at increased risk for suicidality when compared to placebo, and there did not appear to be a specific demographic subgroup of patients to which the increased risk could be attributed.  The relative risk for suicidality was higher in the patients with epilepsy compared to patients who were given one of the drugs in the class for psychiatric or other conditions.  All patients who are currently taking or starting on any antiepileptic drug should be closely monitored for notable changes in behavior that could indicate the emergence or worsening of suicidal thoughts or behavior or depression." Medications specifically mentioned: 

Carbamazepine (Tegretol, Tegretol XR)

Felbamate (Felbatol)

Gabapentin (Neurontin)

Lamotrigine (Lamictal)

Levetiracetam (Keppra]

Oxcarbazepine (Trileptal)

Pregabalin (Lyrica)

Tiagabine (Gabitril)

Topiramate (Topamax)

Valproate (Depakote, Depakote ER, Depakene, Depacon)

Zonisamide (Zonegran)

 

 

The Editor-In-Chief of DSM-IV-TR, Michael First, Columbia U, looked over our Axis V Form and made some recommended changes, which we have made, now at RogerPeele.com >> clinical issues >> scoring Axis V [avoid "Printer Friendly" as that will give you the outdated version]. Michael likes our column approach. 

 

Roger

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