Geaux Tigers!
Bluelighter
- Joined
- Nov 15, 2010
- Messages
- 393
Hello, Bluelight community!
I am treating a patient that I diagnosed with narcolepsy featuring minor episodes of cataplexy. It has been 17 months now, and she is satisfied with my prescribed medicine cocktail, but doses continue to escalate because she claims tolerance at diminutive doses.
I have her "maintained" currently, but I feel like I have her consummated on every option. She desires perfection, and I am doing the best I know how; however, psychopharmacology may not alleviate every symptom of narcolepsy. I want her to be satisfied with her medical treatment.
I am infamous as being the "most interesting" psych in town. I believe in off-label too, and I go by my own judgement when it comes to prescribing the doses because I always keep the patient's response and tolerance to medication in my mind.
In this case, I suppose that this is more neurology than psychology, but I digress.
What augmentation would you suggest with this regiment below?
7.5g at night of Xyrem (sodium oxybate)
#180 Zenzedi (dexamphetamine IR) 10mg. [60mg.]
#120 Provigil (modafinil) 200mg. [800mg.]
#120 Vivactil (protriptyline) 10mg. [30mg.]
#90 Wellbutrin SR (bupropion) 100mg.
The patient's most problematic symptom is excessive daytime sleepiness. As you can tell, the doses are capacious, and there is really no more proliferation. She is satisfied right now with her treatment, but I am anxious about her tolerance aggrandizing leading to dissatisfaction with treatment that was once effacious. I make it my goal to not have to see every patient every month (just come in for script) because they are stable so this is something I'm concerned with; essentially, this is my professional impetuosity.
She claims that the most effective medication is the GHB which makes sense to me. She stated that it helps her get the type of sleep she needs thus reducing the severity of her EDS. She is on the third tier of the FDA recommended dosage, however.
The Zenzedi (dexamphetamine), you may be questioning why I chose it over Adderall (amphetamine salts), a drug that might be more stimulating due to the l-amp. Zenzedi is specifically indicated for narcolepsy via a brand name. The highest dose is 10mg., just like the generic Dexedrine IR. The patient has very good insurance. Also, I believe this is better for her blood pressure than amphetamine salts.
For months, she said the modafinil was worthless yet "had potential". It took awhile, but she is now on 800mg. and it is no longer placebo. I do not believe modafinil is very toxic at high doses, but according to the FDA, it is not proven to be any more effective over 400mg. I believe this an atypical case.
The protriptyline was initiated with the cataplexy specifically in mind. It seems to be rarely used. (I find it to be a great augmentation agent for ADHD as well.) I thought the cataplexy suppressing effects of its TCA properties and its stimulation, unique among TCAs, made it a felicitous selection for this patient.
The bupropion is sort of a desperation attempt due to its relevant reuptake inhibition. I was concerned with it due to the cataplexy. She takes her medicine throughout the day; therefore, I thought that having higher plasma levels of bupropion would make its negligible stimulation more active. I need to monitor bupropion more closely.
So, there ya have it, Bluelight.
What approach should I take pharacologically to best ameliorate this patient's narcolepsy?
Thanks!
I am treating a patient that I diagnosed with narcolepsy featuring minor episodes of cataplexy. It has been 17 months now, and she is satisfied with my prescribed medicine cocktail, but doses continue to escalate because she claims tolerance at diminutive doses.
I have her "maintained" currently, but I feel like I have her consummated on every option. She desires perfection, and I am doing the best I know how; however, psychopharmacology may not alleviate every symptom of narcolepsy. I want her to be satisfied with her medical treatment.
I am infamous as being the "most interesting" psych in town. I believe in off-label too, and I go by my own judgement when it comes to prescribing the doses because I always keep the patient's response and tolerance to medication in my mind.
In this case, I suppose that this is more neurology than psychology, but I digress.
What augmentation would you suggest with this regiment below?
7.5g at night of Xyrem (sodium oxybate)
#180 Zenzedi (dexamphetamine IR) 10mg. [60mg.]
#120 Provigil (modafinil) 200mg. [800mg.]
#120 Vivactil (protriptyline) 10mg. [30mg.]
#90 Wellbutrin SR (bupropion) 100mg.
The patient's most problematic symptom is excessive daytime sleepiness. As you can tell, the doses are capacious, and there is really no more proliferation. She is satisfied right now with her treatment, but I am anxious about her tolerance aggrandizing leading to dissatisfaction with treatment that was once effacious. I make it my goal to not have to see every patient every month (just come in for script) because they are stable so this is something I'm concerned with; essentially, this is my professional impetuosity.
She claims that the most effective medication is the GHB which makes sense to me. She stated that it helps her get the type of sleep she needs thus reducing the severity of her EDS. She is on the third tier of the FDA recommended dosage, however.
The Zenzedi (dexamphetamine), you may be questioning why I chose it over Adderall (amphetamine salts), a drug that might be more stimulating due to the l-amp. Zenzedi is specifically indicated for narcolepsy via a brand name. The highest dose is 10mg., just like the generic Dexedrine IR. The patient has very good insurance. Also, I believe this is better for her blood pressure than amphetamine salts.
For months, she said the modafinil was worthless yet "had potential". It took awhile, but she is now on 800mg. and it is no longer placebo. I do not believe modafinil is very toxic at high doses, but according to the FDA, it is not proven to be any more effective over 400mg. I believe this an atypical case.
The protriptyline was initiated with the cataplexy specifically in mind. It seems to be rarely used. (I find it to be a great augmentation agent for ADHD as well.) I thought the cataplexy suppressing effects of its TCA properties and its stimulation, unique among TCAs, made it a felicitous selection for this patient.
The bupropion is sort of a desperation attempt due to its relevant reuptake inhibition. I was concerned with it due to the cataplexy. She takes her medicine throughout the day; therefore, I thought that having higher plasma levels of bupropion would make its negligible stimulation more active. I need to monitor bupropion more closely.
So, there ya have it, Bluelight.
What approach should I take pharacologically to best ameliorate this patient's narcolepsy?
Thanks!
