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deepaks

prescribing below BNF limits

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Friends,

With great interest, i went through the thread 'Prescribing above BNF limits', all posts are quiet impressive.

It compelled me to wirte about the other end of the spectrum. Have you ever had experience of prescribing minute dose (may qualify for homeopathic dose) of psychotropic medication with good results?

I have, can vividly remember two instances. Once, when i was SHO, inherited a Jewish patient in my clinic who used to take 8 drops of thioridazine liquid, for many years and was stable. She had obsessional disorder.It didnt make sense but review of notes proved it was effective. This dose was agreed by the consultant who too was a Jew.

Currently, i have a patient with behavioural problem (screams numerous times in loud voice), was treated with various antidepressants including SSRI's on a presumed diagnosis of depressive disorder, albeit unsuccessfully. Had difficulty with compliance due to non-tolerance. Tried her on Mirtazepine, carers reported extreme sedation on 15mg. Dose titrated down by carers, currently doing well on 1 drop of Mirtazepine liquid on alternate days, believe it or not.

I would appreciate if you share similar experiences, critical comments, rationalisation, legal implications etc.

Thanks in advance

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I feel that BNF doses are already not high enough in UK, if u compare psychotropic being prescribed in USA and Australia.

Cheers

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I guess everyone has different sensitivities to medication as a result of different receptor balances, hepatic enzyme subtypes and other genetically mediated metabolic pathways. I've never seen doses as low as 1 drop of mirtazepine, and I would question the role of the placebo effect in such cases. I have however seen low doses of amitriptyline used in elderly depression to better effect than standard doses of other classes of antidepressants. The old age consultant I worked for had seen several such responders.

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Response to 1 drop of mirtazepine couldnt be placebo effect because patients daughter administers it covertly.

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it is simmilar to the placebo effect, but the effect is on the carers not the patient, cos presumably it's the carers who are saying she is well on it, but not well off it if it is being covertly administered.

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I agree with wetrain...

BNF max doses themselves are homeopathic....

I can definitely say that according to Indian standards...

Possibly pharmacogenetic differences... or the possibility of high amounts of chalk powder in medications in India...

Delirium is one condition where low dose Haloperidol works well... just 0.5 to 1.5 mg TDS can give amazing results....

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it is simmilar to the placebo effect, but the effect is on the carers not the patient, cos presumably it's the carers who are saying she is well on it, but not well off it if it is being covertly administered.

Yeah I'd agree with this. It's similar to the reason that homeopathic medicines are reported to work in animals by their owners. When actually they have no effect at all.

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it is simmilar to the placebo effect, but the effect is on the carers not the patient, cos presumably it's the carers who are saying she is well on it, but not well off it if it is being covertly administered.

Yeah I'd agree with this. It's similar to the reason that homeopathic medicines are reported to work in animals by their owners. When actually they have no effect at all.

I have thought about that too but doesnt appear to be the case. if it were to be placebo effect on the carer, like i said earlier, this patient was tried on many different antidepressants before mirtazepine. The carer should have had placebo effect earlier, why with mirtazepine and why with one drop alternate days dose, should have happened with 15mg daily.

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this patient used to scream about 20 times at night, after current treatment, the frequency has dropped to 1 to 3 times at night as reported by the carer. How can i believe it is a placebo effect on the carer?

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it is simmilar to the placebo effect, but the effect is on the carers not the patient, cos presumably it's the carers who are saying she is well on it, but not well off it if it is being covertly administered.

I have thought about that too but doesnt appear to be the case. if it were to be placebo effect on the carer, like i said earlier, this patient was tried on many different antidepressants before mirtazepine. The carer should have had placebo effect earlier, why with mirtazepine and why with one drop alternate days dose, should have happened with 15mg daily.

Slightly out of topic...

Just about Mirtazapine...

Mirtazapine is generally used in high doses in Europe...

But what most people dont realise is that it has differential effects on different receptors...

It has highest potency on H1 receptors... even at 7.5mg it block H1... hence a good sedative at low dose... at slightly higher dose, it blocks loads of 5HT...

Even at 15mg, it acts as a presynaptic alpha 2 blocker, which increases both 5HT and NE...

and the dose response is curvelinear...

At higher doses (even 15 mg), due to the increase in NE secretion, Mirtazapine is a poor sedative when compared to 7.5mg...

Unfortunately, we dont get 7.5 mg tabs here... but we get liquid...

some people find this most helpful... because 15 mg is too activating for them due to the effect on the NE system... probably with drops, the action kind of stops in between...

That wud be my explanation rather than attributing it all to 'placebo response'

In India, we used Mirtazapine at 7.5 mg to help sleep rather than temazepam or zopiclone... as well as to get the 5HT2 and 3 block to counter intolerable side effects of SSRIs...

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Just that I have started rambling..... I had to continue...

We dont use much of escitalopram in our trust... because studies have not shown that it is more cost effective than citalopram...

Escitalopram unlike Citalopram has dual action... (not in the sense of Venlafaxine)

Escitalopram, binds to to the serotonin transporter thus blocking the reuptake... it is also an allosteric modifier of this site... thus enhancing its own effect...

The R enantiomer, prevents the binding and hence the modification... thus rendering Citalopram to be not as effective as Escitalopram...

Now whether this actually translates to the antidepressant action is the question....

Surprisingly, studies (all industry sponsored) with escitalopram have shown that the antidepressant action starts surprisingly within a week... whether this can be explained by the dual mechanism is another question....

Sorry for the ramble....

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Doriannevergreys,

your post was not a ramble, it is impressive indeed. Nevertheless, would like to mention that one of my teachers in my medical school had a stock phrase 'EVERY PATIENT IS A BOOK'. We students, used to make a joke of him because he had obsessive compulsive disorder. Over the years, I always remember him and think he was the wisest guy I have ever met in medical field (provided the phrase is his own). I always remember it and find it very true not only in psychiatry but also in most branches of medicine. One has to have that sharpness of observation to see it.

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