Treatment history as it pertains to treatment planning

“X med did not work for me”; Efficacy vs Tolerability

Efficacy

Can only speak to it if they had an “adequate trial”

Adequate trial: 1) high enough dose for 2) long enough time (usually at least 3-4 weeks on the given dose for any reuptake inhibitor, at least a week for other meds)

Causes of inadequate trials

• practitioner failing to increase it high enough

• patient stopping the medication

• side effects

Practical implications:

If it was not an adequate trial, and not because of a side effect that limited the titration, you can still try the same medication

If patient had a partial response, you can use the same med just titrate higher

Tolerability = side effects

1. Clarify reported side effects

2. Timeline

Did it start SOON AFTER you started the medication?

Correlation ≠ causation

Most side effects happen at the outset of treatment and at dose increases

1. Dosing

What was the starting dose?

How fast was the titration?

Practical implications:

Dose dependent side effect (GI, sexual, numbing, motor)

NOT a contraindication if possible to slow down titration (it is not possible to slow down if pt had intolerable side effects on the starting dose)

However be aware that the side effect can come back every time the dose is increased

Non dose dependent “idiosyncratic” side effect (rash, EPS, weight gain)

IS a contraindication

Related: Pt with extreme sensitivity to side effects page HERE

“X med worked for me”

1. Same set of sxs?

2. Established effective dose: the dose pt needed in the past for resolution of sxs

Get there in a timely manner…

If pt used to need Prozac 60mg the equivalents of that are Zoloft 150mg, Paxil 40mg, Lexapro 20mg, Celexa 30mg

Fast dose increase needed: use 0.5 - 1 - 1.5 tablets of the existing supply while Propel delivers instead of sending them to the local pharmacy

Review the entire chart

Previous Nurx tx episodes - review for

• Suicidality/kickouts

• Previously used meds (prescriptions, scores)

Past med trials

• Did not work

Efficacy: Was it an adequate trial

Tolerability: 1) clarify side effects 2) establish timeline 3) clarify dosing

• Worked

1. Did they have the same set of sxs…? 2) Established effective dose

Current meds: Fully effective or partial response?

If pt states a combination regimen worked well for them in the past

Start only one medication at a time

Evaluate its effect over time

Only add the second one if necessary

Consider checking in with patient more frequently to get to a satisfactory treatment plan fast