Category Archives: Drug Evaluations

Interesting Study of the Week–”Overactive Bladder”

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Mici, fabulous jail nurse, Bonneville Co. Jail, Idaho Falls, Idaho.

Shamliyan T, Wyman JF, Ramakrishnan R, Sainfort F, Kane RL. Benefits and harms of pharmacologic treatment for urinary incontinence in women. A systematic review. Ann Intern Med 2012;156:861-874.

We have all seen the commercials touting medications for the conditon the advertisements call “overactive bladder.”  This ,of course, refers to a sudden and unexpected urge to urinate, even when the bladder is not full.  These patients tend to have frequent nocturia.  And some patients who do not step lively enough will sometimes pee their pants a little bit, and this is termed “urge incontinence.”  If the incontinence occurs when the patient has a sudden increase of intra-abdominal pressure (like laughing or coughing), this is called “stress incontinence.”  Patients who have both have “mixed incontinence” and may not like good jokes.

This syndrome tends to occur in women more than men and in the elderly more than the young.  The term “overactive bladder,” as far as I can determine, was coined by the pharmaceutical industry as a way of labeling the condition in a friendlier way.  “Do you have ‘Overactive Bladder’” sounds better than”Do you have to run to the bathroom a lot and sometimes pee your pants?”  The medications advertised to help this condition are anti-cholinergics with muscarinic activity such as Ditropan (oxybutynin), Enablex (darifenacin) and Detrol (tolerodine).  In the advertisements, of course, the women who take these drugs are suddenly able to attend important events that they used to miss because of their embarrassing “overactive bladder.”

This great study asks the question:  just how effective are these medications for urge incontinence?  The study was done by a wonderful little government entity called the Agency for Healthcare Research and Quality.  They consistently do great work.  The researchers reviewed 72 different studies of anti-cholinergic drugs used in the treatment of urge incontinence.  The results:

1.  Approximately 10% (range 8.5% -13%) of patients become fully continent when taking these drugs.  That, of course, means that 9 out of 10 continue to have incontinence despite being on the medications.

2.  The researchers defined “clinically significant decrease” in incontinence as a reduction in episodes of at least 50%.  How many patients reached this threshold?  The answer is approximately half.  However, that barely outperformed placebo.

3.  There was not difference in response rates between those with urge incontinence, stress incontinence or “mixed” incontinence.

To my eye, these results are underwhelming.

Another consideration important in corrections is that since these medications are anti-cholinergics, they can be used by inmates to get high.  I wrote about this phenomenon previously in Is This Inmate Gaming Me?  Since I wrote that blog post, I have heard from medical personnel in several other correctional facilities who have also either suspected or discovered inmate abuse of these drugs, particularly oxybutynin.

So keep this in mind the next time an inmate says they must urinate a lot and want to be prescribed that pill they saw on television.  Some patients legitimately have this condition and may be helped by anti-cholinergic drugs.  Far more who truly have this condition will not be helped by these medications.  And still others may not really have bladder problems at all, but want the anti-cholinergic for its abuse potential.

Do you have a good strategy to sort out these three types of patient?  Please comment!

Interesting Study of the Week–MRSA

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Antibacterial drugs and the risk of community-associated methicillin-resistant Staphylococcus aureus in children. Schneider-Lindner, et.al., Arch Pedicatr Adolesc Med, 2011 Dec:165(12):1107-14.

This is a great study done in England, where a database of medical treatment for the whole country is available for research (unlike in the US).  These researchers asked the question, “If you are prescribed an antibiotic, does that increase your risk of subsequently contracting a MRSA infection?”  So the researchers reviewed records for children between 1994 and 2007, including ~300 MRSA cases and >9000 controls.

Not surprisingly, they found that a child who is prescribed an antibiotic does, in fact, have an increased risk of a subsequent MRSA infection.  The surprising thing is how much of an increased risk this represents.

If you receive one antibiotic prescription, your risk of MRSA infection within the next 6 months more than doubles. If you receive two antibiotic prescriptions within 150 days, your risk of MRSA more than triples.  Then the risk really goes up.  If your receive three antibiotic prescriptions within 150 days, your risk of subsequent MRSA infection goes up eleven fold.  Four antibiotic prescriptions and your risk for MRSA rises more than 18 fold.

Quinalones are particularly prone to increase the risk of subsequent MRSA infections.

These researchers had previously studied adults and found the same thing.  (Antimicrobial drugs and community-acquired methicillin-resistant Staphylococcus aureus, United Kingdom).

Perfect lawn

I’m going to prevent weeds by killing the grass.

This, of course, makes sense.  A great analogy that I like to use with inmates who want an antibiotic prescription for their viral syndrome is of a lawn of grass.  The grass itself prevents noxious weeds, like thistle, from sprouting.  The grass chokes them out.  But if I were to kill the grass by spraying Roundup, what are the odds that thistle will grow now?  The grass is like our normal, healthy colonies of bacteria.  They help us in many ways, including “choking out” noxious bacteria like MRSA. There has been some great recent research into the beneficial effects of our personal bacterial colonies, such as this report on the  Human Biome Project.

Using antibiotics is very like using grass killer.  Antibiotics are a great medical tool when used properly, but they also have the potential to cause great harm.  If you prescribe an antibiotic for a viral syndrome, like a typical case of sore throat or bronchitis, your potential for benefit is zero.  It’s a virus!  But your potential for harm is the same as it always is.  This study shows that one unnecessary prescription doubles your patient’s subsequent risk of MRSA.  If you prescribe Augmentin, the risk of diarrhea is one in six!  So you cannot help this patient with a virus by prescribing an antibiotic; you can only harm them.

The CDC has published excellent guidelines on the proper use of antibiotics for sore throats, bronchitis and sinusitis.  I have written about these guidelines previously here (Evidence-Based Use of Antibiotics Can Save Your Jail Money! and here (Don’t Use Antibiotics for Most Cases of Pharyngitis!, although my focus then was how inappropriate antibiotic prescribing wastes money.

The more important message is that inappropriate antibiotic prescribing harms your patients.  According to these studies, if you reduce your antibiotic prescribing by following these guidelines, you may find that your MRSA infection rate goes down, too! Bonus!

 

 

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Don’t Get Burned by Serotonin Syndrome (like I did)

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A 46 year old man comes to the medical clinic complaining of muscle aches and twitching, which he first noticed two days ago.  He had been booked two weeks ago and his prescribed outside medications were continued:  sertraline 100mg a day, amitriptyline 100mg at bedtime and lisinopril.

He walks into clinic with a stiff legged gait. His vital signs show a heart rate of 124.   He has sweat on his forehead and a noticeable tremor of the hands.  His speech is pressured.

So what is going on with this patient?  The answer, as you may have guessed from the title, is Serotonin Syndrome.  If you tap on his knees, he will have exaggerated reflexes.  Fortunately, he has only a mild case.

Serotonin Syndrome is a constellation of symptoms caused by an excess of the neurotransmitter serotonin. It ranges in severity from mild cases (like the one above) to fatal.  In my opinion, all medical personnel in correctional facilities should be aware of Serotonin Syndrome.  It is not as uncommon as you might have been taught; if you look carefully for it, you will find cases.

Serotonin Syndrome Defined

Serotonin Syndrome is characterized by a trinity of abnormalities:

  1. Neuromuscular hyperactivity:  Muscle twitching, tremor, hyperreflexia.
  2. Autonomic effects:  tachycardia, hypertension, hyperthermia, sweating, shivering.
  3. Mental status effects:  anxiety, agitation, hypomania, confusion, hallucinations.

Mild cases of Serotonin Syndrome may only manifest as tremor, hyperreflexia, tachycardia and sweating and shivering.

Moderately severe patients will additionally have an increased temperature, clonus and agitation.

Severe cases are usually confused and hallucinating, and have very high temperatures (sometimes over 106F) which can lead to all sorts of very bad effects, like rhabdomyolysis, seizures, renal failure, and, yes, death.

Treatment of Serotonin Syndrome

The most important treatment of Serotonin Syndrome is to immediately stop all of the serotonergic drugs the patient is taking!  Benzodiazepines are helpful in treating the agitation and neuromuscular effects of moderate cases.  Severe cases, of course, need to go to the ER for big time supportive care and treatment.

Causes of Serotonin Syndrome

So what causes Serotonin Syndrome?  The answer is that Serotonin Syndrome is caused by drugs that act by increasing serotonin levels. These are mostly psychiatric drugs, of course.  The Big Three Categories of serotonergic drugs are:

  1. Selective Serotonin Reuptake Inhibitors (SSRIs).  There are lots of these.  I won’t list them; you know what they are.
  2. Tricyclic antidepressants (TCAs), which act by blocking serotonin reuptake as well as norepinephrine reuptake.  The ones I see used most are amitriptyline, imipramine and doxepin.
  3. Serotonin-norepinephrine Reuptake Inhibitors (SNRIs).  This group includes Trazodone Venlafaxine and desvenlafaxine (Effexor and Pristiq), and duloxetine (Cymbalta).

You should memorize that list!  However, many other drugs increase serotonin levels besides those in The Big Three Categories.  Interesting examples include amphetamines, Buspirone, Tramadol and tryptans.

There are two main ways that the drugs in the Big Three Categories can cause Serotonin Syndrome.  One way is just to use large doses of a serotonergic agent, usually an SSRI.  Big dosing of SSRIs was done in the past more than it is now.  My psychiatrist mentor here in Boise, Dr. Estess, told me that when Prozac was first introduced and doctors were experimenting with big doses, like 80mg a day, he used to see lots of mild-moderate cases of Serotonin Syndrome.  It is less common to see large doses of SSRIs used nowadays, since it has been pretty well established that you get little, if any, additional anti-depressant benefit from SSRIs by using big doses.  But still, occasionally, someone will arrive at one of my jails taking, say, 200mg a day of sertraline.  If you see a patient like that, check their reflexes and look carefully for a tremor and you may indeed find evidence of systemic serotonin effect.

However, the more important cause of Serotonin Syndrome, by far, is by combining agents from two different categories.  This practice is very common; I see this all the time. For example an SSRI is prescribed along with Trazodone as a sleeper or an SSRI is combined with a tri-cyclic antidepressant like amitriptyline on the dubious premise that two anti-depressants are better than one.  However, try this:  plug an SSRI and a TCA or trazodone into a drug interaction checker (like this one that I like to use).  A big red stop sign will pop up saying (approximately) “Major potential drug interaction!  Risk of Serotonin Syndrome! Do you really want to do this?”  And the risk here is real.

Serotonin Syndrome Develops Quickly

One thing that I did not mention yet about full-blown Serotonin Syndrome is that it tends to develop quickly.  I personally learned this the hard way.  I had a patient in one of my jails die from Serotonin Syndrome.  Dead.  The patient was a middle-aged man who came to the jail taking Paxil and Imipramine prescribed by his outside psychiatrist.  I continued these medications.  A couple of months into his incarceration, in the middle of the night, he developed agitation, hallucinations and vomiting.  He became unresponsive.  An ambulance was called.  At the ER, he had a temp of 107F, intense muscle rigidity, and full blown shock.  He died there in the ER.

Benefits?  Risk!

This tragic case occurred early in my correctional medicine career.  It has made me vigilant in looking for evidence of Serotonin Syndrome—and I have found a few mild-moderate cases since.  It also made me question whether the benefit of combining two serotonergic agents in one patient ever outweighs the risk.  I personally don’t believe so.

Whether you agree or disagree with this conclusion, please remember the danger of Serotonin Syndrome when you combine serotonergic agents.  You may have used this combination a hundred times and have never seen ill effects.  That does not mean you never will.  Consider whether the benefit of the drug combination you are considering truly outweigh the risk of Serotonin Syndrome.

Have you had a case of Serotonin Syndrome in your facility?

What is your opinion of combining serotonergic drugs?

 

Staged medical clinic at the Bonneville County Jail, Idaho Falls, Idaho. (The "patient" is actually one of the medical staff)

Thoughts on an Untreated Type 2 Diabetic

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Staged medical clinic at the Bonneville County Jail, Idaho Falls, Idaho. (The “patient” is actually one of the medical staff)

We recently had a 46-year-old male patient booked into our jail who reported a history of diabetes but who had not seen a physician or taken any medications for “years.”  He said he used to take a medication for diabetes “a long time ago” but he could not remember the name.  He also could not remember the name of the doctor he had once seen.  He reported basically no other medical history. Continue reading →

Is This Inmate Gaming Me?

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Lanea runs the pharmacy at the Ada Co. Jail in Boise. Should I have her order in some oxybutynin?

I have seen several patients recently with an unusual complaint.

A typical presentation would be this:  a male in his early 30s and without medical history  complains of frequent urination: “I have to get up 10-12 times a night to pee.”  He reports no other symptoms, like dysuria or discharge or pain.  This reportedly has been going on for years, though he has never before sought medical attention for it.  He says it got worse once he arrived at his current jail around three months ago. Continue reading →

Do these go into property?

Where Should the Hydrocodone Go?

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Do these go into property?

My friend Sherry Stoutin, Medical Director of the Nez Perce County Jail in Lewiston, Idaho, shared an interesting case.

She sent a patient in her jail to the Emergency Department to be evaluated for chest pain.  He was cleared in the ER but was sent back to the jail with six hydrocodone tablets to be used PRN for chest pain as well as a prescription for 20 more.  The patient actually had no further complaints of chest pain when he returned to the jail, so whether to give the six tablets to him was a moot point.

The real question is what to do now with the six hydrocodone tablets and the prescription for 20 more.  Should they be placed in his property and given to him when he is released from jail?

What would you do?  Read on for my thoughts, such as they are: Continue reading →

Are There Medications that are Inappropriate for Use in Jails and Prisons?

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All medications have side effects and potential complications. Of course we all know this. Whether to prescribe and what to prescribe should involve a careful weighing of the expected benefits vs. the potential harm for each individual patient.  This math—risks vs. benefits—can change for many reasons.  For example, drug X may be great for most people but this patient has kidney disease and should not take drug X.  This patient does well on drug Y but that patient has no health insurance and cannot afford drug Y.

Being incarcerated changes the risk-benefit equation for many drugs.  This is especially true for drugs that are addictive or have the potential to be abused.  Some medications may be inappropriately used by inmates to continue or maintain their drug addiction while incarcerated. Such medications have value in the jail system and are commonly shared and sold.  Individuals taking these medications may be at risk from other inmates, who may coerce patients to “cheek” and share.  This additional extraordinary risk must be considered when prescribing medications in a correctional setting and for many drugs, the risks always (or almost always) outweigh any benefit a patient may derive from them. Continue reading →

Review Articles of the Month–Emphasis Psychiatry

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Like most physicians, I subscribe to several medical education and CME sites.  One of my favorites is Primary Care Medical Abstracts.  PCMA chooses 30 papers a month of interest to primary care physicians and then these papers are reviewed by two physicians (usually Rick Bukata and Jerry Hoffman).  The reviews are insightful and funny and pretty fun to listen to.  These guys have no problem calling B.S. when they review certain papers.  I like that!  (By the way, I have no affiliation with PCMA). Continue reading →

Embracing the Placebo Effect of Antidepressants.

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Social Worker Shanna at work in the Ada County Jail Boise, Idaho

I recently ran across this interesting article (found here) which is the latest in a long series over the years comparing antidepressant efficacy to placebos.  I know that this is a controversial subject with some believing that all (or most) of antidepressant effect is placebo effect and others believing that antidepressants do indeed work better than placebos, especially among the most severely depressed patients.  The researchers in this article did a review of several trials and concluded that antidepressants work better than placebo in those with mild and moderate depression.  The most interesting statistic from this paper in my mind is this:  in this, the most positive analysis that I have read  on the effect of antidepressants, the “Number Needed to Treat” (NNT) to have one patient do better than by placebo alone was five (5).  In other words, 4 out of 5 patients in this study got no benefit from the antidepressant over placebo. Continue reading →

Diabetic Snacks: Part Two!

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Full Service Prison Cafeteria

In my previous post on Rethinking Diabetic Snacks for Type 2 Diabetics, I mentioned that there are two theoretical justifications for the practice or prescribing bedtime snacks for type 2 diabetics.  I would like to expound on these two issues here and also comment on another issue that I failed to mention in the first article but that is important:  the non-medical security issues of having diabetic snacks.

Myth:  Four Meals are Better than Three for Type 2 Diabetics

The first justification for diabetic snacks is the idea that if Type 2 diabetics eat several small meals rather than 3 big meals, there will be more even absorption of calories and carbs.  This would cause smaller blood sugar spikes at meals.  In other words, four meals (counting the bedtime snack) is better than three meals. Continue reading →