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Interesting Case for Discussion

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Interesting Case for Discussion

Post  Admin on Sat Aug 17, 2013 7:31 pm

Hi Friends. I am about to see this new patient next week. Based on notes I received, he is coming for management of depression.

Male in Early 40s with medical history of:
Panhypopituitarism
Hypogonadism
Acromegaly with arthropathy
Fibromyalgia
Inflammatory arthritis
Migraines
Low back pain
Obesity
Lumbo-Sacral Degenerative Disc Disease
Vitamin D deficiency
Thyroid disease (details not known?)
Asthma
 
Past Surgical History:
Laproscopic Band surgery done few months ago

Hx substance abuse (Cocaine), but sober now per records

He is on following medications:
Nortriptyline 25 mg PO QHS for inflammatory arthritis
Welbutrin 150 mg BID
Tramadol 50 mg #2 PO Q6 hr PRN pain
Sumatriptan 50 mg  PRN migraine
Meloxicam 15 mg PO Daily
Cyclobenzaprine 10 mg PO Q PRN HS for spasms
Testosterone Enanthate 200 mg/ml #1Inj IM Q 14 days
Hydroxychloroquine 200 mg #2 PO daily
Fluticasone 50 mcg/actuation nasal spray, instill 1 spray into each nostril once daily
Ketoconazole 2 % cream, Apply topically 2 times daily.
Prochlorperazine 5 mg tablet Q 6hr PRN nausea


This medication regimen has so many drug interactions including:
- High risk of Serotonin Syndrome
- Increased risk of seizures
- Increased CNS depression
- Increased TCA levels

Patient is presently following with Endocrinologist, Bariatric surgery and Internal medicine, but looks like their is less or no collaboration of care here.

What are your views regarding this case in terms of:
- Which antidepressant is preferred for pt with panhypopituitarism- any good articles.
- He also has migraine, fibromyalgia and disk disease issues- Role of Duloxetine in this patient?
- Role of TCA in inflammatory arthritis. I didn't knew about this. What else can we try for this condition?

I am very excited to see this patient next week. Please recommend any good articles based on this case.

Thanks Smile

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Re: Interesting Case for Discussion

Post  P450 on Sun Aug 18, 2013 1:22 am

It's interesting that he has acromegaly and panhypopituitarism. You would think he would have less growth hormone/IGF given the latter. HPA axis upregulation is generally thought to occur in MDD, evidenced by nonsuppression on the dexamethasone suppression test and also increase in serum cortisol levels of MDD vs non-MDD. Some theorize, Robert Hedaya, specifically, that "adrenal fatigue" can cause depressive symptoms. This psychiatrist actually recommends giving hydrocortisone 20mg daily in certain cases. This recommendation, from his book 'Depression: Advancing the Treatment Paradigm' is not accompanied by any references to studies to this effect. In any case, if he indeed has reduced serum cortisol levels, this very well may causing/contributing to depressive symptoms.

On top of that he has vit D deficiency and thyroid disease (probably hypothyroidism given the hypopituitarism), both of which are associated with depression. There were two papers published this year (molecular psychiatry and British Journal of Psychiatry) associating low vit D with depression. I don't believe there are any strong data supporting vit D supplementation with improvement of MDD, but I would certainly give this a shot if he were my patient. Hypothyroidism goes without saying.

The drug interactions are interesting, which you pointed out: Nortriptyline is mainly a 2d6 substate, which is strongly inhibited by bupropion. So rising nortyptiline concentration plus buprorion could low his seizure threshold. Serotonin syndrome risk compounded from the SSRI plus tramadol plus triptan.

On to your concerns:
1. ADs for panhypopituitarism: I have not read any data on this.
2. Migraine/fibromyalgia/disc disease - Should you add duloxetine. I was sort of alluding to this above but I would want this patient's hormones to be within normal range, if possible, before changing his psych meds. I would discontinue the nortriptyline before starting duloxetine though, which would be a better idea than starting an SSRI.
3. I don't know of any data showing efficacy of TCAs for inflammatory arthritis either, but overall, I would try to minimize the polypharmacy, sticking to one agent at a time: If he's having a trial on duloxetine, there's no need for a tca and bupropion. If you want to have a trial of a tca, keep him off bupropion and duloxetine.

Thanks for the interesting case! Keep us posted!

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Re: Interesting Case for Discussion

Post  Admin on Sun Aug 18, 2013 6:46 pm

Thanks for this detailed explanation. Clap 

I totally agree with above approach. Most studies have shown that low levels of serum 25(OH)D are associated with depressive symptoms, but no effect was found with vitamin D supplementation.

I will keep you updated.

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Re: Interesting Case for Discussion

Post  Admin on Fri Aug 23, 2013 7:57 pm

Updates on above case:

Pt presented for first session with complaints of both "depression" and "increased irritability" in last 4 weeks.
Recent death in family ~5 months ago, worsening depression since then with disturbed sleep (both increased & decreased sleep), not socializing, decreased energy, loss of interest, decreased concentration and psychomotor retardation (no SI or passive death wishes reported). Stopped going to his job (as intern) ~ 1 month ago.
For last ~4 weeks: pt also complaints of  irritable mood, increased anger, "mood swings", "energy swings", racing thoughts, easily distractible, decreased sleep (with tired feeling during day time), increased unusual spending, hypersexual behavior and racing thoughts.

Past history of command auditory hallucination form age 21. Denies hallucinations for last 4 years- which is consistent with no substance use for last ~4 years.
Extensive history of substance abuse (Alcohol, Marijuana, Crack, Xanax, Vicodin and Percocet), but sober for ~4 years now.

Multiple inpatient psychiatry hospitalizations in past, but pt was using substances during all suicide attempts.
Following medications prescribed in past: Paroxetine (few months), Fluoxetine (> 1 year), Citalopram, Wellbutrin and Risperidone. Not giving history consistent with hypomanic switches with antidepressants (but pt was not clean during these medications trial)

Education: average student per patient, but kicked out of school twice for behavior issues (put locker room on fire and fight with kids resulting in incarceration). left school after 10th grade.
Unstable occupation history
Extensive legal history for burglary and other charges

Medical Hx:
Panhypopituitarism; Hypogonadism; Acromegaly with arthropathy ; Fibromyalgia; Inflammatory arthritis; Migraines; Obesity; Lumbo-Sacral Degenerative Disc Disease; Vitamin D deficiency; Thyroid disease (details not known?); Asthma; Migraines

Medications:
Nortriptyline 25 mg PO QHS for inflammatory arthritis
Welbutrin 150 mg BID
Tramadol 50 mg #2 PO Q6 hr PRN pain
Sumatriptan 50 mg  PRN migraine
Meloxicam 15 mg PO Daily
Cyclobenzaprine 10 mg PO Q PRN HS for spasms
Testosterone Enanthate 200 mg/ml #1Inj IM Q 14 days
Hydroxychloroquine 200 mg #2 PO daily
Fluticasone 50 mcg/actuation nasal spray, instill 1 spray into each nostril once daily
Ketoconazole 2 % cream, Apply topically 2 times daily.
Prochlorperazine 5 mg tablet Q 6hr PRN nausea

I discussed with him role of different medication interactions also one of the likely cause of his present mood symptoms.
My rule outs after first visits are: bipolar disorder mixed vs substance induced mood disorder vs mood disorder secondary to general medical condition vs MDD with psychotic features.

Labs done in past:
CBC, BMP, TSH, Lipid profile: Normal (done 4 months ago)
Karyotype: 46 XY normal
FSH <0.7 LH <0.2 (done 4 months ago)
Free Testo: Low

MRI or CT Head: Not done so far

I contacted all the physicians but only PCP replied back so far. PCP received pt on all these medications and no changes were made.
PCP agreed with plan of discontinuing followings:
Nortriptyline
Welbutrin
Tramadol
Sumatriptan
Prochlorperazine

No changes made to following medications so far.
Meloxicam 15 mg PO Daily
Cyclobenzaprine 10 mg PO Q PRN HS for spasms
Testosterone Enanthate 200 mg/ml #1Inj IM Q 14 days
Hydroxychloroquine 200 mg #2 PO daily
Fluticasone 50 mcg/actuation nasal spray, instill 1 spray into each nostril once daily
Ketoconazole 2 % cream, Apply topically 2 times daily.

I am still waiting for collaboration from Endocrinologist.

Pt recently visited ER with recent worsening of migraine:- complaints of vertigo (lasted 4 hours) with tinnitus, cold sweats, nausea and headache. His past vertigo never lasted >15 minutes. He took Compazine with no relief this time.
Following medications added:
- Gabapentin 300 mg tablet 2 times daily.
- Metoclopramide injection 10 mg IM given once.
- DiphenhydrAMINE 25 mg IM Q6hr PRN Itching
- Meclizine 25 mg 3 times daily PRN for Dizziness or Nausea.
- Ondansetron 4 mg Q8 hours PRN for Nausea.

I will be seeing him in next few days.

I am planning on doing MRI Brain for the presence of acromegaly with panhypopituitarism.
To follow him without these medications and observe for changes in mood symptoms.

What are your views on this case.

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Re: Interesting Case for Discussion

Post  Admin on Fri Aug 30, 2013 11:06 pm

Updates:

Lab work done:
FSH, LH and Vit D-25-OH are low
ACTH, prolactin, TSH within normal range
Urine Drug Screen: Negative

MRI- Pending

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Re: Interesting Case for Discussion

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