A patient is being seen at your clinic for depression and has been prescribed Zoloft. At todays visit, she admits to still taking St. Johns Wort. What do you tell her?
St. John’s Wort is a plant that has been used for centuries for mental health conditions, and it is still widely prescribed in Europe for depression. In the United States, it is sold as a dietary supplement (National Center for Complementary and Integrative Health, 2017). St. John’s Wort’s effectiveness for depression is mixed. Some studies determine it does not decrease symptoms of depression, with other studies stating they are as effective as standards antidepressants (National Center for Complementary and Integrative Health, 2017). Regardless, combining St. John’s Wort with Zoloft needs to be discouraged as this combination can lead to a life-threatening increase of serotonin called serotonin syndrome. Symptoms can occur within minutes to hours and include diarrhea, agitation, tachycardia, high blood pressure, increased body temperature, and hallucinations (National Center for Complementary and Integrative Health, 2017). Also, there have been reports of St. John’s Wort worsening psychotic symptoms on bipolar or schizophrenic patients (National Center for Complementary and Integrative Health, 2017).
A patient asks if they would benefit from taking Aricept from their mild dementia. What is your response?
Aricept is an acetylcholinesterase inhibitor commonly used to treat mild, moderate, and severe Alzheimers disease (Kumar et al., 2021). When acetylcholine is released from the presynapse, the enzyme acetylcholinesterase degrades it, and Aricept works by binding to acetylcholinesterase and inhibiting its action (Kumar et al., 2021). This increases the availability of acetylcholine at the synapses, improving cholinergic transmission. However, it is important to inform the patient that this medication does not alter the progression of the disease but can decrease some of the symptoms by improving cognition and behavior (Kumar et al., 2021).
Your patient asks if he or she should take Propranolol at the beginning of a migraine headache. How do you respond?
Propranolol is a beta-blocker used for migraine prophylaxis but has not proven successful in aborting an acute attack (Linde & Rossnagel, 2017). Beta-blockers are the first choice for migraine prophylaxis, although it is not sure how they decrease the frequency of migraine attacks. It is believed they may affect the central catecholaminergic system and brain serotonin receptors (Linde & Rossnagel, 2017).
A patient requires treatment for his ADHD, but is drug tested at his job and they have a zero tolerance policy. Is there a medication he can take to help his attention and focus?
Antidepressants, especially those acting as noradrenaline or dopamine enhancers, have shown efficacy in the treatment of ADHD, as well as metadoxine and lithium, in some cases (Childress, 2016). In 2002, the U.S. Food and Drug Administration approved atomoxetine (Strattera) as an effective non-stimulant treatment option for ADHD. Even though the effect is lower than stimulants, the American Academy of Child and Adolescent Psychiatry Practice Parameter lists atomoxetine as a first-line treatment alternative (Childress, 2016). Atomoxetine is widely prescribed, and several studies have found that it improves the quality of life and emotional lability, aside from treating core ADHD symptoms (Childress, 2016).
What is the most commonly used dopaminergic drug used for Parkinsons?
The most commonly used dopaminergic drug used for Parkinsons disease is levodopa-based preparations. They are designed to replace dopamine (Zahoor et al., 2018). Dopamine cannot cross the blood-brain barrier and cannot be used to treat Parkinsons disease, but levodopa is a dopamine precursor able to cross the blood-brain barrier and is converted into dopamine by DOPA decarboxylase (Zahoor et al., 2018). Patients are usually started on a low dose of levodopa. Then it is titrated up based on the patients response to the treatment, with a dose range of 150-1000 mg daily, divided into multiple doses (Zahoor et al., 2018). As the disease becomes more advanced, usually the effect of the drug wears off after shorter durations, requiring an increased frequency of dosing (Zahoor et al., 2018).
What other disorder are many of the Antiepileptic drugs used for? Name 2 of the drugs.
Antiepileptic drugs can be used for conditions such as migraine prophylaxis, bipolar disorder, and neuropathic pain, fibromyalgia, and restless legs syndrome (Leong et al., 2016). Two examples include gabapentin and lamotrigine. Gabapentin is widely used to treat neuropathic pain, while lamotrigine is often used to treat bipolar disorders (Leong et al., 2016).
Childress A. C. (2016). A critical appraisal of atomoxetine in the management of ADHD. Therapeutics and clinical risk management, 12, 2739. https://doi.org/10.2147/TCRM.S59270
Kumar, A., Gupta, V., & Sharma, S. (2021). Donepezil. Treasure Island (FL): StatPearls Publishing. Retrieved September 8, 2021, from: https://www.ncbi.nlm.nih.gov/books/NBK513257/
Leong, C., Mamdani, M. M., Gomes, T., Juurlink, D. N., Macdonald, E. M., & Yogendran, M. (2016). Antiepileptic use for epilepsy and nonepilepsy disorders: A population-based study (1998-2013). Neurology, 86(10), 939946. https://doi.org/10.1212/WNL.0000000000002446
Linde, K., & Rossnagel, K. (2017). Propranolol for migraine prophylaxis. The Cochrane database of systematic reviews, 2(2), CD003225. https://doi.org/10.1002/14651858.CD003225.pub3
National Center for Complementary and Integrative Health. (2017). St. Johns Wort and depression: In depth. Retrieved September 8, 2021, from https://www.nccih.nih.gov/health/st-johns-wort-and-depression-in-depth
Zahoor, I., Shafi, A., & Haq, E. (2018). Pharmacological treatment of Parkinsons disease. Stoker TB, Greenland JC, editors. Parkinsons Disease: Pathogenesis and Clinical Aspects [Internet]. Brisbane (AU): Codon Publications; Chapter 7. Retrieved September 8, 2021, from: https://www.ncbi.nlm.nih.gov/books/NBK536726/ doi: 10.15586/codonpublications.parkinsonsdisease.2018.ch7