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Notes -
Y'all don't have eprescribing in the GB?
Also why no Addy (or better yet - Vyvanse).
We do have e-prescription! It's the default, but while the psychiatrist didn't mention a rationale behind a written one, it was likely because he did it in a hurry, or because he's the old-fashioned type.
https://www.astralcodexten.com/p/know-your-amphetamines
Purely d-amphetamine works better than l-amphetamine or a racemic mixture. And I read elsewhere that dexedrine beats methylphenidate in terms of pure efficacy in adults.
I was the one who suggested it, mainly because I'm sick of the side effect profile of methylphenidate. If I experience anything too unbearable, and I hope some of that is idiosyncratic and dexedrine would be more tolerable. I'll probably ask for an extended release formulation during the next follow-up appointment.
Low-key I prefer it most of the time because if the pharmacy is out of whatever the patient can just roll to the next one. Clearly I am positively geriatric.
Okay soooooo
Puts on attending hat.
This is eventually going to become part of your bread and butter - you should feel very certain that amphetamines of all kinds are better than methylphenidate (or not!) and eventually be familiar with the considerations for use of one or the other (especially since it impacts your own personal life).
You should also stop reading Scott for these things, he writes for lay people and in a very entertaining way, but you have the toolset to actually do a lit review and deal with the less engaging/more scientific writing.
This is going to be important for a few reasons, one is that Scott often elides some of the practical concerns that we need to know about (like actual availability, as you ran into) and he cues into very specific old evidence bases at times which is fine for what/who he writes about but misses new innovation (lets see.....psych example....how about the conversation about Trazodone as a sleep aid?) and importantly isn't necessarily the standard of care - your attendings, billing processes, and potentially malpractice attorneys (yes yes UK) are going to look at you funny if you take him seriously.
He also has a tendency to miss or underemphasize some of the research errors (some spotted in this article! What they are is left to the learner lol).
IIRC Vyvanse is now generic in the U.S. but in short supply (as is basically everything else for ADHD), I don't know what it is like in the UK but for my money it is almost always the better choice if the patient can get it and afford it. Being a prodrug presents a ton of advantages and I'm mildly irked at the way Scott is minimizing it.
Very much my choice for "if my family member asked me what to get for ADHD I'd say try this first..."
Caveat: like all doctors I have my things I am very insistent and convinced about, others may not agree.
It turns out that at least in outpatient settings, the rule is that controlled substances need a hand-written prescription. Which strikes me as odd given that in all my inpatient work, I just had to tick a few boxes and sign a physical copy when it came to those classes of drugs.
Unfortunately, that's going to take a while. My current placement is psychiatry of old age, and the next one ought to be General Adult. It's probably not till I do one for children and adolescents (or learning disabilities) that I would be personally prescribing any. I can only go off my own experience, having exhausted the options back in India, and what I read online for now.
I did do a literature review! (though given that I have ADHD and unmedicated when I did it, it's not going to be published anytime soon haha)
The effect sizes for dexedrine vs methylphenidate were 0.9 vs 0.8 in adults, within spitting distance. My impression is that methylphenidate is better tolerated in some, but it's already been so unpleasant for me that I am eager to try anything else. (Don't even ask what fucking atomoxetine did, it was highly NSFW to say the least).
It's exceptionally cruel for you to burden a neurodivergent trainee with additional research burdens :(
That being said, I do hold Scott in very high esteem. I don't consider him infallible, of course, but I would have the presumption of deferring to him unless I had overwhelming evidence of error. I certainly wouldn't formally cite him in my medical decisions at least at the resident level, but thankfully consultants have significantly more leeway in that regard, and I hope I get to that point eventually.
(I'm aware of trazodone as a sleep aid being an occasional prescription decision, do I take this as you asking me to evaluate whether it's ineffective at that job? I've only heard weak evidence, and mirtazapine would be the first port of call anyway for insomnia)
The UK is also grappling with a supply shortage. I think dexedrine is comparatively uncommon enough that I have better odds of getting it than the alternatives!
I've previously been on an extended release formulation of methylphenidate, and it did nothing good for due to the increased duration of action. I've never tried an immediate release variant of either, but I'm willing to try the devil I don't know at this point.
Hmm probably helps prevent fraud and such.
....Priapism from the Atomoxetine? Meds you would not expect can cause that.
It does sound like you did do some research but you should be looking things up, reading /r/psychiatry and /r/medicine - always be learning! (especially if you feel like you aren't getting enough at work). Be curious! Just the other day I was looking up the pharmacology of a med I use all the time (ODT Zofran) because I realized I had forgotten some details. Chasing stuff like that will make you a better doctor.
Scott is smart and is a good writer but he has a very idiosyncratic bent to his medical views that often doesn't match other clinicians. Beware. The Last Psychiatrist on the other hand is fucking incredible (and importantly - equally entertaining). I make everyone in every specialty I see who has deep questions about pharmacology of any kind read his receptor article.
In the U.S. Family Medicine, Sleep Medicine, Neurology, and Psychiatry all have different views on Trazodone (and everything else). For a long time lots of these were like "the evidence says it does jack shit" but some recent literature has some weird noodly explanation about why that's all wrong. It's hard to evaluate. Many docs go off anecdotes.
In the U.S. we do use Remeron but are often cautious because we have enough weight to go around... for the right patient it is great though.
Officially the answer is sleep hygiene and other lifestyle mods/therapy (and especially CBT-I first and foremost and all the time before using meds).
I mean if it works who cares, but if you end up needing something else going forward keep that in mind.
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