Question:
I showed my psychiatrist your
medication plan for borderlines like
me. He said you are using old
drugs to treat the BPD when we now have
much better newer drugs. He was very
adamant that you were wrong to use these
older drugs.
Dr. Heller's Answer:
The most important reason is
many "older medications" is
that they work, and they work far better
than any of the newer medications.
It helps of course that 30 pills of
Prozac (fluoxetine) 20mg or 40mg costs
$4 a month, that 30 Tegretol
(carbamazepine) 200mg pills costs
$4 a month and that Haldol (haloperidol)
also costs $4 per month. This has
made BPD treatment much more cost
effective and manageable.
I often give 6 days of Zyprexa
(olanzapine) 5-10 to start treatment. This
is a newer medication that costs ~ $12 per
pill. If a patient needs a long
term antipsychotic, I'll use the newer
medication Abilify (aripiprazole) which
costs ~ $33 per pill.
Risperdal (risperidone) 3mg just went
generic, but remains a remarkable
medication for the BPD. No matter
how severe the dysphoria (anxiety, rage,
depression and despair), borderlines
already taking Prozac (fluoxetine) and
Tegretol (carbamazepine) will always
respond 24 hours later with the Risperdal.
If the patient is allergic to Tegretol
(carbamazepine), I will try Depakote (valproic
acid or valproate) first, Topamax (topiramate)
second and Lamictal (lamotrigine) third.
Tegretol (carbamazepine) and Depakote
(valproic acid or valproate) are
"old" drugs, while Topamax and
Lamictal are "newer drugs."
If Prozac (fluoxetine) makes the
individual worse, the cognitive generalized
anxiety disorder is usually the problem and
BuSpar (buspirone) needs to be used so that
Prozac (fluoxetine) doesn't worsen the GAD.
If truly unbearable side effects occur from
Prozac (fluoxetine) such as a rash, I'll
usually use high doses of relatively older
drug Effexor (venlafaxine) or the new
Effexor (venlafaxine) derivative
Pristiq (desvenlafaxine). BuSpar
(buspirone) is an "old drug" that
costs approximately $12 per month.
The "older drugs" Wellbutrin
(buproprion) and lithium are rarely
effective for the BPD. The older
antidepressant Remeron (mirtazapine) is
useful for PTSD (post traumatic stress
disorder), which can sometimes be worsened
by BuSpar (buspirone) and for severe
sleep problems.
Some of the other newer, and very
expensive medications, just don't work as
well for most individuals with the
BPD. They include the
antidepressants Cymbalta (duloxetine)
and Lexapro (escitalopram), and the
mood stabilizers Topamax (topiramate),
Keppra (levetiracetam), and Lamictal
(lamotrigine). Geodon (ziprasidone)
and Seroquel (quetiapine) have been
ineffective, although the newer drug
Seroquel (quetiapine) can help for
severe sleep problems.
I prefer the newer forms of the
"old" medications for ADHD
because they are more long lasting
and easier to use. In children I
prefer the methylphenidate molecule
(a.k.a. "Ritalin). If
finances are a concern generic
Ritalin is used, otherwise I prefer
the newer delivery systems and
"isomers" such as Concerta,
Focalin, and Daytrana. In
adolescents and adults I prefer the
dexedrine molecule (usually prescribed
as "Adderall." I
greatly prefer to new form Vyvanse
because of its lower addiction and
abuse potential. Sometimes
Adderall XR or generic Adderall is
necessary. The newer drug for
ADHD, Strattera (atomoxetine), has
been disappointing. When it
works it lasts 24 hours and it's
not addicting. In my
experience it only works ~20% of
the time, makes many people irritable
or hostile, and it's expensive (~$300
per month).
As you can see I use a mix of older
and newer medications. I want
to use the most effective medications,
particularly if they are now
inexpensive. The same philosophy
is in all areas of medication including
high blood pressure, heart disease,
diabetes, asthma, heart failure, etc.
When possible we use older, less
expensive medications with good track
records in the literature, saving the
newer more expensive medications for
conditions where older, less expensive,
and equally effective medication options
are not available.
The longer the drug has been on the market
the more information we have about the
safety and potential risks. Newer
drugs haven't had the time for this
information to be compiled. For
this reason, many physicians like to wait
one to two years prior to trying a new drug.
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