61 year old male with a history of diabetes, neuropathy, BPH presents complaining of not being able to sleep well at night. He states that he has been diagnosed with BPH and hasn’t wanted to be treated because it hasn’t been that bad.
His current meds include:
- metformin
- aspirin
- gabapentin
- Vitamin C
For his insomnia, his primary provider recommends Elavil 25mg daily, which could possibly help with his neuropathy symptoms as well as his sleep issue.
He begins taking the Elavil for a few nights but notices that he is having a much more challenging time urinating. His BPH symptoms are indeed worsening and this is likely due to highly anticholinergic effects of the old Tri-cyclic antidepressant Elavil (amitriptyline).
At the gentleman’s follow up visit when complaining about these symptoms, he gets prescribed Flomax to help alleviate the symptoms likely worsened by the Elavil. When using Flomax for BPH symptoms, we have to make sure that anticholinergics are not making this problem worse. This is a classic example of the prescribing cascade.
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Thanks for this case. Here is a classic example of prescribing an agent due to its side effect rather than its indication. Amitriptyline is a tricyclic antidepressant with norepi, serotonergic, antihistaminic and anticholinergic effects. The fact that the agent causes somnolence is the side effect.
In this case, due to Beers criteria and the patients age the MD may have thought that it was a safer bet than let’s say zolpidem or a short acting benzo like alprazolam. But agents that are LESS broad spectrum, even if they are anticholinergic, may be more beneficial.
What I mean is, this agent targets both 5ht3 AND acetylcholine and therefore has a potentially greater ability to affect the genitourinary tract than lets say 12.5g of diphenhydramine (yes I know an antihistamine w/anticholinergic properties 🙂 but a VERY low dose and not nearly as broad acting) or even 3mg melatonin (Yes, I know 🙂 a serotonin precursor, but again not a broad brush).
This is where PharmD’s are to be utilized – to help the MD’s get better information to help them choose the best agent possible.
Thanks for another great case!!
Good input…thanks Johanna!
im curious about what you think about nortriptyline instead.
I might have to make a post on that question! 🙂
I make this as quick / SUMPLE as I can.
BPH … Chronic
PTSD …60 years
Sexual Identity Issues .. 50 years
GAD .. Controlled, 50 years
My post:
.8 mg generic Flomax has totally eliminated all “fears” of al, the above.
No other Rx added.
Very interesting..
I know Flomax off shelf for PTSD..
Dosage .8mg once a day. / 2 weeks into initial Rx..
This is Not a manic etc response