cryinginmoscow

Is this a dangerous combination?

18 posts in this topic

I'm already on Bupropion (Wellbutrin) and Sertraline (Zoloft) and now I also take 150mg of Trazodone. Would this be dangerous?

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If your pdoc prescribed it, then I'm sure he doesn't think it is dangerous.

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19 minutes ago, jt07 said:

If your pdoc prescribed it, then I'm sure he doesn't think it is dangerous.

I was just thinking though Trazodone and Sertraline can cause serotonin syndrome plus increase the risk of seizure with Bupropion

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Yes, but sertraline and trazadone have different mechanisms of action. My pdoc would not prescribe me two SSRIs, but he has no problem prescribing me citalopram and mirtazapine. If the risk of seizures were great, then nobody would be on med cocktails. Do you have a propensity towards seizures? If not, I don't think you have to worry.

Of course, it's always a good idea to make your fears known to your pdoc so that he/she can allay them.

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Yup, my meds can have interactions too if it's anything major I'm sure pdoc wouldn't prescribe it. 

Another person to ask is your pharmacist. 

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I've never had a seizure and also the only reason I asked was because I woke up with a huge headache the next I took Trazodone 150mg Ambien (Zolpidem) 10mg and 4mg of Lorazepam.

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In general, IMO I think it is hard to tell which meds will interact with which meds.  Someone might have interactions with 2 meds, while another person might not.

Even when your DR prescribes, I don't think s/he knows 100% that there will be no interactions because anything is possible with medications.  Not every person has the same reaction with meds.  Maybe they might think there is a low chance of interactions, but still, I don't think a DR would say 100% that you will not have any interactions with x and y meds.

YMMV.

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I agree with the suggestion of talking to your pharmacist. They're great sources of information about the meds they prescribe, including interaction issues.

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Sometimes a doc's gut and experience is what I trust over any med checker...my combo has like 17 possible interactions...but I trust my doc

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Posted (edited)

There is no realistic special risk with this cocktail. You'd need to throw another strongly serotonergic drug into there before it'd be time to start getting worried.

8 hours ago, cryinginmoscow said:

I've never had a seizure and also the only reason I asked was because I woke up with a huge headache the next I took Trazodone 150mg Ambien (Zolpidem) 10mg and 4mg of Lorazepam.

A very common side effect of trazodone (actually a side effect of its active metabolite) is headaches/migraines. The active metabolite of trazodone (mCPP) is actually used in clinical trials of anti-migraine drugs to induce headaches. It's pretty nasty initially for some people but you usually develop a tolerance to the negative effects very quickly with daily use of trazodone.

Edited by JustNuts
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According to some online drug interaction checkers, the meds I'm currently on supposedly have some potentially serious interactions...........But I've been on this combination for over a year and nothing bad has happened.

Bottom line: I trust my pdoc and my pharmacist more than online drug interaction checkers.......

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Posted (edited)

On 3/9/2017 at 11:01 PM, Iceberg said:

Sometimes a doc's gut and experience is what I trust over any med checker...my combo has like 17 possible interactions...but I trust my doc

I trust my pdoc also, given his experience and what he knows about me, other meds I am on, and whether a new med (or one I am already on) would be a good idea or not.  Same with adjusting doses.

In the end the pdoc has the "say" as to what can be done with meds, added, stopped, etc.  The pharmacist can recommend things, and tell possible interactions, possible side effects, I agree, but they can't change a DRs prescriptions and plan for (a person's) treatment.

For me, I still trust my DR more with all of this than a pharmacist.

**NOT putting pharmacists down, just saying IMO how I feel about them vs my DR.

Edited by melissaw72

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The trouble with interaction checkers is that they include every possible theoretical interaction whether or not these interactions are seen clinically or not. A doctor presumably has prescribed these combos multiple times and has seen them in his/her residency. I trust the doctor's experience and education over any online checker.

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Posted (edited)

On 3/14/2017 at 7:46 AM, melissaw72 said:

I trust my pdoc also, given his experience and what he knows about me, other meds I am on, and whether a new med (or one I am already on) would be a good idea or not.  Same with adjusting doses.

In the end the pdoc has the "say" as to what can be done with meds, added, stopped, etc.  The pharmacist can recommend things, and tell possible interactions, possible side effects, I agree, but they can't change a DRs prescriptions and plan for (a person's) treatment.

For me, I still trust my DR more with all of this than a pharmacist.

**NOT putting pharmacists down, just saying IMO how I feel about them vs my DR.

Pharmacists have some limited influence, honestly more than you'd think. They're responsible for catching most inappropriate prescriptions and inappropriate drug combinations (on multiple levels), partially because they're usually in one of the best places to do that (greater access to current/historical pt medication records), and partially because they are also generally just the last line of defense (outside of the infrequent action taken by regulatory agencies and professional organizations). If there's any cause for concern, they can block you from filling your RX while they contact the doctor (who they may contact for any of a large number of reasons including discussing alternate therapies).

In some countries pharmacists have much more influence - in Quebec, Canada for example pharmacists are allowed to prescribe medication for already-diagnosed conditions as well as a number of specific conditions that do not require a prior diagnosis or are deemed minor enough to allow the pharmacist to diagnose it, they are allowed to extend/renew prescriptions (with some limits), they are allowed more freedom with adjustments including wholesale substitutions within a subclass if medication is unavailable, they are allowed to order and interpret lab results (with some limits), and they are allowed to administer medication directly to patients (with a number of limits - it's primarily for demonstration purposes).

But yeah, a generalized/specialist doctor, nurse practitioner, or physician's assistant with appropriate experience and knowledge is generally the best suited for prescribing meds.

Edited by JustNuts

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1 hour ago, JustNuts said:

Pharmacists have some limited influence, honestly more than you'd think. They're responsible for catching most inappropriate prescriptions and inappropriate drug combinations (on multiple levels), partially because they're usually in one of the best places to do that (greater access to current/historical pt medication records), and partially because they are also generally just the last line of defense (outside of the infrequent action taken by regulatory agencies and professional organizations). If there's any cause for concern, they can block you from filling your RX while they contact the doctor (who they may contact for any of a large number of reasons including discussing alternate therapies).

In some countries pharmacists have much more influence - in Quebec, Canada for example pharmacists are allowed to prescribe medication for already-diagnosed conditions as well as a number of specific conditions that do not require a prior diagnosis or are deemed minor enough to allow the pharmacist to diagnose it, they are allowed to extend/renew prescriptions (with some limits), they are allowed more freedom with adjustments including wholesale substitutions within a subclass if medication is unavailable, they are allowed to order and interpret lab results (with some limits), and they are allowed to administer medication directly to patients (with a number of limits - it's primarily for demonstration purposes).

 

(bold 1)  Unfortunately pharmacists don't have access to medical records here.  They have a history of what meds I've taken, but nothing other than that.

(bold 2) I agree pharmacists call DRs to ask about something/catch an interaction, etc, but the DRs here have the final say with filling a prescription or not (they can listen to the pharmacist and take their advice, or not ... but in the end whatever the DR says, goes).

I know here pharmacists do not discuss alternative therapies (if you mean like natural medicine, like herbs/spices/etc?).  Pharmacists might suggest to a DR another med in its place, but don't discuss other than that.

(bold 3) ... Wow ... You are very fortunate that your pharmacists have much more influence than they do here ... IME at least. 

I would be golden if pharmacists here were allowed to prescribe/fill meds for already-diagnosed conditions ... other meds for which it doesn't require a prior diagnosis, or giving a person a diagnosis for minor enough things, and then fill the prescription/s for it ... so pharmacists there can diagnose minor things and then fill the prescription?  What is considered minor enough for a pharm to diagnose it/fill prescription?  I mean I honestly have never in my life heard of this happening until I read what you've written here.  What if the person is sicker than the pharmacist thinks, and then mistakes are made in that sense?  Pharmacists can also order lab tests too? 

Unfortunately this doesn't happen in any of my experiences here; if so I have never heard of any of it ever happening ... if anyone in the US has a pharmacist that has been trained to do all of these things (mentioned above), please post ... I am just curious if there are pharmacists in the US who can do all of these things.  Maybe the pharmacists are trained differently in Canada?

That is a lot different here than in Canada.  Maybe other countries are different also in what they know and can do.

1 hour ago, JustNuts said:

But yeah, a generalized/specialist doctor, nurse practitioner, or physician's assistant with appropriate experience and knowledge is generally the best suited for prescribing meds.

I agree.

Thanks for the info on pharmacists where you live.  I can only wish that pharmacists in the US could have more influence than they do.

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5 hours ago, melissaw72 said:

(bold 1)  Unfortunately pharmacists don't have access to medical records here.  They have a history of what meds I've taken, but nothing other than that.

(bold 2) I agree pharmacists call DRs to ask about something/catch an interaction, etc, but the DRs here have the final say with filling a prescription or not (they can listen to the pharmacist and take their advice, or not ... but in the end whatever the DR says, goes).

I know here pharmacists do not discuss alternative therapies (if you mean like natural medicine, like herbs/spices/etc?).  Pharmacists might suggest to a DR another med in its place, but don't discuss other than that.

(bold 3) ... Wow ... You are very fortunate that your pharmacists have much more influence than they do here ... IME at least. 

I would be golden if pharmacists here were allowed to prescribe/fill meds for already-diagnosed conditions ... other meds for which it doesn't require a prior diagnosis, or giving a person a diagnosis for minor enough things, and then fill the prescription/s for it ... so pharmacists there can diagnose minor things and then fill the prescription?  What is considered minor enough for a pharm to diagnose it/fill prescription?  I mean I honestly have never in my life heard of this happening until I read what you've written here.  What if the person is sicker than the pharmacist thinks, and then mistakes are made in that sense?  Pharmacists can also order lab tests too? 

Unfortunately this doesn't happen in any of my experiences here; if so I have never heard of any of it ever happening ... if anyone in the US has a pharmacist that has been trained to do all of these things (mentioned above), please post ... I am just curious if there are pharmacists in the US who can do all of these things.  Maybe the pharmacists are trained differently in Canada?

That is a lot different here than in Canada.  Maybe other countries are different also in what they know and can do.

I agree.

Thanks for the info on pharmacists where you live.  I can only wish that pharmacists in the US could have more influence than they do.

Pharmacists generally have far greater access to your actual, complete, and current medication history thanks to the combination of comprehensive patient RX tracking systems and government-mandated databases for scheduled meds. The doctor generally has what the patient said and little else.

Consider a case where a patient is on 13 drugs, but told her doctor that she was on 7 drugs because that's all she could remember (or whatever reason - there are a lot of plausible and alarmingly common scenarios where this occurs). Of the other 6 drugs, three of them have extremely dangerous interactions with each other, compounded significantly further by the doctor's decision to prescribe another drug of the same class - because he doesn't know that she's actually on other drugs of this class. Assuming that the patient consistently fills all of their meds at a single pharmacy (or even just a single chain of pharmacies), which is a very common practice, the pharmacist will know all 13 meds that the patient is currently on and can thus detect the presence of an extremely dangerous four-way drug interaction that could easily kill the patient. This is something that the doctor cannot detect without a full and honest history being taken and reviewed - and as anyone in the medical field will tell you, patients who can give you a full and honest history are depressingly rare, especially when it comes to current/past medications. At any rate, the pharmacist can then contact the doctor, inform them of the issue, suggest possible resolutions to the problem, and will tell the patient that they will not fill the prescription for safety reasons (and in fact they will likely even ask the doctor to immediately void the prescription in order to ensure that it cannot be filled no matter what and would no longer be hypothetically transferable).

Pharmacists don't just have records of what meds you're currently on - they also have historical records. Need to know if your patient has been filling their antipsychotic RX? The pharmacy can confirm that for you. The same goes for making sure the patient isn't doctor shopping, or just checking for med compliance in general in cases of suspected noncompliance. They can't confirm that the patient is taking it if the patient actually filled and paid for the medication, but it's still quite helpful data - even something as minor as a pattern of filling the prescription too late is a big tip-off that the medication is not being taken as prescribed. Likewise, pharmacists are a major part of the effort to track and stop opiate misuse/overprescribing as they can assess patterns in the prescriptions coming from certain doctors and identify an emerging pill mill faster than other more official system components generally can (DEA's response time is slooowwww). They are also able to react to the issue by choosing not to fill the inappropriate prescriptions and informing other pharmacies in the area about problematic prescribers and patients alike.

A pharmacist's professional judgement always supersedes a doctor's instructions on a RX. In this capacity, they have a very similar degree of professional freedom and ethical/legal responsibility as a doctor does when prescribing the medication in the first place. However there is the impact of state laws, which can limit or expand this freedom in specific cases or even in all cases - although for controlled substances in particular the DEA's regulations likely supersede state law in the few states that attempted to limit freedoms.

Pharmacists do not generally discuss "natural" or "alternative" treatments because they are highly educated individuals who are generally all too painfully aware of how utterly useless and potentially dangerous these poorly-regulated products are. Many pharmacists have strong opinions about this topic and the ethicality of practicing pharmacy in a store that also sells ineffective and potentially harmful "natural"/"alternative" treatments it is a particularly controversial point of debate, tempered by the complicated relationships between pharmacy and corporate, as well as the isolation factor of the pharmacy.

I live in the US at the moment, but I used to live in QC. The practice scope expansion was alive and well while I lived in QC, but I can't say it was ever useful for me as I had access to semi-private healthcare and didn't require any of the more specialized services from the pharmacists I interacted with there at the time.

The changes to Quebec pharmacists scope of practice have been evolving for a while but yes they are very different from US pharmacists in what they're allowed to do, although the scope of practice for US pharmacists has also been evolving: https://www.pharmacist.com/sites/default/files/files/APhA - PAPCC Scope of Services.pdf

>While pharmacists remain committed to assisting patients with access and information related to their prescription medications, pharmacists today are providing a broad spectrum of services, within their scope of practice, including conducting health and wellness testing, managing chronic diseases and performing medication management, administering immunizations, and working in and partnering with hospitals and health systems to advance health and wellness and helping to reduce hospital readmissions.

>In 47 states and the District of Columbia, pharmacists are authorized to enter into collaborative practice agreements with a physician or another prescriber, further expanding the services they are able to provide. Depending on the particular state, collaborative practice agreements enable pharmacists to provide a range of services such as initiation, monitoring, and modification of a patient’s drug therapy. This is particularly effective with patients who have single or multiple chronic conditions. In 31 states pharmacists are also allowed to order and interpret lab tests. This collaborative approach, using pharmacists for the management of chronic conditions, has been utilized by the Indian Health Service for 40 years, as well as the Department of Veterans’ Affairs and the Department of Defense.

It may surprise you to learn that pharmacists are not the only ones who have had their scope of practice drastically evolve - laws permitting psychologists to prescribe prescription medication are becoming increasingly popular for example (my first and long-term psychologist was heavily involved in our state's successful effort to pass legislation enabling psychologists to prescribe psychiatric prescription medication, which was a bit ironic given that he's a child psychologist (who aren't allowed to prescribe meds at all under our new laws)). He believes quite strongly in the usefulness of RxP legislation in general though for improving mental health treatment, and I have quite a lot of respect for him given how much he's accomplished in his career (his list of accomplishments is really quite impressive - I mean it's not much compared to, say, Russell Barkley, but Barkley is at the absolute top of the field and much more research-focused / less clinically focused).

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Ok.

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