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jt07

Stupid Psychiatrist

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I just found out yet another mistake by my pdoc. I was put on Remeron 30 mg. To tell the truth, I requested Remeron, but didn't specify the dosage. Anyway I read the PI information today and found out that carbamazepine decreases the plasma concentration of Remeron by 60%! So my 30 mg is effectively 12 mg. Not even considered a therapeutic dose (15 mg).

So what do I do? Call my pdoc and tell him this which is basically calling him an idiot? Or wait a month until my next appointment with him? How should I handle it?

I just wish he would have gotten it right in the first place so I wouldn't waste a month taking a useless dose.

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I'm not doubting you, but where did you find the figure on the plasma concentration with cabamazepine? Is it in one of the respective PI sheets?

He may have given you the Remeron pretty much as a placebo because you requested it while expecting the carbamanzepine to do all the work.

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Your doctor is responsibly titrating you.

From the Prescribing Info Sheet.

The recommended starting dose for REMERONSolTab® (mirtazapine) Orally Disintegrating

Tablets is 15 mg/day, administered in a single dose, preferably in the evening prior to sleep. In

the controlled clinical trials establishing the efficacy of REMERON® in the treatment of major

depressive disorder, the effective dose range was generally 15 to 45 mg/day.

So, 60% of 30mg puts you close to 15mg, standard starting dosage. There is no problem with what you pdoc is doing. In fact, he is doing a standard titration. There is a problems with you jumping to conclusions with insufficient knowledge. Your doc is the doc. He has the medical degree. He's not stupid. He's doing his job competently.

Edited by Stacia

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I'm not doubting you, but where did you find the figure on the plasma concentration with cabamazepine? Is it in one of the respective PI sheets?

He may have given you the Remeron pretty much as a placebo because you requested it while expecting the carbamanzepine to do all the work.

Yeah, it's on the Remeron PI sheet. I highly doubt that he has given my the Remeron as a placebo because, well we discussed it at length, and because I've been on carbamazepine for years and am sliding backwards.

Tamagotchi: Yeah, I'm thinking about doing just that. But it's not so simple with this pdoc. He doesn't like to hear from patients between visits unless it's an emergency. So I'm still torn.

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If he doesn't like taking calls, maybe there is someone else in his office you can call with questions like this? It sounds like from Stacia's post that you may not need to call him about this particular thing -- but in general?

I often end up with questions after my pdoc visit, when I get home and look over the PI sheets and stuff. Sometimes I have a legitimate concern, and sometimes I am the one making the dumb mistake, but it helps to have someone you can call / email with questions or unexpected side effects, especially if you are going a month between visits?

Edited by tamagotchi

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Your doctor is responsibly titrating you.

From the Prescribing Info Sheet.

The recommended starting dose for REMERONSolTab® (mirtazapine) Orally Disintegrating

Tablets is 15 mg/day, administered in a single dose, preferably in the evening prior to sleep. In

the controlled clinical trials establishing the efficacy of REMERON® in the treatment of major

depressive disorder, the effective dose range was generally 15 to 45 mg/day.

So, 60% of 30mg puts you close to 15mg, standard starting dosage. There is no problem with what you pdoc is doing. In fact, he is doing a standard titration. There is a problems with you jumping to conclusions with insufficient knowledge. Your doc is the doc. He has the medical degree. He's not stupid. He's doing his job competently.

Hi Stacia, I guess I'm really, really disappointed in him and comparing him to my previous psychiatrist. My old pdoc told me flat out that you only get the full effectiveness of Remeron at 30 mg, and he started me out right away at a very high dose (because of the carbamazepine). He said that 15 mg is mostly all sedation and it becomes effective at 30 mg. I guess that's why I'm very dissapointed.

EDIT: And I'm talking in circles.

Edited by jt07

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If he doesn't like taking calls, maybe there is someone else in his office you can call with questions like this? It sounds like from Stacia's post that you may not need to call him about this particular thing -- but in general?

I often end up with questions after my pdoc visit, when I get home and look over the PI sheets and stuff. Sometimes I have a legitimate concern, and sometimes I am the one making the dumb mistake, but it helps to have someone you can call / email with questions or unexpected side effects, especially if you are going a month between visits?

Probably I will call because this is setting my mood on a downward spiral. I know it sounds petty, but he is titrating me off the Paxil, and then I'm left with one less effective AD. I'm scared that I will become unglued, and because of events in my life, I can't afford to become unglued at the moment. As you can see, it doesn't take too much to make me depressed.

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You should definitely call him. Even if Stacia's right, and his intention is a slow titration, a month is an awfully long time to be on the lowest dose.

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I just found out yet another mistake by my pdoc. I was put on Remeron 30 mg. To tell the truth, I requested Remeron, but didn't specify the dosage. Anyway I read the PI information today and found out that carbamazepine decreases the plasma concentration of Remeron by 60%! So my 30 mg is effectively 12 mg. Not even considered a therapeutic dose (15 mg).

So what do I do? Call my pdoc and tell him this which is basically calling him an idiot? Or wait a month until my next appointment with him? How should I handle it?

I just wish he would have gotten it right in the first place so I wouldn't waste a month taking a useless dose.

12 mg. isn't proper titration. 15 mg is. 12 mg. doesn't begin titration. It's not a therapeutic dose. What's the point of prescribing a non-therapeutic dose for placebo effect? I think he made a mistake. Would love to hear the answer.

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12 mg. isn't proper titration. 15 mg is. 12 mg. doesn't begin titration. It's not a therapeutic dose. What's the point of prescribing a non-therapeutic dose for placebo effect? I think he made a mistake. Would love to hear the answer.

Uh, many times you're started on a non-therapeutic dose and then titrated up, responsibly (which doesn't necessarily mean a month before med changes, I will admit).

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So what do I do? Call my pdoc and tell him this which is basically calling him an idiot?

Yes, call him. Hey - this is a consumer issue, IMO. You are a medical consumer. Someone is paying the bill, right?

Just be polite about it: "I know you probably may not have realized this, and I could be wrong, but ____ " At least get an explanation.

If he gets huffy because you '"had the nerve to ask"- then I'd be more assertive. If he doesn't like it, and penalizes YOU somehow (or tries to)- time for a new doc. He can explain what his intentions are. Maybe if he'd done that already, you wouldn't be in this position.

Or wait a month until my next appointment with him? How should I handle it? Why should you suffer another month? I cannot think of any reason that's good enough, in this case. He's a doctor. You pay him for competent medical advice.

I just wish he would have gotten it right in the first place so I wouldn't waste a month taking a useless dose. I guess so! I would feel like that, probably, too.

Good luck.

-suzie

Edited by suzie

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if it were me, I would call. And let him know your concerns about the interaction, and the low dose. I've heard of people responding to 15 m.g. of remeron though, so you may be almost covered. But more for your own peace of mind, I would call and discuss concerns with him.

I will also add that any doc who refused to take my phone calls when i had questions/concerns, I would fire. Fuck that! I like my pdoc, he DID just make a genuine prescribing mistake which is costing me dearly, but things happen, and overall I like him. I've called him 3 times since then to try and get my med induced episode under control, (and you better believe that had he not called me back, he woulda been fired, probably) but I've also called him many other times, sometimes for non emergency information. He's always called me back within 24 hrs, even on a weekend. So.....

I would talk to pdoc, and if he gives you grief, ask him why he's doing that and why he is unwilling to take phone calls from pts. Advocate for yourself.

Tegretol is known for causing interactions with other drugs and can be a pain in the ass, so your doc should have known that and taken it into consideration. Granted, I don't know whether he did or not, since starting out at 15 m.g. is fairly ok in my book, but I wouldn't see a problem with a dose increase in a few weeks rather than a whole month, as remeron is one of those ADs that acts fairly quickly, i believe, so if you aren't seeing benefit..... Well, with severe depression, that's an emergency, IMO, even if you aren't "hospital worthy" or whatnot. If you need to "keep it together" i don't blame you for feeling anxious.

Anna

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