I'm no Dr. but what is your opinion ??

Meriwhen, ASN, BSN, MSN, RN · Dec 15, 2010

According to my drug guide, for a kid you can go up to 200mg daily of Thorazine and up to 30mg daily of Abilify. That doesn't necessarily mean those doses should be given. Also, my guide doesn't show significant interactions between the two...again, that doesn't necessarily mean both should be given simultaneously.

The only thing I can think of is that Medicaid doesn't want to pay for them giving two antipsychotics (duplicate therapy). Wish I could give you more help but neither peds psych nor Medicaid is my specialty.

Davey Do · Dec 15, 2010

Yes, Tippy-Ta-Ta, we are not Doctors, however, that's one of the cool things about being a Nurse: We can discuss perspectives frome a totally conceptual/theorectical viewpoint utilizing our education and experience.

I give you kudo(s) for merely questioning the action of the Doctor in order to gain knowledge. Discussing the situation with your Peers and gathering data is an intricate part of the problem-solving process.

As Meriwhen said, both are antipsychotics/dopamine antagonists. Thorazine (chlorpromazine) is one of the older antipsychotics which have a higher rate of untoward effects than the newer atypical antipsychotics.

Although it is not in my recallable experience for Abilify (aripiprazole)and Thorazine to be concurrently prescribed, it is certainly not out of the question. As your example indicates with your Doctor. Even though you were informed by Medicaid of possible interactions.

Atypical antipsychotics first came into general use in the 1990's. I remember I was working at a Mental health Clinic when the Psychiatrist first gave the staff information on these revolutionary new medications. I supervised Sample and Patient Assistance Programs at two Mental Health Clinics in the 90's and early 'aughts, so I got to be privy to some of the newer meds coming on the market. Abilify was first introduced to me in the early 'aughts. The Drug Rep proclaimed, "With Abilify, your Patients will have the ability to fly!"

Thanks for bearing with me while I took a little trip down Memory Lane. And now, back to our program:

There were Patient Assisted Programs 8 years ago when I last worked in a Community Mental Health Clinic. Bristol Meyers Squibb, the makers of Abilify, were one of the many Pharmaceutical companies offering this service. This is an obtion, if need be.

Regarding discussing the Doctor's prescribing actions: I have experienced no problems discussing these matters directly with the Doctor. Many welcomed the enquiries and I often learned valuable information, their rationale, and modis operendi. Any deviations rom their typical approach often spurred interesting and informative conversations. Perhaps you could consider this tact.

Well, that was fun. I hope you got something out of it.

Dave

Jules A, MSN · Dec 15, 2010

I'm not a fan of Thorazine because imo there are usually better, newer options out there but that said I have seen it help a few children after other meds failed. I'm definitely not a fan of running in terror from "adult doses"! With most medications, one exception being anesthetics of course, there aren't usually set guidelines based on age or weight. While it is one goal to effectively target the symptoms with the least medication I have also seen many, many children underdosed and left to live in extreme chaos because, usually pediatricians, are clueless as to therapeutic doses or acceptable trial periods. FWIW I would prefer to add the Focalin first and see what gives before doing two at once but then again I'm not the Doc.

stephva1008 · Dec 18, 2010

In my experience, Medicaid will only pay for Abilify when other traditional antipsychotics (with generics) have been trialed and failed. I actually think his dose of Abilify is high, combined with a high scheduled dose of Thorazine (has a short half-life but is more used on a prn basis than scheduled, but that doesn't necessarily mean it's contraindicated) I would worry about EPS and/or weight gain. Has he tried Guanfacine (tenex)? Seroquel?

I guess the real question is: Is it working? Is he less aggressive on all these meds? For an 11 y/o, I would expect him to be snowed on this but, if he's a big boy and/or if it's working, the benefits would outweigh the risks. We rarely combine antipsychotics but when we do, they need to do a MD to MD review with the insurance company. So I would expect that to happen here.

At some point, he may have to do a drug holiday and start fresh. We do that a fair amount when there is polypharmacy to see what is really underneath. It's a nightmare for staff but can be helpful for treatment.

Good luck. Does this kid have intensive in home therapy? It sounds like he needs it in addition to the behavioral school. What happens after school can carry over easily into the class. If they are not working with the family, any gains he may have will be quickly lost. A good in home therapist can do wonders for a chaotic home life. The sick kid tends to hold the rest of the family "hostage" by his moods and they forget how to parent and interact in a healthy way.

Hope he gets the help he needs!

I'm no Dr. and I really don't like to question the docs in what they do...but please give me your honest psychiatric nursing opinion on this.
11 yo boy with a diagnosis of Oppositional Defiance DO, Impulse Control, Major Depression DO, ADHD (combined type) Mood DO NOS.
Mom and Dad have been divorced since 2000, mom has had numerous live-in boyfriends/fiances the most recent boyfriend has been since 06. There is no abuse of any kind noted. Boy has 2 half brothers that lives with him and 3 half sisters that live with dad. Boy has anger outburst, some physical violence with fighting at school and attacking teachers, was kicked out of school and placed in an alternative behavioral school where he got physically violent with a teacher there also. He was hospitalized and discharged with these meds.
Abilify 10mg BID
Clonidine HCL .1mg BID
Celexa 20mg 1 1/2 daily
Melatonin 3 mg HS PRN
Benadryl 50mg HS PRN
He is now in outpatient therapy and med management.
Doc that he see's for med management started him on
Focalin XR 20mg daily
Thorazine 50mg TID
in addition to the meds listed above.
Kid is on mediciad. I was asked to do the prior auth because medicaid would not pay for the Abilify. When I called to get the PA. Medicaid said they would not approve Abilify with Thorazine. They would need a letter of medical necessity for that to be approved. Apparently there are interactions.
My question to you all is. Is this too much for an 11 yo ???
Abilify 20mg daily and Thorazine 150mg daily are adult doses right ??
I'm not really questioning the doc. but everytime I am asked to do a Prior Authorization for one of his patients because Medicaid won't pay for it is because of something like this. Medicaid thinks he is over medicating.
What do you think ??

justashooter · Dec 19, 2010

11 yo boy with a diagnosis of Oppositional Defiance DO, Impulse Control, Major Depression DO, ADHD (combined type) Mood DO NOS.
Mom and Dad have been divorced since 2000, mom has had numerous live-in boyfriends/fiances the most recent boyfriend has been since 06. There is no abuse of any kind noted. Boy has 2 half brothers that lives with him and 3 half sisters that live with dad. Boy has anger outburst, some physical violence with fighting at school and attacking teachers, was kicked out of school and placed in an alternative behavioral school where he got physically violent with a teacher there also. He was hospitalized and discharged with these meds.
Abilify 10mg BID
Clonidine HCL .1mg BID
Celexa 20mg 1 1/2 daily
Melatonin 3 mg HS PRN
Benadryl 50mg HS PRN
What do you think ??

i think the kid is way overdiagnosed/overscripted and has every right to be angry and occasionally violently expressive, but then, i'm old school. look at how he got to where he is. split parents and 5 new siblings? multiple trust objects lost in the maternal home in the formative years? talk about abandonment issues. a sociopath in the making.

too late for his parents to keep their pants up, so lets trank the kid and move on. no need for re-parenting here.

Tippy-ta-ta · Dec 20, 2010

i think the kid is way overdiagnosed/overscripted and has every right to be angry and occasionally violently expressive, but then, i'm old school. look at how he got to where he is. split parents and 5 new siblings? multiple trust objects lost in the maternal home in the formative years? talk about abandonment issues. a sociopath in the making.
too late for his parents to keep their pants up, so lets trank the kid and move on. no need for re-parenting here.

I was hoping someone else would say that. I think he is over medicated as well. When you have parents like that who keep putting men/women before their kids, it's just gonna make things soo much harder for that kid.

In my experience, Medicaid will only pay for Abilify when other traditional antipsychotics (with generics) have been trialed and failed. I actually think his dose of Abilify is high, combined with a high scheduled dose of Thorazine (has a short half-life but is more used on a prn basis than scheduled, but that doesn't necessarily mean it's contraindicated) I would worry about EPS and/or weight gain. Has he tried Guanfacine (tenex)? Seroquel?
I guess the real question is: Is it working? Is he less aggressive on all these meds? For an 11 y/o, I would expect him to be snowed on this but, if he's a big boy and/or if it's working, the benefits would outweigh the risks. We rarely combine antipsychotics but when we do, they need to do a MD to MD review with the insurance company. So I would expect that to happen here.
At some point, he may have to do a drug holiday and start fresh. We do that a fair amount when there is polypharmacy to see what is really underneath. It's a nightmare for staff but can be helpful for treatment.
Good luck. Does this kid have intensive in home therapy? It sounds like he needs it in addition to the behavioral school. What happens after school can carry over easily into the class. If they are not working with the family, any gains he may have will be quickly lost. A good in home therapist can do wonders for a chaotic home life. The sick kid tends to hold the rest of the family "hostage" by his moods and they forget how to parent and interact in a healthy way.
Hope he gets the help he needs!

I don't know what all has been tried on this kid. He is a new pt and came with the meds he left the hosp with. I don't know a whole lot about his prognosis as he is not my patient and this particular doc only works on Saturdays and there is usually a different nurse working with him on those days. I do a lot of the PA's for this doc tho. And it seems like everytime I am asked to do a PA it's for a med in addition to thorazine. Since the doc doesn't want to go thru the red tape with medicaid he will prescribe them something from the $4 list at Wal mart or one of those pharmacy deals.

It just seems like thorazine is his drug of choice for kids. And they are really high doses. I don't really like to question it but when all the PA's are denied because of thorazine won't medicaid get suspicious ??

Jules A, MSN · Dec 20, 2010

In my experience, Medicaid will only pay for Abilify when other traditional antipsychotics (with generics) have been trialed and failed. I actually think his dose of Abilify is high, combined with a high scheduled dose of Thorazine (has a short half-life but is more used on a prn basis than scheduled, but that doesn't necessarily mean it's contraindicated) I would worry about EPS and/or weight gain. Has he tried Guanfacine (tenex)? Seroquel?
I guess the real question is: Is it working? Is he less aggressive on all these meds? For an 11 y/o, I would expect him to be snowed on this but, if he's a big boy and/or if it's working, the benefits would outweigh the risks. We rarely combine antipsychotics but when we do, they need to do a MD to MD review with the insurance company. So I would expect that to happen here.
At some point, he may have to do a drug holiday and start fresh. We do that a fair amount when there is polypharmacy to see what is really underneath. It's a nightmare for staff but can be helpful for treatment.
Good luck. Does this kid have intensive in home therapy? It sounds like he needs it in addition to the behavioral school. What happens after school can carry over easily into the class. If they are not working with the family, any gains he may have will be quickly lost. A good in home therapist can do wonders for a chaotic home life. The sick kid tends to hold the rest of the family "hostage" by his moods and they forget how to parent and interact in a healthy way.
Hope he gets the help he needs!

Have you seen much EPS with Abilify and/or Thorazine? I've given a fair amount of both and don't recall ever seeing it and was under the impression that it shouldn't be a huge risk with either of these medications.

Whispera, MSN, RN · Dec 24, 2010

So....the Thorazine is prescribed because it's cheap? I've seen oodles of EPS in patients who take Thorazine, as well as tardive dyskinesia from it. I wouldn't give it to a child and would try to avoid it in an adult unless it's only going to be used for a short time.

mentalhealthRN · Dec 25, 2010

Personally I would never let my own kid be on Thorazine. I say Thorazine is too high risk for kids #1. and #2- I agree, how about increasing the kids therapy.

leevil · Dec 27, 2010

My opinion is: Yes. If you admit that you're no doctor, then that's the first step in recognizing your problem and dealing with your delusions of grandeur.

Jules A, MSN · Dec 27, 2010

My opinion is: Yes. If you admit that you're no doctor, then that's the first step in recognizing your problem and dealing with your delusions of grandeur.

Lol. I'm always amused by OPs that ask for opinions but only seem interested in the ones that match theirs. So much for expanding our knowledge.