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PMHNP prescribing questions

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by Joebird21 Joebird21 (Member)

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So I am just curious if a PMHNP can ever prescribe any non psych medications in certain situations?

For example, an elderly patient has a ua done to r/o a uti due to a change in mental status. The ua comes back positive.... does the pmhnp go ahead and order an antibiotic? I know of psychiatrists that will. 

If a patient is in pain are there any type of pain meds a pmhnp would be ok with ordering? Or medications that will alleviate side effects of a prescribed psychotropic (ie colace for constipation, etc?) Or what about refilling routine meds? (Simvastatin, etc?)

Lastly, are all abnormal labs referred to a pcp?

Sorry, probably dumb questions, but I am just curious.......

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20 Posts; 500 Profile Views

I'm interested in this as well, but mostly just from the standpoint of managing psychotropic-related medication effects as you mentioned. For instance metformin for antipsychotic-induced weight gain, glycopyrrolate for antidepression-induced excessive sweating, colace for constipation (you can get colace OTC now). As a PMHNP (not yet, but eventually...) I'd rather encourage patients to see their PCPs for things like gen med refills.

I would think it depends on the state and the prescribing agreement with the physician, if one is required for your state. I'm under the impression that it won't be a problem, but I'd like to hear from those with more experience in this area.

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myoglobin has 11 years experience as a ASN, BSN, MSN and specializes in ICU, trauma, neuro.

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I would say in general that prescribing outside your scope is a bad idea even in an IP state.  I could see a case for prescribing an antibiotic for a suspected UTI, but only as a bridge to the PCP. Keep in mind that PCP will have a better handle on bacteria resistance trends in your area (as well as possible previous antibiotics that the patient has been treated with. Now the metformin  for antipsychotic induced weight gain might be a different matter, although uncommon it could be considered enlightened practice in some circumstances (for example as part of a holistic diet and exercise program to manage weight and DM2 risk).  One of the problems with simply giving metformin is that it can contribute to "the cycle of insulin resistance" that is to say the cell receptors become more sensitive to insulin, but if people keep eating a diet with a high glycemic load (or taking a second generation anti-psychotic like olanzapine or quetiapine without modifying their diet and exercise routine) they will find that their insulin resistance has worsened in a few years (or sooner) and will need to be started on insulin therapy (definitely from their PCP).  I have seen some psych providers prescribe OTC Tylenol off label for pain especially when someone was experiencing and adjustment disorder given new evidence that it may blunt emotional pain in the amygdala https://www.npr.org/sections/health-shots/2017/12/04/567762087/tylenol-may-help-ease-the-pain-of-hurt-feelings.  There is also evidence that turmeric may not only help with joint pain, but also be useful in augmenting the effectiveness off SSRI's possibly via the reduction of inflammation within the brain (Saffron has also been shown to have efficacy in this role, although greater potential for toxicity exists at higher dosages) https://universityhealthnews.com/daily/depression/2-natural-antidepressants-found-to-be-as-effective-as-prozac/ .

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1,245 Posts; 6,439 Profile Views

No. I do not order antibiotics, metformin, colace, pain killers, etc. Not a good idea, and why borrow trouble?

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myoglobin has 11 years experience as a ASN, BSN, MSN and specializes in ICU, trauma, neuro.

504 Posts; 3,752 Profile Views

I look at metformin for 2nd gen antipsychotics much like cogentin for 1 st gen side affects or using propranolol or mirtazapine for akatthesia from Abilify. Side effect mitigation.

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1,245 Posts; 6,439 Profile Views

Maybe so, but in my state still no.

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20 Posts; 345 Profile Views

100% agree with OldMaHubbard. I am an adult NP and would be fairly annoyed, to the point of not referring patients anymore, if I found they are being started on medications for diabetes and antibiotics in a psych office without calling me. Why not just call and coordinate with the PCP? 

Edited by egg122

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umbdude has 2 years experience as a BSN, RN and specializes in Psych/Mental Health.

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I would be wary about putting someone on a medication every time there's a side effect. That's why I see patients coming in with 15+ meds. If it comes to a point where it's necessary, collaborate with FNP/AGNP/MD (at least for meds like metformin). If you live in a rural area with very few providers and you plan on working in the area, consider adding a FNP or AGNP cert.

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myoglobin has 11 years experience as a ASN, BSN, MSN and specializes in ICU, trauma, neuro.

504 Posts; 3,752 Profile Views

Again, I ask what is the functional difference between adding a drug like Cogentin to manage dystonic reactions from 1st generation antipsychotic medications or Austedo to manage tardive dyskinesia and putting a patient on a drug like metformin to manage pre-diabetes from Seroquel or perhaps Topamax to mitigate weight gain from Zyprexa? In both cases the PMHNP is attempting to mitigate side effects directly attributable to their primary psychotropic intervention. Also, in the real world of 15 minute medication management appointments significant collaboration between providers is largely a fantasy.

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20 Posts; 345 Profile Views

If that is the argument- why is there a line drawn at insulin in your prior post? Wouldn't prescribing insulin be prescribing to mitigate the effects of anti-psychotic therapy? Why not also prescribe an ACEI for renal protection since the patient is having sequelae related to the antipsychotic therapy? Are you  going to refer them to an ophthalmologist and do the recommended foot exams?

What if the patient develops a sequelae of diabetes and you were the only one managing it? People can, and do, get reported to their respective licensing boards for mismanagement of diabetes or face lawsuits. 

Starting down that path can distract from their psych management. Also, coordination of care is truly an expectation. 

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myoglobin has 11 years experience as a ASN, BSN, MSN and specializes in ICU, trauma, neuro.

504 Posts; 3,752 Profile Views

We know that diabetes related morbidity is a leading cause of death in patients on many 2nd generation antipsychotics, metformin is aimed at risk mitigation rather than insulin which would treat active disease and is optimally managed in a PCP setting. Most PCP’s will not mitigate risks based on this indication since they see it as a psychiatric complication.

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djmatte has 7 years experience as a ADN, MSN, RN, NP.

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2 hours ago, myoglobin said:

We know that diabetes related morbidity is a leading cause of death in patients on many 2nd generation antipsychotics, metformin is aimed at risk mitigation rather than insulin which would treat active disease and is optimally managed in a PCP setting. Most PCP’s will not mitigate risks based on this indication since they see it as a psychiatric complication.

I think most would if presented to them in a collaborative manner.  especially if they started to see things like a1c start to go up.  I see this often in notes sent to us indicating the plans they intend to implement and the suggestions that we should implement on our end. When you start managing a range of ancillary meds, you will need to start managing the side effects and required labs that go along.  

Imo the bigger annoyance is when I start to see changes in renal function and then find out a patient is being prescribed a medication by a different provider (usually a specialist) who isn't acting fast enough to stop medications when they become a problem.  Had this issue recently where a patient was kept on an oral diabetic med well below the recommended limits of renal disease. 

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