Amy is a 32 year old woman who presents with 3 weeks of depressed mood, depressed libido, anhedonia, sleep disturbance on a background of recent bereaval of her husband.  She has been drinking more than usual. Her past medical history includes recent right rotator cuff tear, on Tramadol 150mg daily, and the OCP.

What pharmacological therapy could be utilised to improve the patients mental state? Please give medication generic name, dose, frequency, duration.

1.    Mirtazapine 15 to 30 mg orally, at night (lowest risk of Serotonin Syndrome)

Antidepressants that Interact with Tramadol include SSRIs, SNRIs, TCAs – but on different sources Im reading all classes. (Source)

Its rare to have seizures on high dose Tramadol and SSRI/TCA, the result is seizures and this combination is one of the most common causes of drug induced seizures. (Source)

As described here, the levels of interaction severity are different for different agents.

Severe (contraindicated/not usually taken concurrently)
Monoamine oxidase inhibitors
Selegiline transdermal

Major (may result in potential deterioration—patient should be monitored)
Bupropion
Duloxetine
Nefazodone
Selective serotonin reuptake inhibitors
Venlafaxine

Moderate (bothersome or unnoticeable—limited clinical effects)
Maprotiline
Mirtazapine
Tricyclic antidepressants
St. John’s Wort

As described in this TGA Report,

Toxicity resulting from excessive intra-synaptic serotonin, historically referred to as serotonin syndrome, is now understood to be an intra-synaptic serotonin concentration-related phenomenon 5. It appears that only combinations of serotonergic drugs acting by different mechanisms are capable of raising intra-synaptic serotonin in the brain stem and spinal cord to a level that constitutes life-threatening serotonin syndrome 5, 6. The most commonly reported life-threatening situations involve the use of monoamine oxidase inhibitors (MAOIs) in combination with serotonin re-uptake inhibitors, such as SSRIs and the phenylpiperidine series opioids.

In Australia, clinicians have been alerted to the risk of serotonin syndrome as an adverse drug reaction on a number of occasions via different publications: · serotonin syndrome with tramadol was the subject of an Adverse Drug Reactions Bulletin article in 2001 18. This was followed in 2004 by a more general Adverse Drug Reactions Bulletin article on the features of and medicines associated with Serotonin Syndrome 19. The latter article highlighted the need for health professionals to note the drugs that may cause serotonin syndrome, alone or in combination with other serotonergic agents, and be alert to the features of syndrome. It also stressed that patients should be informed of the risk and symptoms of serotonin syndrome when serotonergic agents are prescribed.

Betty later comes to you stating that she has been feeling worse after 2 weeks of the medication, and has recurrent thoughts of killing herself.

What are the key elements of the suicide risk assessment? List 6

1. Current thoughts of suicide
2. Suicidal intent
3. Plans for suicide
4. Past suicide attempts
5. Suicide of family member or friend
6. Alcohol use
7. Psychotropic medication use
8. Access to method e.g. gun

RACGP Feedback – Case 11

This case focused on a female patient presenting with progressive reduction in her mood and mental wellbeing. Candidates were required to consider additional medication to improve the patient’s mental state, taking into account her current medication and other information provided.

The scenario unfolds and the patient develops suicidal ideation, and candidates were required to assess her suicide risk by providing key elements of their suicide risk assessment. In providing appropriate medication, candidates needed to take all of the information in the question into consideration, such as the fact the patient was taking tramadol.

Candidates should therefore not prescribe medication that would interact and cause possible harm. The question also required specific dosing in addition to naming the drug chosen, and providing both name and dose regimen gained more marks than the name alone.

The suicide risk assessment was done well by the majority of candidates. The main sources of error were providing answers that would help explore her low mood, but that were not specific to assessing suicidal risk, and repeating information already provided in the case.

RACGP Conclusion on Technique

As outlined above, there are some common themes and key issues to consider when approaching the KFP exam:

• The KFP exam is not a simple short-answer paper. You must answer the question in the context of the clinical scenario provided, utilising all of the information provided. Read the scenario at least twice.
• Keep your answers succinct.
• Only provide the number of answers requested. Review your answer – have you created a list rather than one answer per line? If so, you will be penalised for extra answers.
• Always read the question at least twice and, after you answer, check that you have answered the actual question asked.
• Be specific in your answers, whether in the investigations being ordered or the treatment you are prescribing. Non-specific answers will not score or will attract a much lower score.
• General answers such as ‘educate’, ‘refer’, ‘reassure’ or ‘review’ do not score without specific detail. For example, providing a review timeline and details about the specialist to whom you are referring (along with degree if urgency, if appropriate) may score marks if relevant to the scenario and question.
• Be aware of clinical guidelines and any important changes or additions to treatments. If guidelines change very close to the exam, the marking keys are adapted to consider the original and the new guidelines so candidates are not penalised if they have not seen a guide published close to the exam sitting.
• Access the practice exams provided after enrolment closes and utilise the RACGP assessment resources provided for candidates.

 

References and Further Reading

1. https://www.drugs.com/drug-interactions/tramadol.html
2. MIMS
3. http://www.medsafe.govt.nz/profs/PUArticles/TramSerious.htm
4. https://www.nps.org.au/medical-info/medicine-finder/tramadol-sandoz-capsules
5. https://www.tga.gov.au/sites/default/files/alerts-medicine-ssri-pdseap-091224.pdf
6. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2714818/table/T1/