Concierge-level support for primary care physicians, pediatricians, PMHNPs and PAs managing psychiatric medications.
A board-certified psychopharmacologist at your fingertips
Subscribers have flexible options for getting answers from our expert psychiatrists. Whether via text, e-mail or our web portal, we guarantee answers to your psychopharmacology questions within 24 hours, and even faster for follow-up questions.
Phone and video conferencing available
Premium subscribers can easily schedule phone and video sessions with our experts in our web portal. An ideal choice for providers with complex clinical questions or those who need additional support and education.
All your psychopharmacology questions answered.
Q My patient had debilitating withdrawal symptoms after stopping the lowest possible dosage of lexapro. What are some tips for successfully weaning this medication?
A Subtherapeutic dosage strengths are needed to successfully taper SSRIs like lexapro.
When a patient is actively withdrawing from an SSRI, it is important reinstate their most recent dose to relieves withdrawal symptoms. When tapering, a good place to start is a 50% dose reduction carried forward every 4 weeks to the lowest dose available in the formulary and to include subtherapeutic dosage strengths before fully stopping. You can consider: 1) using a pill cutter or prescribing a liquid formulation to achieve smaller dosage strengths; (2) using a compounding pharmacy; or (3) cross-titrations to fluoxetine, an SSRI with a long half-life. Let’s talk more about how we generally do that.
Q I have patients with bipolar 1 disorder who are doing really well on lithium, but I’m concerned about risks of kidney injury. How can I maximize safety of ongoing lithium treatment?
A Lithium can cause a range of adverse effects and careful monitoring is necessary. Strategies that may minimize kidney injury include: dosing the lithium once-nightly, treating to a range of 0.6-0.75mEq/L, and avoiding interactions that can cause lithium toxicity including concurrent NSAIDS and blood pressure medications such as ACEs, ARBs or thiazide diuretics.
Q Are there any drug-drug interactions I should be aware of when starting lamotrigine?
A The two most clinically relevant interactions involve valproate and estrogen-based oral contraceptive pills (OCPs). Co-treatment with even very low doses of valproate (e.g. 500mg daily) inhibit the glucoronidation of lamotrigine and raises its serum levels. It is generally advised to reduce lamotrigine titration dosages and the target dose by 50% when treating with valproate. Conversely, treatment with OCPs lowers lamotrigine levels by 50% and requires higher lamotrigine dosages. Let’s discuss how those dosage adjustments would look like in practice.
Bryan Shapiro, MD MPH
Founder, Psychopharmacology OnDemand
Director of Psychopharmacology at the UCI Train New Trainees (TNT) Primary Care Psychiatry Fellowship
Dr. Shapiro is a board-certified psychiatrist and clinical professor at UC Irvine Medical Center in California. His practice involves a mix of outpatient adult clinic, emergency and consultation-liaison psychiatry, clinic research and teaching. He has published over 30 peer-reviewed manuscripts with an emphasis in psychopharmacology.
Dr. Shapiro’s primary research interest is antidepressant withdrawal and tapering psychiatric drugs. He has mentored numerous psychiatric mental health nurse practitioners and primary care physicians, and provides formal psychopharmacology training to psychiatric providers across the US as part of the UCI Train New Trainees program. He also provides longitudinal psychopharmacology didactics to 1st, 3rd, and 4th year resident physicians at UC Irvine. He has presented at national conferences on various topics related to psychopharmacology including antidepressant withdrawal and serotonin toxicity. He also serves as a Medical Advisor for Outro, Inc., a virtual deprescribing platform for psychiatric drugs.
Sign up today to get immediate access to the nation’s leading medication management consult service.
No long term commitments required . Cancel anytime. See Terms of Service.