Sedation of Patient with Depression and ADD

A DOCS Education member inquires:

I am about to begin treatment on a patient suffering from depression and ADD. She currently takes daily: Lexapro 15 mg, Welbutrin 300 mg, and Vyvanse 50mg for ADD. She does not take the Vyvanse every day. The patient is female, age 33. She is otherwise healthy, 5'4" and about 125 lbs.

I planned to treat her by asking her to not take the Vyvanse prior to this appointment. I would use protocol 1 (treatment with triazolam) but skip the valium the night before as we will see her at 12 pm. I expect treatment to take 2 hours.

What can I expect in dosing this patient? Is she likely to be more or less susceptible to the triazolam's effect? What should I look out for that might be different than I have experienced when sedating a patient not on these antidepressants (i.e. amount of triazolam needed)?

I look forward to your reply.

Dr. PJ Goyal, DOCS Education faculty member, responds:

This is difficult question to answer – how well a patient could possibly respond to the sedation. The goal with our protocols that you should get to a level of sedation that will cause no respiratory consequences. When you have a patient who is on CNS depressants AND stimulants the problems with sedation level are difficult. She is a young female with psychological concerns, she could be resistant to the effects of OCS due to her personal anxiety. I would do a noninvasive short procedure as a trial sedation to gauge the OCS effects. If she does well book her for a longer appointment, if she does not respond well, consider another form of sedation.

Dr. Anthony S. Feck, DOCS Education Dean of Faculty, responds:

First of all, I would not take the patient off her Vyvanse. The most important question is not how the Vyvanse will affect her sedation, but how uncontrolled ADD will affect the safety and efficacy of the sedation.

Secondly, one of the reasons we use diazepam the night before, is its long half-life. It will still be effective the next day whether the appointment is at 7am or 7pm. I would have the patient take 2.5mg of diazepam the night before.

As far as how the patient will respond, it's hard to say. That is the reason for the incremental dosing techniques. You dose triazolam at appropriate doses and appropriate intervals and stop dosing when the patient reaches a comfortable level or TOP Dose is reached. I expect this patient to hyporespond.

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