Off Label Prescribing

Question 1

Pramipexole

Answer 1

• D3 agonist
• Indications: Parkinson’s, restless leg syndrome
• Psychiatric uses: unipolar depression monotherapy/adjunct, bipolar depression adjunct
• D3 in mesolimbic DA tracts associated with rewards/pleasure

Question 2

Pramipexole SE

Answer 2

• Nausea
• HA
• Somnolence
• Orthostasis
• Edema
• Rare: psychosis, compulsive/hedonistic behavior, sleep attack, withdrawal related NMS

Question 3

Pregabalin

Answer 3

• Alpha 2 delta Ca channel antagonist
• Primary indications: diabetic neuropathy, SCI neuropathy, fibromyalgia, seizure adjunct
• Psychiatric uses: GAD, social anxiety disorder

Question 4

Pregabalin AE

Answer 4

• Somnolence
• Dizziness
• HA
• Weight gain
• Abnormal thinking
• Aesthenia
• Amnesia
• Rare: edema, abuse, hypersensitivity, ED

Question 5

GAD + Off-Label Options

Answer 5

• Quetiapine

- Lavender oil extract

Question 6

Social Anxiety Disorder + Off-Label Options

Answer 6

• Gabapentin

- Pregabalin

Question 7

Prazosin

Answer 7

• Alpha 1 antagonist
• Primary indication: hypertension
• Psychiatric use: PTSD augmentation
• Impacts nightmares, avoidance, hyperarousal
• Studied in combination with other therapies, not monotherapy

Question 8

Prazosin AE

Answer 8

• Dizziness
• Drowsiness
• HA
• Aesthenia
• Nausea
• Palpitations
• Rare: Edema, orthostasis, syncope, polyuria, constipation, xerostomia

Question 9

Prazosin vs Quetiapine

Answer 9

• Prazosin only studied in combination therapy
• Quetiapine studied for monotherapy and combination
• Prazosin can only be used for augmentation while Quetiapine can also be used when standard monotherapy isn’t working
• Prazosin is better tolerated than Quetiapine

Question 10

PTSD + Off-Label Options

Answer 10

• Mirtazapine
• Nefazodone
• Amitriptyline
• Imipramine
• Desipramine

Question 11

Lithium

Answer 11

• Primary indication: bipolar mania, bipolar mood stabilization
• Other psychiatric uses: augmentation of TCA therapy in major depressive disorder

Question 12

Lithium AE

Answer 12

• Nausea
• Diarrhea
• Cognitive dulling
• Tremor
• Drowsiness
• Hypothyroidism
• Renal dysfunction
• DI
• Rare: arrhythmia, seizure, coma, death

Question 13

Liothyronine

Answer 13

• Active thyroid hormone
• Primary indication: hypothyroidism, myxedema coma
• Psychiatric uses: augmentation of TCA therapy in major depressive disorder

Question 14

Liothyronine AE

Answer 14

• Arrhythmia

- Rare: Tachycardia, hypotension, MI, heart failure, HTN, osteoporosis

Question 15

Other Off-Label Depression Treatments

Answer 15

• Eicosapentaenoic Acid
• Modafinil
• Buspirone
• Buprenorphine

Question 16

Gabapentin

Answer 16

• For alcohol use disorder
• 900-1800 mg/day
• Monotherapy and naltrexone augmentation

Question 17

Off-Label Cocaine Use Disorder Treatments

Answer 17

• Topiramate

- Mixed amphetamines (when ADHD also present)

Question 18

Off-Label Amphetamine Use Disorder Treatments

Answer 18

• Mirtazapine
• Bupropion
• Supratherapeutic dose methylphenidate (when ADHD also present)

Question 19

Off-Label AUD Treatments

Answer 19

-Topiramate

Question 20

Off-Label Opioid Use Disorder Treatments

Answer 20

-Clonidine augmentation of buprenorphine