MISUSE OF THE ANTIPSYCHOTIC DRUG, “SEROQUEL” (QUETIAPINE).

Quetiapine is the scientific name of a commonly prescribed antipsychotic drug, better known by its trade name, SEROQUEL. Its main use in Psychiatry, is in the acute and chronic treatment of Diseases known as “Psychoses” such as Schizophrenia, Bipolar Disorder and in certain cases of Substance intoxication or withdrawal.

This week’s Medical press has witnessed the exposure of a somewhat worrying phenomenon involving this drug. In fact,I have seen at least a dozen Veterans with PTSD this year who have been commenced on Seroquel for insomnia, outbursts of anger, agitation and panic symptoms , prior to coming to see me. Dosage has varied from 25mg to 300mg daily. Not a single patient had any evidence of psychosis. No patient had been properly informed that they were being prescribed an antipsychotic drug being used off label ( for reasons not approved by Federal authorities), none were warned of the now well established association of Seroquel and Metabolic Syndrome ( aberrant Carbohydrate metabolism, leading in some cases to Diabetes ) or about the high rate of significant weight gain as a likely side-effect.

None of my Seroquel taking patients had enjoyed consistent relief from the symptom being targeted. It is primarily the well described psychological and behavioural treatment of Post Traumatic Stress Disorder that leads to reduced symptoms. Medication is of particular value for when non-pharmacological approaches fail or cannot be conducted effectively because of severe, crippling symptoms. The most useful drugs to use in PTSD, according to the evidence base, are the SSRI & SNRI antidepressants. I’ve prescribed most of these drugs but have found Escitalopram ( Brand name: Lexapro and various others) best tolerated and most effective.

Concerns regarding QT prolongation ( the graphical representation on Electrocardiodram of cardiac muscle repolarisation following a contraction ) at doses over 40mg/day have recently been queried by a much larger and more rigorous study that found no such association. For those with disabling adrenergic hyperarousal symptoms, such as insomnia, tremor, excessive sweating, palpitations, exaggerated startle response and hypervigilance, Beta-Blockers are an oft forgotten but potentially very helpful adjunct.

Leaving the best for last, I have found that the most effective & rapid relief from high levels of anxiety, panic, hyperarousal & agitation, is achieved by rapidly raising CO2 via plastic bag rebreathing using any of the large vaporiser bags now widely available in Australia. These bags are strong, last forever and have a mouthpiece that prevents escape of exhaled CO2 and minimises slobbery discomfort. Two or three minutes of rebreathing induces hours of calm that patients liken to taking diazepam. Interestingly, patients with Post Traumatic Stress Disorder rarely detect their own hyperventilation because the most common form occurs by repeated sighing, as if tired & frustrated, rather than by a rise in baseline respiratory rate. The bag can be slipped into a back pocket or glove box for discreet use when out and several patients consider the bag the best and cheapest piece of emergency medical equipment they have ever seen.

Use of this technique has allowed Seroquel to be ceased in all the patients who arrived taking it. In my experience with thousands of War Veterans with Post Traumatic Stress Disorder, Insomnia is often intractable and the use of sleeping tablets rarely provides the Veteran with restorative, high value sleep. Many Veterans with PTSD complain of insomnia for years without ever receiving a solution. Relaxation training, Meditation, Self-Hypnosis and instruction in good sleep hygiene ( habits & routines that improve the chances of satisfactory sleep ) may help and for those who want to try medication to improve sleep, I have had quite good results from Vallergen Forte.

Vallergan Forte Syrup contains 30 mg trimeprazine tartrate in 5 mL and is little used nowadays. It is a Phenothiazine that has powerful antihistamine effects as well as being strongly anti-emetic and anti-itch. It was often used to control motion sickness in children. It is very similar to the better known Phenergan but is an even better sedative. It is not dependency forming.

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