Re: nortriptyline first.
At a recent drug utilization review, we were surprised to learn that
Pamelor, a generic itself, was about 10 times as expensive than the
other original tricyclics.  We also discovered that the major usage
was internal medicine presumably treating headaches.   Yes, every
internist and family practice type does have a Pamelor pen, a
Sandoz appointment calendar, etc.

Shannon

|Re: nortriptyline first.
|At a recent drug utilization review, we were surprised to learn that
|Pamelor, a generic itself, was about 10 times as expensive than the
|other original tricyclics.  We also discovered that the major usage
|was internal medicine presumably treating headaches.   Yes, every
|internist and family practice type does have a Pamelor pen, a
|Sandoz appointment calendar, etc.

I am not going to argue about prescribing "Pamelor" instead of
"nortriptyline." It is obviously preferable to prescribe the generic,
or to encourage the patient to get the script filled with the generic
if possible.

However, there are many reasons to prefer nortriptyline over other
tricyclics in many cases, and that internists would be expected to be
more sensitive to some of these concerns, particularly the problems of
sedation, anticholinergic effects, and orthostatic hypotension.
Internists typically see patients who may be older than the typical
patient a psychiatrist would see, and ones who have more medical
problems. For this reason, their concern over side effects and
problems from other tricylics would be greater than in the population
that the psychiatrist sees.

Internists are prescribing nortriptyline for things other than headaches.
A great deal of depression is seen and treated by internists, and this
is not going to change until thet Surgeon General comes to arrest us.
Many people, especially the elderly, attach a great stigma to seeing
a psychiatrist, but will accept treatment from their internists.

In summary, I think the issue is a bit deeper than the level you are
looking at. I have an office full of "Cardura" (doxazosin) pens and I
never use the drug. Occassionally, internists do think at just a little
bit deeper level than you give them credit for. The logic implied by
your utilization review group's conclusions makes me even more
distrustful of the future of medicine as a spectator sport.

 -km

I agree with Dave Nye that amitriptyline and imiprimine seem to
be a bit better than nortriptyline for headaches at the same
dosage levels.  I reserve nortriptyline for those who can't
tolerate the more potent ones.

--
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Gordon Banks  N3JXP      | "I have given you an argument; I am not obliged

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< Pamelor, generics, internists, etc
Pamelor is the generic version of the drug.
So far we've only been able to find one study that shows superiority over
other tricyclics, that in a population with decreased left ventricular
output.  Yet even in that population about 50% could tolerate imipramine.
In a cost conscious age that hardly justifies starting with the ten
times as expensive generic.  (JAMA 1986;256:3253-3257)

People in different specialties always complain about side effects
of medications prescribed by other specialties that they have to treat.
I see a fairly large number of problems from tricyclics in the patient
population that I treat, and I am thankful that most of the psychiatrists
we work with have gravitated to nortriptyline.

 -km

--
Steve Dyer

--
----------------------------------------------------------------------------
Gordon Banks  N3JXP      | "I have given you an argument; I am not obliged

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 -km

Re: Pamelor not generic,   yes of course any drug protected by a trade
name is not generic.  Aventyl is the one that was protected by a patent
which usually gets the high prices  to pay development costs, etc.  Pamelor
has only the lack of competition and its heavy marketing to keep its price
up.  I think the reason Aventyl stopped production was that most of us
found that to get the same treatment effect you wound up with at least the
same level of side effects.  I know of no studies to support this, I just
know that I and most of my collegues stopped using it in the late 60's.
We assumed that since it was long off patent that its price would be about
the same as the other older tricyclics.
If competition appears on the market then this whole thread will become
irrevelant.