Case outcome: second and third interim follow-up visits at three months

Care was coordinated with her rheumatologist

• – Modafinil (Provigil) is increased to 300 mg/d to improve fatigue and increase wakefulness for her FM

• – Pregabalin (Lyrica) is lowered to 50 mg twice a day to lessen fatigue adverse effects

• – Other medications are left unchanged

This approach begins to maximize the stimulant-like treatment while trying to minimize side effects

Patient was counseled and supported regarding her ability to tolerate the side effects and efforts to balance these versus promoting greater effectiveness

Despite these efforts, patient returns later stating she is too scared and had left her dose of modafinil (Provigil) at the previous 200 mg/d

• – The patient was supportively shown the approved package insert

• – She was also shown a well-renowned psychopharmacology guide

• – Both clearly delineated safe dosing strategies; she then was agreeable to dose escalation

After this, unfortunately, the patient showed no symptom improvement as she did not make the suggested changes yet again

Attending physician’s mental notes: second interim follow-up visit at three months

This is going to be a difficult case given the patient’s fear and ambivalence about medications and health issues, her hypochondriasis, and possible functional somatic syndromes

On a positive note, she is relatively side-effect free for now

Question

What would you do next?

Further escalate one medication at a time to balance efficacy and tolerability

Begin removing ineffective medications to streamline her regimen and improve compliance

Refer for more organized, specific psychotherapy

Attending physician’s mental notes: second interim follow-up visit at three months (continued)

As this patient is somewhat accepting of using her wakefulness medicine and sees it as bridging the gap between her mental and medical issues, it makes sense to work with this drug instead of adding anything else

Increasing her sedative–anxiolytic or neuropathic pain medication are unlikely to remit her MDD and may promote more fatiguing side effects

Combination or augmentation strategies can certainly be utilized in both depressive and pain disorders

• – Therefore, an increase in her SNRI (duloxetine [Cymbalta]) may also be called for to enhance noradrenergic functioning, but given her side-effect prone nature, changing one medication at a time is likely warranted

Escalating the SNRI would have been a better monotherapy choice, but the intervention of multiple providers has increased her polypharmacy, and in her case, a likely risk of adverse effects and more non-adherence

Case outcome: interim follow-up visits through five months

No change in status; patient is still depressed, anxious, in pain, but not suicidal

Modafinil (Provigil) is increased to full 400 mg/d dose

Patient calls one to two weeks later stating she has ankle edema

• – She insists on lowering and discontinuing the modafinil

• – A few days later the swelling continues

• – Conversation with primary care provider shows no other medical issue at hand

• – Usual side-effect profile suggests this might be her pregabalin (Lyrica), even though there was no recent dose change

• – Pregabalin was discontinued and the edema resolved