What is the next step in management for a 49-year-old female with a history of insomnia on Trazodone (trazodone), presenting with recent complaints of vertigo and noticeable skipped beats on exam, with an electrocardiogram (EKG) showing normal results with multiple premature ventricular contractions (PVCs), who is also seeking to initiate Phentermine (Adipex) for weight loss?

From the Guidelines

For a 49-year-old female with insomnia on trazodone, recent vertigo, and multiple PVCs on EKG, Adipex (phentermine) should be avoided at this time. Instead, a cardiology referral is recommended for evaluation of the PVCs before considering weight loss medications. The patient should undergo further cardiac workup, including an echocardiogram and possibly Holter monitoring to assess the frequency and nature of the PVCs, as suggested by the 2018 guidelines for management of patients with ventricular arrhythmias and the prevention of sudden cardiac death 1. Phentermine is a sympathomimetic amine that increases heart rate and blood pressure, which could potentially worsen cardiac arrhythmias like PVCs. The vertigo symptoms may also be related to the cardiac issues or could represent a separate concern requiring neurological evaluation. For weight management in the interim, lifestyle modifications including caloric restriction and increased physical activity (after cardiac clearance) would be safer approaches. Once cardiac status is clarified and if no significant abnormalities are found, the patient could be reconsidered for weight loss medications, potentially including options with better cardiovascular safety profiles than phentermine.

It's also important to note that the patient's current medication, trazodone, is not recommended as a first-line treatment for insomnia, according to the 2017 clinical practice guideline for the pharmacologic treatment of chronic insomnia in adults 1. Alternative sleep aids, such as eszopiclone or zolpidem, may be considered after the patient's cardiac status is evaluated and stabilized.

Key considerations in this patient's management include:

• Cardiac evaluation and monitoring to assess the frequency and nature of PVCs
• Avoidance of phentermine due to its potential to worsen cardiac arrhythmias
• Lifestyle modifications for weight management
• Reconsideration of sleep aids, potentially including alternatives to trazodone
• Neurological evaluation if vertigo symptoms persist or worsen.

From the FDA Drug Label

4 CONTRAINDICATIONS History of cardiovascular disease (e.g., coronary artery disease, stroke, arrhythmias, congestive heart failure, uncontrolled hypertension)

The patient has a history of insomnia on trazadone, recent vertigo complaints, and noticable skipped beats on exam, with an EKG showing normal results with multiple PVC. Given the patient's cardiovascular symptoms, including skipped beats and PVCs, phentermine is contraindicated due to the risk of exacerbating underlying cardiovascular disease.

• The patient's symptoms suggest potential cardiovascular issues, which are a contraindication for phentermine use 2.
• Phentermine may worsen cardiovascular conditions, such as arrhythmias, and is therefore not recommended for patients with a history of cardiovascular disease 2.

From the Research

Patient Evaluation and Management

The patient's recent complaints of vertigo and noticeable skipped beats on exam, along with the EKG results showing multiple PVCs, suggest the need for further evaluation and management.

• The presence of PVCs is relatively common, occurring in 3%-20% of the general population, and are often considered benign but can be a sign of underlying cardiac disease 3.
• The patient's current medication, trazodone, has been associated with the occurrence of life-threatening premature ventricular contractions and angina in some cases 4.
• Given the patient's symptoms and EKG results, it is essential to consider the potential relationship between trazodone and the development of PVCs.

Considerations for Treatment

• Treatment for PVCs often consists of catheter ablation, although antiarrhythmic medications may also provide both reduction in PVC frequency and resolution of left ventricular dysfunction 5.
• The patient's desire to try adipex for weight loss should be carefully considered in the context of their current cardiac symptoms and medication regimen.
• It is crucial to exercise caution when prescribing trazodone, especially in patients with preexisting cardiovascular disease or ventricular irritability 6.

Medication Interactions and Safety

• The potential interaction between trazodone and other medications, such as omeprazole, should be carefully evaluated, as it may lead to serious cardiovascular adverse effects 7.
• The patient's medication regimen should be carefully reviewed to minimize the risk of adverse interactions and ensure the safe management of their cardiac symptoms.