How steroids can accelerate your ADHD with Brittany Panico

Dr. Diana Mercado-Marmarosh: [00:00:00] Come join me May 1st through the 6th, so that you can rest, rediscover your strengths, reconnect yourself and those physicians like you who are ready to leave, work at work and re-energize. This is the invitation for you. 2023 your year. Join me in Costa Rica in this really amazing, non-judgmental, intimate decision community.

I am gonna show you how to rest and how to recharge. Let's transform your brain up so that you can start to dream the life that you always wanted this year in 2023. I can't wait to learn all about what kind of year you're gonna have after this conference. Take care. Hello, hello. Welcome to Beyond ADHD, a Physician's Perspective.

I am Dr. Diana Mercado-Marmarosh. I'm a family medicine physician practicing in rural Texas. I used to be hindered by my adhd, but I now. See it as a gift that helps me show up as a person. I was always meant to be both in my work and in my personal life. In the past two years, I've come to realize that unlearning some of my beliefs and some of my habits were just as important as learning the new set of.

Well, hello. Hello everybody. I am so excited today. I have a very special friend with me, Dr. Brittany Panico, and she is from Arizona and she's a physician. She's a rheumatologist. She's an. Autoimmune guru. Okay. A guru. Okay. So she's gonna talk to us about all the things but I wanna tell you about her because it's very special.

She is a board certified internal medicine doctor, and she's an also adult rheumatologist with experience both in inpatient and outpatient. And she is, Her platform is that we need to make sure we are doing this together. So she's an advocate for shared decision making and she really wants you to realize that we're a team here that you know, while I might not know everything, you might not know everything, but when we put our heads together, Everybody wins Your health wins.

And she is the chief of rheumatology at Summit Rheumatology and Gilbert, Arizona. So today we're gonna have a really cool talk about how sometimes steroids can make her A D H D misbehave a little bit . . Also, we're gonna talk about how sometimes we need to be aware that, again, when we are deciding that the course that we are getting from using certain medications are not, Exactly what we want.

We have to have this conversation about decision making so that we can pivot or figure out what the next best thing could be. So, without further ado, I wanna invite Dr. Brittany Panko today to share with us how she got excited about rheumatology.

Dr. Brittany Panico: Thank you so much Dr. Mercado. So Yeah, I'm really excited to be here and basically, like Dr.

Mercado said, I practice adult rheumatology and really, really want my patients to be a part of the team. So when we talk about medications, when we talk about diagnosis and what that means to you as a patient, , it's really important that we're all on the same page together. So excited to chat about different things that can contribute to either A D H D exacerbation or more trouble concentrating or trouble at work or at school or at home.

So yeah.

Dr. Diana Mercado-Marmarosh: So how did you land with ad with rheumatology? Like is that something you knew you wanted to do all the long, when you were in medical school or, or did just come about once you were like deciding towards the end?

Dr. Brittany Panico: So I became interested in a rheumatology actually, after a dermatology rotation.

I noticed that a lot of patients with psoriasis were coming in and really struggling with wanting to talk more about their condition, about more about how they felt, how their bodies felt. And in dermatology it was about treating their rash, their psoriasis, and we would see patients. You know, talk about medications, talk about prescriptions, and then the attending would often say, now you go see your rheumatologist.

And I didn't really know what rheumatology was at that point, but it really triggered me to think about. Okay, if, if this specialist is sending you now to this person, what is so special about that team that can fix the things going on? So I really started paying more attention to the way that rheumatologists kind of fit a lot of the pieces together.

And we're often kind of referred to as the problem solvers when things don't seem like they're going right or when we don't have an answer. Patients will often be sent to rheumatology to try to understand the puzzle of what's happening. So I really, really enjoy that problem solving approach. And then also it's just a really exciting time in the time of biologics, the time that so many new medications are coming out and really can change the way.

Patients feel and we can see it happening. So it's really, really exciting just to be a part of a field of medicine where we can really impact somebody's way of life for the better. And I just love being a part of that. Awesome.

Dr. Diana Mercado-Marmarosh: And. in your years of, of practicing have you seen a lot of us with a D H D come through to your clinic or some of us, or what have you noticed with like, the use of steroids?

Dr. Brittany Panico: So I definitely try to pay attention to that. If a patient talks about. Diagnosis of A D H D and how that might impact the way that they're feeling, because again, we're trying to put all of the pieces together with, with the person and what's going on, so, A lot of times in rheumatology, we focus on the way medications interact with each other, and I think that's really important when we consider the use of steroids or prednisone is the most common one that we use because a lot of people not in rheumatology are nervous about prednisone and patients come in oftentimes already having that kind of mindset of, oh, I can't really be on this, or, oh, I know it's gonna do something to my body.

And we use prednisone to calm down inflammation. That's our most powerful way to. Control of the inflammatory process, the fastest or quickest way. So I do find that, you know, we have to talk to patients and we have to, to talk together about the way that this medication might make you feel. So if you're already somebody who is trying to, you know, use systems to concentrate or have very specific ways of, of categorizing time, for example, steroid.

Are another way to rev up your system. So you might feel like you're caff the caffeinated version of yourself. So if you're sensitive to that, then steroids are probably gonna make you feel that even more powerful. And so, It's really important that we talk about potential mood changes or distractability or just ways that you might feel like you're kind of jittery inside when you're on something like Prednisone.

So it, it's something that I definitely sit down and talk with my patients about. and if they don't like how they feel, for example, if you're having trouble with insomnia or staying awake too long, or balancing your mood or feeling more anxious or more depressed or angry, or have changes in your temper, then it's really important that we talk about those things so that we can adjust the dose of your medication or modify how you're taking it.

Dr. Diana Mercado-Marmarosh: So did you say D caffeinated version or caffeinated?

Dr. Brittany Panico: Caffeinated version . Okay. Steroids give you more energy.

Dr. Diana Mercado-Marmarosh: Okay, gotcha. And so if they take the steroids and then they use their own medication, I mean, again, and some of the, some of us are on many me medications, so you, we can't simplify. And again, we're not trying to be your physicians per se, we're just having a discussion here.

And you have to check with your own physicians to get all the specifics for. Specific situation, but just so that I understand let's say you have somebody who takes a D H D medications and it's a stimulant, and then they take the steroid, it might enhance, like, and therefore they might have more anxiety.

Is that what we're saying?

Dr. Brittany Panico: Yes, yes. So sometimes I'll recommend to patients that they kind of stagger how they take their two medications or multiple medications so that you're kind of getting more of like an even flow throughout the day instead of those dramatic ups and downs of, of the feeling that you get.

And so, a lot of times, Prednisone as well can, if you take it too late in the day, kind of like a D H D medication, if you take it too late in the day, you can have trouble sleeping. So it is recommended that, that we talk about ways to, to help with that and sometimes just staggering the way you take your medications can be really helpful.

Dr. Diana Mercado-Marmarosh: Yeah, I mean we, like you said, sometimes we underestimate. The possible interactions or possible. Things that can happen. I remember not too long ago, maybe two or three months ago, I had a patient who came in and you know, she was having severe, severe headaches and I, and I wasn't sure if it was because she was withdrawing from the medication for A D H D because some people can have headaches whenever they're don't drink enough water.

Or, you know, if they went from a regular medication to an extended release medication and. I decided it would be cool to kind of reset her headaches or her with five days of steroids, . And sometimes that works wonderful for some people and for her, not so much. I think she was back within like two or three days and she's like, I don't know what happened, doc, but my husband says I'm a raging, blah, blah, blah, blah, and I cannot be on these two meds together.

And so I'm. And so again, we don't realize sometimes because it could be that, I mean, I've given that treatment a thousand times to somebody with headache and they've done wonderful and I've given the, you know, the A D H D and, and sometimes you don't. Think together until they come back and you're like, oh yes.

Okay. Yes. I, I see. And and so they swear they don't wanna be on one or the other, but I'm like, no. I think it was the combo of each, I think you would be okay if you just had to do steroids, if you have bronchitis or if you have an asthma attack or something like that. And like you said, being mindful of when can I take it and not taking them together exactly.

At the same time. Right. And then also, like, did you. Lunch, they just skip everything else. Right. And, and so it, it's so important to talk about this because both of those mets can be so common, right? And we don't, because they're so common. Sometimes we don't slow down enough to evaluate like what else is going on.

And so, yeah, that you. That's why I'm asking these questions and then we think back at our experience and you're like, oh yeah, I remember that scenario. .

Dr. Brittany Panico: Exactly. And sometimes too, when we think about the dosage, right? If you're on a chronic medication, let's say for adhd, you're getting the same dose pretty much all the time, and then you try something new or short term like steroids.

Sometimes our dose that we would think of, we just have to lower that for certain people and just think, okay, maybe try half a tab instead of the whole thing at once. But yeah, everybody reacts differently and, and again, a lot of times patients get really angry and upset that we should know better, but we don't necessarily know how medications are gonna affect individuals and.

What makes it so powerful to provide that feedback? Like you said, you know, if your follow up wasn't supposed to be for a week or so, but you're really, really struggling with how you feel, check in with us sooner so we know that you're struggling because if we don't hear from you, we don't know what's happening.

Dr. Diana Mercado-Marmarosh: Yeah, exactly. We cannot read minds, right, and and that's the thing too, like sometimes when things are going so well because they're going so well, you're like, oh, I don't think I need that anymore. You'd be surprised how many times like people just stop taking their antibiotics or they stop taking their anxiety or depression meds, or they stopped taking their blood pressure meds because they're like, but it's been so good and I'm.

Because you were on it. That's why it was so good. . And then they start like saying, but then it stopped being good. And I'm like, well, how long has it not been good? And then you like backing up and trying to find out the half-life. You're like, yeah, that's why, because now it's almost a hundred percent outta your system.

And, and so. This is why it's so important to have a conversation. Of course, we don't know all the possibilities that could happen. We're not like, if we knew that this is gonna cause a harm to you, why would we prescribe it? We would never do that. Like we took a oath first, you know, harm. But this is why we.

We need feedback because there's no way that we would know one way or the other. And if it is going so well, like you said, again, come tell us because then there's ways that we, of course, the less meds that you're on, we're happier because you know, less interactions. But we can help you like taper off so that we do it in a safe way so that.

Maybe you are in the, we get you to one fourth the dose of what you currently are on, but it still gives you that benefit that you need. And so that's why it's so important, like you said, to have that conversation.

Dr. Brittany Panico: Exactly. And you, you mentioned the tapering part too. So as a rheumatologist, a lot of. Our medications to wean off of them are designed to taper.

So just like I'm sure you talk with your patients all the time, don't abruptly stop something, you may have to slowly taper off of it. And that's true in rheumatology too. We don't want our patients to just cold Turkey stop something because. You mentioned the headaches or kind of those withdrawal symptoms that can happen with some of our medications too, so definitely that's part of the process as well.

Dr. Diana Mercado-Marmarosh: Is there any other medications other than steroids that you've noticed that can sometimes have interactions or Like for any mental health stuff that you've noticed or, or anything that just like as a primary care physician who's listening might be, you know, keeping that in the back of our

Dr. Brittany Panico: minds.

Definitely. And I think we kind of, you know, Talked with the about the prednisone as sort of a negative side effect, but a lot of the positive stuff that we're seeing, especially for patients with rheumatoid arthritis, with lupus and with psoriatic arthritis, is that the biologics or the injectable medications actually have a really positive effect on mood.

And things like anxiety and depression. And so the longer that a patient is in remission, meaning controlled disease from that condition, so controlled rheumatoid arthritis, controlled lupus, controlled psoriatic arthritis, then a lot of the mental health aspects are getting a lot better as well. So I've had several patients who come, About three months later and have been able to cut back on the dose of some of their medications, like antidepressants, anti-anxiety medications, just because they feel so much better in regards to their underlying autoimmune condition.

So I think that's a really powerful thing too, is that as we're following up with our patients, What aspects are getting better because you are on treatment for your other things and maybe we can start to taper some of those medications that have been pretty long term for people. So that's something that I really encourage my patients to talk to their primary care.

Team members about is, you know, I'm feeling a lot better, I'm having less pain, I'm having less anxiety, less depression, I'm sleeping better, I'm exercising, eating healthier. At what point am I able to maybe consider cutting back to see if, if I can manage and feel good with less medication?

Dr. Diana Mercado-Marmarosh: Yeah, you bring such a good point.

Like I am constantly. Cutting or taking away some of the blood pressure medication because their blood pressure was uncontrolled because they were in pain and now that their arthritis is controlled, like you said, now they don't need like three blood pressure medications because of course, even though I was giving them medications for the pain or whatever, like.

When you are living with chronic pain, like it's crazy, and then all of a sudden you start on methotrexate or you start the rheumatologist finally like can get in to see them and they can get them on the right thing and they come back. They're like, no, I feel great. I feel great. Like, no, I haven't used.

That Tramadol doc, I don't need it. Or, or, and then your, their pl blood pressure is like, I'm like, are you feeling okay? It's like nighty over, like, and I'm like, look, like testing them over and over. And they're like, I feel great. I'm like, are you dizzy? They're like, no. And I'm like, okay, well let's cut this off.

Right? Because like you said, all of a sudden you don't realize that we are like, pain can affect us in so many different ways. Right. You, you, you can feel hopeless or helpless and, and so you don't feel like. You know, you can function and so all of a sudden when you start to, yeah, you should be looking, how can I get off of some of the medications or decrease the dose.

So maybe you don't need 40 milligrams of Paxil, you just need 10 now. And, and like, we wouldn't know again because. We're so used to, this is what we've been doing forever. But then again, like you said, what is getting better and, and keep looking at it because sometimes medicine keeps focusing on like, what's wrong, what's wrong, what's wrong, instead of what is Right.

Dr. Brittany Panico: Right. Exactly. Yeah, and, and I'm glad you mentioned the pain aspect of it too. I see that a lot with my gout patients. Once we finally. Gout under control, then the need for pain medication specifically can go away. Meaning that you can completely come off of things like tramadol or narcotics if you've been using them and, and blood pressure, kidney function.

There are so many things that can start to go right once you treat the underlying issue that was making those. Become problematic in the first place. So exactly this, this whole philosophy doesn't apply just to depression or anxiety or A D H D. It applies to, to the whole body function as well.

Dr. Diana Mercado-Marmarosh: Yeah, because I mean, so much can change because if you were taking like.

The max dose of ibuprofen, the max dose of Tylenol. And like we were very careful watching your kidney, right? Because it was like right at the tip and all of a sudden I had to send you to that specialist and that specialist. Right? Like it, it, it's so important to realize that we, we are the whole system, not just one part of the, of the system.

Right? And so, yeah, I, I think it's, And of course when you, you realize that your insomnia was also steaming from your anxiety, and now you started to treat your anxiety, oh, maybe you don't need a sleepy medication because you're no longer anxious about that . Right? And, and so it goes round and round and round, but it's, it's so important that.

And I know sometimes it feels like we don't have enough time to talk about all the things, but if you, in general, before you go to the doctor's appointment, can like brainstorm what is going well, like that can help facilitate the discussion and then figure out where to go from it. From there, tell me more.

Like what your passion is in, in your practice? Like what, what, like what lights you up, .

Dr. Brittany Panico: So I'm really passionate about in a couple of things, but I think at the heart of what really lights me up is finding areas where we're sort of ignoring a population of patients. So, One of the things that I'm doing in my practice Summit Rheumatology, is we've created a gout center of excellence and we're really focusing on trying to network and reach out to the community about properly treating gout, and that can be.

Either through oral medication, there's an IV medication that we use, and really just identifying that gout is a problem that a lot of people suffer with and live with, and just periodically will seek care when they're having an event or a flare. Rather than addressing gout as a whole body systemic issue.

So there's a lot more research being done, a lot of work going into, you know, helping educate all sorts of, you know, medical specialties, primary care, podiatry, surgery, orthopedics, even cardiology about how gout fits within all of. Systems. So that's what I'm working on currently and I'm really excited about that.

I also really, really like treating psoriatic arthritis because again, it's kind of one of those sort of under-recognized fields where patients will most often, you know, see a dermatologist for psoriasis. But then not really realize that their back pain, for example, is related. They may just think, oh, I have back pain or neck pain, and I go to a chiropractor and it gets better after I'm adjusted.

But in reality, it might actually be related to the psoriasis and be a form of psoriatic arthritis, and that can be episodic for people too. So a lot of times these more episodic conditions are hard to identify. And I think just helping patients understand that there is access to rheumatologists, even when it seems like we're few and far between.

And so I'm just really trying to, to get the word out and help patients understand that. You know, a lot of the conditions, a lot of the things that you feel like are not related to anything else are actually tied to an arthritis syndrome. So those are the two things that I'm most passionate about. I also really like to treat osteoporosis.

That's another gap in care, especially in my area that. Patients who fall and break a hip are then not necessarily treated for thinning of their bones, right? We kind of just think, oh, the surgeon fixed it and I'm mobile and I'm doing okay. When in reality, we wanna treat the reason that it happened in the first place.

So that's another sort of avenue that I'm trained to target as well.

Dr. Diana Mercado-Marmarosh: Yeah. And realizing that, you know, it is part of the preventative, right? Like you need to have your DEXA scan so that you can see if you're preo osteopenic already, and maybe you need to be started on something and don't wait until you had the fracture, right?

Like, like do it beforehand. And especially if again, you might have other comorbidities that. Can predispose you, and not necessarily just age-wise, but like whatever medical conditions you might have and medications that you might be on that can, I don't wanna say ages a little more, but in a way they kind of do.

Right? So we just gotta be aware that it's not just the age per se, but that, you know, a 50 year old might. Very different than a 70 year old that looks like the 50 year old. And the 50 year old looks like the 70 year old. Right. Not looking but like in terms of bone wise and health-wise. Right. And so it's so important to keep all that in mind.

And yes, I so much about this thoratic arthritis, like you said, sometimes we don't, I think as primary. Physicians, you might get a glimpse of it more than if you just are somebody who's like in urgent care or in the hospital where you might not see them as often. Because like you said, sometimes they might come in for the back pain and oh, by the way, I'm so stressed.

And then like this rash came up, doc and I, it always comes up when I'm like, so stressed about taking this test. And you, you, you might not put it together until , you know, they've come up several times or somewhere you put psoriasis or somewhere somebody else put arthritis and you're like, ha. Like, is it happening at the same time or not?

Right. And and like you said, when you do finally get that diagnosis right, oh my God, it's like life changing for them. And I

Dr. Brittany Panico: think too, there's there we're kind of in this sort of split. Chasm right now where, where a lot of us have, you know, patients that are younger and maybe around our age. And then we also have patients who are aging and, and friends who have aging parents and really trying to fit that spectrum of, you know, disease processes of preventative for the younger folks.

And then we're reacting to things from. Our older patients and trying to put those together and make sense of it. So I really do try to, you know, not only as I'm taking care of a patient but may be younger, you know, also addressing as they have aging parents who may or may not live in the same town as they do.

You know, there's ways that we can help prevent things in that population as well. Yeah.

Dr. Diana Mercado-Marmarosh: And like something and now I'm gonna go off a little bit off course, but I thought it was something that I, I found it interesting and I don't know if you knew this or not, but I read like a study saying that sometimes when your, your, the mom has like arthritis, like that, that might increase the risk for like a D H D or bipolar by 50%.

But I don't really know if. Like like just coincidental, you know, because it could be that, you know, some people sometimes, as we. If the mom had gestational diabetes, then they might have diabetes later on. And sometimes people can have autoimmune conditions and then that can like predispose people for other stuff.

I, and I mean, at the end of the day, D H D is genetic, right? And so we don't know if there is direct associations or not. And I don't know if you have ever. How about any of this data yourself? Do you know? I haven't

Dr. Brittany Panico: read that particular study, but I do think that it's really fascinating because when we think about.

childhood events and how that can lead to health conditions as adults. It is very interesting if a parent is struggling with a chronic disease that maybe isn't treated optimally or isn't diagnosed and acknowledged how that affects the home, right? So, right. If I'm a mom and I'm in pain and struggling to get out of bed every day, my children are gonna be affected by that.

And as my children grow up and realize, What is quote unquote normal for their household that then will translate to the next generation and can develop into health conditions in, in that own person. So we're, we're in this phase where things that our grandparents or parents didn't really acknowledge or didn't have the tools to even be able to address when they were in their thirties or forties even.

How that's affecting, you know, us or our children. And, and so the more that we can get patients to see their doctor regularly get treated for the things that they're facing and just have these conversations about how to get help and how to address things that they're struggling with, that's only gonna help our children as.

Go through this process as teens and young adults be more comfortable with preventative medicine as well.

Dr. Diana Mercado-Marmarosh: Yeah, exactly. You, you bring such a good point because like you said, sometimes we just think, well, this is the way it's always been like, you know growing pains or you, whatever you name it. And people don't realize that yes, there could be juvenile arthritis.

Yes. There could be like depression in a kid, or there could be, you know, other things that are going on that are not just oh, they'll get over it, type of thing. Right. And, and so, Sometimes, I mean, our parents are always doing the best that they can with what the knowledge they had. But like you said information being at our fingertips, we should it's okay to get a second or third opinion sometimes just to make sure we're not missing anything.

Mm-hmm.

Dr. Brittany Panico: exactly. Awesome.

Dr. Diana Mercado-Marmarosh: Well, where can people find you? Do you only do in-person or do you do virtual too in Arizona? Or how, how can people cuz I know there's a lot of people with gout and sciatic arthritis and now that people know, okay, she understands my d h adhd, she can help me. Like, I'm sure they're gonna be coming to you.

How can they find you?

Dr. Brittany Panico: Well, I would welcome that. So I'm at Summit Rheumatology. And you can find me@summitrheumatology.com and we have a you can fill out a form if you're interested in becoming a patient. I do do in-person and virtual appointments to all of Arizona, so currently only licensed in Arizona, but I am looking to expand that.

So hopefully soon I'll have some updates there. But yes, in-person virtual summit, rheumatology. And then I'm also on Facebook and Instagram, az like Arizona AZ room, r h u m Doc, d o c AZ room Doc.

Dr. Diana Mercado-Marmarosh: Perfect. Thank you. With my podcast, I say you have people who are listening and sometimes we have wondering attention, and so we just tuned in and we just started p ta paying attention right this second.

What is the takeaway point that you would want them to walk

Dr. Brittany Panico: away with? So my best advice as a rheumatologist is to just ask for help and be a part of the decision making. So I love it when patients come in prepared for their visit and ready to talk about how they feel. and just being involved in their health healthcare decisions is the most empowering thing that we as physicians can impart to our patients.

Awesome.

Dr. Diana Mercado-Marmarosh: And I always ask this question too what are you hoping to do for the next three years

Dr. Brittany Panico: for fun? Well, that's a good one. So I'm hoping to travel more. I have three young boys and we're just really excited to get out there and, and see a little bit more of Arizona and to travel. So that's my goal for the next couple years.

Dr. Diana Mercado-Marmarosh: So are you hoping to like, go to the mountains, go to the beaches? Like I, I'm trying to see this big picture

Dr. Brittany Panico: here. , , so all over. We haven't been to the Grand Canyon yet, yet. I think that'll be a fun one for, for the kids. And then we love beach vacations. We have family in California, so exploring more of California.

And we came from the Midwest. We moved from Chicago, so taking them back to that area would be fun as well. But my son, my older son is almost ready for the national parks perk at school, so I think we'll take advantage of that as well.

Dr. Diana Mercado-Marmarosh: Awesome. Thank you so much for sharing all your knowledge today and being here.

And all the people in Arizona are so lucky to have her there. So, but everybody else who's not in Arizona, hang tight, follow her, listen to her content, and she's expanding soon, so you'll get to get in on that too. So thank you so much. And again, remember it is a conversation between the doctor and the. We don't know everything.

You don't know everything together. We can put it together but do pay attention to what's going on with you because you are with you 24 hours and we don't know unless you tell us what's going on. So thank you so much again for coming and it was a pleasure to have you today. Thank you. Thank you.

Thank you for spending your time with me. I really believe that time is your most valuable. Please subscribe to the podcast, share with your colleagues, and don't forget to check out my website@hdlivecoach.com where you can find out about my upcoming coaching group classes, as well as free masterclass and other exciting events that are happening.