Welcome to my blog, a place to explore and learn about the experience of running a psychiatric practice. I post about things that I find useful to know or think about. So, enjoy, and let me know what you think.

Tuesday, December 9, 2014

App Review: NbNomenclature

A while back, I wrote a post called, What's In A Name?, about a proposed 5-Axis drug nomenclature system. The idea was that our current system of describing psychoactive medication involves terms like "Antidepressant" and "Antipsychotic", even though antidepressants are sometimes prescribed for anxiety, and antipsychotics for depression, and this is confusing, especially to patients.

Instead, the new system has a different way of describing drug class, along with mechanism of action,  indications uses, and relevant side effects, as well as neurobiology.

I had some concerns about how this system would be used, and by whom. There was talk of a future merge with DSM, whatever that would mean. It was created by people with strong ties to industry. The claim is that it would be a collaborative model, and I wondered what the charge for that collaboration would be. And I also wondered if reporting off-label uses as part of the drug description would influence future drug indication.

This was over a year ago.

More recently, Clinical Psychiatry News reported the launch of the drug terminology overhaul. The launch was accompanied by the release of a paperback book, as well as a new app, NbNomenclature, available for free download on iTunes App store and google play.  See also Nigella's comments on The Practical Psychosomaticist.

Not sure why Nigella had difficulty downloading it. Maybe because she was using an ipad. I put it on my iphone, and it does work. I haven't attempted an ipad yet.

So  I thought I'd share some of my thoughts. The home screen looks like this:

If I type in say, nortriptyline, I get this (the screen shot is missing the neurobiology section, down at the bottom, but I'll get to that):

It gives the official indication as Major Depressive Disorder, under the check mark (or tick, if you're British), but the + sign gives you the conditions it's used for.

Common and serious side effects under the - sign, that's useful.

What it doesn't give you is what you do get on something like Epocrates, dosing:

(Yes, I get crappy signal. Thanks, Verizon)

This lack of further information is strange in light of what I read in the app's stated mission:

"This proposed nomenclature aims to reflect the current pharmacological knowledge base and cannot necessarily represent the ultimate scientific truth...we feel that it's better to present a cutting-edge scientific interpretation than to wait for the definitive conclusion. We need to treat our patients now, and we cannot postpone treatment until all the facts are known.

Therefore this nomenclature is based on:

1. The need to treat now.

2. Updated neuroscience insights.

3. The judgement of the members of the task force." (italics mine)

With all this emphasis on the need to treat NOW, it would be nice to know how to dose the patient sitting in front of me, and what dosing forms are available for writing a prescription.

Maybe the Nb people didn't think that was important since we'll all be using electronic prescribing software that will tell us dosing options and forms. But for me, it keeps the app from being really useful, except perhaps to medical students who don't prescribe anything and don't need to know dosages. (Don't freak. I do remember most dosage forms, but there are some meds I don't prescribe very often, and I look those up just to be sure. Also, when titrating or tapering, sometimes you need weird, in-between dosage strengths.)

One nice feature is that if you're looking at a drug, and you swipe left, you get a similar drug. One left swipe from nortriptyline takes me to amoxapine.

Curious about this feature, I looked up Strattera, which it lists as a norepinephrine reuptake inhibitor (NE-RI in the app's abbreviation system). One left swipe takes me to desipramine, another NE-RI, then to lofepramine, maprotiline, and reboxetine, all indicated for Major Depression, unlike Strattera. So the new classification system is based strictly on mode of action.

Again, my question-who is going to use this? If I'm looking up Strattera, then presumably I want a medication for ADHD. If I'm looking for an alternative, I don't want to end up with an antidepressant. As an experienced clinician, I already know what other ADHD meds are out there. For an inexperienced clinician, this could cause a lot of problems. Or maybe the idea is for doctors to experiment based on mode of action.

Okay, so I couldn't find another ADHD med by swiping. I went back to the home page, clicked on "approved indication", and looked up ADHD. I got two hits: amphetamine and lisdexamfetamine. Aren't they missing a few? It turns out, they have several categories of ADHD. The one I checked was just ADHD. ADHD in children in Canada gives me guanfacine, ADHD in children >6y in the US gives me clonidine, and ADHD in children >6y and adults gives me methylphenidate and atomoxetine, right back where I started. Those are all the ADHDs they had.

In contrast, looking up ADHD in Epocrates gives me a list of 31 drugs, from Adderall to Zenzedi. Kinda easier to find alternatives.

As for the neurobiology section, nortriptyline looks like this:

Those highlighted phrases don't link to anything. Maybe they will down the line.

Bottom line: I can't think why this would be useful to anyone who already prescribes medications. And I'm not sure what the long term implications of a system like this are.

If an app rating consists of "A", "AP", and "APP", from worst to best, I rate it a "A".


  1. As an old organic chemist I think the KEGG site should have an app: http://www.kegg.jp/kegg-bin/get_htext?htext=br08901.keg&query=antidepressant+

    Just click on the numbers to the left of the drug classifications. They also give you two additional classifications.

  2. Nice site! Pictures you can click on, and CYP information. Thanks!