Psychotropics in problem areas

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LIAISON PSYCHIATRY

Psychotropics in problem areas

  1. 1. Choosing PsychotropicChoosing Psychotropic in Patientsin Patients with Medical Problemswith Medical Problems A. Albehairy , M.DA. Albehairy , M.D Psychiatry Consultant, MOHPPsychiatry Consultant, MOHP
  2. 2. Medical Problem ConditionsMedical Problem Conditions ( one or more):( one or more):  Breast feeding.Breast feeding.  Pregnancy.Pregnancy.  Old age.Old age.  CardiovascularCardiovascular diseases.diseases.  Chest problem.Chest problem.  Renal impairment.Renal impairment.  Liver impairment.Liver impairment.  Diabetes.Diabetes.  Epilepsy .Epilepsy .  In surgery.In surgery.  Glaucoma .Glaucoma .
  3. 3. General Principles , in approachingGeneral Principles , in approaching the problemsthe problems - Breast-feedingBreast-feeding: no risk free, drug level in milk 1% of: no risk free, drug level in milk 1% of maternal plasma. Drug accumulates in milk bec. Ofmaternal plasma. Drug accumulates in milk bec. Of acidity and lipid and protein binding .drugs should beacidity and lipid and protein binding .drugs should be avoided if premature or has renal.liver.cardiac,oravoided if premature or has renal.liver.cardiac,or neurological problem.neurological problem. Avoid sedating,long half-lives. Once daily dose before theAvoid sedating,long half-lives. Once daily dose before the infant longest sleep,dnt switch drug (preg- lactat),avoidinfant longest sleep,dnt switch drug (preg- lactat),avoid polypharmacy.polypharmacy.
  4. 4. General Principles , in approachingGeneral Principles , in approaching the problems (cntthe problems (cnt(.(.  PregnancyPregnancy :FDA, 5 categories, to indicate drug:FDA, 5 categories, to indicate drug teratogencity. Each drug has to be sought.teratogencity. Each drug has to be sought.  Teratogenecity in the 1Teratogenecity in the 1stst trimester, growth retardationtrimester, growth retardation and neurological damage in 2and neurological damage in 2ndnd &3&3rdrd trimester.trimester.  Drug withdrawal.Drug withdrawal.  Diabetus vulnerability, macrosomia.Diabetus vulnerability, macrosomia.  Hyperyensive mother .Hyperyensive mother .  Psycho education for care in planned and non plannedPsycho education for care in planned and non planned conception.conception.  Lowest viable dose.Lowest viable dose.  Adjusting dose.Adjusting dose.
  5. 5. General Principles , in approachingGeneral Principles , in approaching the problems (cntthe problems (cnt(.(.  11stst 2 wks –stop medications, nutritional supplement folic2 wks –stop medications, nutritional supplement folic acid, reduce dose if after 60 days,dnt stop lithiumacid, reduce dose if after 60 days,dnt stop lithium abruptly,care in stop anticonvulsants.abruptly,care in stop anticonvulsants.  TCA & Discontinuation,/ myclonus ttt byTCA & Discontinuation,/ myclonus ttt by phenobarbitol.phenobarbitol.  If depakin unavoidable , low , divided doses and folicIf depakin unavoidable , low , divided doses and folic acid 5mg .acid 5mg .  Most serious, bzd,lithium, phenytoin,topraimate, andMost serious, bzd,lithium, phenytoin,topraimate, and vigabatrin and valproate.vigabatrin and valproate.
  6. 6. General Principles , in approachingGeneral Principles , in approaching the problems (cntthe problems (cnt(.(.  Old age :Old age : age related increases SE, sedation,age related increases SE, sedation, orthostatic hypotension, reduced metabolism oforthostatic hypotension, reduced metabolism of liver.liver.  Inc. fat in body--- inc half life of the drugs used.Inc. fat in body--- inc half life of the drugs used.  Other system affected.Other system affected.  Low and slowLow and slow  Poor compliancePoor compliance
  7. 7. General Principles , in approachingGeneral Principles , in approaching the problems (cntthe problems (cnt(.(.  CardiovascularCardiovascular :: Polypharmacy avoided, with drug likely to affectPolypharmacy avoided, with drug likely to affect pulse or electrolyte balance, QTprolongation.pulse or electrolyte balance, QTprolongation. Low and slowLow and slow Angina,avoidAngina,avoid drugs of othostatic hypotension,drugs of othostatic hypotension, tachycardia.tachycardia. ArrhythmiaArrhythmia:TCA, phenothiazines and:TCA, phenothiazines and butyrophenones and pimozide arebutyrophenones and pimozide are harmfulharmful.. Sulpride, olanzapine ofSulpride, olanzapine of low risklow risk..
  8. 8. General Principles , in approachingGeneral Principles , in approaching the problems (cntthe problems (cnt(.(.  CHFCHF: avoid B blocker, drugs causing orthostatic: avoid B blocker, drugs causing orthostatic hypotension(phenothiazines, clozapine , risperidone and TCA).hypotension(phenothiazines, clozapine , risperidone and TCA).  MIMI: SSRI, TRAZODONE , mianserin,safer: SSRI, TRAZODONE , mianserin,safer Butryphenone safer than pimozide, phenothizines.Butryphenone safer than pimozide, phenothizines.  Lithium & diuretic may be serious.Lithium & diuretic may be serious.  HypertensionHypertension, avoid MAOI, venlafaxine of high dose,, avoid MAOI, venlafaxine of high dose, clozapineclozapine  QTC prolongationQTC prolongation 450ms,care of electrolyte, and drug450ms,care of electrolyte, and drug combination , antipsychotics, TCA, flouroquinolone abio,combination , antipsychotics, TCA, flouroquinolone abio, antimalarila, antihistamine.antimalarila, antihistamine.
  9. 9. General Principles , in approachingGeneral Principles , in approaching the problems (cntthe problems (cnt(.(.  Chronic lung dis. - Depression 18.8% in COPD, & up to 62% in severe COPD. - Panic disorder among COPD,8-34%. - Buspirone and SSRI are preferred anxiolytic more than BZD. - TCA, is good for COPD, esp for somatic sx. without heart effect, - ECT, only in severe depression with COPD , BUT take care of prolonged seizure in thyophylline use. - In asthma , Avoid non specific b blocker , bupropion , relaxation therapy and CBT are promising in depression and anxiety sx.
  10. 10. General Principles , in approaching theGeneral Principles , in approaching the problems (cnt).problems (cnt). Liver and renal impairmentLiver and renal impairment  Grade of renalGrade of renal impairment,impairment, Mild 150-300 S.cre.micromole/LMild 150-300 S.cre.micromole/L Moderate 300-700Moderate 300-700 Severe > 700Severe > 700  Low and slowLow and slow  SE, of anticholinergic, urinary retentionSE, of anticholinergic, urinary retention  Accumulation of drugAccumulation of drug
  11. 11. General Principles , in approachingGeneral Principles , in approaching the problems (cntthe problems (cnt(.(.  In surgery:In surgery: DecisionDecision to continue or not the drug during surgery andto continue or not the drug during surgery and perioperative period.perioperative period.  Discussing the anesthetistDiscussing the anesthetist Enflurane---seizure in TCAEnflurane---seizure in TCA Pethidine ---fatal excitatory reaction with SSRI (serotenorgicPethidine ---fatal excitatory reaction with SSRI (serotenorgic syndrome or respiratory depression ) and MAOI --- switch tosyndrome or respiratory depression ) and MAOI --- switch to moclobamide 2wks before operation.moclobamide 2wks before operation. operation stress:Elyctrolyteoperation stress:Elyctrolyte distubance and cortisol anddistubance and cortisol and catecholamine changes.catecholamine changes. Gastric stasis.Gastric stasis. Abrupt cessation of nicotine in some pt.Abrupt cessation of nicotine in some pt.
  12. 12. General Principles , in approachingGeneral Principles , in approaching the problems (cntthe problems (cnt(.(.  In surgeryIn surgery:: - AnticonvulsantAnticonvulsant CNS depressant activity may reduceCNS depressant activity may reduce anaesthetic requirements.anaesthetic requirements. - SSRISSRI, may induce seizure,, may induce seizure, VenlafaxineVenlafaxine may provokemay provoke opioid rigidity, increase bleeding time. ( avoid anyopioid rigidity, increase bleeding time. ( avoid any serotenorgic agent).serotenorgic agent). - TCA:TCA: seizure, seroenorgic s, hypotension, it needs o beseizure, seroenorgic s, hypotension, it needs o be stopped several days before surgery.stopped several days before surgery. - Antipsychotics,hypotension,arrythmia,hypothermia,Antipsychotics,hypotension,arrythmia,hypothermia, clozapine may delay recovery .clozapine may delay recovery .
  13. 13. General Principles , in approachingGeneral Principles , in approaching the problems (cntthe problems (cnt(.(.  in surgeryin surgery BZDBZD, sedation and withdrawel, sedation and withdrawel LithiumLithium : electrolyte imbalance may ppt, toxicity,: electrolyte imbalance may ppt, toxicity, avoid dehydration/arrythmia develop.avoid dehydration/arrythmia develop. OpiateOpiate, methadone, naloxone may induce, methadone, naloxone may induce withdrawel– avoid bupernorphinwithdrawel– avoid bupernorphin NaltrexoneNaltrexone
  14. 14. Low Risk PsychotropicsLow Risk Psychotropics  Br.feedingBr.feeding,sulpride, moclobamide, TCA,,sulpride, moclobamide, TCA, tryptophan,BZD,chloral,temazepam,carbamezaptryptophan,BZD,chloral,temazepam,carbamezap ine,valproate.ine,valproate.  Pregnancy : moderate riskPregnancy : moderate risk. All antipsychotic. All antipsychotic except zotepine high. All antidepressant exceptexcept zotepine high. All antidepressant except reboxetin high, safer carbamezapine and ox,, andreboxetin high, safer carbamezapine and ox,, and lamotriginelamotrigine
  15. 15. Low Risk PsychotropicsLow Risk Psychotropics  Old age: sulprideOld age: sulpride, amisulpride,, amisulpride, risperidine,ariperazole/deloxetin,mitazepine,SSRI,velafarisperidine,ariperazole/deloxetin,mitazepine,SSRI,velafa xine,mocobamide/alprazolam,buspiron,lorazepam,zaloxine,mocobamide/alprazolam,buspiron,lorazepam,zalo plon/carbamezapin,ox,topramate,clobazam.plon/carbamezapin,ox,topramate,clobazam.  Cardiac prob:Cardiac prob: sulpride,amisulpride,flupentixol,olanzapine,quatapine,/sulpride,amisulpride,flupentixol,olanzapine,quatapine,/ SSRI,mirtezapine,mianserin,trazdone/bzd,buspiron,zalSSRI,mirtezapine,mianserin,trazdone/bzd,buspiron,zal oplon,zolpidiem/valproate,lamictal,pregabalin,gabapentoplon,zolpidiem/valproate,lamictal,pregabalin,gabapent in.in.
  16. 16. Low Risk PsychotropicsLow Risk Psychotropics  DiabetusDiabetus:sulpride,amisulpride,aripiprazole,butyr:sulpride,amisulpride,aripiprazole,butyr ophenon, pimozide,ophenon, pimozide, risperodone/deluxetin,moclobamide,SSRI,trazdrisperodone/deluxetin,moclobamide,SSRI,trazd on,venlafaxin/bzd,buspar,zaleplon,zolpedim,/bzon,venlafaxin/bzd,buspar,zaleplon,zolpedim,/bz d,carb,oxcarb,lamictal,pregabalin.d,carb,oxcarb,lamictal,pregabalin.  Renal impairment:Renal impairment: sertindole,mianserin,moclobamide,TCA,TRAZDOsertindole,mianserin,moclobamide,TCA,TRAZDO NE,BZD,zalplon,phyenytoin,lamotrigenNE,BZD,zalplon,phyenytoin,lamotrigen
  17. 17. Low Risk PsychotropicsLow Risk Psychotropics  Liver impairmentLiver impairment :sulpride,amisulpride,aripirazole,flupentixol,zuclpentixol:sulpride,amisulpride,aripirazole,flupentixol,zuclpentixol ,pimozide,/mian,pimozide,/mian serin,paroxetin/lorazepam,oxazepam,/carb,oxcarb,tpraiserin,paroxetin/lorazepam,oxazepam,/carb,oxcarb,tprai mate.mate.  Epilepsy:Epilepsy: sulpride ,sulpride , amisulpride,aripirazole,haloperidol,pimozide,quatiapine,amisulpride,aripirazole,haloperidol,pimozide,quatiapine, risperidone,/MAOI,mocolbamide,SSRI,/BZD,BLOCKrisperidone,/MAOI,mocolbamide,SSRI,/BZD,BLOCK ER,zalplon,zolpediumER,zalplon,zolpedium  Glaucoma:Glaucoma: olanzapine TCA areolanzapine TCA are serious,,trazdone,flupentxol,butyrophenone,risperidon,serious,,trazdone,flupentxol,butyrophenone,risperidon, sulpridesulpride
  18. 18. CASESCASES  Depressed patient, insomnia ,75y, diabetic ,Depressed patient, insomnia ,75y, diabetic , hypertension, IHD.hypertension, IHD.  Depressed female, 45, anxiety,, insomnia ofDepressed female, 45, anxiety,, insomnia of renal impairment and diabetes.renal impairment and diabetes.  Post partum psychosis in hypertensive mother.Post partum psychosis in hypertensive mother.
  19. 19. Thank youThank you

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