psychotropics in problem areas

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Choosing Choosing Psychotropic Psychotropic in Patients in Patients with Medical with Medical Problems Problems A. Albehairy , M.D A. Albehairy , M.D Psychiatry Consultant, MOHP Psychiatry Consultant, MOHP

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Page 1: Psychotropics  in problem areas

Choosing Choosing Psychotropic Psychotropic in Patients in Patients

with Medical with Medical ProblemsProblemsA. Albehairy , M.DA. Albehairy , M.D

Psychiatry Consultant, MOHPPsychiatry Consultant, MOHP

Page 2: Psychotropics  in problem areas

Medical Problem Medical Problem Conditions Conditions

( one or more):( one or more):

Breast feeding.Breast feeding. Pregnancy.Pregnancy. Old age.Old age. Cardiovascular Cardiovascular

diseases.diseases. Chest problem.Chest problem. Renal Renal

impairment.impairment.

Liver Liver impairment.impairment.

Diabetes.Diabetes. Epilepsy .Epilepsy . In surgery.In surgery. Glaucoma .Glaucoma .

Page 3: Psychotropics  in problem areas

General Principles , in General Principles , in approaching the problemsapproaching the problems

- Breast-feedingBreast-feeding: no risk free, drug level in : no risk free, drug level in milk 1% of maternal plasma. Drug milk 1% of maternal plasma. Drug accumulates in milk bec. Of acidity and lipid accumulates in milk bec. Of acidity and lipid and protein binding .drugs should be and protein binding .drugs should be avoided if premature or has avoided if premature or has renal.liver.cardiac,or neurological problem.renal.liver.cardiac,or neurological problem.

Avoid sedating,long half-lives. Once daily dose Avoid sedating,long half-lives. Once daily dose before the infant longest sleep,dnt switch before the infant longest sleep,dnt switch drug (preg- lactat),avoid polypharmacy.drug (preg- lactat),avoid polypharmacy.

Page 4: Psychotropics  in problem areas

General Principles , in General Principles , in approaching the problems approaching the problems

(cnt)(cnt).. Pregnancy Pregnancy :FDA, 5 categories, to indicate :FDA, 5 categories, to indicate drug teratogencity. Each drug has to be drug teratogencity. Each drug has to be sought.sought.

Teratogenecity in the 1Teratogenecity in the 1stst trimester, growth trimester, growth retardation and neurological damage in 2retardation and 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 Psycho education for care in planned and non

planned conception.planned conception. Lowest viable dose.Lowest viable dose. Adjusting dose.Adjusting dose.

Page 5: Psychotropics  in problem areas

General Principles , in General Principles , in approaching the problems approaching the problems

(cnt)(cnt).. 11stst 2 wks –stop medications, nutritional 2 wks –stop medications, nutritional

supplement folic acid, reduce dose if after 60 supplement folic acid, reduce dose if after 60 days,dnt stop lithium abruptly,care in stop days,dnt stop lithium abruptly,care in stop anticonvulsants.anticonvulsants.

TCA & Discontinuation,/ myclonus ttt by TCA & Discontinuation,/ myclonus ttt by phenobarbitol.phenobarbitol.

If depakin unavoidable , low , divided doses If depakin unavoidable , low , divided doses and folic acid 5mg .and folic acid 5mg .

Most serious, bzd,lithium, Most serious, bzd,lithium, phenytoin,topraimate, and vigabatrin and phenytoin,topraimate, and vigabatrin and valproate.valproate.

Page 6: Psychotropics  in problem areas

General Principles , in General Principles , in approaching the problems approaching the problems

(cnt)(cnt).. Old age : Old age : age related increases SE, age related increases SE,

sedation, orthostatic hypotension, sedation, orthostatic hypotension, reduced metabolism of liver.reduced metabolism of liver.

Inc. fat in body--- inc half life of the Inc. fat in body--- inc half life of the drugs used.drugs used.

Other system affected.Other system affected. Low and slowLow and slow Poor compliance Poor compliance

Page 7: Psychotropics  in problem areas

General Principles , in General Principles , in approaching the problems approaching the problems

(cnt)(cnt).. CardiovascularCardiovascular : : Polypharmacy avoided, with drug likely to Polypharmacy avoided, with drug likely to

affect pulse or electrolyte balance, affect pulse or electrolyte balance, QTprolongation.QTprolongation.

Low and slowLow and slowAngina,avoid Angina,avoid drugs of othostatic drugs of othostatic

hypotension, tachycardia.hypotension, tachycardia.ArrhythmiaArrhythmia:TCA, phenothiazines and :TCA, phenothiazines and

butyrophenones and pimozide are butyrophenones and pimozide are harmfulharmful. Sulpride, olanzapine of . Sulpride, olanzapine of low low riskrisk..

Page 8: Psychotropics  in problem areas

General Principles , in General Principles , in approaching the problems approaching the problems

(cnt)(cnt).. CHFCHF: avoid B blocker, drugs causing orthostatic : avoid B blocker, drugs causing orthostatic hypotension(phenothiazines, clozapine , risperidone hypotension(phenothiazines, clozapine , risperidone and TCA).and TCA).

MIMI: SSRI, TRAZODONE , mianserin,safer: SSRI, TRAZODONE , mianserin,saferButryphenone 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 450ms,care of electrolyte, and drug combination , antipsychotics, TCA, drug combination , antipsychotics, TCA, flouroquinolone abio, antimalarila, antihistamine.flouroquinolone abio, antimalarila, antihistamine.

Page 9: Psychotropics  in problem areas

General Principles , in General Principles , in approaching the problems approaching the problems

(cnt)(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.

Page 10: Psychotropics  in problem areas

General Principles , in General Principles , in approaching the problems approaching the problems

(cnt).(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 slow Low and slow SE, of anticholinergic, urinary SE, of anticholinergic, urinary

retentionretention Accumulation of drugAccumulation of drug

Page 11: Psychotropics  in problem areas

General Principles , in General Principles , in approaching the problems approaching the problems

(cnt)(cnt).. In surgery: In surgery: DecisionDecision to continue or not the drug during surgery to continue or not the drug during surgery

and perioperative period.and perioperative period.

Discussing the anesthetistDiscussing the anesthetistEnflurane---seizure in TCAEnflurane---seizure in TCAPethidine ---fatal excitatory reaction with SSRI Pethidine ---fatal excitatory reaction with SSRI

(serotenorgic syndrome or respiratory depression ) (serotenorgic syndrome or respiratory depression ) and MAOI --- switch to moclobamide 2wks before and MAOI --- switch to moclobamide 2wks before operation.operation.

operation stress:Elyctrolyteoperation stress:Elyctrolyte distubance and cortisol distubance and cortisol and catecholamine changes.and catecholamine changes.

Gastric stasis.Gastric stasis.Abrupt cessation of nicotine in some pt. Abrupt cessation of nicotine in some pt.

Page 12: Psychotropics  in problem areas

General Principles , in General Principles , in approaching the problems approaching the problems

(cnt)(cnt).. In surgeryIn surgery::- AnticonvulsantAnticonvulsant CNS depressant activity may CNS depressant activity may

reduce anaesthetic requirements.reduce anaesthetic requirements.- SSRISSRI, may induce seizure, , may induce seizure, VenlafaxineVenlafaxine may may

provoke opioid rigidity, increase bleeding provoke opioid rigidity, increase bleeding time. ( avoid any serotenorgic agent).time. ( avoid any serotenorgic agent).

- TCA:TCA: seizure, seroenorgic s, hypotension, it seizure, seroenorgic s, hypotension, it needs o be stopped several days before needs o be stopped several days before surgery.surgery.

- Antipsychotics,hypotension,arrythmia,hypotheAntipsychotics,hypotension,arrythmia,hypothermia, clozapine may delay recovery .rmia, clozapine may delay recovery .

Page 13: Psychotropics  in problem areas

General Principles , in General Principles , in approaching the problems approaching the problems

(cnt)(cnt).. in surgeryin surgery

BZDBZD, sedation and withdrawel, sedation and withdrawel

LithiumLithium : electrolyte imbalance may ppt, : electrolyte imbalance may ppt, toxicity, avoid dehydration/arrythmia toxicity, avoid dehydration/arrythmia develop.develop.

OpiateOpiate, methadone, naloxone may induce , methadone, naloxone may induce withdrawel– avoid bupernorphinwithdrawel– avoid bupernorphin

Naltrexone Naltrexone

Page 14: Psychotropics  in problem areas
Page 15: Psychotropics  in problem areas

Low Risk PsychotropicsLow Risk Psychotropics

Br.feedingBr.feeding,sulpride, moclobamide, ,sulpride, moclobamide, TCA, TCA, tryptophan,BZD,chloral,temazepam,tryptophan,BZD,chloral,temazepam,carbamezapine,valproate.carbamezapine,valproate.

Pregnancy : moderate riskPregnancy : moderate risk. All . All antipsychotic except zotepine high. antipsychotic except zotepine high. All antidepressant except reboxetin All antidepressant except reboxetin high, safer carbamezapine and ox,, high, safer carbamezapine and ox,, and lamotrigine and lamotrigine

Page 16: Psychotropics  in problem areas

Low Risk PsychotropicsLow Risk Psychotropics

Old age: sulprideOld age: sulpride, amisulpride, , amisulpride, risperidine,ariperazole/deloxetin,mitazepirisperidine,ariperazole/deloxetin,mitazepine,SSRI,velafaxine,mocobamide/ne,SSRI,velafaxine,mocobamide/alprazolam,buspiron,lorazepam,zaloplon/alprazolam,buspiron,lorazepam,zaloplon/carbamezapin,ox,topramate,clobazam.carbamezapin,ox,topramate,clobazam.

Cardiac prob:Cardiac prob: sulpride,amisulpride,flupentixol,olanzapinsulpride,amisulpride,flupentixol,olanzapine,quatapine,/SSRI,mirtezapine,mianserin,te,quatapine,/SSRI,mirtezapine,mianserin,trazdone/bzd,buspiron,zaloplon,zolpidiem/razdone/bzd,buspiron,zaloplon,zolpidiem/valproate,lamictal,pregabalin,gabapentin.valproate,lamictal,pregabalin,gabapentin.

Page 17: Psychotropics  in problem areas

Low Risk PsychotropicsLow Risk Psychotropics DiabetusDiabetus:sulpride,amisulpride,aripipraz:sulpride,amisulpride,aripipraz

ole,butyrophenon, pimozide, ole,butyrophenon, pimozide, risperodone/deluxetin,moclobamide,SSRIrisperodone/deluxetin,moclobamide,SSRI,trazdon,venlafaxin/bzd,buspar,zaleplon,z,trazdon,venlafaxin/bzd,buspar,zaleplon,zolpedim,/olpedim,/bzd,carb,oxcarb,lamictal,pregabalin.bzd,carb,oxcarb,lamictal,pregabalin.

Renal impairment:Renal impairment:sertindole,mianserin,moclobamide,TCA,TRsertindole,mianserin,moclobamide,TCA,TR

AZDONE,BZD,zalplon,phyenytoin,lamotriAZDONE,BZD,zalplon,phyenytoin,lamotrigengen

Page 18: Psychotropics  in problem areas

Low Risk PsychotropicsLow Risk Psychotropics Liver Liver

impairmentimpairment :sulpride,amisulpride,aripirazo :sulpride,amisulpride,aripirazole,flupentixol,zuclpentixol,pimozide,/mian le,flupentixol,zuclpentixol,pimozide,/mian serin,paroxetin/lorazepam,oxazepam,/carb,oserin,paroxetin/lorazepam,oxazepam,/carb,oxcarb,tpraimate.xcarb,tpraimate.

Epilepsy: Epilepsy: sulpride , sulpride , amisulpride,aripirazole,haloperidol,pimozidamisulpride,aripirazole,haloperidol,pimozide,quatiapine,risperidone,/e,quatiapine,risperidone,/MAOI,mocolbamide,SSRI,/MAOI,mocolbamide,SSRI,/BZD,BLOCKER,zalplon,zolpediumBZD,BLOCKER,zalplon,zolpedium

Glaucoma:Glaucoma: olanzapine TCA are olanzapine TCA are serious,,trazdone,flupentxol,butyrophenone,serious,,trazdone,flupentxol,butyrophenone,risperidon, sulpriderisperidon, sulpride

Page 19: Psychotropics  in problem areas

CASESCASES

Depressed patient, insomnia ,75y, Depressed patient, insomnia ,75y, diabetic , hypertension, IHD.diabetic , hypertension, IHD.

Depressed female, 45, anxiety,, insomnia Depressed female, 45, anxiety,, insomnia of renal impairment and diabetes.of renal impairment and diabetes.

Post partum psychosis in hypertensive Post partum psychosis in hypertensive mother.mother.

Page 20: Psychotropics  in problem areas

Thank youThank you