Choosing Choosing Psychotropic Psychotropic in Patients in Patients
with Medical with Medical ProblemsProblemsA. Albehairy , M.DA. Albehairy , M.D
Psychiatry Consultant, MOHPPsychiatry Consultant, MOHP
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 .
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.
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.
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.
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
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..
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.
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.
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
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.
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 .
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
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
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.
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
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
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.
Thank youThank you