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Transcript
Patrick Klenk, PA-C Psychiatry Physician Assistant Resident Michael E. DeBakey VA Medical Center Houston, TX Good, Bad, and the Ugly of Psychiatric Medications Objectives Good labs and drug interactions to be mindful of Common side effects of psychiatric medications Black Box Warnings and other major problems Caveats Not going to cover every psychiatric medication Not all inclusive Not going to go over indications Topics Antidepressants Mood stabilizers Antipsychotics Anxiolytics Antidepressants Antidepressants - Suicidality Black box warning Increased suicidality risk in children, adolescents, and young adults with major depression or other psychiatric disorders Antidepressants - TCAs Side Effects Anticholinergic Antihistamine Orthostatic hypotension, reflex tachycardia, arrhythmias Sexual Black Box or Serious “3 Cs”: Cardiotoxicity, Convulsions, Coma 2nd most common cause of OD death (after acetaminophen) Contraindicated Recent MI, ischemic heart disease, conduction defects, urinary retention, narrow angle glaucoma, renal failure Delirium Increased LFTs Sedation, weight gain Antiadrenergic dry mouth, constipation, blurred vision, urinary retention Can lead to acute hepatitis Labs/Drug interactions Lab: EKG, TCA plasma levels, CMP Antidepressants - MAOIs Side Effects Black Box or Serious Orthostatic hypotension Sedation Sexual Weight gain Hypertensive crisis Liver toxicity Labs/Drug interactions Serotonin syndrome w/ SSRI, SNRI, TCA, buspirone, decongestants Antidepressants – Hypertensive Crisis Cause MAOIs + tyramine-rich food Tyramine-rich food examples Aged cheese, fava beans, red wine, cured meats, chicken liver Symptoms HTN, HA, N/V, chest pain, arrhythmias, death Antidepressants – Serotonin Syndrome Cause Symptoms Too much serotonin in the brain Fever, diaphoresis, tachycardia, HTN, delirium Hyperreflexia Myoclonus Switching Antidepressants Wait at least 2 weeks Except fluoxetine, wait 5-6 weeks Antidepressants - SSRIs Antidepressants - SSRIs Side Effects GI Sexual Numbing of emotions Discontinuation syndrome Black Box or Serious Black box flu-like, give fluoxetine or taper QTc: citalopram Caution in high bleeding risk Hyponatremia and seizures Labs/Drug interactions Warfarin: increased levels of free warfarin Antidepressants - SNRIs Side Effects Similar to SSRI Discontinuation syndrome: venlafaxine Black Box or Serious GI, sexual Can have more dry mouth and constipation from NE HTN Caution in liver disease, ESRD, narrow angle glaucoma Labs/Drug interactions BP Antidepressants - Bupropion Side Effects No sexual side effects Stimulating: Anxiety, Insomnia Worsen OCD/tics Worsen psychosis Black Box or Serious Contraindicated Black Box History of seizures, anorexia nervosa, bulimia Neuropsychiatric symptoms Labs/Drug interactions CMP Antidepressants - Mirtazapine Side Effects Black Box or Serious Sedation Weight gain Increased appetite Dry mouth and constipation Fewer sexual side effects Agranulocytosis, neutropenia Labs/Drug interactions CBC Antidepressants - Trazodone Side Effects Drowsiness No sexual side effects Orthostatic hypotension Black Box or Serious Priapism Cardiac arrhythmias Labs/Drug EKG interactions Mood Stabilizers Mood Stabilizers - Lithium Side Effects Fine tremor (coarse tremor at toxic levels) Weight gain and sedation Skin (acne to psoriasis) Black Box or Serious Black Box Lithium Toxicity (N/V/D, delirium, ataxia, stupor) Hypothyroidism, hyperparathyroidism, Diabetes insipidus Pregnancy: Ebstein’s anomaly Labs/Drug interactions Serum level Baseline: Renal, thyroid, CMP, CBC, urinalysis, EKG, pregnancy ↑ Li: Thiazide diuretics, furosemide, caffeine, ACEI/ARB, NSAID, reduced Na intake, sweating, impaired renal ↓ Li: Theophylline, osmotic diuretics, increased Na intake, Na Bicarb antacids Mood Stabilizers - Valproate Side Effects Tremor Weight gain and sedation Alopecia Black Box or Serious Black box: Hepatoxicity, Increased hepatotoxicity risk in mitochondrial disease, Pancreatitis, Fetal risk (neural tube) Stephens-Johnson Thrombocytopenia: check hx of agranulocytosis Polycystic ovaries Labs/Drug interactions Serum level CBC-diff, platelets, LFTs, PT, PTT, amylase Pregnancy Protein bound (ASA, warfarin, digoxin) Mood Stabilizers - Lamotrigine Side Effects HA, dizziness, sedation Peripheral edema Rash Black Box or Serious Black Box Stephens-Johnson syndrome Labs/Drug interactions ↑ Lamotrigine: Valproate LFTs and CBC Mood Stabilizers – Gabapentin Side Effects Sleepiness Dizziness Black Box or Serious Renal adjustment Labs/Drug interactions Not protein bound, not metabolized Few drug interactions Antipsychotics Antipsychotics – Black box Dementia related psychosis Increased mortality risk in elderly dementia patients on antipsychotics Most deaths due to cardiovascular or infectious events Antipsychotics – Typical – Low Potency Side Effects Anticholinergic Antihistamine Orthostatic hypotension, reflex tachycardia, arrhythmias Lower EPS Hyperprolactinemia Chlorpromazine: blue-gray skin Black Box or Serious Sedation, weight gain Antiadrenergic dry mouth, constipation, blurred vision, urinary retention Overdose: QTc prolongation Chlorpromazine: depositis in lens and cornea Thioridazine: retinitis pigmentosa, proarrhythmic effects Labs/Drug interactions EKG Tobacco Antipsychotics – Typical – High Potency Side Effects Anticholinergic, Antihistamine, Antiadrenergic Higher extrapyramidal symptoms (EPS) Black Box or Serious Overdose: QTc prolongation Neuroleptic malignant syndrome Labs/Drug EKG interactions Antipsychotics – EPS Rule of 4’s 4 hours = acute dystonia 4 days = Parkinsonism Bradykinesia, rigidity, tremor 4 days to 4 weeks = akathisia Muscle spasms Restlessness 4 months = tardive dyskinesia involuntary, repetitive movements of facial, tongue, neck muscles Antipsychotics – Neuroleptic malignant syndrome Cause Symptoms Idiopathic, life-threatening reaction to antipsychotics Fever Autonomic instability Leukocytosis Tremor Elevated CPK Rigidity (“lead pipe”) Excessive sweating Delirium Most likely Young muscular male on high potency Antipsychotics – Atypical Side Effects Black Box or Serious Some antihistaminic, antiadrenergic, antimuscarinic Hyperprolactinemia, EPS: risperidone Akathisia: abilify Metabolic syndrome: weight gain, hyperlipidemia, hyperglycemia QTc prolongation Clozapine: Agranulocytosis, neutropenia, orthostatic hypotension, seizure, myocarditis, cardiomyopathy Labs/Drug interactions EKG Weight, waist?, BP, fasting glucose/lipids LFTs Anxiolytics Anxiolytics - Benzo Side Effects Black Box or Serious Dependence, addiction, abuse Drowsiness Reduced motor coordination Respiratory depression Delirium Labs/Drug interactions Vitals Additive cognitive impairment with anticholinergics Anxiolytics - Hydroxyzine Side Effects Antihistamine Sedation, dry mouth, constipation, urinary retention, blurry vision Black Box or Serious QT prolongation Labs/Drug interactions EKG Pimozide: contraindicated Anxiolytics - Buspirone Side Effects Takes several weeks to take effect HA, nausea, dizziness No weight gain, sedation, sexual No cognitive impairment No respiratory depression No addiction or tolerance No withdrawal Labs/Drug interactions Grapefruit can increase concentration Anxiolytics - Prazosin Side Effects HA Dizziness Black Box or Serious No black box warnings Hypotension – 1st dose orthostasis or syncope Labs/Drug BP interactions Questions? References Ganti L, Kaufman MS, Blitzstein SM. Psychopharmacology. In: First Aid for the Psychiatry clerkship. 4th ed. New York, NY: McGraw-Hill Education; 2016:189-208. Papadakis MA, McPhee SJ. Psychiatric Disorders. In: Current Medical Diagnosis & Treatment. 53rd ed. New York, NY: McGrawHill Education; 2014:1000-1052. Toy, Klamen. Case Files Psychiatry. 5th ed. New York, NY: McGraw-Hill Education; 2016.
