Medical complications of psychiatric illness/treatment

expectancy compared to the general population • Majority of this is due to cardiovascular • 80% of schizophrenics worldwide smoke • 30% of known diabetics, 62% of hypertensives and 88% of hyperlipidemics
were not receiving treatment at enrollment
in CATIE trial.
• 20% SMI are infected with HCV • Between 1988 and 2002 rates of obesity and diabetes in schizophrenics increased 6% to 19% • Polypharmacy should be minimized • Generally no indication for >1 SSRI/SNRI, >1 atypical antipsychotic, or >1 BZD • In Bipolar illness often need medications from multiple classes and can use multiple mood stabilizers. – Addition of WBT to an SSRI – Addition of atypical antipsychotic to SSRI – Addition Thyroid hormone – Addition low dose Lithium – Addition Folate – Addition SAMe – Addition Lamotrigine • Mood Stabilizers • Antipsychotics • Antidepressants • Typical (First Generation) Antipsychotics • Atypical (Second Generation) • Mood Stabilizers • Antidepressants (Zyprexa)> Quetiapine (Seroquel), Risperidone (Risperdal)>Aripiprazole (Abilify)> Ziprazidone (Geodon) • Metabolic side effects- wt gain, diabetes, hyperlipidemia listed above in decreasing order of risk for these complications came up with consensus guidelines for atypical antipsychotic screening (see next slide). – Diabetics started on atypical antipsychotics monitored – If RF for DM get baseline and periodic fasting glucose – Any pt placed on atypical antipsycotic monitored for sx’s of hyperglycemia if sx’s get fasting glucose • Haldol, Prolixin, etc (but remember atypicals also can cause these SE’s at a lower rate) – Dystonic rxn within hours (treat with IM/IV benadryl) – Akithesia within days to weeks (Treat with – Parkinsonism within months to years (treat with – fever, muscular rigidity, altered mental status, and – 90% cases occur within 10 days of initiation of med • QT prolongation • Hyperprolactenemia – Gynecomastia, decreased libido, amenorrhea – Most commonly from Risperidone/Invega/typical • Orthostatic Hypotension • Anticholinergic side effects • Leukopenia/Agranulocytosis- weekly CBC for 6 months then q2wk CBC for 6 months then monthly CBC. • Drooling (Sialorrhea) • Siezures • Similar to Zyprexa in metabolic effects • Probably most effective tx for classic Bipolar I • Renally cleared only • Narrow therapuetic window • Initial labs: BMP, TSH • BMP, TSH, Li level q6-12 months • Therapuetic serum level 0.6-1.2 (check 12h after • Common maintinence doses 600-1500mg/day • QHS dosing optimal – Tremor – Polyuria – GI (nausea/diarrhea) • Toxicity- continued use of lithium with renal insufficiency most common cause, lithium levels above 1.0 can cause toxicity • Sxs of toxicity: ataxia, confusion, nausea/vomiting • Toxicity requires hospitalization for telemetry • Hypothyroidism – Generally not severe, often will treat with synthroid and can keep • Diabetes Insipidus • Hypercalcemia • Renal Failure? – Many medications can increase Lithium – Avoid NSAIDs, diuretics, ACE/ARB unless you are carefully monitoring lithium level – Anything that decreases renal fxn can cause • Treatment for Bipolar d/o • Common maintenance doses 1000-2500mg/day • Serum levels used for dosing; therapuetic serum level 60-125 (drawn 12h after last dose) • Baseline labs: CBC, LFTs. • Monitor CBC, LFTs, Valproic acid level q6-12 • Ammonia level if symptomatic (note ammonia level often elevated in asymptomatic patients on Depakote) – Nausea/diarrhea – Wt gain – Sedation – Thrombocytopenia – Alopecia – Would not rec in women of child bearing age – If you do us it in this population put in an IUD • Pancreatitis • Polycystic ovary syndrome • Pancytopenia • Encephalopathy – Many drug-drug interactions – Autoinducer therefore levels will decrease over time – Lab monitoring: tegretol level, CBC, LFTs, sodium – Side effects: hyponatremia, SJS, liver tox, pancytopenia, – SJS, d/c med if develops rash, most common in asians – Metabolic acidosis – Wt loss – “dopamax” – Sexual side effects (anorgasmia, decreased libido) – Hyponatremia – Serotonin Syndrome (requires 3 of below) • • Diarrhea • Heavy sweating not due to activity • Fever • Mental status changes such as or hypomania • Muscle spasms (myoclonus) • Overactive reflexes ( • Shivering • Tremor • Uncoordinated movements (ataxia) – Initial anxiety (for first 2 weeks) – Mania/hypomania – Wt gain – Discontinuation syndrome – FDA warning for birth defects • Wt gain: Mirtazapine>paxil>zoloft, celexa, • Sedation: Mirtazapine>paxil, zoloft>celexa, • Drug/Drug interactions: Prozac, Paxil have the most; Lexapro, Celexa, Zoloft have the least. • Sexual side effects: Wellbutrin and Mirtazapine only two antidepressants without sexual SE’s • Elderly: celexa, lexapro, zoloft, remeron • Pregnant: zoloft (but probably would not change any antidepressant if pt is responding to it except maybe paxil) • Children/Adolescents: Prozac, Lexapro • Multiple medical problems: celexa, zoloft, • Concurrent anxiety: SSRI • Concurrent ADHD: WBT • Chronic/Neuropathic Pain: Effexor, Cymbalta, • Nortriptyline best choice in elderly due to sedation, wt gain, constipation, urinary retention • Not a good choice in those with cardiac dz • Good effectiveness for chronic pain • Tranylcypromine (Parnate), Phenelzine (Nardil), Isocarboxazid (Marplan), Selegiline (EMSAM) • EMSAM transdermal patch 6mg and less no • Otherwise all MAOIs require adherence to low tyramine diet to avoid hypertensive crisis • Never combine SSRI and MAOI • Always check for drug/drug interations when prescribing a medication to a person on MAOI – SSRI but rarely used except sometimes for • Use great care when combining TCAs and SSRIs the SSRI will increase the TCA level • Tramadol and SSRI/WBT increase sz risk, • Never combine MAOI and SSRI • Avoid TCAs in heart dz • Avoid combining triptans and SSRIs

Source: http://www.cchealthnetwork.com/media/22199/complex%20medication%20management%203%2023%2011.pdf