medical complications of psychiatric drugs
TRANSCRIPT
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Medical Complications of Psychiatric Drugs
Theodore A. Stern, M.D. Chief, Avery D. Weisman, Psychiatric Consultation Service
Massachusetts General Hospital Ned H. Cassem Professor of Psychiatry in the field of
Psychosomatic Medicine/Consultation, Harvard Medical School
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Disclosures/Conflicts • Dr. Stern has no direct conflicts of interests
or disclosures to report related to the content of this presentation
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Introduction • General principles of psychopharmacology • Antidotes • Use of psychotropics
• antidepressants • antipsychotics • anxiolytics • anticonvulsants/mood stabilizers • narcotics
– side effects and drug-drug interactions • Important drug-induced syndromes
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Pre-Test: Question 1
• Which of the following is not a characteristic feature of neuroleptic malignant syndrome? – A. autonomic instability – B. leukopenia – C. hyperthermia – D. increased creatine phosphokinase – E. rigidity
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Pre-Test: Question 2
• Which of the following agents would not be expected to increase serum lithium levels? – A. aminophylline – B. NSAIDs – C. tetracycline – D. thiazide diuretics – E. metronidazole
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Pre-Test: Question 3
• Which of the following agents would be most likely to contribute to a delirium with prominent myoclonus? – A. digoxin – B. phenobarbital – C. atropine – D. meperidine – E. lorazepam
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General Principles of Psychopharmacology
.
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Types of Drug Interactions
• Pharmacokinetic • Pharmacodynamic • Idiosyncratic
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Pharmacokinetic Drug Interactions
• Drug interactions that result in changes in plasma levels and/or tissue concentrations caused by the changes in: – absorption – distribution – metabolism – elimination
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Pharmacokinetic Effects: Absorption
• Interactions that may alter the time to reach the maximum drug concentration
• Effects are usually less important than are the effects of metabolism and excretion – even in the elderly
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Decreased Absorption
• Caused by drugs that bind to a drug and form unabsorbable complexes – antacids – charcoal – cholestyramine – kaolin-pectin
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Increased Absorption • Caused by drugs that speed gastric emptying
– cisapride (Propulsid) & metoclopromide • Caused by drugs that inhibit intestinal motility and
promote greater contact with absorptive mucosal surfaces in the upper portion of the small intestine – e.g., TCAs & narcotics
• Caused by drugs that inhibit gut enzymes (e.g., MAO) that may increase amounts of substrates (e.g., tyramine) reaching the portal circulation
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Pharmacokinetic Effects: Distribution
• Regional blood flow • Lipophilicity • Adiposity and lean body mass • Protein binding
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Protein Binding • Interactions that involve competition for protein-
binding sites by two or more drugs • Results in displacement of previously bound
(inactive drug) which in its unbound form is active • Most psychotropics are highly bound • Effects are usually inconsequential, except when:
– drugs are highly bound and have a low therapeutic index and/or
– low levels of serum proteins are present (e.g., liver failure or malnutrition)
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Psychotropics with Low to Moderate Levels of Protein Binding
• Minimally Bound – lithium <3% – gabapentin <3% – topiramate <20% – venlafaxine <30%
• Moderately Bound – lamotrigene <60% – carbamazepine <80% – fluvoxamine <80% – citalopram <80% – bupropion <85%
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Pharmacokinetic Effects: Distribution
• Decreases in lean body mass and total body water lead to increased plasma concentrations of water-soluble drugs
• Increases in total body fat lead to decreased plasma concentrations and to slower elimination of fat-soluble drugs
• Decreases in serum albumin lead to a higher % of unbound, metabolically-active drugs
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Pharmacokinetic Effects: Metabolism
• Phase I reactions – oxidation, reduction, and hydrolysis – often rate-limiting – often produces potentially active metabolites
• e.g., diazepam to desmethyldiazepam to oxazepam
• Phase II reactions – conjugation and acetylation – typically produces inactive metabolites that are
highly water-soluble and renally excreted
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Metabolism: Induction and Inhibition
• Induction – Levels of substrate fall gradually – Mechanism involves enhanced synthesis of metabolic
enzymes • Inhibition
– Levels of substrate rise rapidly – Mechanism:
• competitive inhibition (with displacement of substrate) • covalent binding (with conformational change of enzyme)
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Common Inducers of Metabolism
• Carbamazepine • Charbroiled meats • Cigarette smoking • Cruciferous vegetables • Chronic alcohol use
• Phenobarbital • Phenytoin • Primidone • Rifampin • Ritonavir • St. John’s Wort
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Common Inhibitors of Metabolism
• Amiodarone • Antifungals • Antiretrovirals • Antimalarials • Beta-blockers • Calcium channel
blockers • Cimetidine
• Disulfiram • Grapefruit juice • Isoniazid • Mexiletine • Phenothiazines • Psychostimulants • Quinidine • SSRIs • Valproic acid
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Cytochrome P450 Isoenzymes
• Largely located on microsomal membranes • Responsible for phase I, oxidative metabolism of
>80% of available drugs – they can be induced or inhibited – they commonly involve 1A2, 2C, 2D6, and 3A3/4
• 5%-10% of Caucasians and 1%-3% of Asian Americans and African Americans are poor metabolizers of P450 2D6
• 15%-20% of Asian Americans and African Americans and 1%-5% of Caucasians are poor metabolizers of P450 2C19
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Cytochrome P450 Isoenzymes
• Some drugs are metabolized by more than one pathway – Tertiary amine TCAs (e.g., amitriptyline) are
metabolized by P450 1A2, 2C, 2D6, and 3A • Some drugs may inhibit one pathway yet
induce another – Omeprazole (Prilosec) inhibits P450 2C19 and
induces P450 1A2
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Cytochrome P450 Nomenclature
• Example: 2D6 – P450 pigment absorbing light at 450 nm – 2 family – D subfamily – 6 individual isoenzyme or gene product
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P450 Isoenzymes: 1A2
• Substrates • acetaminophen, aminophylline, caffeine, clozapine,
haloperidol, olanzapine, phenothiazines, TCAs (tertiary amines)
• Inhibitors • fluoroquinolones, fluoxetine, fluvoxamine,
grapefruit, paroxetine, TCAs (tertiary amines)
• Inducers • omeprazole, tobacco
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P450 Isoenzymes: 2C
• Substrates • barbiturates, diazepam, ibuprofen, omeprazole,
phenytoin, propranolol, TCAs (tertiary amines)
• Inhibitors • fluoxetine, fluvoxamine, ketaconazole, omeprazole,
sertraline
• Inducers • rifampin
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P450 Isoenzymes: 2D6
• Substrates • codeine, dextromethorphan, ecanide, flecanide,
haloperidol, maprotiline, paroxetine, propranolol, risperidone, TCAs, timolol, trazodone, venlafaxine
• Inhibitors • fluoxetine, haloperidol, paroxetine, perphenazine,
quinidine, TCAs (secondary amine), sertraline, thioridazine
• Inducers • ---
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P450 Isoenzymes: 3A3/4 • Substrates
• alprazolam, amiodarone, calcium channel blockers, carbamazepine, cisapride, cyclosporine, diazepam, disopyramide, lidocaine, midazolam, nefazodone, omeprazole, quinidine, sertraline, steroids, tamoxifen, TCAs, vinblastin, zolpidem
• Inhibitors • dapsone, erythromycin, fluoxetine, fluvoxamine,
ketaconazole, grapefruit, nefazodone, sertraline, TCAs
• Inducers • carbamazepine, phenobarbital, phenytoin, rifampin
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Pharmacokinetic Effects: Elimination
• Elimination involves liver metabolism, renal excretion, and excretion into bile and sweat
• For example, in the elderly: – decreased hepatic enzyme activity
• leads to decreased effectiveness of metabolism
– decrease in renal function • leads to decrease in renal excretion and to a
prolonged half-life of renally-excreted drugs
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Pharmacodynamic Drug Interactions
• Pharmacological effects produced directly by interactions at a common biological site (receptor) or indirectly, at separate but interrelated biological sites
• e.g., respiratory depression from combined use of alcohol, benzodiazepines, and barbiturates
• e.g., anticholinergic toxicity from combined use of TCAs. low-potency antipsychotics, paroxetine, diphenhydramine, and benztropine
• e.g., hypotension from combined use of TCAs, low-potency antipsychotics, trazodone, and atypical antipsychotics
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Idiosyncratic Drug Interactions
• Episodic interactions that occur in a small number of individuals
• Not predicted by knowledge of pharmacokinetic or pharmacodynamic properties of drugs – e.g., agranulocytosis secondary to
chlorpromazine
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Antidotes
.
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Beneficial Effects and Side Effects
– for benzodiazepine overdose • flumazenil (Mazicon)
– for narcotics overdose • naloxone (Narcan)
– for anticholinergic toxicity/delirium • physostigmine (Antilirium)
– for acute dystonic reactions • benztropine (Cogentin); lorazepam (Ativan)
– for nausea • compazine; omeprazole
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Antidepressants
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Somatic Therapies for Depression
• Polycyclic antidepressants • SSRIs • MAOIs • Lithium • Mood stabilizers/anticonvulsants • Psychostimulants • Electroconvulsive therapy (ECT)
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Polycyclic Antidepressants: Side Effect Profile
• Orthostatic hypotension • Anticholinergic effects • Conduction system effects • Drug-drug interactions • Effects secondary to overdose
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Orthostatic Hypotension (OH) • Related to alpha blockade • IMI/DMI/AMI>DOX>NT
– 8%-20% stop tx b/c of OH – IMI causes OH in 7% of patients w/normal ECG, in 32%
w/BBBs, and in 50% w/CHF • OH is predicted by pre-drug orthostatic fall (>15
mm Hg) in BP – it predicts response to treatment
• OH occurs before therapeutic plasma levels achieved
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Anticholinergic Side Effects
• Tertiary agents > secondary agents • Tachycardia may persist > 1 year
– typically trivial (7 beats/min) it may be clinically relevant
• Propranolol may decrease PCA-induced tachycardia
• Trazodone, fluoxetine, bupropion, and MAOIs have essentially no anticholinergic effects
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Conduction System Effects • All TCAs prolong atrial and ventricular
depolarization – increases the PR, QRS, and QTc interval
• Conduction prolonged mainly in the H-V portion of the His bundle
• Significant clinical problems with conduction are uncommon with therapeutic levels – after TCA OD problems are evident in 6%-10%
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Conduction System Effects
• Sudden death may occur with a QTc > 440 msec
• Since mortality is increased with class IA antiarrhythmics, TCAs (although they can decrease PVCs) should be used only after careful assessment of the risk:benefit ratio in patients with ventricular arrhythmias
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Drug-Drug Interactions
• TCAs may block the effects of adrenergic-blocking antihypertensives – e.g., guanethidine, clonidine, reserpine
• TCAs are additive with antiarrhythmics and anticholinergics
• TCAs may potentiate the pressor effects of sympathomimetics (EPI, NE) by blocking reuptake of these pressors
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SSRIs • Less anticholinergic, antihistaminic, and
alpha-adrenergic than TCAs • Associated with fewer effects on cardiac
activity than TCAs – OH uncommon
• Well-absorbed from the GI tract • Extensively metabolized in the liver • Half-life:
– sertraline, paroxetine, citalopram: 1 day – fluoxetine: 2-3 days
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Non-Cardiac Side Effects of SSRIs
• Agitation • Anorgasmia • Anorexia • GI distress • Insomnia • Irritability
• SIADH • Tremor • A potentially fatal
serotonin syndrome in combination with MAOIs
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Cardiac Effects of SSRIs
• May: – raise TCA levels and increase conduction delays – cause bradycardia and syncope – cause AF, atrial flutter, and A-V block – increase intracoronary serotonin and cause
vasospasm of diseased coronary arteries – slow metabolism and raise levels of ecanide,
flecanide, and beta-blockers
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Atypical Antidepressants
• Trazodone – causes significant OH – is associated with priapism (in 1: 6,000)
• Amoxapine – a dopamine blocker; it can lead to tardive dyskinesia
• Bupropion – carries low risk of cardiac toxicity – facilitates smoking cessation
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Monoamine Oxidase Inhibitors (MAOIs)
• Cause OH: 47% mild; 5%-10% severe – maximum effect appears after 3rd or 4th week – not predicted by pre-drug orthostatic fall in BP – may be helped by addition of fludrocortisone or
1-inch cubes of cheddar cheese • May cause profound hypertensive crises
when taken with sympathomimetic medications or tyramine-containing foods – treated with IV phentolamine
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Psychostimulants • Used to treat medically-ill, apathetic, and
anorexic, geriatric depressed patients • Appears to work through release of dopamine and
NE • Primarily renally excreted • Rarely causes tachycardia, HTN, or arrhythmia • Relatively contraindicated with:
– HTN, pregnancy, seizures, delirium, psychosis, angina, or with MAOIs
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Lithium Carbonate
• Almost entirely renally excreted • Causes flat or inverted T-waves and U-waves • Can cause sinus node dysfunction and 1st
degree A-V block • Associated with sudden death in some patients
with cardiac disease on brochodilators • Hypothyroidism • Problems with urinary concentration
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Lithium: Factors that Increase or Decrease Serum Levels
• Increase – diuretics
• thiazides, ethacrynic acid, spironolactone, triamterene
– NSAIDs • indomethacin,
ibuprofen, naproxin
– antibiotics • metronidazole (Flagyl),
tetracycline
• Decrease – aminophylline – theophylline – caffeine – osmotic diuretics
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Lithium Toxicity
• Tremor • GI distress & diarrhea • Delirium • Seizures
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Electroconvulsive Therapy • The most effective treatment for major depression • No absolute contraindications • Associated with exaggerated increases in BP,
circulatory collapse, MI, arrhythmias, and ECG changes – ST depressions and repolarization abnormalities
• Can be used safely, even in the setting of cardiac disease – with beta-blockers and good anesthesia back-up
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Antipsychotics
.
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Typical Antipsychotics Drug Mg
equiv.Sedation OH Ach EPS
Chlorpromazine 100 +++ +++ ++ +Thioridazine 100 +++ +++ +++ +Molindone 10 + + + ++Perphenazine 8 + + + ++
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Typical Antipsychotics Drug Mg
equiv.Sedation OH Ach EPS
Trifluoperazine 5 + + + +++Thiothixene 5 + + + +++Fluphenazine 2 + + + +++Haloperidol 2 + + + +++
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Atypical Antipsychotics Drug Brand Sedation OH Ach EPS
Risperidone Risperdal ++ ++ + +Clozapine Clozaril +++ +++ +++ +Olanzapine Zyprexa ++ + + +Quetiapine
Ziprasidone
Seroquel
Geodon
++ +
+++ ++
+ +
+ +
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Antipsychotics: Side Effects
• Sedation • Hypotension • Extrapyramidal effects
– akathisia – dystonia – Parkinsonism
• Anticholinergic effects – dry mouth – urinary retention – blurred vision
• Weight gain – diabetes; DKA
• Hyperprolactinemia – amenorrhea – galactorrhea – sexual dysfunction
• Impaired heat regulation • Conduction system effects • Neuroleptic malignant
syndrome
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Antipsychotics: Drug Interactions
• Anticonvulsants (except valproate) – lower antipsychotic
blood levels • Tobacco
– lowers antipsychotic blood levels
• Erythromycin – increases clozapine
levels
• Fluvoxamine – increases levels of
clozapine and thioridazine
• Fluoxetine – increases neuroleptic
levels • TCAs
– levels are increased
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Benzodiazepines
.
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Benzodiazepines Drug Mg
equivalentsOnset ofaction
Half-life (hrs)
Alprazolam(Xanax)
0.5 intermediateto fast
12-15Chlordiazepoxide(Librium)
10.0 intermediate 5-30Clonazepam(Klonopin)
0.25 intermediate 15-50Clorazepate(Tranxene)
7.5 fast 30-200
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Benzodiazepines Drug name Mg
equivalentsOnset ofaction
Half-life (hrs)
Diazepam(Valium)
5 fast 20-100
Flurazepam(Dalmane)
5 Fast 40
Lorazepam(Ativan)
1 intermediate 10-20OxazepamSerax)
15 slow 5-15
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Anticonvulsants (Mood-Stabilizers)
.
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Carbamazepine
• First-line for secondary generalized tonic-clonic seizures and partial seizures
• Usual dose: 400-1600 mg/d • Therapeutic levels: 4-12 micro gm/ml • Carbamazepine induces its own metabolism
– therapeutic doses need to be adjusted
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Valproic Acid
• First-line for primary generalized tonic-clonic seizures and absence seizures; second-line for secondarily generalized tonic-clonic seizures and partial seizures
• Usual dose: 750-3000 mg/d • Therapeutic levels: 50-100 micro gm.ml
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Ethosuximide
• First-line for absence seizures • Usual dose: 75-1500 mg/d • Therapeutic levels: 40-100 micro gm/ml
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Lamotrigine
• Second-line for primary generalized tonic-clonic seizures, secondary generalized tonic-clonic seizures, and partial seizures
• Usual dose: 300-500 mg/d • Therapeutic levels: ?
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Gabapentin
• Second-line for secondary generalized tonic-clonic seizures and partial seizures
• Usual dose: 1200-3600 mg/d • Therapeutic levels: ?
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Phenobarbital
• Third-line for partial seizures • Usual dose: 30-180 mg/d • Therapeutic levels: 10-40 micro gm/ml
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Narcotics
.
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Narcotics Genericname
Brand name Equiv. dose(mg) IM
Equiv. dose(mg) PO
Morphine -- 10 60Codeine -- 120 200Hydromorphone Dilaudid 1.5 7.5Meperidine Demerol 80-100 300Methadone Dolophine 8-10 20Oxycodone Percodan -- 30
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Drug-Induced Syndromes
.
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Drug-Induced Syndromes
• Dystonic reactions – e.g., with high-potency neuroleptics
• Hypertensive crisis – e.g., with MAOIs and sympathomimetics
• Neuroleptic malignant syndrome (NMS) • Serotonin syndrome
– e.g., with MAOIs and meperidine, TCAs, mirtazapine, St. John’s Wort, sumatriptan, or lithium
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Drug-Induced Syndromes
• Aplastic anemia – e.g., with neuroleptics
• Torsades de pointes • Hepatitis • Normeperidine toxicity • SIADH • Allergic reactions
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Post-Test • Which of the following is not a characteristic feature of neuroleptic
malignant syndrome? – Autonomic instability; Leukopenia; Hyperthermia; Increased creatine
phosphokinase; Rigidity • Which of the following agents would not be expected to increase
serum lithium levels? – Aminophylline; NSAIDs; Tetracycline; Thiazide diuretics; Metronidazole
• Which of the following agents would be most likely to contribute to a delirium with prominent myoclonus? – Digoxin; Phenobarbital; Atropine; Meperidine; Lorazepam
– Answers: BAD
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Selected References • Stevens JR, Fava M, Rosenbaum JF, Alpert JE:
Psychopharmacology in the medical setting. Massachusetts General Hospital Handbook of General Hospital Psychiatry, 6/E. Stern TA, Fricchione GL, Cassem NH, Jellinek MS, Rosenbaum JR, eds., Saunders/Elsevier, Philadelphia, 2010; 441-466.
• Henderson DC, Thakurathi N: Antipsychotic drugs. Psychiatry Update and Board Preparation, 3/E. Stern TA, Herman JB, Gorrindo T, eds. MGH Psychiatry Academy, Boston, 2012; 359-365.
• Beach SR: Anticonvulsants and psychiatric illness. Psychiatry Update and Board Preparation, 3/E. Stern TA, Herman JB, Gorrindo T, eds. MGH Psychiatry Academy, 2012; 385-390.
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Selected References • Alpert JE: Drug-drug interactions: the interface between
psychotropics and other agents. The MGH Guide to Primary Care Psychiatry, 2/E. Stern TA, Herman JB, Slavin PL, eds. McGraw-Hill, New York, 2004; 653-669.
• Heckers S, Cole AJ: Approach to the patient with seizures. The MGH Guide to Primary Care Psychiatry, 2/E. Stern TA, Herman JB, Slavin PL, eds. McGraw-Hill, New York, 2004; 225-236.
• Huffman JC, Tesar GE, Stern TA: Cardiovascular side effects of psychotropic agents.The MGH Guide to Primary Care Psychiatry, 2/E. Stern TA, Herman JB, Slavin PL, eds. McGraw-Hill, New York, 2004; 629-652.
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Selected References
• Smoller JW, Pollack MH, Lee DK: Management of antidepressant-induced side effects. The MGH Guide to Primary Care Psychiatry, 2/E. Stern TA, Herman JB, Slavin PL, eds. McGraw-Hill, New York, 2004; 613-627.
• Alpay M: The patient with acute or chronic pain. The MGH Guide to Primary Care Psychiatry, 2/E. Stern TA, Herman JB, Slavin PL, eds. McGraw-Hill, New York, 2004; 311-328.
• Alpert JE: Drug-drug interactions in psychopharmacology. MGH Comprehensive Clinical Psychiatry. Stern TA, Rosenbaum JF, Fava M, Biederman J, Rauch SL, eds. Mosby/Elsevier, Philadelphia, 2008; 687-704.