SlideShare ist ein Scribd-Unternehmen logo
1 von 20
Downloaden Sie, um offline zu lesen
Choosing PsychotropicChoosing Psychotropic
in Patientsin Patients
with Medical Problemswith Medical Problems
A. Albehairy , M.DA. Albehairy , M.D
Psychiatry Consultant, MOHPPsychiatry Consultant, MOHP
Medical Problem ConditionsMedical Problem Conditions
( one or more):( one or more):
 Breast feeding.Breast feeding.
 Pregnancy.Pregnancy.
 Old age.Old age.
 CardiovascularCardiovascular
diseases.diseases.
 Chest problem.Chest problem.
 Renal impairment.Renal impairment.
 Liver impairment.Liver impairment.
 Diabetes.Diabetes.
 Epilepsy .Epilepsy .
 In surgery.In surgery.
 Glaucoma .Glaucoma .
General Principles , in approachingGeneral Principles , in approaching
the problemsthe problems
- Breast-feedingBreast-feeding: no risk free, drug level in milk 1% of: no risk free, drug level in milk 1% of
maternal plasma. Drug accumulates in milk bec. Ofmaternal plasma. Drug accumulates in milk bec. Of
acidity and lipid and protein binding .drugs should beacidity and lipid and protein binding .drugs should be
avoided if premature or has renal.liver.cardiac,oravoided if premature or has renal.liver.cardiac,or
neurological problem.neurological problem.
Avoid sedating,long half-lives. Once daily dose before theAvoid sedating,long half-lives. Once daily dose before the
infant longest sleep,dnt switch drug (preg- lactat),avoidinfant longest sleep,dnt switch drug (preg- lactat),avoid
polypharmacy.polypharmacy.
General Principles , in approachingGeneral Principles , in approaching
the problems (cntthe problems (cnt(.(.
 PregnancyPregnancy :FDA, 5 categories, to indicate drug:FDA, 5 categories, to indicate drug
teratogencity. Each drug has to be sought.teratogencity. Each drug has to be sought.
 Teratogenecity in the 1Teratogenecity in the 1stst
trimester, growth retardationtrimester, growth retardation
and neurological damage in 2and 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 plannedPsycho education for care in planned and non planned
conception.conception.
 Lowest viable dose.Lowest viable dose.
 Adjusting dose.Adjusting dose.
General Principles , in approachingGeneral Principles , in approaching
the problems (cntthe problems (cnt(.(.
 11stst
2 wks –stop medications, nutritional supplement folic2 wks –stop medications, nutritional supplement folic
acid, reduce dose if after 60 days,dnt stop lithiumacid, reduce dose if after 60 days,dnt stop lithium
abruptly,care in stop anticonvulsants.abruptly,care in stop anticonvulsants.
 TCA & Discontinuation,/ myclonus ttt byTCA & Discontinuation,/ myclonus ttt by
phenobarbitol.phenobarbitol.
 If depakin unavoidable , low , divided doses and folicIf depakin unavoidable , low , divided doses and folic
acid 5mg .acid 5mg .
 Most serious, bzd,lithium, phenytoin,topraimate, andMost serious, bzd,lithium, phenytoin,topraimate, and
vigabatrin and valproate.vigabatrin and valproate.
General Principles , in approachingGeneral Principles , in approaching
the problems (cntthe problems (cnt(.(.
 Old age :Old age : age related increases SE, sedation,age related increases SE, sedation,
orthostatic hypotension, reduced metabolism oforthostatic hypotension, reduced metabolism of
liver.liver.
 Inc. fat in body--- inc half life of the drugs used.Inc. fat in body--- inc half life of the drugs used.
 Other system affected.Other system affected.
 Low and slowLow and slow
 Poor compliancePoor compliance
General Principles , in approachingGeneral Principles , in approaching
the problems (cntthe problems (cnt(.(.
 CardiovascularCardiovascular ::
Polypharmacy avoided, with drug likely to affectPolypharmacy avoided, with drug likely to affect
pulse or electrolyte balance, QTprolongation.pulse or electrolyte balance, QTprolongation.
Low and slowLow and slow
Angina,avoidAngina,avoid drugs of othostatic hypotension,drugs of othostatic hypotension,
tachycardia.tachycardia.
ArrhythmiaArrhythmia:TCA, phenothiazines and:TCA, phenothiazines and
butyrophenones and pimozide arebutyrophenones and pimozide are harmfulharmful..
Sulpride, olanzapine ofSulpride, olanzapine of low risklow risk..
General Principles , in approachingGeneral Principles , in approaching
the problems (cntthe problems (cnt(.(.
 CHFCHF: avoid B blocker, drugs causing orthostatic: avoid B blocker, drugs causing orthostatic
hypotension(phenothiazines, clozapine , risperidone and TCA).hypotension(phenothiazines, clozapine , risperidone and TCA).
 MIMI: SSRI, TRAZODONE , mianserin,safer: SSRI, TRAZODONE , mianserin,safer
Butryphenone 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 drug450ms,care of electrolyte, and drug
combination , antipsychotics, TCA, flouroquinolone abio,combination , antipsychotics, TCA, flouroquinolone abio,
antimalarila, antihistamine.antimalarila, antihistamine.
General Principles , in approachingGeneral Principles , in approaching
the problems (cntthe problems (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 approaching theGeneral Principles , in approaching the
problems (cnt).problems (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 slowLow and slow
 SE, of anticholinergic, urinary retentionSE, of anticholinergic, urinary retention
 Accumulation of drugAccumulation of drug
General Principles , in approachingGeneral Principles , in approaching
the problems (cntthe problems (cnt(.(.
 In surgery:In surgery:
DecisionDecision to continue or not the drug during surgery andto continue or not the drug during surgery and
perioperative period.perioperative period.
 Discussing the anesthetistDiscussing the anesthetist
Enflurane---seizure in TCAEnflurane---seizure in TCA
Pethidine ---fatal excitatory reaction with SSRI (serotenorgicPethidine ---fatal excitatory reaction with SSRI (serotenorgic
syndrome or respiratory depression ) and MAOI --- switch tosyndrome or respiratory depression ) and MAOI --- switch to
moclobamide 2wks before operation.moclobamide 2wks before operation.
operation stress:Elyctrolyteoperation stress:Elyctrolyte distubance and cortisol anddistubance and cortisol and
catecholamine changes.catecholamine changes.
Gastric stasis.Gastric stasis.
Abrupt cessation of nicotine in some pt.Abrupt cessation of nicotine in some pt.
General Principles , in approachingGeneral Principles , in approaching
the problems (cntthe problems (cnt(.(.
 In surgeryIn surgery::
- AnticonvulsantAnticonvulsant CNS depressant activity may reduceCNS depressant activity may reduce
anaesthetic requirements.anaesthetic requirements.
- SSRISSRI, may induce seizure,, may induce seizure, VenlafaxineVenlafaxine may provokemay provoke
opioid rigidity, increase bleeding time. ( avoid anyopioid rigidity, increase bleeding time. ( avoid any
serotenorgic agent).serotenorgic agent).
- TCA:TCA: seizure, seroenorgic s, hypotension, it needs o beseizure, seroenorgic s, hypotension, it needs o be
stopped several days before surgery.stopped several days before surgery.
- Antipsychotics,hypotension,arrythmia,hypothermia,Antipsychotics,hypotension,arrythmia,hypothermia,
clozapine may delay recovery .clozapine may delay recovery .
General Principles , in approachingGeneral Principles , in approaching
the problems (cntthe problems (cnt(.(.
 in surgeryin surgery
BZDBZD, sedation and withdrawel, sedation and withdrawel
LithiumLithium : electrolyte imbalance may ppt, toxicity,: electrolyte imbalance may ppt, toxicity,
avoid dehydration/arrythmia develop.avoid dehydration/arrythmia develop.
OpiateOpiate, methadone, naloxone may induce, methadone, naloxone may induce
withdrawel– avoid bupernorphinwithdrawel– avoid bupernorphin
NaltrexoneNaltrexone
Psychotropics  in problem areas
Low Risk PsychotropicsLow Risk Psychotropics
 Br.feedingBr.feeding,sulpride, moclobamide, TCA,,sulpride, moclobamide, TCA,
tryptophan,BZD,chloral,temazepam,carbamezaptryptophan,BZD,chloral,temazepam,carbamezap
ine,valproate.ine,valproate.
 Pregnancy : moderate riskPregnancy : moderate risk. All antipsychotic. All antipsychotic
except zotepine high. All antidepressant exceptexcept zotepine high. All antidepressant except
reboxetin high, safer carbamezapine and ox,, andreboxetin high, safer carbamezapine and ox,, and
lamotriginelamotrigine
Low Risk PsychotropicsLow Risk Psychotropics
 Old age: sulprideOld age: sulpride, amisulpride,, amisulpride,
risperidine,ariperazole/deloxetin,mitazepine,SSRI,velafarisperidine,ariperazole/deloxetin,mitazepine,SSRI,velafa
xine,mocobamide/alprazolam,buspiron,lorazepam,zaloxine,mocobamide/alprazolam,buspiron,lorazepam,zalo
plon/carbamezapin,ox,topramate,clobazam.plon/carbamezapin,ox,topramate,clobazam.
 Cardiac prob:Cardiac prob:
sulpride,amisulpride,flupentixol,olanzapine,quatapine,/sulpride,amisulpride,flupentixol,olanzapine,quatapine,/
SSRI,mirtezapine,mianserin,trazdone/bzd,buspiron,zalSSRI,mirtezapine,mianserin,trazdone/bzd,buspiron,zal
oplon,zolpidiem/valproate,lamictal,pregabalin,gabapentoplon,zolpidiem/valproate,lamictal,pregabalin,gabapent
in.in.
Low Risk PsychotropicsLow Risk Psychotropics
 DiabetusDiabetus:sulpride,amisulpride,aripiprazole,butyr:sulpride,amisulpride,aripiprazole,butyr
ophenon, pimozide,ophenon, pimozide,
risperodone/deluxetin,moclobamide,SSRI,trazdrisperodone/deluxetin,moclobamide,SSRI,trazd
on,venlafaxin/bzd,buspar,zaleplon,zolpedim,/bzon,venlafaxin/bzd,buspar,zaleplon,zolpedim,/bz
d,carb,oxcarb,lamictal,pregabalin.d,carb,oxcarb,lamictal,pregabalin.
 Renal impairment:Renal impairment:
sertindole,mianserin,moclobamide,TCA,TRAZDOsertindole,mianserin,moclobamide,TCA,TRAZDO
NE,BZD,zalplon,phyenytoin,lamotrigenNE,BZD,zalplon,phyenytoin,lamotrigen
Low Risk PsychotropicsLow Risk Psychotropics
 Liver impairmentLiver impairment
:sulpride,amisulpride,aripirazole,flupentixol,zuclpentixol:sulpride,amisulpride,aripirazole,flupentixol,zuclpentixol
,pimozide,/mian,pimozide,/mian
serin,paroxetin/lorazepam,oxazepam,/carb,oxcarb,tpraiserin,paroxetin/lorazepam,oxazepam,/carb,oxcarb,tprai
mate.mate.
 Epilepsy:Epilepsy: sulpride ,sulpride ,
amisulpride,aripirazole,haloperidol,pimozide,quatiapine,amisulpride,aripirazole,haloperidol,pimozide,quatiapine,
risperidone,/MAOI,mocolbamide,SSRI,/BZD,BLOCKrisperidone,/MAOI,mocolbamide,SSRI,/BZD,BLOCK
ER,zalplon,zolpediumER,zalplon,zolpedium
 Glaucoma:Glaucoma: olanzapine TCA areolanzapine TCA are
serious,,trazdone,flupentxol,butyrophenone,risperidon,serious,,trazdone,flupentxol,butyrophenone,risperidon,
sulpridesulpride
CASESCASES
 Depressed patient, insomnia ,75y, diabetic ,Depressed patient, insomnia ,75y, diabetic ,
hypertension, IHD.hypertension, IHD.
 Depressed female, 45, anxiety,, insomnia ofDepressed female, 45, anxiety,, insomnia of
renal impairment and diabetes.renal impairment and diabetes.
 Post partum psychosis in hypertensive mother.Post partum psychosis in hypertensive mother.
Thank youThank you

Weitere ähnliche Inhalte

Was ist angesagt?

Anti seizure and rescue medications.updated 8.7.2014
Anti seizure and rescue medications.updated 8.7.2014Anti seizure and rescue medications.updated 8.7.2014
Anti seizure and rescue medications.updated 8.7.2014Cleveland Clinic
 
New anti epileptic drugs
New anti epileptic drugsNew anti epileptic drugs
New anti epileptic drugsImran Rizvi
 
Jacqueline French, MD
Jacqueline French, MDJacqueline French, MD
Jacqueline French, MDNYU FACES
 
Drug profile of pregabalin and lacosamide: A deep insight!
Drug profile of pregabalin and lacosamide: A deep insight!Drug profile of pregabalin and lacosamide: A deep insight!
Drug profile of pregabalin and lacosamide: A deep insight!RxVichuZ
 
Antiepileptic drugs
Antiepileptic drugsAntiepileptic drugs
Antiepileptic drugsRavish Yadav
 
Newer and classical Anti Epileptic Drugs in Paediatrics
Newer and classical  Anti Epileptic Drugs in PaediatricsNewer and classical  Anti Epileptic Drugs in Paediatrics
Newer and classical Anti Epileptic Drugs in PaediatricsDrHardik Shah
 
APA Workshop Slides 05.20.15 What Every Psychiatrist Needs to Know About Epi...
APA Workshop Slides 05.20.15  What Every Psychiatrist Needs to Know About Epi...APA Workshop Slides 05.20.15  What Every Psychiatrist Needs to Know About Epi...
APA Workshop Slides 05.20.15 What Every Psychiatrist Needs to Know About Epi...gbaslet
 
Pharmacotheparapy of epilepsy
Pharmacotheparapy of epilepsyPharmacotheparapy of epilepsy
Pharmacotheparapy of epilepsyshubhangi buchade
 
Thyroid gland - disordesa , symptomes and treatment
Thyroid gland - disordesa , symptomes and treatment Thyroid gland - disordesa , symptomes and treatment
Thyroid gland - disordesa , symptomes and treatment Areej Abu Hanieh
 
Newer antiepileptic drugs
Newer antiepileptic drugsNewer antiepileptic drugs
Newer antiepileptic drugsFariha Shikoh
 
Levera (Levetiracetam Tablets)
Levera (Levetiracetam Tablets)Levera (Levetiracetam Tablets)
Levera (Levetiracetam Tablets)Clearsky Pharmacy
 
Supportive Care of Cancer
Supportive Care of CancerSupportive Care of Cancer
Supportive Care of CancerChirag Dave
 

Was ist angesagt? (19)

Antiepileptic drugs 21 12 2005
Antiepileptic drugs 21 12 2005Antiepileptic drugs 21 12 2005
Antiepileptic drugs 21 12 2005
 
Anti seizure and rescue medications.updated 8.7.2014
Anti seizure and rescue medications.updated 8.7.2014Anti seizure and rescue medications.updated 8.7.2014
Anti seizure and rescue medications.updated 8.7.2014
 
Levetiracetam
LevetiracetamLevetiracetam
Levetiracetam
 
New anti epileptic drugs
New anti epileptic drugsNew anti epileptic drugs
New anti epileptic drugs
 
antiepileptic drugs
antiepileptic drugsantiepileptic drugs
antiepileptic drugs
 
Jacqueline French, MD
Jacqueline French, MDJacqueline French, MD
Jacqueline French, MD
 
Drug profile of pregabalin and lacosamide: A deep insight!
Drug profile of pregabalin and lacosamide: A deep insight!Drug profile of pregabalin and lacosamide: A deep insight!
Drug profile of pregabalin and lacosamide: A deep insight!
 
Antiepileptic drugs
Antiepileptic drugsAntiepileptic drugs
Antiepileptic drugs
 
Newer and classical Anti Epileptic Drugs in Paediatrics
Newer and classical  Anti Epileptic Drugs in PaediatricsNewer and classical  Anti Epileptic Drugs in Paediatrics
Newer and classical Anti Epileptic Drugs in Paediatrics
 
APA Workshop Slides 05.20.15 What Every Psychiatrist Needs to Know About Epi...
APA Workshop Slides 05.20.15  What Every Psychiatrist Needs to Know About Epi...APA Workshop Slides 05.20.15  What Every Psychiatrist Needs to Know About Epi...
APA Workshop Slides 05.20.15 What Every Psychiatrist Needs to Know About Epi...
 
Pharmacotheparapy of epilepsy
Pharmacotheparapy of epilepsyPharmacotheparapy of epilepsy
Pharmacotheparapy of epilepsy
 
Newer antiepileptic drugs
Newer antiepileptic drugsNewer antiepileptic drugs
Newer antiepileptic drugs
 
Anti- epileptic Drugs
Anti- epileptic DrugsAnti- epileptic Drugs
Anti- epileptic Drugs
 
Thyroid gland - disordesa , symptomes and treatment
Thyroid gland - disordesa , symptomes and treatment Thyroid gland - disordesa , symptomes and treatment
Thyroid gland - disordesa , symptomes and treatment
 
ANTI EPILEPTIC DRUGS
ANTI EPILEPTIC DRUGSANTI EPILEPTIC DRUGS
ANTI EPILEPTIC DRUGS
 
Newer antiepileptic drugs
Newer antiepileptic drugsNewer antiepileptic drugs
Newer antiepileptic drugs
 
Levera (Levetiracetam Tablets)
Levera (Levetiracetam Tablets)Levera (Levetiracetam Tablets)
Levera (Levetiracetam Tablets)
 
Supportive Care of Cancer
Supportive Care of CancerSupportive Care of Cancer
Supportive Care of Cancer
 
Seizure
SeizureSeizure
Seizure
 

Andere mochten auch

Andere mochten auch (6)

Mood disorders
Mood disordersMood disorders
Mood disorders
 
Mini part2
Mini part2Mini part2
Mini part2
 
الثقافة و تأثيرها علي السلوك الادماني
الثقافة و تأثيرها علي السلوك الادمانيالثقافة و تأثيرها علي السلوك الادماني
الثقافة و تأثيرها علي السلوك الادماني
 
خطورة استخدام المواد النفسية
خطورة استخدام المواد النفسيةخطورة استخدام المواد النفسية
خطورة استخدام المواد النفسية
 
Clinical evaluation of addiction
Clinical evaluation of addictionClinical evaluation of addiction
Clinical evaluation of addiction
 
المشاكل النفس جنسية لدي المرأة ؟
المشاكل النفس جنسية لدي المرأة ؟المشاكل النفس جنسية لدي المرأة ؟
المشاكل النفس جنسية لدي المرأة ؟
 

Ähnlich wie Psychotropics in problem areas

Ähnlich wie Psychotropics in problem areas (20)

Antidepressants
Antidepressants Antidepressants
Antidepressants
 
Adverse Drugs Reactions
Adverse Drugs ReactionsAdverse Drugs Reactions
Adverse Drugs Reactions
 
Bipolar Disorder
Bipolar DisorderBipolar Disorder
Bipolar Disorder
 
Cain dex peds board review
Cain dex peds board reviewCain dex peds board review
Cain dex peds board review
 
01 antiemetics 1
01 antiemetics 101 antiemetics 1
01 antiemetics 1
 
Chf
ChfChf
Chf
 
Antianginal Drugs
Antianginal DrugsAntianginal Drugs
Antianginal Drugs
 
Chapter 10 anti-tb, art...
Chapter 10 anti-tb, art...Chapter 10 anti-tb, art...
Chapter 10 anti-tb, art...
 
Drug Therapy of Epilepsy (Antiepileptic Drugs)
Drug Therapy of Epilepsy (Antiepileptic Drugs)Drug Therapy of Epilepsy (Antiepileptic Drugs)
Drug Therapy of Epilepsy (Antiepileptic Drugs)
 
Local Anesthesia Injection Technique
Local Anesthesia Injection TechniqueLocal Anesthesia Injection Technique
Local Anesthesia Injection Technique
 
Antidepressants
AntidepressantsAntidepressants
Antidepressants
 
Antiepileptics I & Ii
Antiepileptics I & IiAntiepileptics I & Ii
Antiepileptics I & Ii
 
9. Bipolar Disorder.pptx for pharmacy students
9. Bipolar Disorder.pptx for pharmacy students9. Bipolar Disorder.pptx for pharmacy students
9. Bipolar Disorder.pptx for pharmacy students
 
Autonomics
AutonomicsAutonomics
Autonomics
 
Basics of hormonal contraception aurangabad
Basics of hormonal contraception   aurangabadBasics of hormonal contraception   aurangabad
Basics of hormonal contraception aurangabad
 
Pediatric intubation pharmacology
Pediatric intubation pharmacology Pediatric intubation pharmacology
Pediatric intubation pharmacology
 
Drug overdose
Drug overdoseDrug overdose
Drug overdose
 
Drug dependence and drug abuse
Drug dependence and drug abuseDrug dependence and drug abuse
Drug dependence and drug abuse
 
Mood stabilising agents
Mood stabilising agentsMood stabilising agents
Mood stabilising agents
 
Common Food Drug Interactions
Common Food Drug InteractionsCommon Food Drug Interactions
Common Food Drug Interactions
 

Mehr von احمد البحيري

Ketamine_assisted_psychotherapy_essential_concepts_and_steps_lecture.pdf
Ketamine_assisted_psychotherapy_essential_concepts_and_steps_lecture.pdfKetamine_assisted_psychotherapy_essential_concepts_and_steps_lecture.pdf
Ketamine_assisted_psychotherapy_essential_concepts_and_steps_lecture.pdfاحمد البحيري
 
تأثير جائحة كوفيد – 19 علي الصحة النفسية.pptx
تأثير جائحة كوفيد – 19 علي الصحة النفسية.pptxتأثير جائحة كوفيد – 19 علي الصحة النفسية.pptx
تأثير جائحة كوفيد – 19 علي الصحة النفسية.pptxاحمد البحيري
 
Proposal for Halfway House Facility: in Addiction Rehabilitation
Proposal for Halfway House Facility: in Addiction RehabilitationProposal for Halfway House Facility: in Addiction Rehabilitation
Proposal for Halfway House Facility: in Addiction Rehabilitationاحمد البحيري
 
الصحة النفسية لكبار السن و المتقاعدين
الصحة النفسية لكبار السن و المتقاعدينالصحة النفسية لكبار السن و المتقاعدين
الصحة النفسية لكبار السن و المتقاعديناحمد البحيري
 
Recovery- Oriented System of Care ,Motivational Approach , in Substance Use D...
Recovery- Oriented System of Care ,Motivational Approach , in Substance Use D...Recovery- Oriented System of Care ,Motivational Approach , in Substance Use D...
Recovery- Oriented System of Care ,Motivational Approach , in Substance Use D...احمد البحيري
 
Telepsychiatry, future implications in mental health services
Telepsychiatry, future implications in mental health servicesTelepsychiatry, future implications in mental health services
Telepsychiatry, future implications in mental health servicesاحمد البحيري
 
اضطراب التوحد و الاضطرابات المصاحبة
اضطراب التوحد و الاضطرابات  المصاحبة اضطراب التوحد و الاضطرابات  المصاحبة
اضطراب التوحد و الاضطرابات المصاحبة احمد البحيري
 
اساسيات الارشاد و العلاج الاسري مع مرضي الادمان
اساسيات الارشاد و العلاج الاسري مع مرضي الادمان اساسيات الارشاد و العلاج الاسري مع مرضي الادمان
اساسيات الارشاد و العلاج الاسري مع مرضي الادمان احمد البحيري
 
مقابلات زيادة الدافعية
مقابلات زيادة الدافعيةمقابلات زيادة الدافعية
مقابلات زيادة الدافعيةاحمد البحيري
 
اساسيات العلاج الجماعي في الادمان
اساسيات العلاج الجماعي في الادماناساسيات العلاج الجماعي في الادمان
اساسيات العلاج الجماعي في الادماناحمد البحيري
 
Critique of Different Approaches to Treat Addiction
Critique of Different Approaches to Treat AddictionCritique of Different Approaches to Treat Addiction
Critique of Different Approaches to Treat Addictionاحمد البحيري
 

Mehr von احمد البحيري (20)

Ketamine_assisted_psychotherapy_essential_concepts_and_steps_lecture.pdf
Ketamine_assisted_psychotherapy_essential_concepts_and_steps_lecture.pdfKetamine_assisted_psychotherapy_essential_concepts_and_steps_lecture.pdf
Ketamine_assisted_psychotherapy_essential_concepts_and_steps_lecture.pdf
 
Ketamine Therapy in psychiatry
Ketamine Therapy in psychiatryKetamine Therapy in psychiatry
Ketamine Therapy in psychiatry
 
تأثير جائحة كوفيد – 19 علي الصحة النفسية.pptx
تأثير جائحة كوفيد – 19 علي الصحة النفسية.pptxتأثير جائحة كوفيد – 19 علي الصحة النفسية.pptx
تأثير جائحة كوفيد – 19 علي الصحة النفسية.pptx
 
Consultation and liaison psychiatry me
Consultation and liaison psychiatry meConsultation and liaison psychiatry me
Consultation and liaison psychiatry me
 
Proposal for Halfway House Facility: in Addiction Rehabilitation
Proposal for Halfway House Facility: in Addiction RehabilitationProposal for Halfway House Facility: in Addiction Rehabilitation
Proposal for Halfway House Facility: in Addiction Rehabilitation
 
الصحة النفسية لكبار السن و المتقاعدين
الصحة النفسية لكبار السن و المتقاعدينالصحة النفسية لكبار السن و المتقاعدين
الصحة النفسية لكبار السن و المتقاعدين
 
Recovery- Oriented System of Care ,Motivational Approach , in Substance Use D...
Recovery- Oriented System of Care ,Motivational Approach , in Substance Use D...Recovery- Oriented System of Care ,Motivational Approach , in Substance Use D...
Recovery- Oriented System of Care ,Motivational Approach , in Substance Use D...
 
Telepsychiatry, future implications in mental health services
Telepsychiatry, future implications in mental health servicesTelepsychiatry, future implications in mental health services
Telepsychiatry, future implications in mental health services
 
Somatic phenomenology in depression
Somatic phenomenology in depressionSomatic phenomenology in depression
Somatic phenomenology in depression
 
اضطراب التوحد و الاضطرابات المصاحبة
اضطراب التوحد و الاضطرابات  المصاحبة اضطراب التوحد و الاضطرابات  المصاحبة
اضطراب التوحد و الاضطرابات المصاحبة
 
Clinical documentations,
Clinical documentations,Clinical documentations,
Clinical documentations,
 
Schizophrenia
SchizophreniaSchizophrenia
Schizophrenia
 
Schizophrenia.ppt489266552
Schizophrenia.ppt489266552Schizophrenia.ppt489266552
Schizophrenia.ppt489266552
 
Telepsychiatry
TelepsychiatryTelepsychiatry
Telepsychiatry
 
Glutamate and schizophrenia
Glutamate and schizophreniaGlutamate and schizophrenia
Glutamate and schizophrenia
 
اساسيات الارشاد و العلاج الاسري مع مرضي الادمان
اساسيات الارشاد و العلاج الاسري مع مرضي الادمان اساسيات الارشاد و العلاج الاسري مع مرضي الادمان
اساسيات الارشاد و العلاج الاسري مع مرضي الادمان
 
مقابلات زيادة الدافعية
مقابلات زيادة الدافعيةمقابلات زيادة الدافعية
مقابلات زيادة الدافعية
 
اساسيات العلاج الجماعي في الادمان
اساسيات العلاج الجماعي في الادماناساسيات العلاج الجماعي في الادمان
اساسيات العلاج الجماعي في الادمان
 
ادمان الكحول
ادمان الكحولادمان الكحول
ادمان الكحول
 
Critique of Different Approaches to Treat Addiction
Critique of Different Approaches to Treat AddictionCritique of Different Approaches to Treat Addiction
Critique of Different Approaches to Treat Addiction
 

Psychotropics in problem areas

  • 1. Choosing PsychotropicChoosing Psychotropic in Patientsin Patients with Medical Problemswith Medical Problems A. Albehairy , M.DA. Albehairy , M.D Psychiatry Consultant, MOHPPsychiatry Consultant, MOHP
  • 2. Medical Problem ConditionsMedical Problem Conditions ( one or more):( one or more):  Breast feeding.Breast feeding.  Pregnancy.Pregnancy.  Old age.Old age.  CardiovascularCardiovascular diseases.diseases.  Chest problem.Chest problem.  Renal impairment.Renal impairment.  Liver impairment.Liver impairment.  Diabetes.Diabetes.  Epilepsy .Epilepsy .  In surgery.In surgery.  Glaucoma .Glaucoma .
  • 3. General Principles , in approachingGeneral Principles , in approaching the problemsthe problems - Breast-feedingBreast-feeding: no risk free, drug level in milk 1% of: no risk free, drug level in milk 1% of maternal plasma. Drug accumulates in milk bec. Ofmaternal plasma. Drug accumulates in milk bec. Of acidity and lipid and protein binding .drugs should beacidity and lipid and protein binding .drugs should be avoided if premature or has renal.liver.cardiac,oravoided if premature or has renal.liver.cardiac,or neurological problem.neurological problem. Avoid sedating,long half-lives. Once daily dose before theAvoid sedating,long half-lives. Once daily dose before the infant longest sleep,dnt switch drug (preg- lactat),avoidinfant longest sleep,dnt switch drug (preg- lactat),avoid polypharmacy.polypharmacy.
  • 4. General Principles , in approachingGeneral Principles , in approaching the problems (cntthe problems (cnt(.(.  PregnancyPregnancy :FDA, 5 categories, to indicate drug:FDA, 5 categories, to indicate drug teratogencity. Each drug has to be sought.teratogencity. Each drug has to be sought.  Teratogenecity in the 1Teratogenecity in the 1stst trimester, growth retardationtrimester, growth retardation and neurological damage in 2and 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 plannedPsycho education for care in planned and non planned conception.conception.  Lowest viable dose.Lowest viable dose.  Adjusting dose.Adjusting dose.
  • 5. General Principles , in approachingGeneral Principles , in approaching the problems (cntthe problems (cnt(.(.  11stst 2 wks –stop medications, nutritional supplement folic2 wks –stop medications, nutritional supplement folic acid, reduce dose if after 60 days,dnt stop lithiumacid, reduce dose if after 60 days,dnt stop lithium abruptly,care in stop anticonvulsants.abruptly,care in stop anticonvulsants.  TCA & Discontinuation,/ myclonus ttt byTCA & Discontinuation,/ myclonus ttt by phenobarbitol.phenobarbitol.  If depakin unavoidable , low , divided doses and folicIf depakin unavoidable , low , divided doses and folic acid 5mg .acid 5mg .  Most serious, bzd,lithium, phenytoin,topraimate, andMost serious, bzd,lithium, phenytoin,topraimate, and vigabatrin and valproate.vigabatrin and valproate.
  • 6. General Principles , in approachingGeneral Principles , in approaching the problems (cntthe problems (cnt(.(.  Old age :Old age : age related increases SE, sedation,age related increases SE, sedation, orthostatic hypotension, reduced metabolism oforthostatic hypotension, reduced metabolism of liver.liver.  Inc. fat in body--- inc half life of the drugs used.Inc. fat in body--- inc half life of the drugs used.  Other system affected.Other system affected.  Low and slowLow and slow  Poor compliancePoor compliance
  • 7. General Principles , in approachingGeneral Principles , in approaching the problems (cntthe problems (cnt(.(.  CardiovascularCardiovascular :: Polypharmacy avoided, with drug likely to affectPolypharmacy avoided, with drug likely to affect pulse or electrolyte balance, QTprolongation.pulse or electrolyte balance, QTprolongation. Low and slowLow and slow Angina,avoidAngina,avoid drugs of othostatic hypotension,drugs of othostatic hypotension, tachycardia.tachycardia. ArrhythmiaArrhythmia:TCA, phenothiazines and:TCA, phenothiazines and butyrophenones and pimozide arebutyrophenones and pimozide are harmfulharmful.. Sulpride, olanzapine ofSulpride, olanzapine of low risklow risk..
  • 8. General Principles , in approachingGeneral Principles , in approaching the problems (cntthe problems (cnt(.(.  CHFCHF: avoid B blocker, drugs causing orthostatic: avoid B blocker, drugs causing orthostatic hypotension(phenothiazines, clozapine , risperidone and TCA).hypotension(phenothiazines, clozapine , risperidone and TCA).  MIMI: SSRI, TRAZODONE , mianserin,safer: SSRI, TRAZODONE , mianserin,safer Butryphenone 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 drug450ms,care of electrolyte, and drug combination , antipsychotics, TCA, flouroquinolone abio,combination , antipsychotics, TCA, flouroquinolone abio, antimalarila, antihistamine.antimalarila, antihistamine.
  • 9. General Principles , in approachingGeneral Principles , in approaching the problems (cntthe problems (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.
  • 10. General Principles , in approaching theGeneral Principles , in approaching the problems (cnt).problems (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 slowLow and slow  SE, of anticholinergic, urinary retentionSE, of anticholinergic, urinary retention  Accumulation of drugAccumulation of drug
  • 11. General Principles , in approachingGeneral Principles , in approaching the problems (cntthe problems (cnt(.(.  In surgery:In surgery: DecisionDecision to continue or not the drug during surgery andto continue or not the drug during surgery and perioperative period.perioperative period.  Discussing the anesthetistDiscussing the anesthetist Enflurane---seizure in TCAEnflurane---seizure in TCA Pethidine ---fatal excitatory reaction with SSRI (serotenorgicPethidine ---fatal excitatory reaction with SSRI (serotenorgic syndrome or respiratory depression ) and MAOI --- switch tosyndrome or respiratory depression ) and MAOI --- switch to moclobamide 2wks before operation.moclobamide 2wks before operation. operation stress:Elyctrolyteoperation stress:Elyctrolyte distubance and cortisol anddistubance and cortisol and catecholamine changes.catecholamine changes. Gastric stasis.Gastric stasis. Abrupt cessation of nicotine in some pt.Abrupt cessation of nicotine in some pt.
  • 12. General Principles , in approachingGeneral Principles , in approaching the problems (cntthe problems (cnt(.(.  In surgeryIn surgery:: - AnticonvulsantAnticonvulsant CNS depressant activity may reduceCNS depressant activity may reduce anaesthetic requirements.anaesthetic requirements. - SSRISSRI, may induce seizure,, may induce seizure, VenlafaxineVenlafaxine may provokemay provoke opioid rigidity, increase bleeding time. ( avoid anyopioid rigidity, increase bleeding time. ( avoid any serotenorgic agent).serotenorgic agent). - TCA:TCA: seizure, seroenorgic s, hypotension, it needs o beseizure, seroenorgic s, hypotension, it needs o be stopped several days before surgery.stopped several days before surgery. - Antipsychotics,hypotension,arrythmia,hypothermia,Antipsychotics,hypotension,arrythmia,hypothermia, clozapine may delay recovery .clozapine may delay recovery .
  • 13. General Principles , in approachingGeneral Principles , in approaching the problems (cntthe problems (cnt(.(.  in surgeryin surgery BZDBZD, sedation and withdrawel, sedation and withdrawel LithiumLithium : electrolyte imbalance may ppt, toxicity,: electrolyte imbalance may ppt, toxicity, avoid dehydration/arrythmia develop.avoid dehydration/arrythmia develop. OpiateOpiate, methadone, naloxone may induce, methadone, naloxone may induce withdrawel– avoid bupernorphinwithdrawel– avoid bupernorphin NaltrexoneNaltrexone
  • 15. Low Risk PsychotropicsLow Risk Psychotropics  Br.feedingBr.feeding,sulpride, moclobamide, TCA,,sulpride, moclobamide, TCA, tryptophan,BZD,chloral,temazepam,carbamezaptryptophan,BZD,chloral,temazepam,carbamezap ine,valproate.ine,valproate.  Pregnancy : moderate riskPregnancy : moderate risk. All antipsychotic. All antipsychotic except zotepine high. All antidepressant exceptexcept zotepine high. All antidepressant except reboxetin high, safer carbamezapine and ox,, andreboxetin high, safer carbamezapine and ox,, and lamotriginelamotrigine
  • 16. Low Risk PsychotropicsLow Risk Psychotropics  Old age: sulprideOld age: sulpride, amisulpride,, amisulpride, risperidine,ariperazole/deloxetin,mitazepine,SSRI,velafarisperidine,ariperazole/deloxetin,mitazepine,SSRI,velafa xine,mocobamide/alprazolam,buspiron,lorazepam,zaloxine,mocobamide/alprazolam,buspiron,lorazepam,zalo plon/carbamezapin,ox,topramate,clobazam.plon/carbamezapin,ox,topramate,clobazam.  Cardiac prob:Cardiac prob: sulpride,amisulpride,flupentixol,olanzapine,quatapine,/sulpride,amisulpride,flupentixol,olanzapine,quatapine,/ SSRI,mirtezapine,mianserin,trazdone/bzd,buspiron,zalSSRI,mirtezapine,mianserin,trazdone/bzd,buspiron,zal oplon,zolpidiem/valproate,lamictal,pregabalin,gabapentoplon,zolpidiem/valproate,lamictal,pregabalin,gabapent in.in.
  • 17. Low Risk PsychotropicsLow Risk Psychotropics  DiabetusDiabetus:sulpride,amisulpride,aripiprazole,butyr:sulpride,amisulpride,aripiprazole,butyr ophenon, pimozide,ophenon, pimozide, risperodone/deluxetin,moclobamide,SSRI,trazdrisperodone/deluxetin,moclobamide,SSRI,trazd on,venlafaxin/bzd,buspar,zaleplon,zolpedim,/bzon,venlafaxin/bzd,buspar,zaleplon,zolpedim,/bz d,carb,oxcarb,lamictal,pregabalin.d,carb,oxcarb,lamictal,pregabalin.  Renal impairment:Renal impairment: sertindole,mianserin,moclobamide,TCA,TRAZDOsertindole,mianserin,moclobamide,TCA,TRAZDO NE,BZD,zalplon,phyenytoin,lamotrigenNE,BZD,zalplon,phyenytoin,lamotrigen
  • 18. Low Risk PsychotropicsLow Risk Psychotropics  Liver impairmentLiver impairment :sulpride,amisulpride,aripirazole,flupentixol,zuclpentixol:sulpride,amisulpride,aripirazole,flupentixol,zuclpentixol ,pimozide,/mian,pimozide,/mian serin,paroxetin/lorazepam,oxazepam,/carb,oxcarb,tpraiserin,paroxetin/lorazepam,oxazepam,/carb,oxcarb,tprai mate.mate.  Epilepsy:Epilepsy: sulpride ,sulpride , amisulpride,aripirazole,haloperidol,pimozide,quatiapine,amisulpride,aripirazole,haloperidol,pimozide,quatiapine, risperidone,/MAOI,mocolbamide,SSRI,/BZD,BLOCKrisperidone,/MAOI,mocolbamide,SSRI,/BZD,BLOCK ER,zalplon,zolpediumER,zalplon,zolpedium  Glaucoma:Glaucoma: olanzapine TCA areolanzapine TCA are serious,,trazdone,flupentxol,butyrophenone,risperidon,serious,,trazdone,flupentxol,butyrophenone,risperidon, sulpridesulpride
  • 19. CASESCASES  Depressed patient, insomnia ,75y, diabetic ,Depressed patient, insomnia ,75y, diabetic , hypertension, IHD.hypertension, IHD.  Depressed female, 45, anxiety,, insomnia ofDepressed female, 45, anxiety,, insomnia of renal impairment and diabetes.renal impairment and diabetes.  Post partum psychosis in hypertensive mother.Post partum psychosis in hypertensive mother.