Cardiac drug and psychotropic drug interactions: significance and recommendations

Drug Interactions of Chronic Neuropsychiatric Drugs in Neuro-critical Care

Neuro psychiatric illnesses are commonly recognised these days in the intensive care especially with the increasing aging population and more intensive care admissions. However they are still inadequately diagnosed and treated disease entities as a majority of these patients do not seek the help of specialists psychiatrists Of course the number of drugs used in psychiatry has explosively increased in recent years. As a corollary to this, the phenomenon of drug- drug interaction between psychiatric drugs and other drugs has come to the forefront. Drug- drug interaction (DDI)) is the response (pharmacological or clinical) of altered drug effects or increase in adverse effects when two or more drugs are used simultaneously^1,2 This effect may be different from the usual action of the individual drugs when used alone. Potential drug- drug interaction (PDDI) are those where theoretically there may be an interaction between the drugs but have not clinically occurred.^1,2

Pharmacological risk factors associated with hospital readmission rates in a psychiatric cohort identified using prescriptome data mining

BACKGROUND

Worldwide, over 14% of individuals hospitalized for psychiatric reasons have readmissions to hospitals within 30 days after discharge. Predicting patients at risk and leveraging accelerated interventions can reduce the rates of early readmission, a negative clinical outcome (i.e., a treatment failure) that affects the quality of life of patient. To implement individualized interventions, it is necessary to predict those individuals at highest risk for 30-day readmission. In this study, our aim was to conduct a data-driven investigation to find the pharmacological factors influencing 30-day all-cause, intra- and interdepartmental readmissions after an index psychiatric admission, using the compendium of prescription data (prescriptome) from electronic medical records (EMR).

METHODS

The data scientists in the project received a deidentified database from the Mount Sinai Data Warehouse, which was used to perform all analyses. Data was stored in a secured MySQL database, normalized and indexed using a unique hexadecimal identifier associated with the data for psychiatric illness visits. We used Bayesian logistic regression models to evaluate the association of prescription data with 30-day readmission risk. We constructed individual models and compiled results after adjusting for covariates, including drug exposure, age, and gender. We also performed digital comorbidity survey using EMR data combined with the estimation of shared genetic architecture using genomic annotations to disease phenotypes.

RESULTS

Using an automated, data-driven approach, we identified prescription medications, side effects (primary side effects), and drug-drug interaction-induced side effects (secondary side effects) associated with readmission risk in a cohort of 1275 patients using prescriptome analytics. In our study, we identified 28 drugs associated with risk for readmission among psychiatric patients. Based on prescription data, Pravastatin had the highest risk of readmission (OR = 13.10; 95% CI (2.82, 60.8)). We also identified enrichment of primary side effects (n = 4006) and secondary side effects (n = 36) induced by prescription drugs in the subset of readmitted patients (n = 89) compared to the non-readmitted subgroup (n = 1186). Digital comorbidity analyses and shared genetic analyses further reveals that cardiovascular disease and psychiatric conditions are comorbid and share functional gene modules (cardiomyopathy and anxiety disorder: shared genes (n = 37; P = 1.06815E-06)).

CONCLUSIONS

Large scale prescriptome data is now available from EMRs and accessible for analytics that could improve healthcare outcomes. Such analyses could also drive hypothesis and data-driven research. In this study, we explored the utility of prescriptome data to identify factors driving readmission in a psychiatric cohort. Converging digital health data from EMRs and systems biology investigations reveal a subset of patient populations that have significant comorbidities with cardiovascular diseases are more likely to be readmitted. Further, the genetic architecture of psychiatric illness also suggests overlap with cardiovascular diseases. In summary, assessment of medications, side effects, and drug-drug interactions in a clinical setting as well as genomic information using a data mining approach could help to find factors that could help to lower readmission rates in patients with mental illness.

Potentially inappropriate medication use in a city of Southeast Brazil

Potentially inappropriate medication use by the Diamantina (Minas Gerais State) population was investigated by analyzing medicine consumption, self-medication, polypharmacy and drug interactions of medicines prescribed among those interviewed. Level of knowledge about rational drug use and its relationship to socio-economic variables was also evaluated using a semi-structured questionnaire. This survey was based on stratified sampling of 423 individuals selected randomly. The prevalence of prescription drug consumption was 42.32% (n=179) and cardiovascular drugs were the most prescribed. Drug interactions were found in 45.81% (n=82) of prescriptions and 92.68% (n=76) of these interactions were moderate, with co-administration of cardiovascular drugs occurring in more than half of the cases. The inappropriate use of medication, according to Beers criteria, occurred in 44.73% of prescriptions to the elderly. The prevalence of self-medication was 63.34% (n=268) while 21.99% (n=91) of individuals administered medications to their children without formal prescriptions, where this practice was associated to analgesic/antipyretic consumption. The population showed a high prevalence of inappropriate use of drugs across all strata of society, representing an issue requiring effective actions to promote rational use of medicines.

Depressive und Angststörungen bei somatischen Krankheiten

Depressiv-ängstliche Störungen sind bei den unterschiedlichen somatischen Erkrankungen häufig. Sie sind nicht nur als Reaktion auf die Situation der Erkrankung zu verstehen, sondern in ein komplexes Bedingungsgefüge eingebettet. Sie sind besonders häufig bei Erkrankungen, die das Zentralnervensystem oder endokrine Regulationssysteme direkt betreffen. Es besteht ein enger Zusammenhang zur Chronizität, Schwere und Prognose der Erkrankung. Eigenständige Effekte von diversen pharmakologischen Substanzgruppen sind wahrscheinlich.

A review on hyponatremia associated with SSRIs, reboxetine and venlafaxine

Hyponatremia, defined as serum sodium below 135 mmol/l, is a potentially life-threatening condition and was shown to be more frequent in elderly and psychiatric patients. In the last years numerous case reports on SSRI- and venlafaxine-induced hyponatremia were published indicating a higher incidence than previously thought. Only few studies have been performed and the incidence reported varies widely from 4.6/1000 people to 25%. It is still unclear if any single SSRI shows a higher incidence of hyponatremia than the others. Some data suggest that venlafaxine may have a stronger association to hyponatremia than SSRIs. Risk factors include age, female sex, low body mass index, severe physical illness, history of former hyponatremia and co-medications known to induce hyponatremia, especially thiazide diuretics. Symptoms of hyponatremia are usually neuropsychiatric (e.g. restlessness, lethargy, cognitive impairment), and any worsening in psychiatric symptoms in patients with a corresponding risk-profile receiving SSRIs or venlafaxine should give cause to check serum electrolytes. Usually SSRI-induced hyponatremia occurs within approximately 30 days and is reported to improve after withdrawal of the drug. Further controlled studies to confirm the true incidence of hyponatremia due to SSRI or venlafaxine and to define predictors more precisely are needed.

Psychotropic Drugs and the Perioperative Period: A Proposal for a Guideline in Elective Surgery

Evidence-based guidelines for the perioperative management of psychotropic drugs are lacking. The level of evidence is low and is based on case reports, open trials, and non-systematic reviews. However, the interactions and effects mentioned indicate that patients who use psychotropics and require surgery have an enhanced perioperative risk. A group of clinicians from several clinical disciplines determined which risks should be considered in an integrated preoperative assessment, as well as how psychotropics might interfere with these risks. The risks that should be considered in the perioperative period are the extent of the surgery, the patient's physical state, anesthesia, the direct and indirect (Phase I and II) effects of psychotropics, risk of withdrawal symptoms, and risk of psychiatric recurrence or relapse. Because of new drug developments, the risk of interactions increases. The literature has not provided articles that systematically address these risks. On the basis of a systematic analysis of the available literature guided by the formulated perioperative risks, a proposal for the perioperative management of psychotropics was formulated. Patients who use lithium, monoamine oxidase inhibitors, tricyclics, and clozepine have serious drug-drug interactions, with increased physical risks, including withdrawal, and therefore qualify for American Society of Anesthesiologists (ASA) Classification 3. From the perspective of the physical risk, they require discontinuation. However, from the perspective of the risk of withdrawal and psychiatric relapse and recurrence, these patients deserve intensive, integrated anesthetic/psychiatric management. For patients on selective serotonin reuptake inhibitors (SSRIs) who are mentally and physical stable (ASA Classification 2), the risk of withdrawal seems to justify their continuation. Yet, patients on SSRIs with higher physical or psychiatric risks should be seen in consultation. Both the physical and psychiatric risks of patients who use antipsychotics and other antidepressants should be regarded as enhanced. From a physical perspective, they qualify for ASA Classification 2. From the perspective of withdrawal and psychiatric recurrence or relapse, they should be seen by (their) psychiatrists. Preoperative assessment clinics offer the opportunity to assess and evaluate these risks in order to deliver patient-tailored integrated care. Authors propose a model for quality management.

Psychotropic drug versus psychotropic drug-update

Psychotropic drugs are not necessarily the drugs of psychiatry. Seventy percent of antidepressants, and 90% of anxiolytics are prescribed by nonpsychiatric physicians. Since psychotropic medications are so frequently employed by nonpsychiatric physicians, e.g., neurologists, primary care physicians, internists, and because large numbers of their patients are concurrently on medical drugs for somatic reasons, the interactions of psychotropic versus medical drugs and psychotropic versus psychotropic drugs as listed below must be understood before primary care physicians or psychiatrists prescribe psychotropic medications, especially to the medically ill. Seventy commonly prescribed psychotropic drugs were examined for their interactions with other psychotropic medications using six reference tools: 1) MEDLINE (PubMed) employing the first generic psychotropic drug name, the second generic psychotropic drug name, and the term "interaction;" 2) Hanston's Drug Interaction Analysis and Management Text (quarterly updated version); 3) Drug Interactions Facts (Facts and Comparisons) (July 2001 quarterly updated version); 4) Micromedex Drug-dex; 5) American Hospital Formulary Service Drug Information; and 6) Food and Drug Administration (MedWatch) (Dear Doctor Letters and new labeling) ( for (1999, 2000, and 2001). The authors recognized that all of the above sources do not necessarily cover the entire information database regarding drug-drug interactions. (Citations regarding children, reports in foreign languages or concerning food, animals, in vitro experiments, analgesics, and naturalistic-herbal or natural products-treatment interactions were excluded).

Psychotropic drugs, cardiac arrhythmia, and sudden death

A variety of drugs targeted towards the central nervous system are associated with cardiac side effects, some of which are linked with reports of arrhythmia and sudden death. Some psychotropic drugs, particularly tricyclic antidepressants (TCAs) and antipsychotic agents, are correlated with iatrogenic prolongation of the QT interval of the electrocardiogram (ECG). In turn, this is associated with the arrhythmia (TdP). This review discusses the association between psychotropic agents, arrhythmia and sudden death and, focusing on TCAs and antipsychotics, considers their range of cellular actions on the heart; potentially pro-arrhythmic interactions between psychotropic and other medications are also considered. At the cellular level TCAs, such as imipramine and amitriptyline, and antipsychotics, such as thioridazine, are associated with inhibition of potassium channels encoded by In many cases this cellular action correlates with ECG changes and a risk of TdP. However, not all psychotropic agents that inhibit HERG at the cellular level are associated equally with QT prolongation in patients, and the potential for QT prolongation is not always equally correlated with TdP. Differences in risk between classes of psychotropic drugs, and between individual drugs within a class, may result from additional cellular effects of particular agents, which may influence the consequent effects of inhibition of repolarizing potassium current.

Depression and anxiety and outcomes of coronary artery bypass surgery

Psychological and psychiatric disorders independently increase the risk of cardiovascular disease and worsen the prognosis in patients with established cardiovascular lesions. The objective of this literature review is to discuss recent data concerning the relationships between depression and anxiety and the outcomes of coronary artery bypass grafting. Pathophysiological hypotheses are put forward to explain observed links. We suggest recommendations aimed at improving the psychological evaluation and management of heart surgery candidates, as well as postbypass patients, in the hope of improving quality of life and cardiovascular outcomes in these patients.

Neurologic drug-psychotropic drug update

It is essential that both the neurologist and the psychiatrist be aware of the neurology drug-psychotropic drug interactions because neurologists prescribe many psychotropic medications and psychiatric consultants often recommend the use of psychotropic drugs for neurology patients. Six methods of examining drug-drug interactions were employed: 1) PubMed (MEDLINE); 2) Hanston's Drug Interaction Analysis and Management Text (July 2001 quarterly updated version); 3)Drug Interactions Facts (quarterly updated version through July 2001); 4) Micromedex Drug-dex; 5) American Hospital Formulary Service Drug Information; 6) Food and Drug Administration (MedWatch) Dear Doctor Letters and new labeling. Over eighty important interactions of significance level 1 (major), or significance level 2 (minor) were found. Furthermore, over one-third of the neurologist's most commonly administered medications were those also employed by the psychiatrist, but not necessarily for the same reason, e.g., carbamazepine, for seizure control (neurologist) or mood stabilization (psychiatrist).

Comparison of three methods for identifying medical drug-psychotropic drug interactions

Three methods for examining drug-drug interactions were compared to understand advantages and disadvantages of each: ePocrates; Interact; The Mount Sinai multiple source for the evaluation of drug-drug interactions (MS). ePocrates is a commonly employed software system utilized in a hand held computer, the PalmPilot. Interact is on a CD-ROM, and promoted by the American Psychiatric Association Press. The MS system was developed by the authors and utilizes six separate references sources to ascertain the presence and significance of drug-drug interactions. Commonly prescribed neurology and psychotropic medication interactions were compared using the three systems. ePocrates did not list the significance level of the interaction, e.g., (major, moderate, minor), often did not include a mechanism of action, and several commonly employed medications were not included. It did permit examining several drugs at the same time, and was easily carried on the person of the physician. Interact often contained old references, several drugs were not included, was not adapted to a hand held computer format, and had no update since 1999. The MS system listed level of significance, provided mechanism of action, and advice to the practitioner including recommendations. It is not portable, requiring a laptop or desk top computer or hard copy, and only searches one drug at a time. It is hoped that the advantages of each of these three systems may be incorporated into systems of the future.

Cardiac drug-psychotropic drug update

This is an update from the report-Cardiac Drug and Psychotropic Drug Interactions: Significance and Recommendations-published in this journal in November-December 1999. As mentioned in that article there has been an explosion of new drugs both in psychiatry and cardiology without a sufficient understanding of their potential interactions. Also there is a need for methods to update drug interactions on an ongoing basis. This report describes: 1) examples of actual adverse interactions from clinical cases that move beyond some of the hypothesized contraindications included in the 2000 millennium publication; 2) confirmation of previous adverse interactions reported if they strengthen the earlier findings; 3) listing of new drugs, e.g., sildenafil (viagra) now commonly prescribed by psychiatrists and cardiologists; 4) reports explaining and/or refining mechanisms of adverse interactions; and 5) cautions and important associated phenomenon of either a cardiac or a psychotropic drug, e.g., valproic acid and cases of life-threatening pancreatitis. Methods of publicizing the new knowledge of cardiac drug-psychotropic drug interactions, e.g., the Internet and web sites are described.

Who develops severe or fatal adverse drug reactions to selective serotonin reuptake inhibitors?

OBJECTIVE

To ascertain the risk factors associated with the development of severe and fatal adverse drug reactions (ADRs) or intentional overdoses by patients on selective serotonin reuptake inhibitors (SSRIs).

METHODS

We undertook a data analysis of Health Canada's database of Adverse Drug Reactions to SSRIs from 1986 to 1996, as well as a literature review.

RESULTS

Among the complete ADR reports in the SSRI database, there were no sex differences in occurrences of all ADRs (n = 1011), severe ADRs (n = 295), drug-drug interactions (n = 312), deaths (n = 87), or intentional overdoses (n = 79), when sex differences in prescription practices were considered. There were no differences in ADR rates among different SSRIs. The most common cause of death among patients taking SSRIs was intentional overdose (n = 65, 74.7%). This was reported in 47 (72.3%) women and 18 (27.7%) men. The most common drugs taken with SSRIs in patients who died of intentional overdoses were benzodiazepines, tricyclic antidepressants (TCAs), narcotics, alcohol, and diphenhydramine. Patients who had severe or fatal ADRs were more likely to be taking an SSRI with 2 or more other drugs, including alcohol. Drug combinations that included another CYP-450 drug were especially problematic. A total of 129 cardiovascular ADRs were reported, most of which were severe. These included rhythm disturbances, blood pressure perturbations, and chest pain or angina. Cardiovascular ADRs most often occurred with concomitant drug use of benzodiazepines, TCAs, histamine H2 antagonists, lithium, and calcium channel blockers. There were 3 deaths from malignant neuroleptic syndrome unassociated with intentional overdose.

CONCLUSIONS

SSRIs are relatively safe when their widespread use is compared with the prevalence of ADRs. SSRIs may, however, be associated with ADRs, and even death, following intentional overdose or when taken with 2 or more other drugs or alcohol (particularly another drug metabolized by CYP-450). Physicians prescribing SSRIs need to consider drug-drug interactions and carefully monitor patients with severe affective disorders, comorbid medical conditions (especially cardiovascular disease), alcohol abuse, or a history of overdosing.