Drug Induced Psychosis
Drug Induced Psychosis is impairment of perception due to gross distortion of reality.
It can be characterized by these 3 things
Hallucinations
-Delusions
-Physical symptoms
Describe HIT
An antibody-mediated, adverse drug reaction characterized by thrombocytopenia high risk for venous or arterial thrombosis
These risk factors can be associated with Stevens Johnson Syndrome (SJS) & Toxic Epidermal Necrolysis (TEN)
-History of SJS/TEN
-Genetic predisposition (Chinese, Southeast ASian or Indian descent)
-Viral infection
-Immunocompromised (Hx of transplant or autoimmune disease
What is an ADR?
Unexpected, unintended, undesired or excessive response to a drug
●May require discontinuing drug
●Changing the therapy
●Modify the dose (excluding minor dose adjustments)
●Prolong stay in healthcare facility
●Require supportive treatment
●Compicates diganis
●Results in temporary or permanent harm, disability or death
Describe Serotonin Syndrome
Excessive serotonergic activity leading to mental status changes, neuromuscular abnormalities, diaphoresis, labile blood pressure
Name some causative agents that could contribute to drug induced psychosis
Amphetamines
Anabolic Steriods
Anticholinergics
Corticosteroids
Dopamine Agonists
Describe a symptom associated with HIT and when it may occur
Greater than or equal to a 50% decrease in platelets count, beginning 5-14 days after starting heparin
These symptoms can occurs 1-3 weeks after start of offending drug?
Malaise, fever, headache, cough & keratoconjunctivitis, macules appearing suddenly on face, neck & upper trunk, could involve palms soles of feet, sloughing
What is the difference between an med error and an ADR?
Med errors are preventable. Always think, was this preventable?
Example of a preventable med error that initially identified as an ADR
PT admitted with symptomatic bradycardia into the 30's and required trans-cutaneous pacing. PT was PD. PT digoxin level documented 5.4. on admission. DigiFab administered. Home dose of digoxin was 250 mcg PO daily.
Additional review noted Digoxin was not a current medication on prior admission before current admission. PT had not filled Digoxin at outside retail pharmacy for almost year.
Due to incorrect admission med rec, PT received digoxin throughout this prior admission, was also discharged on digoxin to ECF.
Digoxin may be increased 10 fold in patient with renal impairment. Concentrations increase after DigiFab. Rebound toxicity occurs in 2% of PT after full dose of DigiFab, can develop 12-24 hr after. Up to 10 days in PT w/ renal failure.
What are some examples of serotonin syndrome?
●Clonus
●Shivering
●Diaphoresis
●Tremor
●Muscle rigidity
●AMS
●Seizures
●ARF
Benzodiazepine withdrawal can be associated with these symptoms
Tremors
Fever
Seizures
What are the 4T’s of HIT?
Thrombocytopenia
Timing of thrombocytopenia
Thrombosis
other reason
What is the common cause of death in SJS/TEN?
-Sepsis
-Multi-organ failure
Name some possible trigger meds for an ADR
(aside from Narcan, Romazicon & Benadryl)
-D50
-Epinephrine
-Anti-emetics
-Sodium polystyrene sulfonate
-Vit K
-Oral vancomycin/metronidazole for cdiff
As a pharmacist, how would you manage or
advise to serotonin syndrome?
Discontinue all serotonergic meds
Supportive measure like cooling, fluid replacement
Continuous cardiac monitoring
Sedation w/ benzo’s
Lorazepam 1-2 mg IV per dose
Antiserotonergic agent
Cyproheptadine
Consider neuromuscular blocking agent for sustained myoclonus
Stimulants withdrawal can be associated with these symptoms
Mydriasis
Tachycardia
Arrhythmias
When HIT is suspected or confirmed, these things should be done
-Discontinue & avoid all heparin
-Document as allergy on patient profile
-Test for HIT antibodies
-Investigate for lower limb deep vein thrombosis
-Avoid prophylactic platelet transfusions
-Postpone warfarin pending substantial platelet count recovery (give vitamin k if warfarin has already been started)
What are the 2 most important elements for treatment?
1)Discontinuing offending agent
2)Transfering to burn unit
Other includes supporting care, systemic therapy such as
-IVIG
-Corticosteroids
-TNF-alpha receptor blockers (etanercept, infliximab, adalimumab, certolizumab, golimumab)
-Plasmapheresis
This is 10 question tool that is used to determine the probability of an ADR
Naranjo Scale
What are some medications that could cause
Drug-induced Parkinsonism?
1st and 2nd generation antipsychotics
Metoclopramide
Valproate
Methyldopa
Reserpine
Management includes
Discontinuing offending agent
Early detection
Administration of an anticholinergic agent, amanatidine, levodopa or a dopamine agonist
Diphenhydramine 10-50 mg per dose IV or IM
Can use 100 mg doses if lower doses ineffective
Can be repeated up to 3 times daily max of 400 mg daily
Benztropine 1-2 mg 2-3 times daily PO, IV or IM
Mydriasis, tachycardia, urinary retention & constipation can be associated with withdrawal from?
Anticholinergics
This should be avoided in patients with prior history of Type II HIT
Use of LMWH or UFH
Pharmacist’s Role can include the following
-Med Rec
-Education
-Reporting ADRs
-Drug Interactions
Explain why an adverse drug reaction would be reported to MedWatch?
The reaction would be caused by the med, not the patients response to the medication.
Name some medications that could cause a drug-induced seizure?
Examples include
Bupropion
Tricyclic antidepressants
Beta-lactam antibodies
Amantadine
Meperidine
Tramadol
Aminophylline/Theophylline
Baclofen withdrawal
Chlorpromazine
Management
Discontinuing offending med
Re-initiation of med if seizure due to drug discotninuation