Reference guide final 2.qxd


Mood DisordersPsychopharmacology UnitUniversity Health NetworkUniversity of Toronto Please note, P450 & Special Considerations sections are designed to contain helpful clinical information, and are not designed to be comprehensive. Medication interactions mediated by P450 enzymesub-systems can be derived from the P450 information sections of the guide. Selected other clinically significant medication interactions are referred to in the Special Considerations columns.
Total Daily
P450 Systems (primary enzymes only)
Special Considerations (Class Effects Boxed)
Dose Range Dosing
Substrate of:
Inhibits or Induces
(Avoid, Caution, Risk of)
Sexual dysfunction common, may be unreported Avoid sympathomimetics, clomipramine or opioids Caution antiarrhythmics & sympathomimetics Dietary restrictions, Extreme Caution with opiods, Tranylcypromine (Parnate) 20 - 80 bid (before 1pm) 2 - 4 Serotonergic drugs, sympathomimetics, OTC meds Avoid with HTN, Vascular disease, Pregnancy Note: Many antidepressants should be tapered gradually to avoid discontinuation syndromes Total Daily
P450 Systems
Special Considerations1
Dose Range
(hours) Substrate of: Inhibits or (Avoid, Caution with, Risk of)
Check CYP interactions of all below & Avoid rapid withdrawal
Risk EPS, hyperprolactenemia, NMS, Caution hypotensives Risk weight gain, NMS, transient transaminase abnormalities Risk NMS, Caution hypotensives, Cataracts in humans not proven Use titration & Monitoring schedule, Caution fluvoxamine, BZD, Li, hypotensives Risk weight gain, seizures, aganulocytosis, cardiac effects, NMS Pregnancy & Lactation, Risk QT prolongation, TD, EPS, NMS, seizures Caution fluvoxamine, Risk TD, NMS, Highest risk EPS, hyperprolactinemia Risk TD, NMS, moderate risk EPS, Hyperprolactinemia Risk TD, NMS, moderate risk EPS, Hyperprolactinemia Risk TD, NMS, moderate risk EPS, Hyperprolactinemia Caution hypotensives, Risk EPS, TD, NMS, weight gain, seizures, hypotension 1 With atypical antipsychotics monitor glucose & lipids IM formulations indicated for acute use; bioavailability up to double that of oral dose. DEPOT ANTIPSYCHOTICS
Dose Range in mg
Clinical Equivalence
(Estimated, mg)
Zuclopenthixol decanoate (Clopixol depot) Zuclopenthixol acetate (Clopixol acuphase) 1 Short term use only: Maximum 4 injections ANXIOLYTICS &
Dose Range
P450 Systems
Special Considerations (Class Effects Boxed)
(Hours) Substrate of:
Inhibits or (Avoid, Caution with, Risk of)
Cumulative effect with other sedatives; Caution in pregnancy In liver disease suggest lorazepam, oxazepam, temazepam Caution with Clozapine, Digoxin; Avoid in sleep apnea Abuse liability--less likely with longer onset of action Withdrawal syndromes -- most severe with short-acting agents Risk of confusion & falls in the elderly; See P450 interactions Risk of mania in elderly; Not effective on prn basis Withdrawal syndrome, Risk hypotension, leukepenia; Caution with sedatives Zolpidem only: Risk delirum & hallucinations combined with SSRIs, SNRI, Caution with other serotonergic agents, lithium; Avoid in pregnancy, diabetes Withdrawal syndrome, Avoid in pregnancy, Avoid with Ginko Biloba Caution with anticholinergics, serotonergics; Risk hypotension, priapism CHOLINESTERASE
Total Daily
Special Considerations (All listed are Class Effects)
Dose Range
Substrate of:
(Avoid, Caution with, Risk of)
Caution with cardiac or coronary artery disease, ulcers, asthma Caution with NSAIDS; Toxic in Overdose; Risk Withdrawal Syndrome Avoid with anesthesia, anticholinergics, cholinomimetics, or in Epilepsy Total Daily
Blood Level
P450 Systems
Special Considerations (Avoid, Caution with, or Risk of)
Dose Range
Inhibits or Induces: (Carefully review mood stabilizers in pregnancy & breastfeeding)
Toxic > 1.5mEq/L, Avoid fluid balance shifts, Avoid with breastfeeding, Iodide salts, Caution in cerebral/cardiac/renal disease, Caution NSAIDS Start 600 - 900mg/day & CBC, lytes, Cr, Ca, TSH, +/- ECG, up 300mg q 5 days, follow levels antihypertensives, Risk hypothyroidism, renal disease, Teratogenic Risk Liver & Pancreatic Toxicity, Blood Dyscrasias including Thrombocytopenia, Serious Rashes, Teratogenic Start 750mg/day divided or qhs & CBC, lytes, Cr, LFT, up 250mg/week to levels Risk Serious Rash, Blood Dyscrasias, SIADH, Teratogenic Caution in Liver Disease, Check CYP interactions, Induces own metab.
Start 200mg bid or qhs & CBC, lytes, Cr, LFT, up 200mg q 3 - 5 days following levels Risk Arrhythmias, Serious Rash, Hyponatremia, Liver Toxicity Caution in Pregnancy, Lactation, Cardiac Disease, Renal Disease Start 300mg bid & check Sodium, 600mg bid average target dose P-450 inducers & DVPX decrease level of active compound Risk Rashes, SJ Synd., PR Prolongation, Titrate slowly Anticonvulsants affect levels, Caution with DVPX, Avoid in pregnancy Start 25 -50mg/day, up 25mg q week to target (300-500mg), use 1/2 these doses if added to DVPX, higher doses if added to CBZ, Caution in Renal Disease, CBZ decreases levels Start 25mg bid, up 25mg bid/week to target (200-400mg/day)1 Initial dose is 1/2 minimum target daily dose, divided bid, increase after 4 weeks to first target dose, can increase further after 4 week intervals ATTENTION-DEFICIT
P450 Systems
Special Considerations (Class Effects Boxed)
Action (hrs)
Substrate of:
Inhibits or (Avoid, Caution with, Risk of)
Can give low dose regular methylphenidate at 4pm if needed Monitor height/weight; Risk anorexia, dysphoria or tolerance Caution with cardiovascular disease, psychosis, tic disorder, hyperthyroidism, seizure disorder; Caution noradrenergics Tricyclic Antidepressants (i.e. desipramine) divide >150mg Refer to Antidepressant Section 1 Slow time of onset, and limited duration of action 2 Methylphenidate metabolism inhibited by phenytoin, phenobarbital, primidone, warfarin SIDE EFFECT
Dosing (# per dose)
Primary Agent
Augmenting Agent + Dosing
1mg/kg IV q6h prn max 10mg/kg Note: Before augmenting, optimize dose of primary agent &
address co-morbid diagnoses, eg personality disorder Caution with other combinations of two antidepressants Combinations involving MAOIs should be monitored by 1SNRI = Serotonin & Norepinephrine Reuptake Inhibitor P-450 System Information for Common Interacting Non-Psychiatric Medications
P450 System Information for Common Interacting Non-Psychiatric Medications
Medications Listed by P-450 System, as Substrate, Medications Listed by P450 System, as Substrate, Inhibitor With Permission: Flockhart, DA. Jan 2002. Drugs Metabolized by Known P450's. Reference Card. Indiana University School of MedicineBezchlibnyk-Butler, KZ & Jeffries, JJ. 2002. Clinical Handbook of Psychotropic Drugs 12 ed. Hogrefe & Huber Publishers.
This reference guide has been developed based on the collaborative research and clinical experience of the authors. Funding for this educational guide was in the form of an unrestricted grant from Wyeth.
Supported by an Unrestricted Educational Grant from



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