Reference guide final 2.qxd
CANADIAN QUICK
REFERENCE GUIDE to
PSYCHIATRIC MEDICATION
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)
ANTIDEPRESSANTS
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
ANTIPSYCHOTICS
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)
SEDATIVES
Anxiolytic
Sedative
(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)
INHIBITORS
Dose Range
Substrate of:
(Avoid, Caution with, Risk of)
(MILD TO MOD. DEMENTIA)
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)
STABILIZERS
Dose Range
Substrate
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
Duration
P450 Systems
Special Considerations (Class Effects Boxed)
HYPERACTIVITY
Action (hrs)
Substrate of:
Inhibits or (Avoid, Caution with, Risk of)
DISORDER IN CHILDREN
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
COMBINATIONS FOR REFRACTORY DEPRESSION
MANAGEMENT
Indication
Dosing (# per dose)
Primary Agent
Augmenting Agent + Dosing
Medication
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
Source: http://www.mdpu.ca/documents/reference.pdf
Health, Nutrition and Population Sector Program (HNPSP) in Bangladesh: Procurement of 32 Million Cycles Low Dose Oral Contraceptive Pills Kreditanstalt für Wiederaufbau Status: Current KEY INFORMATION Project Reference No(s): 2003 66 237 / 2005 70 424 DGFP/L&S-3/KfW/2009/6443/ WB308-767/10 Contacts: Director (Logistics and Supply) and Line Director (Procurement, Storage & Supply Managemen
THE JOURNAL OF ALTERNATIVE AND COMPLEMENTARY MEDICINE Volume 13, Number 7, 2007, pp. 771–776 © Mary Ann Liebert, Inc. DOI: 10.1089/acm.2006.6203 Holotropic Breathwork: The Potential Role of a Prolonged, Voluntary Hyperventilation Procedure as an JOSEPH P. RHINEWINE, Ph.D.,1 and OLIVER J. WILLIAMS, B.A.2 ABSTRACT Objectives: To pose the question of whether Holotropic Breathwork (HB), a