21: Restarting Medications after OD Flashcards
What are the “7 Principles” to guide restarting meds after an OD?
1) look for opportunities for…..
2) ___ vs_____
3) ___vs _____
4) Is the pt experiencing _____?
5)
6) Is a _______ likely?
–> must ask, what we given anythign to pt to treat their poisioning that now might interact if we restart med?
–> and are we SWITCHIGN antidepressants, whcih may need a washout period?
7) Implementation and minimizing___
1) Do they even need the med? look for opportunities for deprescribing.
2) Risk vs Benefit
3) PK vs Toxicokinetics
4) Is the pt experiencing withdrawal/discontinuation syndrome?
5) Is there a blood level that can be done?
–> USUALLY, if pt’s levels are in therapeutic range, they can be restarted on meds.
6) Is a drug interaction likely?
–> must ask, what we given anythign to pt to treat their poisioning that now might interact if we restart med?
–> and are we SWITCHIGN antidepressants, whcih may need a washout period?
7) Implementation and Minimizing risk
If someone OD’s once, are they more likely to OD again vs someone who’s never?
yes!
Principle 2: Risk vs. Benefit
- What is the FIRST question should you ask when asseessing this?
- what are 3 other questions to ask?
What’s the worst possible thing that could hapen if I restart the med right now?
1) does pt look toxic?
2) Pt disposition? and where are they going? home? psych unit? icu? a monitored bed?
2) are they a risk to themslelves or others if they continue to hold antipsychotics for ex?
Principle 2:
- What are 4 characteristics of HIGH RISK situations, where you might considering delaying re-start.
- If still actively CNS depressed.
- Displaying elements of cardiotoxicity.
- If they’ve OD’d on a HYPOGLYCEMIC agent (sulfonylurea), have to be able to show they can control blood sugar withotu exogenous glu drip or octreotide antidote. Must show overnight fast = can control sugards on own.
- If showing any signs of opiate toxidrome.
Principle 3: Kinetics
- 97% of drugs are eliminated in how many half lives?
- 99.9%?
- 5 half lives.
- 99.9% in 10 half lives. [from steady state]
Principle 3: Kinetics
- How many days does it take for MOST pts to recover from an overdose?
1-4 days.
Principle 3: Kinetics
- What are some important considerations when assessing kinetics of ODs? (4)
- ACTIVE METABOLITES: Are we considering active metabolites from drugs.
- GENETIC VARIATION IN CYP ENZYMES:
- SATURATION OF ENZYMES: what other factors can saturate enzymes?
- CHANGES IN PHYSL MILIEU: Changing blood/urine pH can affect elim of certain drugs
Principle 4: is the pt in withdrawal?
What acronym can you used to assess withdrawal sx? what does it stand for?
Flu like symptoms
Insomnia
Nausea
Imbalance
Sensory Disturbances
Hyperarousal (Agitation/Anxiety)
What are the most likely culprits leading to withdrawal?
- SSRIs
- SNRIs
- Baclofen
- Opiates
- Benzodiazepines
- Ethanol
- Beta-blockers
- Clonidine
Which drug is known for mimicking brain death on overdose?
Baclofen
What is an unlikely drug associated with withdrawal?
- what does it look like clinically?
- what is the trx? (2)
baclofen! GABA-B agent.
It looks like ALCOHOL WITHDRAWAL. {think: ACHAT - ass hat}
Agitation
Confusion
Hallucinations
Autonomic volatility
Tremors
- Restart at LOWER dose then titrate up slowly.
- Can use BENZOS.
Principle 7:
- Which drug should you restart first?
most clinically imp. drug first; if multiple are imp, restart one with SHORTEST HALF LIFE first.
repeat OD is most likely in _____ months after first OD
9-10mths
CEASE stands for
Current medications, Estimate RISK, Assess for individual Pt, Sort + plan + implement, Eliminate and follow up
T or F: Toxicokinetics ≠ pharmacokinetics
T
