Lecture 11 - patient safety Flashcards
describe the steps in treatment for acute and chronic depression.
- discuss choice of drug with the patient - potential therapeutic effects, adverse effects, likely time to respsond etc.
- start antidepressant - titrate to recognised therapeutic doses. assess
-efficacy after 2 weeks.
assess weekly for a further 1-2 weeks. f still no response, consider increasing dose.
- effective: continue for 6-9 months at full treatment dose. consider longer term treatment in recurrent depression
- poorly tolerated: switch to a a different antidepressant. titrate to therapeutic dose. assess efficacy over 3-4 weeks. - no effect or poorly tolerated: switch to a different antidepressant. titrate to therpeauti c dose. assess over 3-4 weeks. increase as necessary
- consider their choice options: mirtazapine, vortioxetine, agomelatine
- no effect: refere to suggested treatments for refractory depression
what are safety issues in antidepressant use
- switching/ cross titration - occurs when no response seen or intolerable side effects. Consult specialised literature for potential switching regimes
- Discontinuation (withdrawal) effects – electric shocks, flu like symptoms, disturbed sleep, GI issues, ataxia/sensory vasomotor,
factors associated with high risk of SSRI/SNRI withdrawal symptoms
- short half life of drug (paroxetine, venlafaxine)
- anticholinergic effects of drug (paroxetine)
- drug has no active metabolites (paroxetine)
- exposure to drug >1 year
- rapid tapering (<1-2months or sudden discontinuation of antidepressant)
- Serotonin Syndrome- likely during augmentation, or when treating Resistant Depression. (range in severity & presentation)
neuromuscular hyperactivity/abnormality (tremor, clonus, rigidity)
autonomic dysfunction/instability (tachycardia, hyperthermia, cold sweats)
altered mental state (agitation, confusion) - Poly Pharmacy - ++ morbidity, ++side effects, potential for CYP interactions (i.e 2D6),
- Co morbidities- at the receptor level (psychotropic response) different organs (kinetics- e.g Na+ excretion)
- C & Adoles- increase in self harm / suicidal thoughts / aggression
what are safety issues with lithium
Lithium is very effective in the maintenance treatment of bipolar affective disorder, recurrent depression and self injurious behaviour.
–Most people receiving lithium are in the community.
-Lithium has a narrow therapeutic index, with a high potential for toxicity and therefore careful monitoring is required for safe use. Consequently if lithium treatment is not managed properly there is a potential risk of significant harm.
- Monitoring frequency and plasma levels
- Pregnancy (teratogenicity
what are the safety issues in antipsychotic use?
Metabolic syndrome – diabetes, dyslipidaemia
Thromboembolism
Myocarditis and cardiomyopathy
QTC elongation – arrhythmias, sudden death (esp at High Dose)
Higher risk of seizures
Neuroleptic Malignant Syndrome (muscle rigidity and rapid rise of body temperature and confusion). Usually reversible but death from renal or cardiovascular failure can happen in 10-20% of cases.
Clozapine – propensity for leukopenia/agranulocytosis
what is lifestyle and health/promotion?
Need to be especially pro-active in people taking SGAs- YOU need to actively engage when dispensing APs.
Tailor your advice- make it relevant / realistic (what does ‘go to the gym’ actually mean?)
Sign post to appropriate services – advocacy, Housing, Social Work
Substance Use – consider role/impact of this… don’t automatically try to stop/prohibit.
what is High Dose Antipsychotic Therapy (HDAT)?
High Dose Antipsychotic Therapy (HDAT) is defined by the Royal College of Psychiatrists as either:
a total daily dose of a single antipsychotic which exceeds the upper limit stated in the BNF or A total daily dose of two or more antipsychotics which exceeds the BNF maximum as calculated by percentage.
When / why does HDAT happen?
1. Acute psychotic episode (switching)
2. Relapse prevention / poor concordance (oral + depot)
3. Acute disturbance / emergency tranquillisation (PRN use oral or IM)
4. Treatment resistance / refractory (augmentation)
what are monitoring requirements for antipsychotic drugs? x7
BASELINE TESTS AND EVERY 3 MONTHS
ECG
Pulse / Heart rate
Blood Pressure
Temperature
FBC
LFTs
U&Es also Ca, Mg – electrolytes associated with homeostasis
what is clozapine background? x4
Up to 60% success in those who have failed to respond to other antipsychotics -TRS
Possibility of developing serious side effects- agranulocytosis, neutropenia
Co ordinated clozapine central monitoring system
Patient must have a valid blood result before supply
NO BLOOD = NO DRUG
what is the clozapine dispensing arrangements? x7
Regular monitoring of WBC, especially neutrophils
Neutrophil count coded green, amber and red
Medication supplied when result is green i.e neutrophil count > 2X109/l
0-18 wks = WEEKLY BLOODS
NEXT 18 wks = FORTNIGHTLY
THEREAFTER i.e duration of treatment = MONTHLY
Gradual titration of dose starting from 25mg daily up to 900mg (max), however, break in treatment of >48hours, MUST re-titrate from starting dose i.e 25mg
what is clozapine specific safety issues?
Red or amber result
Management of leukopenia / agranulocytosis
Missed doses (> 48 hrs)
CYP induction / inhibition
Co-prescribing (esp other neutropenic drugs e.g CBZ)
One stop dispensing – hospital / Comm Pharm
Other medicines via GP10 Rx or depot (different supply routes)
comment on Dependence / Tolerance
Mostly drugs which act on dopamine, noradrenaline / GABA receptors or transmitters ie the pleasurable pathways
e.g Benzos- z drugs, opioids, (for pain relief)
Long term / repeat Rx- consider the need and impact on patient- variable review approach required.
Need to withdraw gradually to prevent ‘re-bound’ (@cellular level) and to avoid relapse (@ behavioural level).
describe BZs dependence / Tolerance and how to withdraw or stop treatment.
Shorter acting BZs tend to be more problematic
To withdraw or stop – need to convert current benzodiazepine dose to ‘diazepam dose equivalents’
Gradual reduction by 1/8th (or 1/6th) of total daily dose every fortnight – over 6 months. (not an exact science- depends on symptoms
Bioavailability / kinetics/ Missed doses
Some drugs need consistency of plasma concentration-
Which drugs is it most important for?
But missed doses are a reality-
HOWEVER- most psychotropic drugs have immediate and delayed effects- so what happens if you miss a dose?
which drugs are you most concerned about?
What advice is needed for an antidepressant /AED/anxiolytic /antipsychotic?
Consider hepatic / renal function and impact on dosing
what are inappropriate uses of psychotropic Medicines?
- Incorrect diagnosis / co-morbidity of Personality Disorder
- To provide relief or sedation in heightened state- easier option, less time consuming, gives validation to symptoms.
- High doses/combination therapy = adverse or different/other effects
- Patient group/status (elderly, pregnancy/breast feeding, puberty)
what are factors associated with Psychotropic drugs & driving?
All psychoactive drugs have impact on behaviour
All rules and restrictions set by the DVLA
Severe depression needs to be notified.
If patient has memory or concentration problem, agitation, behavioural disturbance or suicidal thoughts
Patients should not drive during a course of ECT & 3 months after
Patients should be advised to inform the DVLA of their circumstances
If clear evidence a patient is driving shortly after ECT against RMO advice the RMO should consider whether it is appropriate to breach confidentiality and contact DVLA
