Psychopharmacology Of COVID-19

Question 1

Only FDA approved drug for treatment of suspected or confirmed severe COVID-19 infection

Answer 1

REMDESIVIR an antiviral that interacts w/ RNA polymerase (infusion; for 5 or 10 days)

Question 2

Organs affected by COVID

Answer 2

liver, kidneys, lungs, and heart, as well as the immune and hematological systems

Question 3

a hematologic feature of severe COVID- 19 cases and may serve as a poor prognostic factor

Answer 3

lymphopenia

lymphocyte count less than 1.0 x 109/L

Question 4

most commonly implicated psychotropics in hematological adverse effects including leukopenia, neutropenia & agranulocytosis

Answer 4

carbamazepine and clozapine
(there is a class effect FDA warning on all 1st and 2nd generation antipsychotics)

Question 5

COVID19 patients on clozapine have a higher risk of?

Answer 5

pneumonia & its complications

Explanations include aspiration, sialorrhea, sedation, & poorly understood effects on the immune system.

Question 6

What to do with Clozapine dose if patient has fever and other signs of infection?

Answer 6

Reduce the dose by up to a half; closely monitor clozapine levels

Question 7

psychotropics associated w/ platelet dysfunction & increased bleeding risk?

Answer 7

SSRIs and Valproic Acid

Question 8

psychotropics of concern that can prolong QT interval

Answer 8

antipsychotics, TCAs, and the SSRI citalopram appear to be the agents of most concern

Question 9

typical antipsychotic that causes greatest QT prolongation

Answer 9

thioridazine

IV Haloperidol also implicated

Question 10

atypical antipsychotics that cause higher risk of QT prolongation

Answer 10

ziprasidone and possibly iloperidone

Question 11

antipsychotics with lowest risk of QT prolongation

Answer 11

aripiprazole & possibly lurasidone

Question 12

psychotropics associated w/ mild hepatoxicity that manifests w/ modest, transient increases in liver enzymes

Answer 12

valproate, carbamazepine, TCAs, SNRIs and second-generation antipsychotics

Question 13

agents that are high risk of causing serious drug-induced liver injury

Answer 13

chlorpromazine, carbamazepine, valproate, duloxetine, and nefazodone (avoid in pxs w/ covid-19-associated liver dx)

Question 14

Psychotropics highly dependent on renal excretion (so nephrotoxic)

Answer 14

lithium, gabapentin, topiramate, pregabalin, and paliperidone (duloxetine not recommended for those w/ severe renal impairment)

Question 15

Neurologic symptoms falling into 3 categories

Answer 15

1. CNS (headache, dizziness, ataxia, acute CVD, impaired consciousness, seizure)
2. PNS (impairment in taste, vision, smell and neuropathic pain)
3. Skeletal muscular injury

Question 16

Avoid these agents in patients with COVID-19 delirium since they can cause or exacerbate confusion, sedation, and/or falls

Answer 16

benzodiazepines, opioids, & drugs with strong anticholinergic properties (tertiary amine TCAs, low- potency antipsychotics, benztropine, diphenhydramine)

Question 17

psychotropics that can lower the seizure threshold in patients with seizures or structural brain lesions.

Answer 17

most antipsychotics (especially clozapine, quetiapine, olanzapine, and FGAs) and certain antidepressants (bupropion, tricyclics)

Question 18

Psychiatric side effects of Chloroquine and Hydroxychloroquine

Answer 18

Psychosis, delirium, suicidality, personality changes, depression, nervousness, irritability, compulsive impulses, preoccupations, and aggressiveness

Question 19

Higher risk of neuropsychiatric side effects when combined with CYP3A4 inhibitors, low- dose glucocorticoids, alcohol intake, family history of psychiatric disease, female gender, low body weight, and supratherapeutic dosing

Answer 19

Hydroxychloroquine

Question 20

a recombinant humanized monoclonal antibody that acts as an IL-6 receptor inhibitor and is FDA approved to treat several types of arthritis.
IL-6 appears to be involved in cytokine storms that have been observed in critically ill patients with COVID-19.

Answer 20

Tocilizumab

has possible positive effects on depressive symptoms

Question 21

Antiviral: RNA-dependent RNA polymerase inhibitor approved in China but not in the US

Answer 21

Favipiravir

mild QT prolongation in a patient with Ebola

Question 22

Psychiatric side effects: Possible abnormal dreams, agitation, anxiety, confusion, & emotional lability
All protease inhibitors associated with paresthesias, taste alterations, & neurotoxicity

Answer 22

Lopinavir/Ritonavir:

Antiviral Lopinavir: protease
inhibitor
Ritonavir: boosts plasma
levels of lopinavir

Question 23

• Extensively metabolized by CYP450– risk of multiple possible interactions
• Contraindicated with pimozide, midazolam, triazolam
• Lowers concentrations of some psychotropics (bupropion, methadone, lamotrigine, & olanzapine)
• Other SEs: SJS, DM, QTc prolongation, pancreatitis, neutropenia, hepatotoxicity, and CKD

Answer 23

Lopinavir/Ritonavir:

Antiviral Lopinavir: protease
inhibitor
Ritonavir: boosts plasma
levels of lopinavir

Question 24

What is Convalescent plasma therapy

Answer 24

Antibody containing convalescent plasma from patients who have recovered from viral infections

Question 25

Antibacterial which may have antiviral & anti-inflammatory properties
Used with hydroxychloroquine.

Answer 25

Azithromycin

Question 26

Psychiatric SEs: psychotic depression, catatonia, delirium, aggressive reaction, anxiety, dizziness, headache, vertigo, and somnolence

Answer 26

Azithromycin

(Risk of QTc prolongation, TDPs &
hepatotoxicity)

Question 27

an antioxidant and reducing agent, for treatment of sepsis because of its enhancement of the immune response and preventing progressive organ dysfunction

Answer 27

Vitamin C

Coadministration with barbiturates may decrease the effects of vitamin C

Question 28

Immune modulators and anti-inflammatory: may lessen cytokine storm and hyperinflammation syndrome

Answer 28

Corticosteroids

Question 29

• Phenytoin—increases hepatic metabolism
• Caution with bupropion—lowers seizure threshold
• Majority of neuropsychiatric side effects occur early in treatment course, usually w/in days, and dosing is the most significant risk factor (ie at prednisone equivalents of .40 mg/d)

Answer 29

Corticosteroids

Depression, mania, agitation, mood lability, anxiety, insomnia, catatonia, depersonalization, delirium, dementia, and psychosis

Question 30

glycoproteins that have immunomodulatory, antiproliferative, and hormone-like activities
antiviral

Answer 30

Interferon
IFN alpha “life-threatening/ fatal neuropsychiatric disorders.” effects include fatigue, mood disorders, suicidality, anxiety disorders, irritability, lability, apathy, sleep disturbance, and cognitive deficits.
Side effects of IFN beta fatigue, weight loss, myalgia, and arthralgia

Question 31

a plant-derived alkaloid with anti-inflammatory properties that is used for rheuma and cardiac conditions.
hypothesized that it could treat COVID-19 through targeting the overactive interleukin-6 pathway.

Answer 31

Colchicine

• has narrow therapeutic index
• metabolized by CYP3A4 and excreted via P-glycoprotein transport system as well as cleared by the kidneys through glomerular filtration

Question 32

the gold standard for managing agitation in COVID-19 delirious patients.

Answer 32

Haloperidol
-a-2 agonists (dexmedetomidine & clonidine) or antiepileptics (valproic acid) should be considered if cardiac risk is high and/or if the antipsychotic is clinically ineffective.

Question 33

psychotropics recently named on a list of FDA-approved medications with potential for in vitro action against SARS-CoV-2

Answer 33

Haloperidol and Valproic Acid

Question 34

SSRI under investigation for its potential to reduce the inflammatory response during sepsis by inhibiting cytokine production

Answer 34

Fluvoxamine