Psychopharmacology Of COVID-19 Flashcards
Only FDA approved drug for treatment of suspected or confirmed severe COVID-19 infection
REMDESIVIR an antiviral that interacts w/ RNA polymerase (infusion; for 5 or 10 days)
Organs affected by COVID
liver, kidneys, lungs, and heart, as well as the immune and hematological systems
a hematologic feature of severe COVID- 19 cases and may serve as a poor prognostic factor
lymphopenia
lymphocyte count less than 1.0 x 109/L
most commonly implicated psychotropics in hematological adverse effects including leukopenia, neutropenia & agranulocytosis
carbamazepine and clozapine (there is a class effect FDA warning on all 1st and 2nd generation antipsychotics)
COVID19 patients on clozapine have a higher risk of?
pneumonia & its complications
Explanations include aspiration, sialorrhea, sedation, & poorly understood effects on the immune system.
What to do with Clozapine dose if patient has fever and other signs of infection?
Reduce the dose by up to a half; closely monitor clozapine levels
psychotropics associated w/ platelet dysfunction & increased bleeding risk?
SSRIs and Valproic Acid
psychotropics of concern that can prolong QT interval
antipsychotics, TCAs, and the SSRI citalopram appear to be the agents of most concern
typical antipsychotic that causes greatest QT prolongation
thioridazine
IV Haloperidol also implicated
atypical antipsychotics that cause higher risk of QT prolongation
ziprasidone and possibly iloperidone
antipsychotics with lowest risk of QT prolongation
aripiprazole & possibly lurasidone
psychotropics associated w/ mild hepatoxicity that manifests w/ modest, transient increases in liver enzymes
valproate, carbamazepine, TCAs, SNRIs and second-generation antipsychotics
agents that are high risk of causing serious drug-induced liver injury
chlorpromazine, carbamazepine, valproate, duloxetine, and nefazodone (avoid in pxs w/ covid-19-associated liver dx)
Psychotropics highly dependent on renal excretion (so nephrotoxic)
lithium, gabapentin, topiramate, pregabalin, and paliperidone (duloxetine not recommended for those w/ severe renal impairment)
Neurologic symptoms falling into 3 categories
- CNS (headache, dizziness, ataxia, acute CVD, impaired consciousness, seizure)
- PNS (impairment in taste, vision, smell and neuropathic pain)
- Skeletal muscular injury
Avoid these agents in patients with COVID-19 delirium since they can cause or exacerbate confusion, sedation, and/or falls
benzodiazepines, opioids, & drugs with strong anticholinergic properties (tertiary amine TCAs, low- potency antipsychotics, benztropine, diphenhydramine)
psychotropics that can lower the seizure threshold in patients with seizures or structural brain lesions.
most antipsychotics (especially clozapine, quetiapine, olanzapine, and FGAs) and certain antidepressants (bupropion, tricyclics)
Psychiatric side effects of Chloroquine and Hydroxychloroquine
Psychosis, delirium, suicidality, personality changes, depression, nervousness, irritability, compulsive impulses, preoccupations, and aggressiveness
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
Hydroxychloroquine
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.
Tocilizumab
has possible positive effects on depressive symptoms
Antiviral: RNA-dependent RNA polymerase inhibitor approved in China but not in the US
Favipiravir
mild QT prolongation in a patient with Ebola
Psychiatric side effects: Possible abnormal dreams, agitation, anxiety, confusion, & emotional lability
All protease inhibitors associated with paresthesias, taste alterations, & neurotoxicity
Lopinavir/Ritonavir:
Antiviral Lopinavir: protease
inhibitor
Ritonavir: boosts plasma
levels of lopinavir
- 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
Lopinavir/Ritonavir:
Antiviral Lopinavir: protease
inhibitor
Ritonavir: boosts plasma
levels of lopinavir
What is Convalescent plasma therapy
Antibody containing convalescent plasma from patients who have recovered from viral infections
Antibacterial which may have antiviral & anti-inflammatory properties
Used with hydroxychloroquine.
Azithromycin
Psychiatric SEs: psychotic depression, catatonia, delirium, aggressive reaction, anxiety, dizziness, headache, vertigo, and somnolence
Azithromycin
(Risk of QTc prolongation, TDPs &
hepatotoxicity)
an antioxidant and reducing agent, for treatment of sepsis because of its enhancement of the immune response and preventing progressive organ dysfunction
Vitamin C
Coadministration with barbiturates may decrease the effects of vitamin C
Immune modulators and anti-inflammatory: may lessen cytokine storm and hyperinflammation syndrome
Corticosteroids
- 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)
Corticosteroids
Depression, mania, agitation, mood lability, anxiety, insomnia, catatonia, depersonalization, delirium, dementia, and psychosis
glycoproteins that have immunomodulatory, antiproliferative, and hormone-like activities
antiviral
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
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.
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
the gold standard for managing agitation in COVID-19 delirious patients.
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.
psychotropics recently named on a list of FDA-approved medications with potential for in vitro action against SARS-CoV-2
Haloperidol and Valproic Acid
SSRI under investigation for its potential to reduce the inflammatory response during sepsis by inhibiting cytokine production
Fluvoxamine
