Benzodiazepines Overview Benzodiazepines Are Prescription Medications That Have Been Around for Over 50 Years
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Table 2. 2012 AGS Beers Criteria for Potentially
Table 2. 2012 AGS Beers Criteria for Potentially Inappropriate Medication Use in Older Adults Strength of Organ System/ Recommendat Quality of Recomm Therapeutic Category/Drug(s) Rationale ion Evidence endation References Anticholinergics (excludes TCAs) First-generation antihistamines Highly anticholinergic; Avoid Hydroxyzin Strong Agostini 2001 (as single agent or as part of clearance reduced with e and Boustani 2007 combination products) advanced age, and promethazi Guaiana 2010 Brompheniramine tolerance develops ne: high; Han 2001 Carbinoxamine when used as hypnotic; All others: Rudolph 2008 Chlorpheniramine increased risk of moderate Clemastine confusion, dry mouth, Cyproheptadine constipation, and other Dexbrompheniramine anticholinergic Dexchlorpheniramine effects/toxicity. Diphenhydramine (oral) Doxylamine Use of diphenhydramine in Hydroxyzine special situations such Promethazine as acute treatment of Triprolidine severe allergic reaction may be appropriate. Antiparkinson agents Not recommended for Avoid Moderate Strong Rudolph 2008 Benztropine (oral) prevention of Trihexyphenidyl extrapyramidal symptoms with antipsychotics; more effective agents available for treatment of Parkinson disease. Antispasmodics Highly anticholinergic, Avoid Moderate Strong Lechevallier- Belladonna alkaloids uncertain except in Michel 2005 Clidinium-chlordiazepoxide effectiveness. short-term Rudolph 2008 Dicyclomine palliative Hyoscyamine care to Propantheline decrease Scopolamine oral secretions. Antithrombotics Dipyridamole, oral short-acting* May -
Appendix A: Potentially Inappropriate Prescriptions (Pips) for Older People (Modified from ‘STOPP/START 2’ O’Mahony Et Al 2014)
Appendix A: Potentially Inappropriate Prescriptions (PIPs) for older people (modified from ‘STOPP/START 2’ O’Mahony et al 2014) Consider holding (or deprescribing - consult with patient): 1. Any drug prescribed without an evidence-based clinical indication 2. Any drug prescribed beyond the recommended duration, where well-defined 3. Any duplicate drug class (optimise monotherapy) Avoid hazardous combinations e.g.: 1. The Triple Whammy: NSAID + ACE/ARB + diuretic in all ≥ 65 year olds (NHS Scotland 2015) 2. Sick Day Rules drugs: Metformin or ACEi/ARB or a diuretic or NSAID in ≥ 65 year olds presenting with dehydration and/or acute kidney injury (AKI) (NHS Scotland 2015) 3. Anticholinergic Burden (ACB): Any additional medicine with anticholinergic properties when already on an Anticholinergic/antimuscarinic (listed overleaf) in > 65 year olds (risk of falls, increased anticholinergic toxicity: confusion, agitation, acute glaucoma, urinary retention, constipation). The following are known to contribute to the ACB: Amantadine Antidepressants, tricyclic: Amitriptyline, Clomipramine, Dosulepin, Doxepin, Imipramine, Nortriptyline, Trimipramine and SSRIs: Fluoxetine, Paroxetine Antihistamines, first generation (sedating): Clemastine, Chlorphenamine, Cyproheptadine, Diphenhydramine/-hydrinate, Hydroxyzine, Promethazine; also Cetirizine, Loratidine Antipsychotics: especially Clozapine, Fluphenazine, Haloperidol, Olanzepine, and phenothiazines e.g. Prochlorperazine, Trifluoperazine Baclofen Carbamazepine Disopyramide Loperamide Oxcarbazepine Pethidine -
Commonly Prescribed Psychotropic Medications
COMMONLY PRESCRIBED PSYCHOTROPIC MEDICATIONS NAME Generic (Trade) DOSAGE KEY CLINICAL INFORMATION Antidepressant Medications* Start: IR-100 mg bid X 4d then ↑ to 100 mg tid; SR-150 mg qam X 4d then ↑ to 150 mg Contraindicated in seizure disorder because it decreases seizure threshold; stimulating; not good for treating anxiety disorders; second Bupropion (Wellbutrin) bid; XL-150 mg qam X 4d, then ↑ to 300 mg qam. Range: 300-450 mg/d. line TX for ADHD; abuse potential. ¢ (IR/SR), $ (XL) Citalopram (Celexa) Start: 10-20 mg qday,↑10-20 mg q4-7d to 30-40 mg qday. Range: 20-60 mg/d. Best tolerated of SSRIs; very few and limited CYP 450 interactions; good choice for anxious pt. ¢ Duloxetine (Cymbalta) Start: 30 mg qday X 1 wk, then ↑ to 60 mg qday. Range: 60-120 mg/d. More GI side effects than SSRIs; tx neuropathic pain; need to monitor BP; 2nd line tx for ADHD. $ Escitalopram (Lexapro) Start: 5 mg qday X 4-7d then ↑ to 10 mg qday. Range 10-30 mg/d (3X potent vs. Celexa). Best tolerated of SSRIs, very few and limited CYP 450 interactions. Good choice for anxious pt. $ Fluoxetine (Prozac) Start: 10 mg qam X 4-7d then ↑ to 20 mg qday. Range: 20-60 mg/d. More activating than other SSRIs; long half-life reduces withdrawal (t ½ = 4-6 d). ¢ Mirtazapine (Remeron) Start: 15 mg qhs. X 4-7d then ↑ to 30 mg qhs. Range: 30-60 mg/qhs. Sedating and appetite promoting; Neutropenia risk (1 in 1000) so avoid in immunosupressed patients. -
Meta-Analysis of the Efficacy of Treatments for Posttraumatic Stress Disorder Bradley V
META-ANALYSIS Meta-Analysis of the Efficacy of Treatments for Posttraumatic Stress Disorder Bradley V. Watts, MD, MPH; Paula P. Schnurr, PhD; Lorna Mayo, MD, MPH; Yinong Young-Xu, PhD; William B. Weeks, MD, MBA; and Matthew J. Friedman, MD, PhD ABSTRACT treatments for posttraumatic stress disorder (PTSD) have Many 1 2 Objective: Posttraumatic stress disorder (PTSD) is been developed over the past 2 decades. , The treatments an important mental health issue in terms of the include a variety of psychotherapies, medications, and somatic and number of people affected and the morbidity and complementary therapies. The most commonly studied types of functional impairment associated with the disorder. psychotherapy are cognitive-behavioral therapies (CBTs), such as The purpose of this study was to examine the prolonged exposure, 3,4 cognitive processing therapy,5, 6 and cognitive efficacy of all treatments for PTSD. therapy,7,8 along with eye movement desensitization and reprocessing.9, 10 Data Sources: PubMed, MEDLINE, PILOTS, and Most of the research has focused on individual treatment, although PsycINFO databases were searched for randomized there have been some studies of group-based treatment as well. 11,12 The controlled clinical trials of any treatment for PTSD most commonly studied medications are antidepressants, particularly in adults published between January 1, 1980, and selective serotonin reuptake inhibitors (SSRIs). Atypical antipsychotic April 1,2012, and written in the English language. medications also have been studied relatively often, although to a far The following search terms were used: post-traumatic 1 3 141 5 lesser extent than antidepressants. , , stress disorders, posttraumatic stress disorder, PTSD, combat disorders, and stress disorders, post-traumatic. -
Prazosin: Preliminary Report and Comparative Studies with Other
298 BRITISH MEDICAL JOURNAL 1 1 MAY 1974 Prazosin: Preliminary Report and Comparative Studies with Other Antihypertensive Agents Br Med J: first published as 10.1136/bmj.2.5914.298 on 11 May 1974. Downloaded from GORDON S. STOKES, MICHAEL A. WEBER British Medical Journal, 1974, 2, 298-300 bilirubin. One patient had minimal grade 3 hypertensive ocu- lar fundus changes, 10 had grade 1 or 2 changes, and four had normal fundi. Serum crea-tinine concentration was normal in Summary every patient. A diagnosis of uncomplicated essential hypertension was In a group of 14 hypertensive patients a 10-week course made in 12 patients. In two other patients pyelographic of treatment with prazosin 3-7 5 mg/day produced a signifi- evidence of analgesic nephropathy was found. The remaining cant reduction in mean blood pressure without serious side patient had essential hypertension and stable angina pectoris. effects. The fall in diastolic pressure exceeded the response After at least two baseline blood pressure readings, taken mm more to a placebo by 10 Hg or in 9 patients. The average when patients were recumbent and standing, treatment was decrease in diastolic pressure was similar to that produced started with prazosin, 1-mg capsules by mouth, three times or by methyldopa 750 mg/day propranolol 120-160 mg/day daily. Thereafter the patient visited the clinic at intervals of was but the fall in systolic pressure comparatively smaller, one to three weeks. At each visit blood pressure was meas- that the consistent with reported experimental work showing ured to the nearest 5 mm Hg with an Accoson sphygmomo- drug causes vasodilatation. -
(PTSD) Executive Summary
Comparative Effectiveness Review Number 92 Effective Health Care Program Psychological and Pharmacological Treatments for Adults With Posttraumatic Stress Disorder (PTSD) Executive Summary Background Effective Health Care Program Posttraumatic stress disorder (PTSD) is a mental disorder that may develop The Effective Health Care Program following exposure to a traumatic was initiated in 2005 to provide event. According to the 4th edition of valid evidence about the comparative the “Diagnostic and Statistical Manual effectiveness of different medical of Mental Disorders: DSM-IV-TR,”1 interventions. The object is to help the essential feature of PTSD is the consumers, health care providers, development of characteristic and others in making informed symptoms following exposure to a choices among treatment alternatives. traumatic stressor. PTSD is characterized Through its Comparative Effectiveness by three core symptom clusters: Reviews, the program supports (1) reexperiencing, (2) avoidance or systematic appraisals of existing numbing (or both), and (3) hyperarousal. scientific evidence regarding The full DSM-IV-TR criteria are listed treatments for high-priority health in Table A. conditions. It also promotes and generates new scientific evidence by Examples of traumatic events include identifying gaps in existing scientific military combat, motor vehicle evidence and supporting new research. collisions, violent personal assault, The program puts special emphasis being taken hostage, a terrorist attack, on translating findings into a variety torture, natural or human-caused of useful formats for different disasters, and, in some cases, being stakeholders, including consumers. diagnosed with a life-threatening illness.1 PTSD develops in up to a third of The full report and this summary are individuals who are exposed to extreme available at www.effectivehealthcare. -
The American Journal Of
The American Journal of Psychiatry Residents’ Journal July 2015 Volume 10 Issue 7 Inside IN THIS ISSUE 2 New Formats and New Opportunities: The Time to Get Involved is “Now”! Rajiv Radhakrishnan, M.B.B.S., M.D. 3 Prevention of Posttraumatic Stress Disorder: Predicting Response to Trauma Jennifer H. Harris, M.D. 7 Weight Gain in Patients With Schizophrenia: A Recipe For Timely Intervention Ammar El Sara, M.B.Ch.B. 10 Hyperprolactinemia and Antipsychotics: Update for the Training Psychiatrist Stephanie Pope, M.D. 13 A Clinical Case Conference on Spiritual Growth and Healing Elizabeth S. Stevens, D.O. This issue of the Residents’ Journal features a variety of topics. Jennifer H. Har- ris, M.D., discusses prevention of posttraumatic stress disorder, with an overview 15 Priapism: A Rare but Serious of various responses to trauma. Ammar El Sara, M.B.Ch.B., presents a review of Side Effect of Trazodone clinically applicable evidence-based interventions targeting obesity in schizophre- Kamalika Roy, M.D. nia patients. Stephanie Pope, M.D., examines antipsychotic-induced hyperprolac- 17 Classifying Psychopathology: tinemia, including variables affecting prolactin and clinical implications. Elizabeth Mental Kinds and Natural Kinds S. Stevens, D.O., discusses several psychological, social, and spiritual developmen- Reviewed by Aaron J. Hauptman, tal frameworks in a clinical case conference. Kamalika Roy, M.D., presents a case M.D. of priapism as a side effect of trazodone in a middle-aged patient. Lastly, Aaron J. Hauptman, M.D., offers his review of the book Classifying Psychopathology: Mental 18 Residents’ Resources Kinds and Natural Kinds. Editor-in-Chief Associate Editors Editors Emeriti Rajiv Radhakrishnan, M.B.B.S., M.D. -
Psychedelics in Psychiatry: Neuroplastic, Immunomodulatory, and Neurotransmitter Mechanismss
Supplemental Material can be found at: /content/suppl/2020/12/18/73.1.202.DC1.html 1521-0081/73/1/202–277$35.00 https://doi.org/10.1124/pharmrev.120.000056 PHARMACOLOGICAL REVIEWS Pharmacol Rev 73:202–277, January 2021 Copyright © 2020 by The Author(s) This is an open access article distributed under the CC BY-NC Attribution 4.0 International license. ASSOCIATE EDITOR: MICHAEL NADER Psychedelics in Psychiatry: Neuroplastic, Immunomodulatory, and Neurotransmitter Mechanismss Antonio Inserra, Danilo De Gregorio, and Gabriella Gobbi Neurobiological Psychiatry Unit, Department of Psychiatry, McGill University, Montreal, Quebec, Canada Abstract ...................................................................................205 Significance Statement. ..................................................................205 I. Introduction . ..............................................................................205 A. Review Outline ........................................................................205 B. Psychiatric Disorders and the Need for Novel Pharmacotherapies .......................206 C. Psychedelic Compounds as Novel Therapeutics in Psychiatry: Overview and Comparison with Current Available Treatments . .....................................206 D. Classical or Serotonergic Psychedelics versus Nonclassical Psychedelics: Definition ......208 Downloaded from E. Dissociative Anesthetics................................................................209 F. Empathogens-Entactogens . ............................................................209 -
Guideline for Preoperative Medication Management
Guideline: Preoperative Medication Management Guideline for Preoperative Medication Management Purpose of Guideline: To provide guidance to physicians, advanced practice providers (APPs), pharmacists, and nurses regarding medication management in the preoperative setting. Background: Appropriate perioperative medication management is essential to ensure positive surgical outcomes and prevent medication misadventures.1 Results from a prospective analysis of 1,025 patients admitted to a general surgical unit concluded that patients on at least one medication for a chronic disease are 2.7 times more likely to experience surgical complications compared with those not taking any medications. As the aging population requires more medication use and the availability of various nonprescription medications continues to increase, so does the risk of polypharmacy and the need for perioperative medication guidance.2 There are no well-designed trials to support evidence-based recommendations for perioperative medication management; however, general principles and best practice approaches are available. General considerations for perioperative medication management include a thorough medication history, understanding of the medication pharmacokinetics and potential for withdrawal symptoms, understanding the risks associated with the surgical procedure and the risks of medication discontinuation based on the intended indication. Clinical judgement must be exercised, especially if medication pharmacokinetics are not predictable or there are significant risks associated with inappropriate medication withdrawal (eg, tolerance) or continuation (eg, postsurgical infection).2 Clinical Assessment: Prior to instructing the patient on preoperative medication management, completion of a thorough medication history is recommended – including all information on prescription medications, over-the-counter medications, “as needed” medications, vitamins, supplements, and herbal medications. Allergies should also be verified and documented. -
PTSD) Comparative Effectiveness Review Number 92
Comparative Effectiveness Review Number 92 Psychological and Pharmacological Treatments for Adults With Posttraumatic Stress Disorder (PTSD) Comparative Effectiveness Review Number 92 Psychological and Pharmacological Treatments for Adults With Posttraumatic Stress Disorder (PTSD) Prepared for: Agency for Healthcare Research and Quality U.S. Department of Health and Human Services 540 Gaither Road Rockville, MD 20850 www.ahrq.gov Contract No. 290-2007-10056-I Prepared by: RTI International–University of North Carolina Evidence-based Practice Center Research Triangle Park, NC Investigators: Daniel E. Jonas, M.D., M.P.H. Karen Cusack, P h.D. Catherine A. Forneris, Ph.D., A.B.B.P. Tania M. Wilkins, M.S. Jeffrey Sonis, M.D., M.P.H. Jennifer Cook Middleton, Ph.D. Cynthia Feltner, M.D., M.P.H. Dane Meredith, M.P.H. Jamie Cavanaugh, Pharm.D. Kimberly A. Brownley, Ph.D. Kristine Rae Olmsted, M.S.P.H. Amy Greenblatt, B.A. Amy Weil, M.D. Bradley N. Gaynes, M.D., M.P.H. AHRQ Publication No. 13-EHC011-EF April 2013 Psychological and Pharmacological Treatments for Adults With Posttraumatic Stress Disorder (PTSD) Structured Abstract Objectives. To assess efficacy, comparative effectiveness, and harms of ps ychological and pharmacological treatments for adults with posttraumatic stress disorder (PTSD). Data sources. MEDLINE®, Cochrane Library, PILOTS, International Pharmaceutical Abstracts, CINAHL®, PsycINFO®, Web of Science, Emba se, U.S. Food and Drug Administration Web site, and reference lists of published literature (January 1980–May 2012). Review methods. Two investigators independently selected, extracted data from, and rated risk of bias of relevant trials. We conducted q uantitative analyses using rando m-effects models to estimate pooled effects. -
The Comorbidity of PTSD and MDD: Implications for Clinical Practice and Future Research
The Comorbidity of PTSD and MDD: Implications for Clinical Practice and Future Research Samantha Angelakis and Reginald D.V. Nixon School of Psychology, Flinders University, Adelaide, South Australia, Australia The high prevalence of post-traumatic stress disorder (PTSD) and major depressive disorder (MDD) comorbidity is well established, with comorbidity rates often be- tween 30 and 50%. However, despite the high prevalence of this comorbidity, very few researchers have explored specific treatments for individuals who present with comorbid PTSD and MDD. Further, there has not been explicit examination of the mechanisms through which MDD influences trauma-focused therapy. As individ- uals with comorbid PTSD and MDD often present with a more chronic course of impairment and in some instances, a more delayed response to treatment, the need for such research is imperative. It will be proposed that there is merit in targeting depression within the treatment of comorbid PTSD and MDD. Accordingly, in this article we review explanations for the high PTSD and MDD comorbid relationship and highlight variables likely to explain such comorbidity. Theoretical accounts for how depression impedes optimal recovery from PTSD and the associated empirical findings are illustrated. We consequently argue that there is a need to develop and test treatments that target both PTSD and MDD symptoms. Directions for future research are highlighted. Keywords: PTSD, MDD, comorbidity, treatment, emotional engagement It is well established that post-traumatic stress disorder (PTSD) often co-occurs with depression. Over a range of sample and trauma types it has been observed that 30– 50% of individuals with PTSD also meet the criteria for a diagnosis of depression (Creamer, Burgess, & McFarlane, 2001; Kessler, Berglund et al., 2005). -
MDMA-Assisted Psychotherapy for Posttraumatic Stress Disorder: a Review of the Literature Erin Solomon [email protected]
Brigham Young University BYU ScholarsArchive All Student Publications 2018-05-01 MDMA-Assisted Psychotherapy for Posttraumatic Stress Disorder: A Review of the Literature Erin Solomon [email protected] Follow this and additional works at: https://scholarsarchive.byu.edu/studentpub Part of the Mental Disorders Commons, and the Psychology Commons BYU ScholarsArchive Citation Solomon, Erin, "MDMA-Assisted Psychotherapy for Posttraumatic Stress Disorder: A Review of the Literature" (2018). All Student Publications. 232. https://scholarsarchive.byu.edu/studentpub/232 This Class Project or Paper is brought to you for free and open access by BYU ScholarsArchive. It has been accepted for inclusion in All Student Publications by an authorized administrator of BYU ScholarsArchive. For more information, please contact [email protected], [email protected]. Running head: MDMA-ASSISTED PSYCHOTHERAPY MDMA-Assisted Psychotherapy for Posttraumatic Stress Disorder: A Review of the Literature Effective psychotherapy may hinge on patients’ openness with therapists, willingness to confront and examine discomfort, and competence in processing emotion (Cloitre, Stovall- McClough, Miranda, & Chemtob, 2004; Doukas, D’Andrea, Doran, & Pole, 2014). For most patients, psychotherapy involves some psychological arousal, such as nervousness in front of a therapist or intense emotion during a discussion about sensitive issues (Doukas et al., 2014; Eftekhari et al., 2013). In some patients, however, arousal quickly rises above psychological control and triggers sympathetic nervous system arousal (Doukas et al., 2014). This kind of arousal is common among people with Posttraumatic Stress Disorder (PTSD) and often leads patients to avoid the triggering thought or emotion (Amoroso & Workman, 2016). The cycle of accessing emotionally charged content, experiencing arousal, and promptly practicing avoidance may render psychotherapy impossible and frustrate patients (Amoroso & Workman, 2016).