Psychiatric Rotation - Abobo Tangu

Front 1

Coumadin (Warfarin)

Back 1

Hepatic Impairment
Specific guidelines not available → lower dosage d/t decr warfarin metabolism & decr production of coagulation factors

Front 2

Heparin, Hep-Lock, Hepflush, Lok Pak
(Heparin)

Back 2

Hepatic Impairment
Hepatic impairment does not affect the elimination of heparin; however, patients with hepatic disease may have increased risk of bleeding during heparin therapy

Front 3

Insulin

Back 3

Hepatic Impairment
Dosage should be modified depending on clinical response and degree of hepatic impairment, but no quantitative recommendations are available. Some studies have noted increased circulating levels of insulin in patients with hepatic failure. Individualize dosage based on blood glucose and other clinical parameters

Renal Impairment
The pharmacokinetics of insulin are generally unchanged with renal impairment, however, pharmacodynamic differences occur in insulin sensitivity as renal function declines, resulting in increased responses to a given dosage. Individualize dosage based on blood glucose and other clinical parameters.

Front 4

Eskalith (Lithium)

Back 4

Hepatic Impairment
Specific recommendations for dosage adjustment in patients with hepatic impairment are not available, use caution.

Renal Impairment
o Dosage should be modified depending on clinical response and degree of renal impairment, but no quantitative recommendations are available. Close monitoring of serum levels and dosage adjustments is warranted

Front 5

Orap (Pimozide)

Back 5

Indication: Tourette’s syndrome
E: Hepatic/Renal
MUE: A: 1-10 mg/d (NTE. 0.2 mg/kg/d)
Maximum Dosage Limits:
•Adults: 0.2 mg/kg/day PO or 10 mg/day PO, whichever is less.
•Elderly: 0.2 mg/kg/day PO or 10 mg/day PO, whichever is less.
•Adolescents: 0.2 mg/kg/day PO or 10 mg/day PO, whichever is less.
•Children 7—12 years: Limited data suggest 6 mg/day PO or 0.2 mg/kg/day PO, whichever is less. Safe and effective use is not established.
Patients with hepatic impairment:
No specific guidelines are available; however pimozide is extensively metabolized by dealkylation in the liver. The presence of hepatic impairment would likely decrease pimozide metabolism.
Patients with renal impairment:
No specific guidelines are available; the manufacturer advises caution in administering pimozide to those with renal impairment because the metabolites are excreted primarily through this route.

Front 6

Clozaril (Clozapine)

Back 6

Indication: Refractory Schizo & BD
E: Hepatic
MUE: A: 100-900 mg/d (See guidelines for titration). C: 6.25-12.5 mg/d; inc to 200-300 mg/d
Maximum Dosage Limits:
•Adults: 900 mg/day PO. Debilitated adult patients may require lower total daily dosages.
•Elderly: 450 mg/day PO. Debilitated elderly patients may require lower total daily dosages. (300-450 mg/d) – High Alert Chart
•Adolescents: 200—300 mg/day PO; data are limited. Debilitated adolescent patients may require lower total daily dosages.
•Children >= 9 years: 200—300 mg/day PO; data are limited. Debilitated children may require lower total daily dosages.
Patients with hepatic impairment:
Use caution in using clozapine in patients with hepatic disease. Modify depending on clinical response and degree of hepatic impairment. Initial normal dosage should be decreased and slowly titrated. Until experience with an individual patient has been gained, the dose should be increased in 25 mg increments no more than once or twice a week. If a patient develops signs or symptoms of liver problems during treatment, liver function tests (LFTs) should be measured. If LFTs are significantly elevated or if jaundice is present, treatment should be discontinued.
Patients with renal impairment:
No quantitative recommendations are available; there is limited clinical experience in patients with concomitant systemic disease. The manufacturer recommends caution in using clozapine in patients with renal disease or dysfunction.

Front 7

Serzone (Nefazodone)

Back 7

Serzone (Nefazodone)
Indication: SSRI Antidepressant – MDD
E: Hepatic
MUE: 100-600 mg/d; (300-500 mg/d) – High Alert Chart
Maximum Dosage Limits:
•Adults: 600 mg/day PO.
•Elderly: 600 mg/day PO.
•Adolescents: 600 mg/day PO.
•Children >= 7 years: 300 mg/day PO has been suggested; limited data are available; not FDA-approved.
Patients with hepatic impairment:
Generally not recommended in hepatic disease. Dosage should be modified depending on clinical response and degree of hepatic impairment, but no quantitative recommendations are available. Elimination is reduced in patients with cirrhosis. Withdraw drug if evidence of hepatocellular injury such as active liver disease or increased LFT levels >3 times the upper limit of normal occurs (see Contraindications).
Note: A baseline LFT is required b4 initiating therapy; Frequent Liver Panel for 1st 6 mo. of therapy and d/c if liver enzymes are abnormal; Reduce dosage in elderly.
Caution: Pre-existing/Hx of liver disease; Elevated liver enzymes

Front 8

Cipro (Ciprofloxacin)

Back 8

Indication: Infection
E: Renal
MUE: 400-800 mg q8-12H – High Alert Chart
Maximum Dosage Limits:
•Adults: 1.5 g/day PO; 1 mg/day otic.
•Elderly: 1.5 g/day PO; 1 mg/day otic.
•Adolescent & Children: Same as adult dosage; 2 g/day PO for pulmonary exacerbations of cystic fibrosis
Patients with renal impairment:
CrCl > 50 ml/min: No dosage adjustment needed.
CrCl 30—50 ml/min: For oral administration, the recommended dosage is 250—500 mg PO every 12 hours.
CrCl 5—29 ml/min: 250—500 mg PO every 18 hours

Front 9

Mellaril (Thioridazine)

Back 9

Indication: Psychotic Disorders – Refractory Schizo
E: Hepatic
MUE: Adult/Children: 25-800 mg/d (Nursing Med Review); (200-800 mg/d) – High Alert Chart
A: 30-800 mg /d (3-6 mg/kg/d); C: 0.5-3 mg/kg/d
Maximum Dosage Limits:
•Adults: 300 mg/day PO; dosage may be increased to 800 mg/day PO for short periods. Debilitated patients require lower dosages.
•Elderly: 300 mg/day PO; dosage may be increased to 800 mg/day PO for short periods. Debilitated patients require lower dosages.
•Adolescents: 300 mg/day PO; dosage may be increased to 800 mg/day PO for short periods. Debilitated patients require lower dosages.
•Children: 3 mg/kg/day PO.
Patients with hepatic impairment:
In general, phenothiazines are contraindicated in patients with significant hepatic impairment.
Note:
Baseline EKG MUST be done b4 the administration of Mellaril to pts.
Doses > 300 mg/d only recommended for severe psychosis (read separate MUE)
Pts w/ QTc interval > 450 msec should not receive mellaril
Mellaril should not be combined with TCA due to Quinidine like side effects of both agents.
Mesoridazine (Serentil) is a major active metabolite of Mellaril.
Should not be used with EPS meds: amantadine, benztropine, diphenhydramine, trihexphenidyl

Front 10

Pregnancy Category B (All others will need a warning for pregnant patients)

Back 10

Atypical Antipsychotic - Clozapine
Non BZD Anxiolytic - Buspirone
Non BZD Hypnotic – Zaleplon, Diphenhydramine
Cognitive Enhancers – Galantamine, Rivastigmine, Memantine