Eliceya®
You should stop using the drug Elitseya if convulsive disorders, epileptic seizures develop, or their frequency increases in case of pharmacologically uncontrolled epilepsy.
If a manic state develops, Elicea® should be discontinued.
Escitalopram may increase blood glucose concentrations in diabetes mellitus, which may require dose adjustments of oral hypoglycemic agents and/or insulin.
Hyponatremia associated with a decrease in ADH secretion occurs rarely with the use of Elitsey® (more often in older people, patients with cirrhosis of the liver, or constantly taking drugs that can cause hyponatremia) and usually disappears when the drug is discontinued.
With the development of serotonin syndrome
the drug should be immediately discontinued and symptomatic treatment prescribed.
Escitalopram should be used with caution in patients with a history of mania/hypomania. If a manic state develops, escitalopram should be discontinued.
Neuroleptic malignant syndrome (NMS) -
a rare, potentially dangerous condition associated with the use of antidepressants, incl. escitalopram. Symptoms of NMS: increased body temperature (hyperpyrexia), muscle rigidity, changes in mental status and instability of the autonomic nervous system (arrhythmia, blood pressure fluctuations, tachycardia, profuse sweating, cardiac arrhythmia). If NMS is detected, you must immediately stop using Elitsey®.
During the first two weeks, akathisia/psychomotor agitation may develop (subjectively unpleasant or irritating restlessness and the need to move, often combined with the inability to sit or stand quietly).
When using the drug Elitsey®, the development of skin hemorrhages (ecchymosis and purpura) is possible. Escitalopram should be used with caution in patients with a tendency to bleeding, as well as those taking indirect anticoagulants and other drugs that affect blood clotting.
The simultaneous use of escitalopram and ethanol is not recommended.
Clinical experience with electroconvulsive therapy and escitalopram is limited and caution is advised.
There is limited experience with the use of escitalopram in patients with coronary artery disease, so Elitseya® is recommended to be used with caution in this group of patients.
When escitalopram therapy is quickly discontinued, withdrawal syndrome often occurs: dizziness, sensory disturbances (including paresthesia), sleep disturbances (insomnia, unusual dreams), psychomotor agitation, anxiety, nausea and/or vomiting, tremor, confusion, sweating, headache, diarrhea, palpitations, emotional lability and visual disturbances. The severity of these reactions is usually mild or moderate and the duration is limited. In this regard, it is recommended to discontinue Elicea® gradually, reducing the dose over several weeks or months.
In children, adolescents and young adults (under 24 years of age) with depression and other mental disorders, antidepressants, compared with placebo, increase the risk of suicidal thoughts and suicidal behavior. Therefore, when using escitalopram or any other antidepressants in children, adolescents and young adults (under 24 years of age), the risk of suicide should be weighed against the benefits of their use. In short-term studies, the risk of suicide did not increase in people over 24 years of age, but it decreased slightly in people over 65 years of age. Any depressive disorder itself increases the risk of suicide. Therefore, during treatment with antidepressants, all patients should be monitored for early detection of disturbances or changes in behavior, as well as suicidality.
Impact on the ability to drive vehicles and operate machinery
During the treatment period, it is necessary to refrain from driving vehicles and engaging in potentially hazardous activities that require increased concentration and speed of psychomotor reactions due to the possibility of dizziness, hallucinations, confusion, depersonalization and other side effects.
Elicea®
When using drugs belonging to the SSRI therapeutic group, including escitalopram, the following should be considered:
Use in children and adolescents under 18 years of age
Antidepressants should not be prescribed to children and adolescents under 18 years of age due to an increased risk of suicidal behavior (suicide attempts and suicidal thoughts), hostility (with a predominance of aggressive behavior, confrontational behavior and irritation). If a decision is made to initiate antidepressant therapy based on clinical assessment, the patient should be closely monitored. In addition, there is insufficient data on long-term safety in children and adolescents regarding growth, maturation, cognitive and behavioral development.
Paradoxical anxiety
Some patients with panic disorder may experience increased anxiety when starting antidepressant treatment. This paradoxical reaction usually disappears within the first two weeks of treatment. To reduce the likelihood of an anxiogenic effect, low initial doses are recommended.
Convulsions
Escitalopram should be discontinued in the event of the primary development of convulsive seizures or in the event of an increase in their frequency (in patients with previously diagnosed epilepsy). SSRIs should not be used in patients with unstable epilepsy; controlled seizures require careful monitoring.
Mania
Escitalopram should be used with caution in patients with a history of mania/hypomania. If a manic state develops, escitalopram should be discontinued. Diabetes
In patients with diabetes mellitus, treatment with escitalopram may alter plasma glucose concentrations. Therefore, dose adjustments of insulin and/or oral hypoglycemic drugs may be required.
Suicide/suicidal ideation or clinical deterioration
Depression is associated with an increased risk of suicidal ideation, self-harm, and suicide (suicidal events). This risk persists until significant remission occurs. Since improvement may not be observed during the first few weeks of therapy or even longer, patients should be closely monitored until their condition improves.
General clinical practice shows that in the early stages of recovery the risk of suicide may increase.
Other psychiatric conditions for which escitalopram is prescribed may also be associated with an increased risk of suicidal events and events. In addition, these conditions may be a comorbidity in relation to a depressive episode. When treating patients with other mental disorders, the same precautions should be taken as when treating patients with a depressive episode.
Patients with a history of suicidal behavior or patients with a significant level of suicidal thoughts before treatment are at greater risk for suicidal ideation or suicide attempts and should be closely monitored during treatment.
A meta-analysis of placebo-controlled clinical trials of antidepressants in adult patients with mental disorders found that there is an increased risk of suicidal behavior in patients under 25 years of age when taking antidepressants compared with placebo. Drug treatment of these patients, and in particular those at high risk for suicide, should be accompanied by careful monitoring, especially early in treatment and during dose changes.
Patients (and caregivers) should be warned to monitor for any signs of clinical worsening, suicidal behavior or ideation, or unusual changes in behavior, and to seek immediate medical advice if these symptoms occur. Akathisia/psychomotor agitation
The use of SSRIs/SNRIs is associated with the development of akathisia, characterized by the development of subjectively unpleasant or depressing restlessness and the need for constant movement, often combined with an inability to sit or stand quietly. This most often occurs during the first few weeks of treatment. In patients with such symptoms, increasing the dose may lead to worsening.
Hyponatremia
Hyponatremia, possibly associated with impaired ADH secretion, occurs rarely with SSRIs and usually disappears when therapy is discontinued. Caution should be exercised when using escitalopram and other SSRIs in persons at risk of developing hyponatremia: elderly patients, patients with cirrhosis of the liver, and those taking drugs that can cause hyponatremia.
Bleeding
Cases of skin hemorrhages (ecchymosis and purpura) have been reported when taking SSRIs. Escitalopram should be used with caution in patients taking oral anticoagulants and drugs that affect blood clotting, as well as in patients with a tendency to bleed.
Electroconvulsive therapy
Because clinical experience with the concomitant use of SSRIs and ECT is limited, caution should be used when escitalopram and ECT are used concomitantly.
The simultaneous use of escitalopram and MAO A inhibitors is not recommended due to the risk of developing serotonin syndrome.
Serotonin syndrome
Escitalopram should be used with caution concomitantly with drugs that have serotonergic effects, such as sumatriptan or other triptans, tramadol and tryptophan. Patients taking escitalopram and other SSRIs concomitantly with serotonergic drugs have rarely developed serotonin syndrome. Its development may be indicated by a combination of symptoms such as agitation, tremor, myoclonus and hyperthermia. If this occurs, concomitant treatment with SSRIs and serotonergic drugs should be discontinued immediately and symptomatic treatment initiated.
QT syndrome, predominantly in female patients with hypokalemia or pre-existing QT prolongation or other cardiac disease.
Caution is required when using the drug in patients with severe bradycardia or in patients with recent acute myocardial infarction or decompensated heart failure.
Electrolyte imbalances, such as hypokalemia and hypomagnesemia, increase the risk of developing malignant arrhythmias; these disturbances must be corrected before starting treatment with escitalopram.
In patients with stable coronary artery disease, an ECG should be performed before starting treatment.
If signs of cardiac arrhythmia occur during treatment with escitalopram, it is necessary to stop therapy and perform an ECG.
Angle-closure glaucoma
SSRIs, including escitalopram, may affect pupil size, leading to mydriasis. This pupil dilation effect has the potential to narrow the anterior chamber angle, leading to increased intraocular pressure and the development of angle-closure glaucoma, especially in patients with a predisposition to this disease. Therefore, in patients with angle-closure glaucoma or a history of glaucoma, caution should be exercised when using escitalopram.
Special information on excipients
Elitsey® contains lactose, so it should not be used for the following conditions: lactose intolerance, lactase deficiency, glucose-galactose malabsorption syndrome.
Elicea, 56 pcs., 10 mg, film-coated tablets
You should stop using the drug Elitseya if convulsive disorders, epileptic seizures develop, or their frequency increases in case of pharmacologically uncontrolled epilepsy.
If a manic state develops, Elicea® should be discontinued.
Escitalopram may increase blood glucose concentrations in diabetes mellitus, which may require dose adjustments of oral hypoglycemic agents and/or insulin.
Hyponatremia associated with a decrease in ADH secretion occurs rarely with the use of Elitsey® (more often in older people, patients with cirrhosis of the liver, or constantly taking drugs that can cause hyponatremia) and usually disappears when the drug is discontinued.
If serotonin syndrome develops, the drug should be immediately discontinued and symptomatic treatment prescribed.
Escitalopram should be used with caution in patients with a history of mania/hypomania.
If a manic state develops, escitalopram should be discontinued.
Neuroleptic malignant syndrome (NMS) is a rare, potentially dangerous condition associated with the use of antidepressants, incl. escitalopram. Symptoms of NMS: increased body temperature (hyperpyrexia), muscle rigidity, changes in mental status and instability of the autonomic nervous system (arrhythmia, blood pressure fluctuations, tachycardia, profuse sweating, cardiac arrhythmia). If NMS is detected, you must immediately stop using Elitsey®.
During the first two weeks, akathisia/psychomotor agitation may develop (subjectively unpleasant or irritating restlessness and the need to move, often combined with the inability to sit or stand quietly).
When using the drug Elicea®, the development of skin hemorrhages (ecchymosis and purpura) is possible.
Escitalopram should be used with caution in patients with a tendency to bleeding, as well as those taking indirect anticoagulants and other drugs that affect blood clotting.
The simultaneous use of escitalopram and ethanol is not recommended.
Clinical experience with ECT and escitalopram is limited and caution is advised.
There is limited experience with the use of escitalopram in patients with coronary artery disease, so Elitseya® is recommended to be used with caution in this group of patients.
When escitalopram therapy is quickly discontinued, withdrawal syndrome often occurs: dizziness, sensory disturbances (including paresthesia), sleep disturbances (insomnia, unusual dreams), psychomotor agitation, anxiety, nausea and/or vomiting, tremor, confusion, sweating, headache, diarrhea, palpitations, emotional lability and visual disturbances.
The severity of these reactions is usually mild or moderate and the duration is limited.
In this regard, it is recommended to discontinue Elicea® gradually, reducing the dose over several weeks or months.
In children, adolescents and young adults (under 24 years of age) with depression and other mental disorders, antidepressants, compared with placebo, increase the risk of suicidal thoughts and suicidal behavior. Therefore, when using escitalopram or any antidepressants in children, adolescents and young adults (under 24 years of age), the risk of suicide should be weighed against the benefits of their use. In short-term studies, the risk of suicide did not increase in people over 24 years of age, but it decreased slightly in people over 65 years of age.
Any depressive disorder itself increases the risk of suicide. Therefore, during treatment with antidepressants, all patients should be monitored for early detection of disturbances or changes in behavior, as well as suicidality.
Impact on the ability to drive vehicles and other technical devices.
During the treatment period, it is necessary to refrain from driving vehicles and engaging in potentially hazardous activities that require increased concentration of attention and speed of psychomotor reactions, due to the possibility of developing dizziness, hallucinations, confusion, depersonalization and other side effects.
Elycea
Use during pregnancy and breastfeeding
Elicea® is not used during pregnancy (safety has not been established).
Due to the fact that escitalopram is secreted into breast milk, the use of the drug during breastfeeding is not recommended. If it is necessary to use Elicea® during lactation, breastfeeding should be discontinued.
Use for liver dysfunction
For liver dysfunction, the initial dose is 5 mg/day for 2 weeks. Depending on the patient's individual response, the dose may be increased to 10 mg/day. In severe liver dysfunction, slower dose titration is recommended.
Use for renal impairment
For mild or moderate renal failure (creatinine clearance more than 30 ml/min), no dose adjustment is required. In severe renal failure (creatinine clearance less than 30 ml/min), the drug should be prescribed with caution.
Use in children
The use of the drug in children under 18 years of age is contraindicated.
Use in elderly patients
The drug should be used with caution in elderly patients.
special instructions
You should stop using the drug Elitseya if convulsive disorders, epileptic seizures develop, or their frequency increases in case of pharmacologically uncontrolled epilepsy.
If a manic state develops, Elicea® should be discontinued.
Escitalopram may increase blood glucose concentrations in diabetes mellitus, which may require dose adjustments of oral hypoglycemic agents and/or insulin.
Hyponatremia associated with a decrease in ADH secretion occurs rarely with the use of Elitsey® (more often in older people, patients with cirrhosis of the liver, or constantly taking drugs that can cause hyponatremia) and usually disappears when the drug is discontinued.
If serotonin syndrome develops, the drug should be immediately discontinued and symptomatic treatment prescribed.
Escitalopram should be used with caution in patients with a history of mania/hypomania. If a manic state develops, escitalopram should be discontinued.
Neuroleptic malignant syndrome (NMS) is a rare, potentially dangerous condition associated with the use of antidepressants, incl. escitalopram. Symptoms of NMS: increased body temperature (hyperpyrexia), muscle rigidity, changes in mental status and instability of the autonomic nervous system (arrhythmia, blood pressure fluctuations, tachycardia, profuse sweating, cardiac arrhythmia). If NMS is detected, you must immediately stop using Elitsey®.
During the first two weeks, akathisia/psychomotor agitation may develop (subjectively unpleasant or irritating restlessness and the need to move, often combined with the inability to sit or stand quietly).
When using the drug Elitsey®, the development of skin hemorrhages (ecchymosis and purpura) is possible. Escitalopram should be used with caution in patients with a tendency to bleeding, as well as those taking indirect anticoagulants and other drugs that affect blood clotting.
The simultaneous use of escitalopram and ethanol is not recommended.
Clinical experience with electroconvulsive therapy and escitalopram is limited and caution is advised.
There is limited experience with the use of escitalopram in patients with coronary artery disease, so Elitseya® is recommended to be used with caution in this group of patients.
When escitalopram therapy is quickly discontinued, withdrawal syndrome often occurs: dizziness, sensory disturbances (including paresthesia), sleep disturbances (insomnia, unusual dreams), psychomotor agitation, anxiety, nausea and/or vomiting, tremor, confusion, sweating, headache, diarrhea, palpitations, emotional lability and visual disturbances. The severity of these reactions is usually mild or moderate and the duration is limited. In this regard, it is recommended to discontinue Elicea® gradually, reducing the dose over several weeks or months.
In children, adolescents and young adults (under 24 years of age) with depression and other mental disorders, antidepressants, compared with placebo, increase the risk of suicidal thoughts and suicidal behavior. Therefore, when using escitalopram or any other antidepressants in children, adolescents and young adults (under 24 years of age), the risk of suicide should be weighed against the benefits of their use. In short-term studies, the risk of suicide did not increase in people over 24 years of age, but it decreased slightly in people over 65 years of age. Any depressive disorder itself increases the risk of suicide. Therefore, during treatment with antidepressants, all patients should be monitored for early detection of disturbances or changes in behavior, as well as suicidality.
Impact on the ability to drive vehicles and operate machinery
During the treatment period, it is necessary to refrain from driving vehicles and engaging in potentially hazardous activities that require increased concentration and speed of psychomotor reactions due to the possibility of dizziness, hallucinations, confusion, depersonalization and other side effects.
Psychotropic drugs and treatment of covid
How to treat COVID-19?
When we cannot understand how to save ourselves from an unknown disease, we begin to try everything, sometimes we feel the benefit from it, but more often we feel nothing, unless, of course, we are talking about self-hypnosis, but it is known that the latter can create miracles. Representatives of the authorities and the Ministry of Health always answer that they treat Covid based on protocols and standards (where would we be without them here), that their recommendations are guided by the best practices of China, the USA, Europe and other countries and you can’t argue with that. True, officials in each country claim that their vaccine or antiviral drug is better than in other countries (there is probably not only politics here, but also economics). We now still have little time to try this or that vaccine or this or that method of treating Covid, and the first thing we can do is look at how different drugs, not only new ones, but also old ones, affect the diagnosis and treatment of Covid . Sinner himself, having discovered some analogy between the characteristics of the blood of patients with Mediterranean fever and COVID-19, wrote a letter to the Ministry of Health in April that it would not be bad to try to treat Covid with colchicine. I received a formal answer, “we are treating according to approved protocols” (I recently read that in September in Canada, 6,000 patients were quite successfully treated with colchicine), but this is a familiar story, and nothing can be done about it.
Mental disorders during Covid
Patients with COVID-19 may develop a mental disorder or experience an exacerbation of an existing mental illness (the second is observed, apparently, more often than the first) in response to the message of the diagnosis, the need for forced self-isolation, the presence of dangerous and therefore alarming symptoms and the possible risk of death. All this contributes to the emergence of anxiety and depressive spectrum disorders. In addition, intensive care and experimental treatments with psychiatric side effects (such as antimalarial drugs or hormones) are an additional risk factor for the emergence of mental disorders, particularly psychosis or states of altered consciousness, including delirium. Epidemiological data, although preliminary, has shown that one in four patients with Covid develop symptoms of anxiety or depression, and around 15% may develop a state of impaired consciousness, which is likely associated with a significantly increased risk of death.
Antidepressants in the treatment of COVID-19
Since I am still a neuropsychiatrist, that is, a doctor who knows neurology and psychiatry more and better, more thoughts about Covid and its consequences, naturally in my Blog, concern neurological and mental disorders. Still, there is another topic that is quite interesting to me, how psychotropic drugs affect the incidence of covid, its clinical picture, features of the course and consequences. What do we know from general pathology and psychoneurology? On the one hand, antipsychotics and antidepressants have an anti-inflammatory effect, but on the other hand, they reduce the number of neutrophils, lymphocytes and platelets, which are already in short supply during Covid, and therefore weaken the body’s defenses against bacteria and viruses. True, to combat hypercoagulation, which also occurs with a reduced platelet count, we are advised, and, in my opinion, of course correct, to take apixaban (Eliquis), an anticoagulant that is a direct inhibitor of factor Xa. However, it is worth reminding the reader of my Blog that many antidepressants from the group of selective serotonin reuptake inhibitors (SSRIs) also increase bleeding, that is, they work as anticoagulants. Is this good or bad in the treatment of Covid? More likely good, in my opinion, than bad, especially if there are indications for prescribing antidepressants (and, of course, almost every patient with Covid will have an anxiety-depressive state). However, it is clear that apixaban and these antidepressants will act synergistically on a Covid patient, therefore the joint prescription of these drugs requires determining the concentration of these drugs in the blood and, probably, reducing the doses.
Data from randomized trials of antidepressants have shown no increased risk of respiratory distress and all-cause mortality in patients with COPD (including older patients) treated with selective serotonin reuptake inhibitors (SSRIs) and tricyclic antidepressants (TCAs), and authoritative guidelines point to SSRI drugs as a safe choice for people with medical conditions (including respiratory diseases). However, data from a large observational study showed a higher risk of exacerbation of COPD or COPD-related hospitalization and mortality in older patients taking SSRIs and SNRIs compared with patients not exposed to these antidepressants.
Fluvoxamine or escitalopram?
And indeed, if you look in the foreign literature, you will find recommendations for patients with Covid to take fluvoxamine (fevarin), supposedly in order to “help prevent breathing problems in patients with a mild form of Covid.” From my point of view, escitalopram would be better (fewer side effects), but again, of course, after consulting a doctor. Each antidepressant from the SSRI group has its own contraindications. Fluvoxamine is a fairly old drug (the first of this group), has its pros and cons, however, let’s believe the pharmaceutical company that advertises it for Covid (according to the JAMA report, none of those who took fluvoxamine for two weeks shortly after the diagnosis of COVID did not develop serious breathing problems, compared with 8% in the placebo group who had shortness of breath and low oxygen levels). Fluvoxamine (like other SSRI drugs) binds to sigma-1 receptors, which also influence the immune response, which can damage the lungs of COVID patients. However, it is worth remembering that fluvoxamine is commonly prescribed for obsessive-compulsive disorder (obsessive-compulsive disorder) and generalized anxiety, and its side effects are similar to other SSRIs, including headaches, nausea, diarrhea, anxiety and fatigue (i.e. part of the Covid symptoms). In my opinion, before prescribing antidepressants, it is always worth prescribing a neural test to understand whether this drug will be beneficial or not.
Fluoxetine
And here's another... A study conducted by virologists and chemists from the University of Würzburg showed that fluoxetine significantly suppresses the viral replication of SARS-CoV-2. Scientists believe this makes it suitable for early treatment of infected patients who are at higher risk of severe disease. And this again, fluoxetine is a relatively old drug with its own side effects, and again, it will be inferior to safer drugs of this series. However, according to the following words: “Other SSRI drugs, such as paroxetine and escitalopram, did not suppress SARS-CoV-2 replication in the study.” , then it turns out that the antiviral effect is not associated with the serotonin reuptake receptor. Instead, fluoxetine inhibits processes upstream or downstream of protein expression in the virus, as shown by immunofluorescence tests. It prevents the virus from producing the building blocks it needs to replicate in human cells. The study also shows that fluoxetine has a specific effect on the SARS-CoV-2 viruses. Scientists have not observed any effect on other viruses, such as rabies virus, human respiratory syncytial virus, human herpes virus 8 or herpes simplex virus type 1. At the same time, after a series of my articles about the consequences of covid, patients began to contact me with back pain and escitalopram was also helpful here. It still seems a little strange to me that the old SSRI antidepressants are more effective against Covid than the new ones with fewer side effects. I note that a drug such as citalopram also stabilizes blood pressure and the blood coagulation system, which, as is known, is disturbed during Covid.
Antipsychotics in the treatment of covid
Antipsychotics are associated with an increased risk of serious respiratory, thoracic, and mediastinal adverse events, according to randomized trials. The risk of respiratory distress syndrome is likely to be greater with potent sedatives, especially at higher doses, in combination, and when given to patients with pre-existing respiratory distress. In cases of psychomotor agitation requiring rapid tranquilization with antipsychotics (eg, hyperkinetic delirium), the risk of acute extrapyramidal symptoms (eg, dystonia with possible swallowing impairment and subsequent risk of aspiration) and decreased mobility may significantly worsen respiratory distress. This gives rise to the idea of preferring the use of atypical antipsychotics over classical ones (haloperidol) in the treatment of mental disorders that arose during or after covid.
Stabilizers in the treatment of covid
Mood stabilizers have a mild to moderate sedative profile, and there is no evidence of a significant risk of excessive sedation and associated respiratory distress.
Tranquilizers in the treatment of covid
Although the risk of respiratory depression with benzodiazepines is markedly lower than with barbiturates or other neuromuscular blockers, it may be quite high in people with acute respiratory distress and especially in the elderly. The risk of respiratory distress syndrome is related to the varying sedative properties of different agents, their half-lives, and is generally dose dependent. Data from randomized trials showed no significant effect on respiratory outcomes in people with chronic obstructive pulmonary disease (COPD) treated with benzodiazepines for insomnia, although the pooled sample size was relatively small
How do covid medications and psychotropic drugs interact with each other?
It should be remembered that psychotropic drugs can interact with medications for COVID-19, and some of their side effects can worsen the course and outcome of the underlying disease. First, the bioavailability and disposal of some psychotropic drugs may be severely affected by systemic inflammatory processes associated with COVID-19, liver dysfunction, and abrupt smoking cessation. Secondly, psychotropic drugs and treatment can mutually influence each other's plasma levels, inducing or inhibiting the activity of cytochrome P450 (CYP) (once again, I understand the importance of personalized therapy for covid and mental disorders, in particular, the role of pharmacogenetics). Third, these combinations are at risk for pharmacodynamic interactions, particularly QT prolongation, immune dysfunction, and blood clotting.
Cardiovascular system during covid
Patients with COVID-19 may have several risk factors for cardiovascular disease, including (a) older age; (b) pre-existing comorbid cardiovascular diseases; (c) use of medications with QTc prolonging properties, often in combination (eg, antivirals, chloroquine/hydroxychloroquine, and antibiotics); (d) possible direct cardiotoxic effects of coronavirus; and (e) electrolyte changes associated with abnormal gas exchange in the respiratory tract. The most important risk factors for severe arrhythmias such as pointe shoes include the magnitude of QTc prolongation, pre-existing heart disease, female gender, bradycardia, hypokalemia, and other electrolyte abnormalities.
Data from randomized trials in patients with coronary artery disease have not shown an increased risk of cardiovascular mortality and nonfatal cardiac events with antidepressants (especially SSRIs). On the other hand, data from observational studies showed an increased risk of coronary heart disease for tricyclic antidepressants (TCAs), but not SSRIs and antidepressants as a class, while SSRIs, but not TCAs, were associated with an increased risk of cerebrovascular disease. Tricyclic antidepressants and, to a lesser extent, citalopram, escitalopram, and venlafaxine have been associated with QT prolongation, with a possible higher risk in elderly patients.
Combination antipsychotics and higher cumulative doses may contribute to QT prolongation. The differential risk of QT prolongation with antipsychotics is not entirely consistent across different data sources and different study designs. In general, the use of any antipsychotic should not lead the physician to ignore the risk of QT prolongation. The risk of arrhythmias is probably very low for mood stabilizers and benzodiazepines, with the possible exception of lithium, for which benign electrocardiographic changes, cases of ventricular arrhythmia, and sudden cardiac death have been described.
Risk of infection
Systemic immune dysregulation and inflammatory response are a key feature of COVID-19. The severity of inflammatory parameters (such as IL-6) has been associated with the risk of death, and immunosuppressive treatments may have a role in treating and preventing covid complications. Antidepressants have been shown to have anti-inflammatory properties, although little is known about their possible role in systemic infections. In vitro studies have shown a protective effect against bacteria and fungi, but clinical data are unclear as a possible higher risk of Clostridium difficile infection has been reported. Tricyclic antidepressants, especially clomipramine and imipramine, have been associated with possible blood dyscrasias, including neutropenia.
Antipsychotics have been associated with immunosuppressive properties, such as decreased levels of proinflammatory cytokines, blood abnormalities, and altered antibody production. the incidence of neutropenia is about 1% for clozapine (3% in the elderly) and 0.1% for phenothiazines. In addition, both first- and second-generation antipsychotics were associated with a higher risk of pneumonia in observational studies. Data from randomized trials involving mainly second-generation antipsychotics have shown a higher risk of infections with these drugs. In addition to immune dysfunction, several mechanisms may be involved, including decreased airway clearance (associated with central sedation and cough suppression), impaired chest movement and swallowing due to extrapyramidal symptoms, and sialorrhea. This risk may be particularly significant with clozapine. Carbamazepine, oxcarbazepine and, to a lesser extent, sodium valproate have been associated with an increased risk of neutropenia, while lithium does not appear to have relevant immunological effects. Data from observational studies have shown an increased risk of pneumonia for benzodiazepines compared with patients not taking benzodiazepines in both older and younger patients, short-term and long-term use.
Risk of coagulation
Blood hypercoagulability associated with inflammatory endothelial dysfunction has been mainly reported in patients with COVID-19, ranging from mild manifestations to life-threatening conditions such as disseminated intravascular coagulation. Low molecular weight heparin has been proposed as an effective prophylactic agent in the early stages of the disease. Antidepressants are associated with various hemostasis disorders. Observational studies have shown that SSRIs and serotonin-norepinephrine reuptake inhibitors (SNRIs) have an increased risk of major bleeding at multiple sites, and all classes of antidepressants have an increased risk of thromboembolism. The risk of bleeding is likely to be greater in vulnerable patients (eg, older age, pre-existing coagulation disorders, anticoagulant therapy, major surgery). Large observational studies have clearly shown that antipsychotic drugs are associated with an increased risk of thromboembolism, with a presumably higher risk in vulnerable populations with pre-existing risk factors. The risk of pro- or anticoagulant effects is likely to be lower for mood stabilizers and benzodiazepines.
Risk of delirium
Although epidemiological data are preliminary, delirium is frequently described in people with COVID-19 and is associated with a poor prognosis. Old age, medical comorbidities, dementia, and multiple pharmacological treatments are well-known risk factors for both delirium and COVID-19 severity. Neurotropic mechanisms of COVID-19 have also been hypothesized. In addition, many experimental treatments for COVID-19 have a well-known risk of neuropsychiatric side effects (eg, antimalarials, antivirals, interferons, corticosteroids) and may pose an additional risk for delirium.
Some psychotropic drugs are also known risk factors for delirium. In particular, benzodiazepines, antidepressants with anticholinergic properties (mainly TCAs, but possibly also paroxetine) and lithium are at high risk. Anticholinergic drugs are often a precipitating factor and are associated with the severity of delirium. It has been estimated that medications alone may account for up to 40% of cases of delirium. Data from a recent meta-analysis of randomized trials showed that olanzapine and risperidone were effective in preventing delirium compared with placebo or usual care, while midazolam increased the incidence of delirium.
Liver and kidneys
Acute multifactorial liver and kidney damage has been described in people with COVID-19, so liver and kidney function should be closely monitored during treatment for Covid. Possibly hepatotoxic (eg, valproate, carbamazepine, tricyclic antidepressants) and nephrotoxic psychotropic drugs (eg, lithium), as well as psychotropic drugs that are extensively metabolized by the liver (eg, most antidepressants, antipsychotics, and mood stabilizers) and must be excreted via the kidney. (eg, lithium, gabapentin, topiramate, pregabalin and paliperidone) should be regularly assessed for the safety of therapy in order to adjust the dose or discontinue treatment if clinical risk is high.
Conclusion
When deciding to prescribe experimental medications to patients undergoing long-term psychopharmacological treatment, clinicians should exercise extreme caution given that treatments for COVID-19 are still experimental and their effectiveness is under debate.
