Neuropsychiatric clinical manifestations in elderly patients treated with hydroxychloroquine: a review article

Clinical Pharmacology in Sarcoidosis: How to Use and Monitor Sarcoidosis Medications

When sarcoidosis needs treatment, pharmacotherapy is usually required. Although glucocorticoids work reliably and relatively quickly for sarcoidosis, these drugs are associated with numerous significant side effects. Such side effects are common in sarcoidosis patients, as the disease frequently has a chronic course and glucocorticoid treatment courses are often prolonged. For these reasons, corticosteroid-sparing and corticosteroid-replacing therapies are often required for sarcoidosis. Unfortunately, many healthcare providers who care for sarcoidosis patients are not familiar with the use of these agents. In this manuscript, we provide a review of the pharmacotherapy of sarcoidosis. We discuss the mechanism of action, dosing, side-effect profile, approach to monitoring and patient counselling concerning glucocorticoids, and the common alternative drugs recommended for use in the recent European Respiratory Society (Lausanne, Switzerland) Sarcoidosis Treatment Guidelines. We also discuss the use of these agents in special situations including hepatic insufficiency, renal insufficiency, pregnancy, breastfeeding, vaccination, and drug-drug interactions. It is hoped that this manuscript will provide valuable practical guidance to clinicians who care for sarcoidosis patients.

Should evidence of an autolysosomal de-acidification defect in Alzheimer and Parkinson diseases call for caution in prescribing chronic PPI and DMARD?

Nearly fifty million older people suffer from neurodegenerative diseases, including Alzheimer (AD) and Parkinson (PD) disease, a global burden expected to triple by 2050. Such an imminent "neurological pandemic" urges the identification of environmental risk factors that are hopefully avoided to fight the disease. In 2022, strong evidence in mouse models incriminated defective lysosomal acidification and impairment of the autophagy pathway as modifiable risk factors for dementia. To date, the most prescribed lysosomotropic drugs are proton pump inhibitors (PPIs), chloroquine (CQ), and the related hydroxychloroquine (HCQ), which belong to the group of disease-modifying antirheumatic drugs (DMARDs). This commentary aims to open the discussion on the possible mechanisms connecting the long-term prescribing of these drugs to the elderly and the incidence of neurodegenerative diseases.Abbreviations: AD: Alzheimer disease; APP-βCTF: amyloid beta precursor protein-C-terminal fragment; BACE1: beta-secretase 1; BBB: brain blood barrier; CHX: Ca2+/H+ exchanger; CMI: cognitive mild impairment; CQ: chloroquine; DMARD: disease-modifying antirheumatic drugs; GBA1: glucosylceramidase beta 1; HCQ: hydroxychloroquine; HPLC: high-performance liquid chromatography; LAMP: lysosomal associated membrane protein; MAPK/JNK: mitogen-activated protein kinase; MAPT: microtubule associated protein tau; MCOLN1/TRPML1: mucolipin TRP cation channel 1; NFE2L2/NRF2: NFE2 like bZIP transcription factor 2; NRBF2: nuclear receptor binding factor 2; PANTHOS: poisonous flower; PD: Parkinson disease; PIK3C3: phosphatIdylinositol 3-kinase catalytic subunit type 3; PPI: proton pump inhibitor; PSEN1: presenilin 1, RUBCN: rubicon autophagy regulator; RUBCNL: rubicon like autophagy enhancer; SQSTM1: sequestosome 1; TMEM175: transmembrane protein 175; TPCN2: two pore segment channel 2; VATPase: vacuolar-type H+-translocating ATPase; VPS13C: vacuolar protein sorting ortholog 13 homolog C; VPS35: VPS35 retromer complex component; WDFY3: WD repeat and FYVE domain containing 3; ZFYVE1: zinc finger FYVE-type containing 1.

COVID-19 therapeutics: Clinical application of repurposed drugs and futuristic strategies for target-based drug discovery

Severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) causes the complicated disease COVID-19. Clinicians are continuously facing huge problems in the treatment of patients, as COVID-19-specific drugs are not available, hence the principle of drug repurposing serves as a one-and-only hope. Globally, the repurposing of many drugs is underway; few of them are already approved by the regulatory bodies for their clinical use and most of them are in different phases of clinical trials. Here in this review, our main aim is to discuss in detail the up-to-date information on the target-based pharmacological classification of repurposed drugs, the potential mechanism of actions, and the current clinical trial status of various drugs which are under repurposing since early 2020. At last, we briefly proposed the probable pharmacological and therapeutic drug targets that may be preferred as a futuristic drug discovery approach in the development of effective medicines.

Systematic Review of Psychiatric Adverse Effects Induced by Chloroquine and Hydroxychloroquine: Case Reports and Population Studies

OBJECTIVE

To perform a systematic review on the psychiatric adverse effects of chloroquine (CQ) and hydroxychloroquine (HCQ); to summarize what is known about psychiatric adverse effects of these drugs; to compare clinical trials, populational studies, and case report studies; and to increase awareness of the potential psychiatric adverse effects of these drugs.

DATA SOURCES

A literature search of PubMed, Scopus, and Web of Science was performed to identify manuscripts published between December 1962 and June 2022. Search terms included CQ, HCQ, psychiatry, psychosis, depression, anxiety, bipolar disorder, delirium, and psychotic disorders.

STUDY SELECTION AND DATA EXTRACTION

Relevant studies included reports of adverse effects after CQ or HCQ ingestion.

DATA SYNTHESIS

The current literature presents evidence for a risk of short-term psychiatric adverse effects induced by either CQ or HCQ. However, the populational-level studies presented some limitations regarding the voluntary response in survey data, self-report adverse effects, and placebo group reporting similar symptoms to the case group. Thus, populational-level studies addressing the discussed limitations and the nature and extent of possible psychiatric adverse effects are needed.

RELEVANCE TO PATIENT CARE AND CLINICAL PRACTICE

Most of the patients who developed such adverse effects did not report a family history of psychiatric disease. The frequency of psychiatric adverse effects depends on the patient's biological sex, age, and body mass index, but not on the drug dosage.

CONCLUSIONS

Based on clinical trials and case reports, the current literature presents evidence for a risk of short-term psychiatric adverse effects induced by either drug.

How toxic is an old friend? A review of the safety of hydroxychloroquine in clinical practice

Hydroxychloroquine (HCQ) and its close relative chloroquine (CQ) were initially used as antimalarial agents but are now widely prescribed in rheumatology, dermatology and immunology for the management of autoimmune diseases. HCQ is considered to have a better long-term safety profile than CQ and is therefore more commonly used. HCQ has a key role in the treatment of connective tissue diseases including systemic lupus erythematosus (SLE), where it provides beneficial immunomodulation without clinically significant immunosuppression. HCQ can also assist in managing inflammatory arthritis, including rheumatoid arthritis (RA). Debate around toxicity of HCQ in COVID-19 has challenged those who regularly prescribe HCQ to discuss its potential toxicities. Accordingly, we have reviewed the adverse effect profile of HCQ to provide guidance about this therapeutic agent in clinical practice.

COVID-19-induced psychosis: two case reports and narrative literature review

Introduction: SARS-CoV-2 infection might be presented in many various specific and non-specific manifest and symptoms from different systems. Also, the psychotic symptoms are documented but the explanation for their pathophysiology remains debatable and a complex matter. The main objective of this paper is to present cases of patients without a history of psychiatric disorders who developed the first episode of psychosis during the SARS-CoV-2 infection.

Material and methods: Two cases of not-related patients with no previous psychiatric history developed psychotic episodes during COVID-19 infection. In both cases chronologically first they experienced symptoms of infection, secondly, delusions and psychomotor agitation that required psychiatric hospitalization. Full remission was observed after antipsychotic treatment in both cases.

Results: Even though the pathophysiology of the post-COVID-19 psychiatric symptoms remains unclear, some reports that indicate associations between the infection and the onset of such symptoms. The infection itself, by the induction of cytokine storm followed by the excessive release of pro-inflammatory cytokines, is considered to stimulate the potential onset of the psychosis, however, other factors such as medications used during treatment (with a particular emphasis on glucocorticosteroids) or psychological factors should be considered as well.

Conclusions: Patients infected with SARS-CoV-2 might develop serious psychotic episodes even without a prior psychiatric history. Besides, psychiatric symptoms might be the first the even the only manifestations associated with the active SARSCoV-2 infection which seems to be very challenging especially in cases of rapid psychotic episodes without any clear respiratory symptoms.

Therapeutic strategies to fight COVID-19: Which is the status artis?

COVID-19 is a complex disease, and many difficulties are faced today especially in the proper choice of pharmacological treatments. The role of antiviral agents for COVID-19 is still being investigated and evidence for immunomodulatory and anti-inflammatory drugs is quite conflicting, whereas the use of corticosteroids is supported by robust evidence. The use of heparins in hospitalized critically ill patients is preferred over other anticoagulants. There are conflicting data on the use of convalescent plasma and vitamin D. According to the World Health Organization (WHO), many vaccines are in Phase III clinical trials, and some of them have already received marketing approval in European countries and in the United States. In conclusion, drug repurposing has represented the main approach recently used in the treatment of patients with COVID-19. At this moment, analysis of efficacy and safety data of drugs and vaccines used in real-life context is strongly needed. LINKED ARTICLES: This article is part of a themed issue on The second wave: are we any closer to efficacious pharmacotherapy for COVID 19? (BJP 75th Anniversary). To view the other articles in this section visit http://onlinelibrary.wiley.com/doi/10.1111/bph.v179.10/issuetoc.

The Impact of the COVID-19 Virus Pandemic on the Incidence of First Psychotic Spectrum Disorders

The effects of COVID-19 on the human body are not yet understood enough. Medical history provides information on cases of psychiatric symptoms during viral infections in the 20th century, such as the influenza pandemic. Currently, it is observed that there is an increasing number of new psychiatric disorders in previously healthy individuals. In addition, because of the decreased amount of reporting to health care providers, including psychiatrists, many physicians suggest that the number of neuropsychiatric disorders may be underestimated. In this paper, we review available studies on the occurrence of first-time psychotic spectrum disorder (PSD) in individuals related to SARS-CoV-2 infection. The reviewed studies suggest that first-time psychotic disorder in COVID-19 patients is statistically significantly more frequent compared to influenza, as well as to other respiratory infections. The emergence of new PSDs is explained by direct neurotropism of the virus on the one hand and by immunological mechanisms on the other. The main conclusions of this review should be treated with caution, and future research on this topic is needed. The authors recognize the particular need to develop standardized laboratory panels that include inflammatory markers (IL-6, TNF-α), cerebrospinal fluid (CSF) testing, and SARS-CoV-2 antibody assays to entirely understand the etiology of neuropsychiatric complications of SARS-CoV-2 infections and the pandemic itself. In addition, public health efforts are required to promote mental health, especially during COVID-19.

Neurological Manifestations Related to Immune Checkpoint Inhibitors: Reverse Translational Research by Using the European Real-World Safety Data

Immune checkpoint inhibitors (ICIs) are widely used improving clinical outcomes in many cancer patients. However, they can induce serious consequences, like neurological immune-related adverse drug reactions (NirADRs). Although these are rare complications, they can be serious with important impact on patients' quality of life. Our purpose is to describe these adverse events observed in the European clinical practice context. We carried out a descriptive analysis of individual case safety reports (ICSRs) related to ICIs collected until February 7, 2020, in the European spontaneous reporting database, EudraVigilance, and reported nervous disorders as suspect adverse drug reactions (ADRs). NirADRs were classified according to the Medical Dictionary for Regulatory Activities (MedDRA). In order to identify a hypothetical different reporting probability of the NirADR types between the ICI classes, we carried out a disproportionality analysis. The reporting odds ratio (ROR) with 95% CI was computed comparing the different ICI classes to each other based on their pharmacological target [the cytotoxic T-lymphocyte antigen-4 (CTLA-4), the programmed death-1 (PD-1) or its ligand (PD-L1)]. Finally, we researched in the literature the hypothesized mechanisms, which could explain the onset of these ICI-related neurological complications. Overall, we found 4,875 cases describing 6,429 ICI-related suspected NirADRs. ICI-related neurotoxicities include a wide range of central and peripheral events. These were mainly related to anti-PD-1 agents and occurred in male patients (59%). Our analysis confirmed a gender difference of NirADRs. Twenty-three percent of the events (comprising myasthenia gravis, neuropathy peripheral, and cerebral infarction) had unfavorable fallouts, including fatal outcome (7%). Majority of the NirADRs were categorized as "Neurological disorders NEC" HLGTs MedDRA (2,076; 32%). In 1,094 cases (22%), more NirADRs overlapped with other neurologic complications. An interesting overlapping of myasthenia gravis with myositis or myocarditis emerged. From our disproportionality analysis, an increased reporting probability of peripheral neuropathies and headaches emerged with ipilimumab when compared to anti-PD-1 and anti-PD-L1 agents. However, neuromuscular disorders were more probably reported with anti-PD-1. Several pathogenic mechanisms, including neuronal damage by T cells and autoantibodies and/or cytokine-mediated inflammation processes, have been hypothesized. However, the pathogenesis of these ICI-related complications is not completely understood. Considering the recent marketing authorizations of ICIs, further studies are strongly needed to monitor their neurologic safety profile.

Hydroxychloroquine in systemic lupus erythematosus: overview of current knowledge

The antimalarial hydroxychloroquine (HCQ) has demonstrated several crucial properties for the treatment of systemic lupus erythematosus (SLE). Herein, we reviewed the main HCQ pharmacologic features, detailed its mechanism of action, and summarized the existing guidelines and recommendations for HCQ use in rheumatology with a systematic literature search for the randomized controlled trials focused on lupus. HCQ has been shown to decrease SLE activity, especially in mild and moderate disease, to prevent disease flare and to lower the long-term glucocorticoid need. The numerous benefits of HCQ are extended to pregnancy and breastfeeding period. Based on cohort studies, antithrombotic and metabolic HCQ’s effects were shown, including lipid-lowering properties, which might contribute to an improved cardiovascular risk. Moreover, early HCQ use in antinuclear antibodies positive individuals might delay the progression to SLE. Finally, HCQ has a significant favorable impact on long-term outcomes such as damage accrual and mortality in SLE. Based on these multiple benefits, HCQ is now the mainstay long-term treatment in SLE, recommended by current guidelines in all patients unless contraindications or side effects. The daily dose associated with the best compromise between efficacy and safety is matter of debate. The concern regarding retinal toxicity rather than proper efficacy data is the one that dictated the daily dosage of ⩽5 mg/kg/day actual body weight currently agreed upon.

Emerging Psychiatric Themes in Post-COVID-19 Patients on a Psychiatry Consultation-liaison Service

The need for consultation-liaison psychiatry on COVID-19 wards has substantially increased since the start of the pandemic. In this cross-sectional study, we aimed to summarize the characteristics of patients admitted to the post-COVID-19 ward of the American University of Beirut Medical Center who received a psychiatric consultation. We collected relevant sociodemographic and medical data, information about past psychiatric history, psychiatry consultation details, hospital course, and disposition outcome. We also conducted chi-square and binary logistic regression analyses to assess the association between the different variables and disposition outcome. A total of 52 patients (mean age 57.33 years; equal gender distribution) were seen by the psychiatry consult-liaison team. Most had medical comorbidities and 21.2% required intubation. The most prevalent psychiatric diagnoses were delirium (30.8%), major depressive episode (15.4%), and other anxiety disorder (15.4%). Pharmacological management was implemented in 90.4% of cases and mainly included second-generation antipsychotics (36.5%). Non-pharmacological interventions consisted of those related to delirium and therapy for anxiety. Only intubation was significantly associated with disposition outcome (p = 0.004). This study highlights the various psychiatric themes emerging during the acute and post-acute periods of hospitalization for COVID-19. Hospitalized individuals recovering from the infection should be diligently screened and referred to the psychiatry consultation-liaison team to ensure the implementation of appropriate interventions.

Chloroquine/Hydroxychloroquine Use and Suicide Risk: Hypotheses for Confluent Etiopathogenetic Mechanisms?

Chloroquine (CQ) and hydroxychloroquine (HCQ) are classical anti-malarial and anti-inflammatory treatments, which were used as first-line therapy at the beginning of the 2019 coronavirus disease (COVID-19) pandemic. Besides the emerging data on their lack of efficacy against COVID-19 infection, such treatments have been associated with some severe health concerns, including those of neuropsychiatric nature, such as a possible increase in suicide risk. Here we report a case of a patient with no history of psychiatric illnesses, who abruptly developed depression with melancholic features, severe suicidal ideation (SI), and attempted suicide (SA) shortly after receiving HCQ for his COVID-19 infection. The case was followed by a mini-review of the heterogeneous scientific literature on the hypothetical association between neuropsychiatric symptoms, with a focus on SI and suicidal behavior (SB, including SA and death by suicide), when CQ and HCQ are used in COVID-19, rheumatologic diseases, and malaria settings. Considering the anti-inflammatory properties of CQ and HCQ and the implications for neuroinflammation in suicide pathogenesis, the possible increase in suicide risk caused by these medications appears paradoxical and suggests that other underlying pathological trajectories might account for this eventuality. In this regard, some of these latter mechanistic postulates were proposed. Certainly the role and contribution of psycho-social factors that a COVID-19 patient had to face can neither be minimized nor excluded in the attempt to understand his suffering until the development of SI/SB. However, while this case report represents a rare scenario in clinical practice and no consensus exists in the literature on this topic, a psychiatric screening for suicide risk in patients using of CQ and HCQ could be carefully considered.

Psychiatric Clinical Profiles and Pharmacological Interactions in COVID-19 Inpatients Referred to a Consultation Liaison Psychiatry Unit: a Cross-Sectional Study

The Coronavirus Disease 2019 (COVID-19) can affect mental health in different ways. There is little research about psychiatric complications in hospitalized patients with COVID-19. The aim of the study was to describe the psychiatric clinical profile and pharmacological interactions in COVID-19 inpatients referred to a Consultation-Liaison Psychiatry (CLP) unit. This is a cross-sectional study, carried out at a tertiary hospital in Spain, in inpatients admitted because of COVID-19 and referred to our CLP Unit from March 17,2020 to April 28,2020. Clinical data were extracted from electronic medical records. The patients were divided in three groups depending on psychiatric diagnosis: delirium, severe mental illness (SMI) and non-severe mental illness (NSMI). Of 71 patients included (median [ICR] age 64 [54-73] years; 70.4% male), 35.2% had a delirium, 18.3% had a SMI, and 46.5% had a NSMI. Compared to patients with delirium and NSMI, patients with SMI were younger, more likely to be institutionalized and were administered less anti-COVID19 drugs. Mortality was higher among patients with delirium (21.7%) than those with SMI (0%) or NSMI (9.45%). The rate of side effects due to interactions between anti-COVID19 and psychiatric drugs was low, mainly drowsiness (4.3%) and borderline QTc prolongation (1.5%). Patients affected by SMI were more often undertreated for COVID-19. However, the rate of interactions was very low, and avoidable with a proper evaluation and drug-dose adjustment. Half of the patients with SMI were institutionalized, suggesting that living conditions in residential facilities could make them more vulnerable to infection.

Intracerebral Hemorrhage, Visual Hallucination and COVID-19: What Is the Connection? A Case-Related Review of the Literature on Peduncular Hallucinosis Following Intracerebral Hemorrhage

Previous publications have discussed the occurrence of intracerebral hemorrhages, hallucinations and psychosis in COVID-19 patients. In this article, we have reviewed the literature on the subject while depicting the case of a 63-year-old female patient who suffered from an intracerebral hemorrhage in the right basal ganglia and thalamus two weeks after a COVID-19 diagnosis and who developed a visual hallucinosis shortly after. We concluded that, while there may be a correlation between COVID-19 and hallucinations according to current literature, more research is yet needed to clarify. In our case, we rather interpreted the hallucinations in the context of a peduncular hallucinosis related to the intracerebral hemorrhage. We compared our patient’s lesion localization to other 15 reported cases of peduncular hallucinations following intracerebral hemorrhages reported on Pubmed. In summary, the lesions were localized in the pons in 52.9% of the cases, 17.7% were in the thalamus and/or the basal ganglia, 17.7% in the mesencephalon and respectively 5.8% in the temporal and occipital lobe. The distribution pattern we found is consistent with the previously proposed mechanism behind peduncular hallucinations.

Evaluation of IGF-1 as a novel theranostic biomarker for schizophrenia

OBJECTIVE

In the current study, we aimed to investigate fasting plasma levels of glucose, insulin, growth hormone, IGF-1, and lipid profile in remission schizophrenia patients, treatment resistant schizophrenia patients and healthy controls and to determine whether IGF-1 levels can be used as a theranostic biomarker in schizophrenia.

METHODS

Sixty-two patients under remission from schizophrenia, sixty-five treatment-resistant patients with schizophrenia and sixty-two healthy controls were included in the study. All patients were recruited and evaluated over 11 months. Symptoms at the time of evaluation were assessed twice using BPRS, PANSS, CGI, and GAF scales by an experienced psychiatrist in accordance with Andreaseen's remission criteria and TRIPS group resistance criteria. Blood samples were collected from all participants to determine fasting glucose, LDL, HDL, Triglyceride, Total Cholesterol, fasting, insulin, GH and IGF-1 levels.

RESULTS

Fasting blood glucose levels were found to be higher in patients with schizophrenia than in healthy controls. Moreover, LDL levels of the treatment sensitive group were higher than that of the treatment resistant group while they were not significantly different from the healthy controls. IGF-1 levels were lower in the treatment sensitive group than in both treatment resistant and healthy control groups. IGF-1, LDL and age of disease onset were found to be significantly associated with treatment resistance in a regression model.

DISCUSSION

In the present study, remitted patients with schizophrenia could be distinguished from treatment-resistant patients and healthy controls with serum IGF-1, fasting glucose and LDL levels. In addition, we found that smoking and age of disease onset together with IGF-1 levels could significantly predict resistance to treatment.

COVID-19 ARDS: A Multispecialty Assessment of Challenges in Care, Review of Research, and Recommendations

Physicians and care providers are familiar with the management of ARDS, however, when it occurs as a sequalae of COVID-19, it has different features and there remains uncertainty on the consensus of management. To answer this question on how it compares and contrasts with ARDS from other causes, the authors reviewed the published literature and management guidelines as well as their own clinical experience while managing patients with COVID-19 ARDS. For research, a PubMed search was conducted on 01.04.2021 using the systematic review filter to identify articles that were published using MeSH terms COVID-19 and ARDS. Systematic reviews or meta-analyses were selected from a systematic search for literature containing diagnostic, prognostic and management strategies in MEDLINE/PubMed. Those were compared and reviewed to the existing practices by the various treating specialists and recommendations were made. Specifically, the COVID-19 ARDS, its risk factors and pathophysiology, lab diagnosis, radiological findings, rational of recommendation of drugs proposed so far, oxygenation and ventilation strategies and the psychological ramifications of the disease were. discussed. Because of the high mortality in mechanically ventilated patients, the above recommendations and findings direct the potential for improvement in the management of patients with COVID-19 ARDS.

Risk of depression, suicide and psychosis with hydroxychloroquine treatment for rheumatoid arthritis: a multinational network cohort study

OBJECTIVES

Concern has been raised in the rheumatology community regarding recent regulatory warnings that HCQ used in the coronavirus disease 2019 pandemic could cause acute psychiatric events. We aimed to study whether there is risk of incident depression, suicidal ideation or psychosis associated with HCQ as used for RA.

METHODS

We performed a new-user cohort study using claims and electronic medical records from 10 sources and 3 countries (Germany, UK and USA). RA patients ≥18 years of age and initiating HCQ were compared with those initiating SSZ (active comparator) and followed up in the short (30 days) and long term (on treatment). Study outcomes included depression, suicide/suicidal ideation and hospitalization for psychosis. Propensity score stratification and calibration using negative control outcomes were used to address confounding. Cox models were fitted to estimate database-specific calibrated hazard ratios (HRs), with estimates pooled where I2 <40%.

RESULTS

A total of 918 144 and 290 383 users of HCQ and SSZ, respectively, were included. No consistent risk of psychiatric events was observed with short-term HCQ (compared with SSZ) use, with meta-analytic HRs of 0.96 (95% CI 0.79, 1.16) for depression, 0.94 (95% CI 0.49, 1.77) for suicide/suicidal ideation and 1.03 (95% CI 0.66, 1.60) for psychosis. No consistent long-term risk was seen, with meta-analytic HRs of 0.94 (95% CI 0.71, 1.26) for depression, 0.77 (95% CI 0.56, 1.07) for suicide/suicidal ideation and 0.99 (95% CI 0.72, 1.35) for psychosis.

CONCLUSION

HCQ as used to treat RA does not appear to increase the risk of depression, suicide/suicidal ideation or psychosis compared with SSZ. No effects were seen in the short or long term. Use at a higher dose or for different indications needs further investigation.

TRIAL REGISTRATION

Registered with EU PAS (reference no. EUPAS34497; http://www.encepp.eu/encepp/viewResource.htm? id=34498). The full study protocol and analysis source code can be found at https://github.com/ohdsi-studies/Covid19EstimationHydroxychloroquine2.

Neurological Effects of Sars-Cov-2 And Neurotoxicity of Antiviral Drugs Against Covid-19

Severe Acute Respiratory Syndrome (SARS) is caused by different SARS viruses. In 2020, novel coronavirus (SARS-CoV-2) led to an ongoing pandemic, known as "Coronavirus Disease 2019 (COVID-19)". The disease can spread among individuals through direct (via saliva, respiratory secretions or secretion droplets) or indirect (through contaminated objects or surfaces) contact. The pandemic has spread rapidly from Asia to Europe and later to America. It continues to affect all parts of the world at an increasing rate. There have been over 92 million confirmed cases of COVID-19 by mid-January 2021. The similarity of homological sequences between SARS-CoV-2 and other SARS-CoVs is high. In addition, clinical symptoms of SARS-CoV-2 and other SARS viruses show similarities. However, some COVID-19 cases show neurologic signs like headache, loss of smell, hiccups and encephalopathy. The drugs used in the palliative treatment of the disease also have some neurotoxic effects. Currently, there are approved vaccines for COVID-19. However, there is a need for specific therapeutics against COVID-19. This review will describe the neurological effects of SARS-CoV-2 and the neurotoxicity of COVID-19 drugs used in clinics. Drugs used in the treatment of COVID-19 will be evaluated by their mechanism of action and their toxicological effects.

Association of antimalarial drugs with decreased overall and cause specific mortality in systemic lupus erythematosus

OBJECTIVE

To evaluate the association and dose-response pattern between antimalarial drugs and overall and cause specific mortality in SLE patients.

METHODS

Medical records including information on HCQ/chloroquine (CQ) prescription were extracted from Jiangsu Lupus database. The database was designed to collect data from SLE patients that first-hospitalized during 1999-2009 in Jiangsu province, China, and a follow-up for survival status was performed in 2010 and 2015. Cox and restricted cubic spline models were used to estimate the hazard ratio and 95% CI.

RESULTS

We identified 221 deaths among 2446 SLE patients in total. Compared with non-users, decreased overall mortality was associated with either HCQ or CQ users, with adjusted hazard ratio (95% CI) of 0.49 (0.35, 0.67) and 0.49 (0.27, 0.87), respectively. The association between HCQ/CQ and overall mortality was similar across subgroups, such as patients with comorbidities and organ involvements. Interestingly, both the time and the daily dosage of HCQ/CQ use were related to decreased mortality of SLE in a linear dose-response relationship. In cause specific analyses, HCQ/CQ was inversely associated with death from renal insufficiency and other organ (cardiopulmonary, gastrointestinal and haematological) involvements, with adjusted hazard ratio (95% CI) of 0.23 (0.09, 0.55) and 0.25 (0.10, 0.62), respectively, yet it was not significantly associated with mortality from infection and neuropsychiatric involvements.

CONCLUSION

Antimalarial drugs were associated with lower risk of SLE mortality, especially renal insufficiency- and other organ involvement-related death. The protective effects for survival might be augmented by adherence and full dosage of these drugs.

Adverse drug reactions in SARS-CoV-2 hospitalised patients: a case-series with a focus on drug-drug interactions

Due to the need of early and emergency effective treatments for COVID-19, less attention may have been paid to their safety during the global emergency. In addition, characteristics of drug-drug interaction (DDI)-related adverse drug reactions (ADRs) in COVID-19 patients have not yet been studied in depth. The aim of the present case-series study is to describe clinical and pharmacological characteristics of SARS-CoV-2 hospitalised patients, focusing on ADRs, particularly those related to DDIs. We evaluated all reports of COVID-19 medication-related ADRs collected within the COVID-19 Units of Careggi University Hospital, Florence (Italy), between January 1st and 31st May 2020. Information regarding COVID-19 medications, patients' demographic and clinical characteristics, concomitant drugs, ADRs description and outcome, were collected. Each case was evaluated for the causality assessment and to identify the presence of DDIs. During the study period, 23 Caucasian patients (56.5% males, mean age 76.1 years) experienced one or more ADRs. The majority of them were exposed to polypharmacy and 17.4% presented comorbidities. ADRs were referred to cardiovascular, psychiatric and gastrointestinal disorders. The most frequently reported preferred term was QT prolongation (mean QT interval 496.1 ms). ADRs improved or resolved completely in 60.8% of cases. For all patients, a case-by-case evaluation revealed the presence of one or more DDIs, especially those related to pharmacokinetic interactions. Despite the small number of patients, our evidence underline the clinical burden of DDIs in SARS-CoV-2 hospitalised patients and the risk of unexpected and uncommon psychiatric ADRs.

Neuropsychiatric Complications of COVID-19

PURPOSE OF REVIEW

To describe the presentation, etiologies, and suggested management of post-acute COVID-19 neuropsychiatric symptoms.

RECENT FINDINGS

Over 30% of patients hospitalized with COVID-19 may exhibit cognitive impairment, depression, and anxiety that persist for months after discharge. These symptoms are even more common in patients who required intensive care for severe effects of the virus. In addition to the pandemic-related psychological stress, multiple biological mechanisms have been proposed to understand the neuropsychiatric symptoms observed with COVID-19. Given limited research regarding effective interventions, we recommend pharmacologic and behavioral strategies with established evidence in other medically-ill populations. Long-term, neuropsychiatric complications of COVID-19 are common and consequential. Because these are likely to co-occur with other medical problems, patients recovering from COVID-19 are best managed in clinics with highly coordinated care across disciplines and medical specialties. Future research is needed to inform appropriate interventions.

Safety management in treatment with antimalarials in rheumatology. Interdisciplinary recommendations on the basis of a systematic literature review

BACKGROUND

Antimalarial medication (AM) plays an important role in the treatment of rheumatic diseases.

OBJECTIVE

Updated evidence-based recommendations on the safety management of rheumatological treatment with AM are presented.

METHODS

A systematic literature search in the databases Medline (PubMed) and Cochrane identified 1160 studies on the safety of treatment with AM in rheumatology. In addition, a manual search was carried out and 67 publications considered to be particularly relevant by the authors were analyzed in more detail. These publications served as a basis for consensus-based recommendations.

RESULTS

Treatment with AM in rheumatology should be carried out with hydroxychloroquine (HCQ) with a dosage not exceeding 5 mg/kg body weight/day. Patients should undergo a basic ophthalmological examination within the first 6 months of AM treatment. Pre-existing maculopathy, renal insufficiency (glomerular filtration rate, GFR <60 ml/min), tamoxifen comedication, a daily dose of >5 mg/kg HCQ or treatment with chloroquine (CQ) show an increased risk for AM-induced retinopathy. These patients should undergo an annual ophthalmological check from the beginning of the treatment, whereas patients with no risk factors are recommended to start this only after 5 years of taking the medication. The ophthalmological examination should comprise at least both an appropriate subjective and an objective method and these are usually an automated visual field test and optical coherence tomography (OCT). A visual field test revealing a parafoveal sensitivity loss and an OCT showing a parafoveal circumscribed loss of the photoreceptor layer or focal interruptions of the structural line of the outer segment are signs of a possible AM retinopathy. Determination of creatine kinase (CK) and lactate dehydrogenase (LDH) in blood is appropriate to screen for cardiomyopathy and myopathy and should be checked before starting the treatment and then ca. every 3 months. The use of cardiac biomarkers, such as brain natriuretic peptide (BNP) or troponin in serum, electrocardiograph (ECG) or cardiac imaging should be considered depending on the situation. An intake of HCQ is safe during pregnancy and breastfeeding according to the current state of knowledge and is protective for mother and child in patients with systemic lupus erythematosus.

CONCLUSION

The updated recommendations on AM treatment in rheumatology in particular include a more rigorous measuring of doses, risk stratification in monitoring and defined ophthalmological examination methods to detect a possible retinopathy.

Prevalence and predictors of posttraumatic stress disorder, depression and anxiety among hospitalized patients with coronavirus disease 2019 in China

BACKGROUND

Coronavirus disease 2019 (COVID-19) has affected more than 5 million people around the world and killed more than 300,000 people; thus, it has become a global public health emergency. Our objective was to investigate the mental health of hospitalized patients diagnosed with COVID-19.

METHODS

The PTSD checklist for DSM-5 (PCL-5), Patient Health Questionnaire (PHQ-9), Generalized Anxiety Disorder Scale (GAD-7), Trauma Exposure Scale, abbreviated version of the Connor-Davidson Resilience Scale (CD-RISC-10), Perceived Social Support Scale (PSSS) and Demographic Questionnaire were used to examine posttraumatic stress disorder (PTSD), depression, anxiety, trauma exposure, resilience and perceived social support among 898 patients who were hospitalized after being diagnosed with COVID-19 in China. The data were analyzed with t tests, one-way ANOVA and multivariable logistic regression analysis.

RESULTS

The results showed that the prevalence of PTSD, depression and anxiety was 13.2, 21.0 and 16.4%, respectively. Hospitalized patients who were more impacted by negative news reports, had greater exposure to traumatic experiences, and had lower levels of perceived social support reported higher PTSD, depression and anxiety.

CONCLUSIONS

Effective professional mental health services should be designed to support the psychological wellbeing of hospitalized patients, especially those who have severe disease, are strongly affected by negative news and have high levels of exposure to trauma.

Pharmacological agents under investigation in the treatment of coronavirus disease 2019 and the importance of melatonin

Coronavirus disease 2019 (COVID-19) is a life-threatening infectious respiratory disease caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). COVID-19 pandemic causing morbidities and even deaths worldwide revealed that there is urgent need to find pharmacological agents or vaccines. Although there are a lot of agents under investigation, there is no approved agent for the prevention or treatment of the COVID-19 yet. Treatment of patients remains mainly supportive as well as compassionate use of the agents under investigation. It is well established that excessive inflammatory and immune response and oxidative injury play a critical role in the pathogenesis of COVID-19. In this review, we aimed to update knowledge about pathogenesis, clinical features, and pharmacological treatment of COVID-19 and review the potential beneficial effects of ancient antioxidant, anti-inflammatory, and immunomodulatory molecule melatonin for prevention and treatment of COVID-19.

Pre-Exposure Prophylaxis for COVID-19 in Pregnant Women

Pregnant women are at higher risk for developing severe complications of COVID-19 including preterm delivery, respiratory failure, and death. Although vaccines to prevent COVID-19 are being developed, pregnant women are not included in the current COVID-19 vaccine trials and initially this population may not be eligible for COVID-19 vaccines due to lack of safety testing in pregnancy. As an alternate approach, we discuss the concept of pre-exposure prophylaxis (PrEP) using medications that are approved for use in pregnant women to prevent gestational problems and severe illness in this high-risk population. In particular, the use of hydroxychloroquine PrEP affords a safe and readily available means to avoid COVID-19 complications in pregnancy.

The SARS-CoV-2 and mental health: From biological mechanisms to social consequences

In December 2019, the first case of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2, COVID-19) infection was reported. In only few weeks it has caused a global pandemic, with mortality reaching 3.4%, mostly due to a severe pneumonia. However, the impact of SARS-CoV-2 virus on the central nervous system (CNS) and mental health outcomes remains unclear. Previous studies have demonstrated the presence of other types of coronaviruses in the brain, especially in the brainstem. There is evidence that the novel coronavirus can penetrate CNS through the olfactory or circulatory route as well as it can have an indirect impact on the brain by causing cytokine storm. There are also first reports of neurological signs in patients infected by the SARS-Cov-2. They show that COVID-19 patients have neurologic manifestations like acute cerebrovascular disease, conscious disturbance, taste and olfactory disturbances. In addition, there are studies showing that certain psychopathological symptoms might appear in infected patients, including those related to mood and psychotic disorders as well as post-traumatic stress disorder. Accumulating evidence also indicates that the pandemic might have a great impact on mental health from the global perspective, with medical workers being particularly vulnerable. In this article, we provide a review of studies investigating the impact of the SARS-CoV-2 on the CNS and mental health outcomes. We describe neurobiology of the virus, highlighting the relevance to mental disorders. Furthermore, this article summarizes the impact of the SARS-CoV-2 from the public health perspective. Finally, we present a critical appraisal of evidence and indicate future directions for studies in this field.

Hipótesis neuroinvasiva en un caso de delirium atípico en paciente con neumonía por COVID-19

Objetivo

El delirium es la complicación neuropsiquiátrica más frecuente en pacientes con afectación grave por COVID-19. Presentamos un caso atípico, desde el punto de vista clínico y fenomenológico, y reflexionamos sobre los mecanismos etiológicos implicados.

Caso clínico

Varón de 55 años, médico en activo, ingresado en la unidad de hospitalización convencional, y estable clínicamente tras un ingreso en la Unidad de Cuidados Intensivos por neumonía por COVID-19 grave. Presenta un delirium atípico, con alteraciones mnésicas y de lenguaje muy significativas, que se miden psicométricamente, mientras mantiene un buen nivel atencional y de alerta. El resto de las pruebas complementarias realizadas son normales o poco concluyentes.

Resultados

La evolución durante el ingreso es buena y la recuperación completa al mes del alta hospitalaria.

Conclusiones

La presentación atípica y la evolución clínica de este cuadro de delirium permiten plantear el papel neuroinvasivo directo de la COVID-19, en este caso.

Hydroxychloroquine Exhibits a Strong Complex Interaction with DNA: Unraveling the Mechanism of Action

In the past months, the use of the drug hydroxychloroquine has considerably increased in many countries, associated with a proposed treatment for the COVID-19 disease. Although there is no conclusive evidence about the efficacy of the drug for this purpose, surprisingly there are no conclusive studies in the literature concerning its mechanism of action inside cells, which is related to its interaction with nucleic acids. Here, we performed a robust characterization of the interaction between hydroxychloroquine and double-stranded DNA using single-molecule force spectroscopy and gel electrophoresis. Two different binding modes were identified, namely, minor groove binding for low drug concentrations and intercalation for high drug concentrations, and the sets of binding parameters were determined for each of these modes. Such results have unraveled in detail the molecular mechanism of action of the drug as a DNA ligand.

Psychiatric Aspects of Chloroquine and Hydroxychloroquine Treatment in the Wake of Coronavirus Disease-2019: Psychopharmacological Interactions and Neuropsychiatric Sequelae

BACKGROUND

Chloroquine and hydroxychloroquine are among several experimental treatments being investigated in the urgent response to the coronavirus disease-2019. With increased use of these medications, physicians need to become knowledgeable of these drugs' neuropsychiatric side effects and interactions with psychiatric medications.

OBJECTIVE

Clarify evidence base regarding the psychiatric side effects and psychiatric drug interactions of chloroquine and hydroxychloroquine.

METHODS

A literature review was performed in PubMed from 1950 to 2020 regarding psychiatric topics and targeted pharmacological properties of chloroquine and hydroxychloroquine.

RESULTS

First, chloroquine and hydroxychloroquine may mildly inhibit CYP2D6 metabolism of psychiatric medications, and psychiatric medications that interfere with CYP2D6 or CYP3A4 activity could alter chloroquine and hydroxychloroquine levels. Second, they may prolong the QT interval, warranting caution with concomitant prescription of other QT prolonging agents. Finally, neuropsychiatric side effects are very uncommon but possible and include a potentially prolonged phenomenon of "psychosis after chloroquine." Hydroxychloroquine has less information available about its neuropsychiatric side effects than chloroquine, with psychosis literature limited to several case reports. Weak evidence suggests a possible association of hydroxychloroquine exposure and increased suicidal ideation. It is not clear whether patients with psychiatric illness are more vulnerable to neuropsychiatric sequela of these medications; however, overdose of these medications by suicidal patients has high risk of mortality.

CONCLUSION

The risk of neuropsychiatric side effects of chloroquine and hydroxychloroquine when used for coronavirus disease-2019 treatment is not known. Best practice may include suicide risk assessment for patients treated with hydroxychloroquine. However, delirium is expected to be a more likely etiology of neuropsychiatric symptoms in critically ill patients treated for coronavirus disease-2019, and adjustment disorder is a much more likely etiology of anxiety and depression symptoms than the side effects of chloroquine or hydroxychloroquine.

Psychiatric Disorders and Hydroxychloroquine for Coronavirus Disease 2019 (COVID-19): A VigiBase Study

INTRODUCTION

In the stressful context of the coronavirus disease 2019 (COVID-19) pandemic, some reports have raised concerns regarding psychiatric disorders with the use of hydroxychloroquine. In this study, we reviewed all psychiatric adverse effects with hydroxychloroquine in COVID-19 patients, as well as in other indications, reported in VigiBase, the World Health Organization's (WHO) global database of individual case safety reports.

METHODS

First, we analyzed all psychiatric adverse effects, including suicide, of hydroxychloroquine in COVID-19 patients reported to 16 June 2020. We also performed disproportionality analysis to investigate the risk of reporting psychiatric disorders with hydroxychloroquine compared with remdesivir, tocilizumab, or lopinavir/ritonavir prescribed in COVID-19 patients. We used reporting odds ratios (RORs) and their 95% confidence intervals (CIs) to calculate disproportionality. Second, we sought to examine the psychiatric safety profile of hydroxychloroquine in other indications (before 2020).

RESULTS

Among the 1754 reports with hydroxychloroquine in COVID-19 patients, we found 56 psychiatric adverse effects. Half of these adverse effects were serious, including four completed suicides, three cases of intentional self-injury, and 12 cases of psychotic disorders with hallucinations. Compared with remdesivir, tocilizumab, or lopinavir/ritonavir, the use of hydroxychloroquine was associated with an increased risk of reporting psychiatric disorders (ROR 6.27, 95% CI 2.74-14.35). Before 2020, suicide was the main cause of death among all adverse drug reactions reported with hydroxychloroquine, followed by cardiac adverse effects (cardiomyopathy) and respiratory failure.

CONCLUSIONS

This pharmacovigilance analysis suggests that COVID-19 patients exposed to hydroxychloroquine experienced serious psychiatric disorders, and, among these patients, some committed suicide. Further real-world studies are needed to quantify the psychiatric risk associated with hydroxychloroquine during the COVID-19 pandemic.

[Safety management of the treatment with antimalarial drugs in rheumatology. Interdisciplinary recommendations based on a systematic literature search]

BACKGROUND

Antimalarial medication (AM) plays an important role in the treatment of rheumatic diseases.

OBJECTIVE

Updated evidence-based recommendations on the safety management of rheumatological treatment with AM are presented.

METHODS

A systematic literature search in the databases Medline (PubMed) and Cochrane identified 1160 studies on the safety of treatment with AM in rheumatology. In addition, a manual search was carried out and 67 publications considered to be particularly relevant by the authors were analyzed in more detail. These publications served as a basis for consensus-based recommendations.

RESULTS

Treatment with AM in rheumatology should be carried out with hydroxychloroquine (HCQ) with a dosage not exceeding 5 mg/kg body weight/day. Patients should undergo a basic ophthalmological examination within the first 6 months of AM treatment. Pre-existing maculopathy, renal insufficiency (glomerular filtration rate, GFR <60 ml/min), tamoxifen comedication, a daily dose of >5 mg/kg HCQ or treatment with chloroquine (CQ) show an increased risk for AM-induced retinopathy. These patients should undergo an annual ophthalmological check from the beginning of the treatment, whereas patients with no risk factors are recommended to start this only after 5 years of taking the medication. The ophthalmological examination should comprise at least both an appropriate subjective and an objective method and these are usually an automated visual field test and optical coherence tomography (OCT). A visual field test revealing a parafoveal sensitivity loss and an OCT showing a parafoveal circumscribed loss of the photoreceptor layer or focal interruptions of the structural line of the outer segment are signs of a possible AM retinopathy. Determination of creatine kinase (CK) and lactate dehydrogenase (LDH) in blood is appropriate to screen for cardiomyopathy and myopathy and should be checked before starting the treatment and then ca. every 3 months. The use of cardiac biomarkers, such as brain natriuretic peptide (BNP) or troponin in serum, electrocardiograph (ECG) or cardiac imaging should be considered depending on the situation. An intake of HCQ is safe during pregnancy and breastfeeding according to the current state of knowledge and is protective for mother and child in patients with systemic lupus erythematosus.

CONCLUSION

The updated recommendations on AM treatment in rheumatology in particular include a more rigorous measuring of doses, risk stratification in monitoring and defined ophthalmological examination methods to detect a possible retinopathy.

Psychotic symptoms in COVID-19 patients. A retrospective descriptive study

Psychotic symptoms have been related to other coronavirus infections. We conducted a single-centre retrospective and observational study to describe new-onset psychotic episodes in COVID-19 patients. Ten patients infected by the novel coronavirus with psychotic symptoms and no previous history of psychosis were identified by the emergency and liaison psychiatry departments. Nine of the cases presented with psychotic symptoms at least two weeks after the first somatic manifestations attributed to COVID-19 and receiving pharmacological treatment. Structured delusions mixed with confusional features were the most frequent clinical presentations. Hence, COVID-19 patients can develop psychotic symptoms as a consequence of multiple concurrent factors.

Affective psychosis after COVID-19 infection in a previously healthy patient: a case report

•Patients COVID19 new-onset psychiatric symptoms because treatments or virus itself

[Psychopharmacotherapy during the COVID-19 pandemic]

Im Rahmen der aktuellen coronavirus disease 2019(COVID-19)-Pandemie müssen sich viele Bereiche der Medizin umstrukturieren. Dies betrifft auch die Versorgung von Patienten mit psychischen Erkrankungen. Die Therapie psychischer Erkrankungen umfasst psychotherapeutische und psychopharmakologische Interventionen. Letztere können mit einer Vielzahl an unerwünschten Arzneimittelwirkungen (UAW) assoziiert sein, stellen aber in der aktuellen Situation mit Kontakt- und Ausgangsbeschränkungen die präferierte Therapieoption dar. Da der direkte Patientenkontakt zugunsten des Telefonats oder der Videokonferenz reduziert ist, müssen angepasste diagnostische und therapeutische Optionen gefunden werden, um eine ausreichende Patientensicherheit zu gewährleisten. Bedeutend sind hierbei die ausführliche Aufklärung der Patienten sowie eine aktive Abfrage von Symptomen zur rechtzeitigen Erkennung von UAW. Unter der Behandlung mit Psychopharmaka sind UAW zu befürchten, die besonders ungünstig sind, wenn sie im Rahmen einer akuten Infektion auftreten oder ein erhöhtes Infektionsrisiko begünstigen. Hierzu gehören Atemdepression, Agranulozytose, Intoxikation durch Hemmung des Arzneistoffmetabolismus und venöse Thromboembolien, die jeweils mit potenziell lebensbedrohlichen Folgen einhergehen. Gleichzeitig sollte auf eine ausreichende Wirksamkeit der Medikation geachtet werden, da die gegenwärtige Krise zu einer Exazerbation vorbestehender psychischer Erkrankungen führen bzw. deren Erstmanifestation begünstigen kann.

Psychopharmacology of COVID-19

Background

With the rapid, global spread of severe acute respiratory syndrome coronavirus 2, hospitals have become inundated with patients suffering from coronavirus disease 2019. Consultation-liaison psychiatrists are actively involved in managing these patients and should familiarize themselves with how the virus and its proposed treatments can affect psychotropic management. The only Food and Drug Administration-approved drug to treat COVID-19 is remdesivir, and other off-label medications used include chloroquine and hydroxychloroquine, tocilizumab, lopinavir/ritonavir, favipiravir, convalescent plasma therapy, azithromycin, vitamin C, corticosteroids, interferon, and colchicine.

Objective

To provide an overview of the major safety considerations relevant to clinicians who prescribe psychotropics to patients with COVID-19, both related to the illness and its proposed treatments.

Methods

In this targeted review, we performed structured literature searches in PubMed to identify articles describing the impacts of COVID-19 on different organ systems, the neuropsychiatric adverse effects of treatments, and any potential drug interactions with psychotropics. The articles most relevant to this one were included.

Results

COVID-19 impacts multiple organ systems, including gastrointestinal, renal, cardiovascular, pulmonary, immunological, and hematological systems. This may lead to pharmacokinetic changes that impact psychotropic medications and increase sensitivity to psychotropic-related adverse effects. In addition, several proposed treatments for COVID-19 have neuropsychiatric effects and potential interactions with commonly used psychotropics.

Conclusions

Clinicians should be aware of the need to adjust existing psychotropics or avoid using certain medications in some patients with COVID-19. They should also be familiar with neuropsychiatric effects of medications being used to treat this disease. Further research is needed to identify strategies to manage psychiatric issues in this population.

Psychopharmacology of COVID-19

Background

With the rapid, global spread of severe acute respiratory syndrome coronavirus 2, hospitals have become inundated with patients suffering from coronavirus disease 2019. Consultation-liaison psychiatrists are actively involved in managing these patients and should familiarize themselves with how the virus and its proposed treatments can affect psychotropic management. The only Food and Drug Administration–approved drug to treat COVID-19 is remdesivir, and other off-label medications used include chloroquine and hydroxychloroquine, tocilizumab, lopinavir/ritonavir, favipiravir, convalescent plasma therapy, azithromycin, vitamin C, corticosteroids, interferon, and colchicine.

Objective

To provide an overview of the major safety considerations relevant to clinicians who prescribe psychotropics to patients with COVID-19, both related to the illness and its proposed treatments.

Methods

In this targeted review, we performed structured literature searches in PubMed to identify articles describing the impacts of COVID-19 on different organ systems, the neuropsychiatric adverse effects of treatments, and any potential drug interactions with psychotropics. The articles most relevant to this one were included.

Results

COVID-19 impacts multiple organ systems, including gastrointestinal, renal, cardiovascular, pulmonary, immunological, and hematological systems. This may lead to pharmacokinetic changes that impact psychotropic medications and increase sensitivity to psychotropic-related adverse effects. In addition, several proposed treatments for COVID-19 have neuropsychiatric effects and potential interactions with commonly used psychotropics.

Conclusions

Clinicians should be aware of the need to adjust existing psychotropics or avoid using certain medications in some patients with COVID-19. They should also be familiar with neuropsychiatric effects of medications being used to treat this disease. Further research is needed to identify strategies to manage psychiatric issues in this population.

Working with Bipolar Disorder During the COVID-19 Pandemic: Both Crisis and Opportunity

Beyond public health and economic costs, the COVID-19 pandemic adds strain, disrupts daily routines, and complicates mental health and medical service delivery for those with mental health and medical conditions. Bipolar disorder can increase vulnerability to infection; it can also enhance stress, complicate treatment, and heighten interpersonal stigma. Yet there are successes when people proactively improve social connections, prioritize self-care, and learn to effectively use mobile and telehealth.

Chloroquine and hydroxychloroquine: potentially inappropriate medications for older adults?

Introduction: Potentially inappropriate medications (PIMs) for older adults cause more adverse effects than benefits. The 2019 American Geriatrics Society Beers Criteria (2019BC) considered five clinical situations as PIM use in older adults. Can drug analysis, according to these situations, assist in the act of making prescriptions for older people? Seeking a practical example for this question, we assessed drugs currently questioned as to their safe use among older people. Objective: To check if chloroquine and hydroxychloroquine fit the PIM criteria for older adults and whether this analysis is clinically applicable. Method: We systematized the objective based on the five clinical situations defined as PIM use in older adults by the 2019BC. Results: Chloroquine and hydroxychloroquine fulfill, respectively, four and five of these clinical situations. This evaluation allowed the likely definition of these drugs as PIMs for older adults in a simple way, based on a brief analysis of the available literature. Conclusion: Chloroquine and hydroxychloroquine may be considered PIMs for older adults. We expect that this analysis can be replicated with other drugs and reduce iatrogenesis in older people.