Ventricular arrhythmias possibly aggravated by trazodone

Cyclic Antidepressant Poisoning: A Review and Case Report

Although newer cyclic antidepressants have been introduced over the past several years, the tricyclic antidepressants (TCAs) continue to be the leading cause of morbidity from drug overdose in the United States. Overdose features depend on the particular cyclic antidepressant ingested and its pharmacological properties, and can include CNS depression, cardiac arrhythmias, hypotension, seizures, and anticholinergic symptomatology. Life-threatening symptomatology almost always begins within 2 hours, and certainly within 6 hours, after arrival to the emergency department. Plasma TCA levels are unreliable predictors of TCA toxicity and are not recommended. An ECG with a prolonged QRS complex more than 100 msec seems to be the best indicator of serious sequelae with TCAs. Management consists of stabilization of vital signs, gastrointestinal decontamination, intravenous sodium bicarbonate, and supportive care. Agents once thought to be useful for the treatment of cardiac dysrhythmias and seizures such as phenytoin and physostigmine should be avoided. The future of TCA antibody fragments in the treatment of TCA overdose seems promising. Newer and, to some degree, safer antidepressants in overdose have recently been introduced, and they include fluoxetine, trazodone, and sertraline. Amoxapine, bupropion, and maprotiline seem to be as toxic as the TCAs. A significant interaction between cyclic antidepressants and monoamine-oxidase inhibitors exists. Management includes supportive care and basic poison management. Prevention of poisoning seems to be the most logical and effective method of maintaining patient safety. TCAs should be avoided in children younger than 6 years old. All adults with suicidal ideations should receive no more than a 1-week supply (about 1 g) of drug. Finally consideration should be given to using one of the newer, safer antidepressants in all patients with suicidal ideations.

Management of ventricular dysrhythmia secondary to trazodone overdose

Torsades de pointes (TdP), a life-threatening ventricular dysrhythmia, was recorded in a 30-year-old woman who had taken a deliberate overdose of trazodone. The patient was successfully defibrillated to normal sinus rhythm and given intravenous magnesium sulfate according to Advanced Cardiovascular Life Support guidelines. The patient was discharged and experienced no further complications.

A postmarketing study of relative abuse liability of hypnotic sedative drugs

AIMS

To demonstrate the utility of postmarketing studies using in-treatment drug and alcohol abusers as informants for assessing the relative abuse liability of sedative-hypnotic drugs.

DESIGN

A survey was conducted that ascertained exposure to a variety of drugs with hypnotic/sedative properties and elicited subjective evaluations indicative of abuse liability.

METHODS

Complete data were obtained from 297 admissions (78% male) to three addiction treatment sites in the United Kingdom. Subjects were asked 15 questions about 12 different drugs, including five benzodiazepines, three antidepressants, two non-benzodiazepine hypnotics and two antihistamines (plus one fictitious drug). Three of the benzodiazepines (diazepam, nitrazipam, temazepam) emerged as having substantially more abuse liability than any of the other drugs tested, as revealed by higher scores on abuse liability items (purchased on street, taken to get high, like drug, potential for addiction to drug). The antihistamines (chlorpheniramine, diphenhydramine) had lowest abuse liability profiles, while the antidepressants (amitriptyline, fluoxetine, trazadone) and non-benzodiazepine hypnotics (zolpidem, zopiclone) had similar profiles.

CONCLUSION

This pilot study suggests that postmarketing information on hypnotic drug use obtained from drug addicts entering treatment produces data consistent with other measures of abuse liability. The data suggest that the risk of misuse of newer non-benzodiazepine hypnotics may be less than that of benzodiazepine drugs, and similar to that of sedating antidepressants. The new methodology may serve to clarify or validate premarketing abuse liability data, and may help to inform the regulatory process and physician practice.

Safety of antidepressant drugs in the patient with cardiac disease: a review of the literature

Patients with cardiac disease, specifically ischemic heart disease and heart failure, have a higher frequency of major depressive disorder than patients without cardiac disease. The pathophysiologic reason for this is not completely understood. Previous depression, other debilitating illnesses, and type A personality are risk factors for the development of depression in cardiac patients. Depression has been shown to lower the threshold for ventricular arrhythmias. Therefore, treatment of depression potentially may prolong life in these patients. Antidepressant options that have been evaluated include several of the tricyclic antidepressants, trazodone, bupropion, and several of the selective serotonin reuptake inhibitors. Individual antidepressant drugs vary in their pharmacologic activity and side-effect profiles. Although clinical data are limited, it is important to individualize therapy in order to minimize cardiac adverse effects. Clinicians are encouraged to evaluate patients with cardiac disease for major depressive disorder and to consider antidepressant drug therapy for these patients when appropriate.

A naturalistic study of trazodone in the treatment of behavioral complications of dementia

Altered serotonin transmission has been associated with behavioral complications of degenerative dementia. This study examined whether trazodone, a serotonergic antidepressant, may be useful in treating behavioral syndromes associated with dementia. Twenty-two dementia patients with behavioral problems were treated with trazodone (mean daily dose 172 ± 107 mg; mean duration 20 days). Seventy of cognitive impairment and behavioral symptoms were rated using the Mini-Mental State Examination (MMSE), the Global Assessment Scale, the Hamilton Rating Scale for Depression, and the Brief Psychiatric Rating Scale. A global assessment of improvement was made by chart review. Mean scores, with the exception of the MMSE, improved modestly but significantly between admission and discharge. Chart review of target symptoms revealed that 82% of the patients showed moderate-to-marked improvement on discharge, with most able to return to their preadmission residence. Trazodone was generally well tolerated except for occasional mild sedation effects. Results suggest that trazodone may be a useful alternative to neuroleptics or benzodiazepines in treating behavior problems in some demented patients.

Proarrhythmia of nonantiarrhythmic drugs

Proarrhythmic effects of nonantiarrhythmic drugs have not been as extensively studied or reported compared with the effects of antiarrhythmic drugs. The proarrhythmic incidence of many of these agents is not accurately known. In some instances, the facilitation of arrhythmias may be the result of compounding clinical factors. Many agents, however, share structural similarities to antiarrhythmics and manifest the same arrhythmic tendencies. Many reports of proarrhythmia may represent toxic rather than proarrhythmic effects, and in vitro studies to elicit the underlying mechanisms may be warranted for the more common drugs. This report summarizes reported arrhythmic effects of a variety of commonly utilized nonantiarrhythmic drugs. The incidence and mechanism of the proarrhythmia is not always clear. The clinician, however, should be aware of reported events to appropriately diagnose and treat the arrhythmia.

Psychopharmacologic issues in organ transplantation. Part 2: Psychopharmacologic medications

This article reviews psychopharmacology in organ transplant patients, with particular attention to the changes in the metabolism and elimination of drugs during organ insufficiency and drug interactions in the immunosuppressed state. The side effects of psychotropic drugs need to be distinguished from those of immunosuppressants. Antidepressants, including tricyclics, heterocyclics, MAOIs, stimulants, and newer agents, are discussed. Use of neuroleptics for delirium, mania, and other organic disorders is described. Lithium may be more difficult to use in the immediate postoperative period. Anxiolytics, including benzodiazepines and buspirone, are useful depending on the underlying medical problem.

Adverse effects of antidepressants in the elderly

Depression is a common problem in old age and the use of antidepressant drugs is particularly prevalent among elderly patients. Limited data suggest that dose requirements may be lower in the elderly because of age-related changes in pharmacokinetics and perhaps also in sensitivity. The side effect profiles of the various antidepressants are reviewed with regard to their potential to cause specific problems in the older patients. Anticholinergic actions, orthostatic hypotension and sedative effects warrant particular care in the elderly.

Psychotropic drug use in the medically ill. Part II

Underlying medical illness and drug interactions may make the use of psychotropic agents problematic in some physically ill patients. This overview, published in two parts, discusses six major classes of psychotropic medications (cyclic antidepressants, monoamine oxidase inhibitors, benzodiazepines, neuroleptics, lithium, psychostimulants, and carbamazepine) and examines their use in the setting of specific types of medical illnesses (e.g., cardiovascular, pulmonary, hepatic, and renal disease). Practical considerations in using psychotropic medications in medical-surgical patients--particularly those who are elderly or medically debilitated--will receive special emphasis.

Psychotropic drug use in the medically ill: Part I

Underlying medical illness and drug interactions may make the use of psychotropic agents in some physically ill patients problematic. This overview, published in two parts, discusses six major classes of psychotropic medications (cyclic antidepressants, monoamine oxidase inhibitors, benzodiazepines, neuroleptics, lithium, psychostimulants, and carbamazepine) and examines their use in the setting of specific types of medical illnesses (e.g., cardiovascular, pulmonary, hepatic, and renal disease). Practical considerations in using psychotropic medications in medical-surgical patients, particularly those who are elderly or medically debilitated, receive special emphasis. In part I, the use of cyclic antidepressants, monoamine oxidase inhibitors, benzodiazepines, and buspirone are discussed.

Psychiatric aspects of congestive heart failure: implications for consulting psychiatrists

Abnormalities of mental function are common problems in patients with congestive heart failure, a problem that is often referred to the consulting psychiatrist. These abnormalities become more frequent and more serious as failure of the heart progresses and they can exhibit a wide variety of manifestations. Cardiac output and cerebral blood flow are preserved due to compensatory mechanisms in mild heart failure but can be severely compromised in advanced failure. Drugs used to treat heart failure, especially digitalis, can produce a wide variety of mental aberrations including delirium, usually when these drugs are used in excess. Diuretics can produce electrolyte abnormalities resulting in mental derangements and vasodilator therapy can produce hypotension. Psychotropic drugs are well recognized as having significant cardiovascular effects that need to be considered when these agents are applied to the cardiac patient. Antidepressant and antipsychotic drugs have anticholinergic, antiadrenergic and quinidine-like effects that can produce further cardiac decompensation in heart failure. Antidepressants are generally well tolerated except when toxic levels occur or in the most extremely compromised cardiac patients. Monoamine oxidase inhibitors should be used only in highly reliable patients to avoid the acute hypertensive crises that are well known to occur with these agents. Antipsychotic drugs with limited cardiovascular side effects can be used effectively and safely but care must be taken to avoid toxic levels which could produce excess hypotension or lethal arrhythmias. Lithium can also be used in heart failure if patients are effectively monitored to avoid toxic levels which could occur due to reduction in renal function, use of diuretics or imposition of a low sodium chloride diet. Evaluation and management of patients with mental symptoms and heart failure provides a strong challenge for the consulting psychiatrist.

The cardiovascular effects of antidepressants

This monograph comprises a review of the cardiovascular effects of the various types of antidepressant drugs in clinical use. The frequency, severity and clinical importance of these effects are placed in perspective. Most antidepressants can cause changes in blood pressure. Both the tricyclic type (TCA) and the monoamine oxidase inhibitors (MAOIs) can produce postural hypotension which may be dose-limiting. In addition, the MAOIs may be associated with severe hypertension when amine-containing foods or medicines are ingested. It is unlikely that therapeutic doses of any available antidepressant drug could impair cardiac contractility. Typical TCAs can cause abnormalities of cardiac conduction and arrhythmias, but this affects less than 5% of patients, mostly to a clinically insignificant extent. Newer compounds such as lofepramine, mianserin, trazodone and viloxazine seem safer in this respect. Reports of an association between therapeutic use of TCAs and sudden death are far from convincing. Overdosage with the MAOIs, lithium and carbamazepine is dangerous but not common; overdose with a TCA is a major source of morbidity and mortality. Lofepramine, mianserin and trazodone are relatively safe in overdose. The use of various antidepressants in patients with hypertension, cardiac failure, angina pectoris, myocardial infarction, or cardiac arrhythmias is discussed and guidelines suggested for the selection and use of antidepressant medication.

Use of cyclic antidepressants in patients with cardiac conduction disturbances

Cyclic antidepressants can produce cardiac complications in patients with certain types of cardiac conduction abnormalities. Most cyclic antidepressants have a quinidinelike effect on the heart, which, in combination with Type I antiarrhythmic agents such as quinidine, disopyramide and procainamide, may induce heart block and potentially lethal arrhythmias in susceptible individuals. Patients with known cardiovascular disease warrant careful evaluation before tricyclic therapy is initiated. Guidelines are presented for identifying high-risk patients and for using cyclic antidepressants in patients with cardiac conduction abnormalities.

Mianserin and trazodone for cardiac patients with depression

In a placebo controlled double-blind cross-over study, the cardiovascular and antidepressant effects of three weeks' treatment with mianserin (30-80 mg daily) and trazodone (150-400 mg daily) were studied in depressed patients who had co-existant cardiac disease. In 14 of the 16 patients, no haemodynamic deterioration occurred with either drug. Two patients withdrew from the study. One with coronary artery disease, whose concomitant medication included a calcium-antagonist and a beta-adrenoceptor blocker and who developed severe postural hypotension after his first dose of trazodone while the other had an increased frequency of transient cerebral ischaemic attacks with both mianserin and trazodone, but not with placebo. Mianserin and trazodone are comparable for both antidepressant efficacy and paucity of cardiovascular effects. Although unwanted effects were generally mild, the incidence of dizziness was greater in those patients receiving trazodone. Caution is advised, however, when prescribing either drug to patients with transient cerebral ischaemic attacks or those with coronary artery disease receiving medication.

The risk-benefit assessment of antidepressant drugs

Antidepressant drugs in common use are reviewed in terms of their risks and benefits. A simple classification divides these into tricyclic antidepressants, monoamine oxidase inhibitors and second generation antidepressants. Risks may arise from the correct use of an antidepressant, from its incorrect or inappropriate use, or due to its failure to reverse the depression. The greatest risk is to leave the depression untreated. Risks due to adverse drug effects are generally predictable but in some cases are unexpected and have led to the withdrawal of the drug from the market. Assessing the benefits of antidepressant drugs is more difficult. Rating scales can be used in this context and the fact that the majority of antidepressant drugs have a similar degree of efficacy serves to emphasise the importance of making a risk-benefit assessment of each drug. This has been presented for the more widely used drugs. Safety in overdose is a particularly important benefit. The ideal antidepressant should specifically reverse depressive illness without toxic effects. Although no drug at present measures up to this it is clear that antidepressants should be prescribed, as their benefits outweigh their risks.

Antidepressants and the elderly

The pharmacologic treatment of depression in the elderly is often complicated by cardiovascular disease and other medical illnesses. Both the tricyclic antidepressants and the monoamine oxidase (MAO) inhibitors have adverse effects that are potentially dangerous in this age group. Second generation antidepressants may have fewer cardiovascular and anticholinergic side effects, but many do not offer any real advantage over the older drugs. In practical terms, the choice of antidepressants for use in elderly patients will be based largely on their degree of tolerance for unwanted effects.

Management of poisoning associated with "newer" antidepressant agents

Overdose of tricyclic antidepressants remains one of the most difficult poisonings to manage optimally in the emergency department, primarily due to the extremely rapid onset of life-threatening symptomatology. The continued high incidence of such overdoses has ensured that morbidity and mortality rates also remain unacceptably high. The development of the "second-generation antidepressants," with apparently different pharmacology and toxicity after overdose, has been an attempt to address this serious medical problem. This report reviews the published literature on the overdose toxicology of the newer cyclic antidepressants currently available in the United States--amoxapine, maprotiline, and trazodone. Nomifensine, released by the FDA in 1984, recently has been voluntarily withdrawn from the world market. Bupropion, released in 1985, also has been voluntarily withdrawn by the manufacturer three months after its release.

Relative toxicity of cyclic antidepressants

To compare the relative central nervous system and cardiac toxicity of amoxapine, maprotiline, and trazodone with the older tricyclic antidepressants, a three-year (1981 through 1983) retrospective review was performed on 1,313 cases involving cyclic antidepressant exposures reported to the Maryland Poison Center. Seizures were more common in the amoxapine (24.5%) and maprotiline (12.2%) groups, compared with either the tricyclic antidepressants (3.0%) or trazodone (0%) (P less than .01). A higher incidence of seizures also was observed in desipramine ingestors (17.9%) compared with other tricyclic antidepressants. No significant differences in the incidence of central nervous system depression or cardiotoxicity was found between the groups. These findings support reports of an increased incidence of seizures in overdoses of amoxapine and maprotiline, but do not substantiate claims of less cardiotoxicity.

Antidepressant drug therapy in the elderly: enhancing safety and compliance

This review article addresses some of the complex issues surrounding antidepressant drug usage among elderly depressives. While primarily geared toward the psychiatrist in general practice, the article provides useful information for the nonpsychiatric physician who is frequently called upon to evaluate and treat affective disorders in the geriatric population. Since tricyclic antidepressants and lithium are the most commonly used psychotropic drugs in the treatment of depression, their side effects and adverse reactions are discussed specifically as these relate to the elderly. Suggestions are offered on how to improve safety and enhance compliance. Brief mention is made of the monoamine oxidase inhibitors and the second generation antidepressants. Dose ranges are recommended for use of these agents in geriatric patients. Finally, a section of the article reviews the most commonly encountered encountered drug interactions between tricyclic and a variety of other psychotropic and nonpsychotropic drugs.

Second generation antidepressants: a comparative review

The authors review four "second generation" antidepressants (maprotiline, amoxapine, trazodone, and nomifensine) in terms of action on biogenic amines and receptors, antidepressive efficacy, and adverse effects. Doxepin is used as a comparative agent and is similar to the prototypical tricyclic agents in all the above categories. Maprotiline is a selective noradrenergic agent, but shares a similar adverse effect profile with doxepin and may be associated with a high frequency of seizures in overdose. Amoxapine is a mixed action antidepressant with significant neuroleptic activity in vivo. Its adverse effect profile is highlighted by symptoms related to its neuroleptic activity, and seizures and acute renal failure in overdose. Trazodone is a selective serotonergic agent with low anticholinergic activity, and minimal morbidity/mortality in overdose. Reports of priapism, leading to impotence in some men, however, is of concern. Nomifensine is a potent noradrenergic and dopaminergic agent with low anticholinergic activity, and minimum cardiotoxicity and low morbidity/mortality in overdose. Its most important adverse effects include overstimulation and infrequent, usually reversible, immunologic hypersensitivity reactions. Trazodone and nomifensine have favorable profiles for use in the elderly. Trazodone may be more favorable in the anxious/agitated patient due to its sedative effects, whereas nomifensine may be more beneficial in the retarded, apathetic patient.

Antidepressants: a clinical update for medical practitioners

Knowledge of the pharmacologic actions of antidepressants enables the physician to develop an appropriate rationale for the use of these medications in the medical setting. The appropriate choice of drug and adequate dose, duration, maintenance, termination, therapy, and alternatives should be considered.