Beware -- the use of MAO inhibitors is increasing again

Drug interactions during anesthesia. General principles

Anesthesia for most procedures in small animal practice involves administration of more than one drug. In addition, many patients concurrently receive a number of other drugs related to their surgical condition or disease. The probability of a drug interaction increases exponentially with the number of drugs a patient receives; therefore, the potential for drug interactions may be greater in anesthesia than for any other area of medicine. This article describes potentially harmful drug interactions that may occur in the anesthetic setting.

Drug-drug interactions in pediatric psychopharmacology

Serious consequences caused by drug-drug interactions continue to plague contemporary pharmacotherapy. The possibility of a drug-drug interaction should be suspected anytime a new or unexpected effect occurs that complicates the clinical management of a patient in the setting where the patient is receiving more than one drug. In this article, the authors address the mechanisms of pharmacokinetic-based drug-drug interactions focusing on important interactions that may occur with the common medications a pediatrician may prescribe to the child receiving psychoactive medication(s) prescribed by a child psychiatrist.

Sedation for the critically ill neurologic patient

OBJECTIVE

To review the scientific basis for sedation of critically ill neurologic patients by summarizing the distinct neurophysiologic disturbances present in this population and presenting the central nervous system effects of sedative agents to permit optimal drug therapy.

DATA SOURCES

Review of the English language clinical and scientific literature using MEDline data search.

STUDY SELECTION

Literature references were selected through a key word search of sedative therapy, drugs used for sedation, and specific neurologic disorders and processes to provide an in-depth overview of sedative drug mechanisms of action, effects on neurophysiology and intracranial dynamics, pharmacokinetics, and toxicity profile. Special emphasis was placed on neurologic side effects.

DATA EXTRACTION

Clinical and scientific literature was reviewed and data relevant to neurophysiologic effects of sedative drug therapy were summarized. Recommendations for institution of sedative therapy and of particular agents were made as a result of analysis of all pooled data.

DATA SYNTHESIS

Critically ill patients with neurologic pathology present as a unique subset of individuals cared for in an acute care setting. Because monitoring of neurologic patients requires frequent assessment of the neurologic examination, the goal of sedative therapy should be to enhance, or to minimally perturb elicitation of the examination. Neurophysiologic disturbances introduce distinct risks for sedation and require their identification and understanding before the initiation of any sedative therapy. Sedative drugs, in particular, act to disturb central nervous system function and their effects may result in diagnostic confusion and further neurologic deterioration. The pharmacokinetic and neurophysiologic actions of the common classes of sedative agents, such as benzodiazepines, opioids, barbiturates, and neuroleptics, as well as ketamine, propofol, and clonidine are discussed. Recommendations are presented based on the specific type of sedation required and the underlying neurologic disturbance. Several specific examples, including head trauma, neuromuscular disease, and alcohol withdrawal, are provided.

CONCLUSIONS

Preservation of the neurologic examination is paramount in documenting clinical improvement or deterioration in the critically ill neurologic patient. Pharmacologic sedation in this unique population of acute care patients requires careful consideration of the underlying neurophysiologic disturbances and potential adverse effects introduced by sedative drugs.

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.

Monoamine oxidase inhibitors and narcotic analgesics. A critical review of the implications for treatment

There has been a recent renewal of interest in the use of monoamine oxidase inhibitors, but the concurrent administration of narcotic analgesics is often a cause for concern. This review clarifies the different types of MAOI/narcotic interactions and offers guidelines for the use of narcotic analgesics in the presence of MAOIs. The MAOI/pethidine interaction has two distinct forms: an excitatory and a depressive form. Pethidine must never be used in the presence of MAOIs because of the risk of a fatal excitatory interaction. Morphine does not cause this excitatory interaction, and is the drug of choice provided an allowance is made for possible potentiation of the depressive narcotic effect. It is inevitable that strong analgesia will occasionally be required as an emergency measure in patients on MAOIs, and insufficient attention is paid in psychiatric textbooks to the two different types of interactions and their therapeutic implications.

Stress-induced hypertensive reaction in a patient receiving monoamine oxidase inhibitors: report of a case

A case illustrating the potential for hypertensive crisis in the ambulatory dental patient under treatment with monoamine oxidase inhibitors is presented. It is somewhat unique in that it appears to contradict much of the literature, which states that circulating, endogenous catecholamines are not expected to be a factor in initiating this potentially severe complication. Since this patient had not taken any food or drink prior to the appointment, it may be conjectured that endogenous catecholamines released as a result of stress and dental pain initiated the crisis.