NEI Podcast E251 - (CME) Prescribing Potentially Unsafe Drug Combinations in Treatment-Resistant Cases
Mar 26, 2025
Dr. Roger S. McIntyre, a leading expert in treatment-resistant depression and bipolar disorder, joins Dr. Andrew Cutler to discuss the complexities of prescribing potentially unsafe drug combinations. They explore the intricacies of pharmacokinetics and pharmacodynamics, emphasizing the risks of polypharmacy. Key topics include the importance of monitoring drug interactions, the implications of anticholinergic medications, and the safety of stimulants in mood disorders. The conversation highlights guidelines for responsible prescribing and the challenges of managing treatment-resistant cases.
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Serotonin Syndrome Example
- Dr. Cutler shared causing serotonin syndrome once, with a patient on high fluoxetine and trazodone doses.
- He highlighted it's difficult to induce and requires high serotonergic drug doses.
Ketamine and Stimulants
- Hold stimulants on ketamine treatment days to mitigate potential blood pressure increases.
- Monitor blood pressure, and consider holding benzodiazepines due to theoretical efficacy concerns.
Hidden Anticholinergic Effects
- Many drugs have hidden anticholinergic effects, especially the 'peens' (i.e., atypical antipsychotics ending in '-apine' or '-pine').
- Combining these can be dangerous, especially in older adults due to increased sensitivity.