The Carlat Psychiatry Podcast How to Start a Psych Medication II
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Aug 11, 2025 Exploring the intricacies of starting psych medications, the hosts discuss the importance of slow titration for antipsychotics to minimize side effects. They highlight potential drug interactions that can elevate medication levels dangerously. A key focus is on the metabolic enzymes affecting antipsychotics, especially for sensitive groups like Asians and first-time users. Listeners learn about the risks of combining clozapine with fluvoxamine, and a Japanese study reveals significant gene interactions impacting antidepressant efficacy. Tune in for valuable insights!
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Start Antipsychotics Much Lower Than PDR
- Start antipsychotics at much lower doses than PDR recommendations unless urgent treatment is needed.
- Use a gentler titration to avoid akathisia, sedation, dizziness, and falls for better adherence.
Halve Doses With Strong CYP2D6 Inhibitors
- Check for CYP2D6 interactions before adding risperidone or cobenefit and halve the starting and target doses if a strong inhibitor is present.
- Consider stopping the inhibitor but wait ~5 half-lives (often ~1 week) for inhibition to clear before adjusting.
Manage Clozapine–Fluvoxamine Interaction Carefully
- When adding fluvoxamine to clozapine, check clozapine levels and reduce clozapine by about 70% before adding fluvoxamine 50 mg/day.
- Monitor levels closely because fluvoxamine typically triples clozapine concentrations and raises seizure and cardiomyopathy risk.
