Psychiatric Transplant Evaluation

Transcription

1 Psychiatric Transplant Evaluation Psychiatry in Medical Settings February 2017 Shehzad K. Niazi, MD, FRCPC 2015 MFMER slide-1

2 Objectives Recognize the impact of psych. comorbidities on outcomes Understand the role of transplant psychiatrist From alive or dead to how well they are living Recognize factors affecting psychiatric medications in transplant pts 2015 MFMER slide-2

3 Mayo Clinic Transplant Center More than 200 physicians, three centers (Arizona, Florida, Rochester) and about 1800 transplants a year MCF MCA MCR Total to date Liver Heart Lungs Kidneys Pancreas Solid organs only; composite tissue grafts, BMT and pediatric transplant volumes not included Data from Mayo Clinic Transplant Centers: accessed on 01/18/ MFMER slide-3

4 :It costs pretty penny! 2015 MFMER slide-4

5 Heart: $1,242,200 Double Lung: $1,037,700 Liver: $739,100 Kidney: $334,300 BMT Allogenic: $930,600 Heart-Lung: $2,313, MFMER slide-5

6 Alive Dead How well are patients living? 2015 MFMER slide-6

7 Psychiatric Comorbidities: Pre Transplant Advanced Lung Diseases Advanced Liver Diseaseas Advanced Cadiac Diseases Incidence of Mood Disorder Adapted from A. DiMartini et al. Crit Care Clin 24 (2008) MFMER slide-7

8 Psychiatric Comorbidities: Post Transplant Kidney Liver Heart Post Tx Mood Disorders Adapted from A. DiMartini et al. Crit Care Clin 24 (2008) MFMER slide-8

9 Treatment can improve outcomes Pre OLT SA Rx only No SA Rx Pre & Post OLT SA Rx 45% 41% 16% % Alcohol Relapse Rodrigue, J. R., et al. (2013). "Substance abuse treatment and its association with relapse to alcohol use after liver transplantation." Liver Transpl MFMER slide-9

10 Impact on Outcomes: Liver Transplant 10 Years Post LT 66% 46% 43% Early Trajectories of Depressive Symptoms after Liver Transplantation for Alcoholic Liver Disease Predicts Long-Term Survival. American Journal of Transplantation. Volume 11. June MFMER slide-10

11 Impact on Outcomes: Liver Transplant Cumulative incidence of death after liver transplant for patients 65 years old with and without anxiety disorder Unpublished data from Mayo Clinic Florida 2015 MFMER slide-11

12 Impact on Outcomes: Lung Transplant Survival (%) PACT <2 7 (6) PACT (59) Total (Events) Increased mortality at 12-year F/U in 111 Lung TX recipients 0.2 PACT <2 PACT Years after transplant Years after transplant The Psychosocial Assessment of Candidates for Transplantation (PACT): A Cohort Study of its Association with Survival among Lung Transplant Recipients. (Submitted data) Mario J. Hitschfeld, MD et al 2015 MFMER slide-12

13 Allogeneic Hematopoietic Stem Cell Transplantation Low/Mod Risk TERS High Risk TERS 68% 42% Median f/u 48 months of 438 BMT recipients Dawn Speckhart et al. Blood 2014;124:207 TERS Prospectively Predicts Inferior Overall Survival Outcome for High Risk Scoring Patients Undergoing Allogeneic Hematopoietic Stem Cell Transplantation. Speckhart, D PhD et al 2015 MFMER slide-13

14 Treatment can improve outcomes Liver TX recipients were followed for median of 9.5 years Rogal, S.S., et al., Early treatment of depressive symptoms and long-term survival after liver transplantation. Am J Transplant, (4): p MFMER slide-14

15 What does a transplant psychiatrist do? 2015 MFMER slide-15

16 Screen for absolute and relative psychiatric contraindications Treat psychological conditions before & after transplant. Transplant Psychiatrist Evaluate donors Educate patient, caregivers and other providers 2015 MFMER slide-16

17 Stanford Integrated Psychosocial Assessment for Transplant (SIPAT) Maldonado et al, 2008 Pt s readiness level Social Support Psychological Stability & Psychopathology Effect of Substance Use Knowledge of Illness Knowledge of Transplant Desire for Treatment Compliance, Lifestyle Factors Availability Functionality Physical living space Depression, Anxiety, Mania, Psychosis, Neurocognitive, Personality, Truthfulness, deception & Overall Risk for Psychopathology Alcohol use & Risk for relapse Substance Use & Risk for relapse Nicotine Use 2015 MFMER slide-17

18 Inadequate social support system Active illicit substance use Active alcohol dependence/abuse Active nicotine abuse Active manic or psychotic symptoms that may impair adherence Current suicidal ideation (in a pt with a h/o multiple suicidal attempts) Dementia (requires a formal diagnosis) Non-adherence with treatment History of recidivism of substance abuse after previous organ TX 2015 MFMER slide-18

19 Immunosuppressant Medications Calcineurin Inhibitors: Cyclosporine (Gengraf, Neoral): encephalopathy, seizures, tremors, neuropathy Tacrolimus (Prograf): Tremors, Headaches Antiproliferative Agents: Azathioprine (Imuran): Not widely used nowadays Mycophenolate Mofetil (Cellcept): nausea, gastritis, diarrhea, Leukopenia and thrombocytopenia mtor Inhibitors: Sirolimus (Rapamycin) Everolimus (Zortress) Prednisone 2015 MFMER slide-19

20 Steroids Neuropsychiatric effects of steroids: 2-60% 1 Associated with Affective, Behavioral and Cognitive changes Symptomatic treatment 2 Manic symptoms Mood stabilizer Atypical antipsychotic Depressive symptoms Mood stabilizer SSRIs Psychotic symptoms Atypical antipsychotic 1. Dubovsky, A. N., et al. (2012). "The neuropsych complications of glucocorticoid use: steroid psychosis revisited. Psychosomatics 53(2): Psychiatric Adverse Effects of Corticosteroids T. WARRINGTON, MD & J. M. BOSTWICK, MD, Mayo Clin Proc. 2006;81(10): MFMER slide-20

21 Fluvoxamine Nefazadone Ketoconazole Itraconazole Fluconazole Cimetidine Clarithromycin Erythromycin Grapefruit juice Pomegranate juice CYP3A4 Sirolimus Everolimus CYP3A4 SUBSTRATES Sirolimus Everolimus Cyclosporine Tacrolimus (SECT) Carbamazepine Oxcarbazepine St. John s Wort Modafinil Rifampin CYP3A4 INDUCERS Cyclosporine Tacrolimus Fluvoxamine Nefazadone Ketoconazole Itraconazole Fluconazole Rifabutin Ritonavir Phenobarbital Phenytoin Carbamazepine Oxcarbazepine Cimetidine St. Clarithromycin John s Wort Modafinil Erythromycin Rifampin Grapefruit juice Rifabutin Ritonavir Phenobarbital Phenytoin Pomegranate juice CYP3A4 INHIBITORS 2015 MFMER slide-21

22 Medication Selection Mirtazapine: Reduced clearance in Liver disease and CrCl < 40 ml/min Escitalopram & Citalopram: Hepatic impairment use up to10 mgs/day for Escitalopram and 20 mgs for Citalopram. No dose adjustment in mild to moderate renal impairment but use lower dose in severe impairment Sertraline: Renal impairment does not require dose adjustment Use lower dose in hepatic impairment Micromedexsolutions.com 2015 MFMER slide-22

23 Medication Selection Fluoxetine: Use lower dose in hepatic impairment No dosage routinely necessary in renal impairment Vilazodone: Does not require adjustment in renal or hepatic impairment Increase dose with strong CYP3A4 inducer and lower dose with strong CYP3A4 inhibitors Vortioxetine: Use in severe hepatic impairment is not recommended Duloxetine: Avoid in hepatic impairment and when CrCl < 30 ml/min Micromedexsolutions.com 2015 MFMER slide-23

24 Medication Selection Lamotrigine: Use 25% lower dose in moderate to severe hepatic impairment Divalproex Sodium: Does not require adjustment in renal impairment Do not use in patients with hepatic insufficiency Carbamazepine: Do not use in severe hepatic impairment/active 50% starting dose and increase slow when CrCl < 30 ml/min Lithium: High risk of toxicity in renal disease Micromedexsolutions.com 2015 MFMER slide-24

25 Medication Selection Quetiapine: Start at mgs and increase slowly in hepatic impairment Increase dose with strong CYP3A4 inducer and lower dose with strong CYP3A4 inhibitors Olanzapine: Does not require adjustment in renal impairment. Aripiprazole: No adjustment in renal or hepatic impairment Increase dose with strong CYP3A4 inducer and lower dose with strong CYP3A4 inhibitors Increase dose with strong CYP2D6 inducer and use 50% dose with strong CYP2D6 inhibitors Micromedexsolutions.com 2015 MFMER slide-25

26 Medication Selection Risperidone: Start at 0.5 mgs and increase slowly in hepatic and renal impairment Lurasidone: Do not exceed 80 mgs if CrCl < 50 ml/min or when hepatic impairment is present Asenapine: Contraindicated in severe hepatic impairment CrCl ml/min: no adjustments necessary Haloperidol Micromedexsolutions.com 2015 MFMER slide-26

27 QTc 35.8 QTc Prolongation Adapted from Joseph F. Goldberg, M., MS; Carrie L. Ernst, MD, Managing the SIDE EFFECTS of PSYCHOTROPICS MEDICATIONS. 1st ed. 2012: APPI (%ages rounded for simplification*) 2015 MFMER slide-27

28 Consider Medical Comorbidities Metabolic Complications after Liver Transplant COMPLICATIONS INCIDENCE (%) Hypertension Hyperlipidemia Diabetes Coronary Artery Disease 9-25 Chronic Kidney Disease 8-25 Singh, S. and K. D. Watt (2012). "Long-term medical management of the liver transplant recipient: what the primary care physician needs to know." Mayo Clin Proc 87(8): MFMER slide-28

29 SUMMARY Psych. comorbidities increase morbidity & mortality Comprehensive assessment Pre TX and ongoing care by transplant psychiatrist is critical Symptomatic Rx of side effects of immunosuppressant medications can improve QOL Drug-Drug interactions and contextual factors need to be considered when selecting psychiatric medications in TX pts 2015 MFMER slide-29