'Menu of options' available to treat psychotropic side effects that decrease adherence

Psychotropic adverse events that affect medication adherence are often non-life threatening and easy to treat, according to a presenter at the NEI Max Virtual Conference.

“The majority of these side effects because of which people stopped taking their medicines are not things that are going to harm your thyroid, kidney or heart, but are simple things, like nausea, shaking hands or diarrhea,” Rajnish Mago, MD, clinical professor of psychiatry at SUNY Upstate Medical University, said. “There is a distinction between nuisance side effects and medically serious side effects.”

Moreover, many adverse events that lead to discontinuation subside after 2 to 4 weeks. Each adverse event has a “menu of options” for treatment, including non-pharmacological and pharmacological, Mago said. He said that he categorizes interventions for individual adverse events into levels one, two and three based on their complexity and risk, with level one being “simple things that there’s no harm in doing,” level two involving a more active treatment and level three saved for only when a medicine is absolutely essential.

In antidepressant clinical trials, nausea is the most frequent cause of discontinuation. A simple level one intervention for nausea is to titrate the antidepressant up one over 1 week. Further, sustained release options can be helpful, and if these are not available, then the dose can be split and taken with separate meals. One or two capsules of ginger root 550-mg capsules three times a day is another level one nausea treatment. Level two nausea treatments include 4 to 8 mg of ondansetron every 6 hours, if needed, and mirtazapine.

Dry mouth is another adverse event of many psychotropic medications and is important to treat given its potential to cause dental issues or oral ulcers, Mago said. Level one interventions include saliva substitutes/oral moisturizers, and level two interventions include medications that stimulate saliva production, such as pilocarpine.

Interventions for other adverse events include the following:

• antidepressant-induced excessive sweating = glycopyrrolate and terazosin;

• tremors level one = caffeine reduction, sustained release-preparations and medication taken at bedtime;

• tremors level two = anticholinergics or amantadine for antipsychotic-induced tremors and beta-blockers, metoprolol and atenolol for lithium-induced tremors;

• akathisia levels one and two = titrate up slowly, check serum ferritin, decreased dose if possible and change antipsychotic to one with lower akathisia risk;

• akathisia level three = propranolol, clonazepam or mirtazapine;

• sexual dysfunction = wait and watch, reduce dose, incorporate drug holidays, switch to another antidepressant and consider switching to bupropion if the patient is still depressed or the problem is mainly with desire; and

• weight gain = metformin extended-release 1,000 to 2,000 mg/day, but not in patients of older age or medically ill.

For tardive dyskinesia, Mago divided treatment options into first-line management and second-line management. First-line included tapering off anticholinergic medication; stopping the causative dopamine-blocking medication, if possible; switching to a second generation antipsychotic; potentially switching to quetiapine; and prescribing a vesicular monoamine transporter inhibitor. Potential interventions for second-line management included switching to clozapine; increasing dopamine blockade; adding a benzodiazepine, such as clonazepam; adding amantadine; and adding Ginkgo biloba.

“Patients care a lot about side effects and frequently stop taking medications because of them, so we should have a menu of options for each side effect,” Mago said.