Psychopharmacology Considerations

Preexisting heart disease may influence the phar-macokinetics of medications (Shaw and DeMaso 2006). Patients with congestive heart failure may experience a decreased perfusion of drug absorption sites in both the gastrointestinal tract and skeletal muscle, thus affecting drugs given orally and by intramuscular injection (Beliles 2000b; Shaw and DeMaso 2006). Additionally, sympathetic activity and local edema may affect drug distribution and increase drug absorption, respectively. Some patients may be administered anticoagulant medications (e.g., warfarin) that are highly protein bound. In these cases, the dosage of highly protein-bound psy-chotropic agents may need to be reduced to lower the risk of elevated levels of anticoagulants (Shaw and DeMaso 2006).

Considerable concern has been shown regarding the use of stimulant medications to treat attention-deficit/hyperactivity disorder in the context of preexisting structural heart defects (Wilens et al. 1999). Although the risk of sudden death is thought to be greater while children with structural defects are taking a stimulant regimen, sudden death in children and adolescents is very rare, and the risk of sudden death may not be higher in children on stimulants than in the general population (Wilens et al. 1999).

Psychotropic agents, including tricyclic antide-pressants and certain atypical antipsychotic medications, have been known to increase the QTc interval and, as a result, increase the risk of torsades de pointes, a life-threatening ventricular arrhythmia (Gutgesell et al. 1999; Labellarte et al. 2003; Shaw and DeMaso 2006). Intravenous haloperidol has been associated with the development of a prolonged QTc interval and torsades de pointes and may depress cardiovascular function (Beliles 2000a). A comprehensive review of psychopharmacology can be found in Chapter 30.

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