Evidence-Based Reviews

How to prevent adverse drug events

Current Psychiatry. 2011 July;10(7):55-64

References

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Suicide assessment is key

Ongoing monitoring for current or developing suicidal ideation is an important strategy to prevent medication-related mortality in patients vulnerable to self-harm. Initial assessments and follow-up appointments should include a detailed inquiry about suicidal ideations, plans, and behaviors. Patients taking medications that carry black-box warnings for suicide risk should be seen frequently during the first few months of treatment. Patients receiving medications that are lethal in overdose (eg, lithium and TCAs) should be carefully screened for suicide risk. Prescribe medications in limited quantities or arrange for a family member to monitor the patient if necessary. Patients with a history of suicide attempts and current suicide plans may require close observation and initiating medications while hospitalized.

Other prevention strategies

Clinical Point

Developing a personal formulary of drugs commonly used in your practice can increase awareness of serious safety concerns

Prescribing psychotropics in a manner that promotes mental well being while minimizing negative outcomes can be challenging. By developing a personal formulary of drugs commonly encountered and prescribed in their practice, psychiatrists can increase their awareness of serious safety concerns, potential DDIs, and appropriate use based on available literature.^7,27

Medication histories and drug reconciliation—comparing a patient’s medication orders to all of the medications the patient has been taking—can help clinicians avoid making inappropriate dose adjustments, duplicating therapy, or prescribing medications patients previously have failed or did not tolerate. Establishing a collaborative practice environment with physicians, pharmacists, nurses, and social workers can minimize medication errors and risk of adverse outcomes by increasing communication regarding the patient’s treatment.⁷

Computerized drug databases and other electronic resources and consultation with pharmacists can help prescribers identify, avoid, and manage clinically significant DDIs.²⁷ Medications could interact with other drugs as long as their effects persist in the body, which could be days to months after the drug is discontinued. Future research may lead to tools to identify patient pharmacogenetic profiles.

Recognizing psychotropic DDIs and adverse effects remains a challenge because of the complexity of the affected organ, the brain. Clinicians should be vigilant to changes in a patient’s presentation because they may be a manifestation of a medication side effect.⁷ Appropriate therapeutic drug monitoring should occur on a routine, scheduled basis. Closer monitoring may be necessary with dose changes, potential DDIs, signs and symptoms of toxicity/efficacy failure, and renal or hepatic function changes.

Clinical Point

For challenging patients, family involvement and ‘eyes on’ medication administration can increase adherence and prevent misuse

Lastly, patients’ education and involvement in their health care may increase their awareness, responsibility, and medication adherence. For challenging patients, family involvement and “eyes on” medication administration can increase adherence and prevent psychotropic misuse.

Related Resources

Arizona Center for Education and Research on Therapeutics. Drugs that prolong the QT interval and/or induce Torsades de Pointes ventricular arrhythmia. www.azcert.org/medical-pros/drug-lists/drug-lists.cfm.
Cates ME, Sims PJ. Therapeutic drug management of lithium. Am J Pharm Educ. 2005;69(5):88.
Wren P, Frizzell LA, Keltner NL, et al. Three potentially fatal adverse effects of psychotropic medications. Perspect Psychiatr Care. 2003;39(2):75-81.
Bishop JR, Bishop DL. How to prevent serotonin syndrome from drug-drug interactions. Current Psychiatry. 2011;10(3):81-83.

Drug Brand Names

Amantadine • Symmetrel
Amiodarone • Cordarone, Pacerone
Amitriptyline • Elavil
Amphetamine/dextroamphetamine • Adderall, others
Aprepitant • Emend
Aripiprazole • Abilify
Asenapine • Saphris
Atomoxetine • Strattera
Bupropion • Wellbutrin, Zyban
Carbamazepine • Tegretol, others
Chloral hydrate • Somnote
Chlorpromazine • Thorazine
Cimetidine • Tagamet
Citalopram • Celexa
Clomipramine • Anafranil
Clozapine • Clozaril
Desipramine • Norpramin
Desvenlafaxine • Pristiq
Diltiazem • Cardia, others
Diphenhydramine • Benadryl, others
Doxepin • Sinequan, Silenor
Duloxetine • Cymbalta
Erythromycin • Ery-Tab, others
Fluconazole • Diflucan
Fluoxetine • Prozac
Fluphenazine • Prolixin
Galantamine • Razadyne
Haloperidol • Haldol
Iloperidone • Fanapt
Imatinib • Gleevec
Imipramine • Tofranil
Isoniazid • Nydrazid, others
Ketoconazole • Nizoral, others
Lamotrigine • Lamictal
Lithium • Eskalith, others
Methadone • Dolophine, Methadose
Methylphenidate/ dexmethylphenidate • Ritalin, others
Mirtazapine • Remeron
Nafcillin • Nafcil, others
Nefazodone • Serzone
Olanzapine • Zyprexa
Omeprazole • Prilosec
Oxcarbazepine • Trileptal
Paliperidone • Invega
Paroxetine • Paxil
Perphenazine • Trilafon
Phenobarbital • Luminal, others
Phenytoin • Dilantin
Protriptyline • Vivactil
Quetiapine • Seroquel
Rifampin • Rifadin, others
Risperidone • Risperdal
Ritonavir • Norvir
Sertraline • Zoloft
Thioridazine • Mellaril
Trazodone • Desyrel, Oleptro
Trifluoperazine • Stelazine
Trimethoprim/Sulfamethoxazole • Bactrim, Septra
Trimipramine • Surmontil
Valproic acid • Depakote, others
Venlafaxine • Effexor
Verapamil • Calan, others
Ziprasidone • Geodon

Disclosure

Drs. Yu and Bostwick report no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.

Dr. Casher is a speaker for AstraZeneca, Pfizer Inc, and Sunovion Pharmaceuticals.