Table 8.
Psychotropic Medications in Transplant Patients
| Medication | Most Common Uses in Transplant | Issues |
|---|---|---|
| Antidepressants | ||
| SSRIs (Selective Serotonin Reuptake Inhibitors) | Depression/Anxiety Disorders1,2 | |
| Fluoxetine | Long half-life – takes many days to clear after discontinuation; potential drug interactions | |
| Paroxetine | Mild anticholinergic effects; discontinuation syndrome more problematic than other SSRIs; potential drug interactions | |
| Sertraline | Potential drug interactions | |
| Fluvoxamine | Raises levels of cyclosporine and tacrolimus via inhibition CYP 450 3A4 | |
| Citalopram | Few drug interactions | |
| Escitalopram | Few drug interactions | |
| Tricyclics | Depression/Anxiety Disorders3 | All have cardiac effects – cardiac conduction changes, tachycardia and arrhythmias have been described; QT prolongation |
| Amitriptyline | Significant anticholinergic side effects | |
| Imipramine | Significant anticholinergic side effects | |
| Nortriptyline | Fewer anticholinergic side effects; therapeutic level established (50–150ng/ml) | |
| Doxepin | Moderate anticholinergic side effects | |
| Desipramine | Fewer anticholinergic side effects; may cause anxiety and agitation | |
| Others | ||
| Trazodone | Sleep | Risk of priapism; poor antidepressant efficacy, may help with medication induced sleep disturbances and mightmares due to PTSD |
| Mirtazapine | Depression/Anxiety Disorders | Increased appetitie/weight gain, can reduce nausea, may cause neutropenia |
| Nefazodone | Depression | Potential severe hepatotoxicity; avoid in liver disease Raises levels of cyclosporine and tacrolimis via inhibition of CYP 450 3A4 |
| Bupropion | Depression/Smoking Cessation | Risk of seizure in high doses; dose reduction in hepatic failure |
| Venlafaxine | Depression/Anxiety Disorders/Pain | Dose reductions in hepatic and renal failure; dose- dependent elevations in blood pressure |
| Duloxetine | Depression/Pain | Potential hepatoxicity; avoid in end-stage renal disease and patients with hepatic dysfunction |
| Benzodiazepines | All have abuse potential; risk of withdrawal syndrome with abrupt discontinuation after continued use | |
| Lorazepam | Anxiety Disorders/Alcohol and Drug Withdrawal4 | No active metabolites; may be given po, IM or IV |
| Diazepam | Anxiety Disorders/Alcohol and Drug Withdrawal | Long half-life; active metabolites |
| Clonazepam | Anxiety Disorders | |
| Temazepam | Sleep | No active metabolites |
| Alprazolam | Anxiety Disorders | Short half-life; risk of withdrawal between doses |
| Antipsychotics | Delirium/Hallucinations/Delusions3 | |
| Typical | ||
| Haloperidol | Use lowest possible dose; risk of extrapyramidal symptoms and neuroleptic malignant syndrome is less with IV administraion | |
| Atypical | Delirium/Hallucinations/Delusions3 | Risk of metabolic syndrome in all; |
| Risperidone | Similar to haloperidol in dose >6mg | |
| Olanzapine | Risk of metabolic syndrome –hyperlipidemia hyperglycemia, weight gain | |
| Aripiprazole | Less risk of metabolic syndrome | |
| Ziprasidone | Less risk of metabolic syndrome; risk of QT prolongation | |
| Quetiapine | Moderate risk of metabolic syndrome; some weight gain | |
| Stimulants | Depression/Fatigue/ADHD 3 | All have abuse potential; should see response within several days; may decrease appetite |
| Methylphenidate | Avoid in agitated depression | |
| Dextroamphetamine | Small risk of cardiac side effects | |
| Other Medications | ||
| Lithium | Bipolar Disorder | Potential nephrotoxicity; serious side effects with toxic levels; drug interactions with diuretics, ACE inhibitors and others |
| Clonidine | Post-traumatic stress disorder | Risk of hypotension, sedation |
| Prazosin | Post-traumatic stress disorder | May help nightmares and sleep disturbance related to PTSD |
| Buspirone | Anxiety Disorders | May have respiratory stimulating properties |
1
Anxiety disorders include: anxiety disorder secondary to medications and medical conditions, Generalized Anxiety Disorder, Post-traumatic Stress Disorder, Phobias including Social Phobia, Panic Disorder, Obsessive Compulsive Disorder And other anxiety disorders
2,3,5,6,7
These uses pertain to all drugs in the class
4
May be used to treat alcohol withdrawal, sedative-hypnotic withdrawal and as adjunctive medication in other withdrawal states