Special Populations Considerations

Pediatric Psychopharm - Kiddie Concoctions

• Pharmacokinetics: ↑ Total body water, ↓ body fat; immature liver (CYP450) & renal clearance. "Start low, go slow."
• Dosing: Often weight-based (mg/kg); titrate to effect & tolerability.
• Monitoring: Growth charts (height, weight), vitals, S/E (e.g., SSRI-induced activation).
• Stimulants (ADHD): Methylphenidate (MPH) (≥6 yrs), Amphetamines (AMP) (some ≥3 yrs).
  • S/E: ↓Appetite, insomnia, growth monitoring essential.
• SSRIs (Depression/Anxiety/OCD): Fluoxetine (MDD ≥8y, OCD ≥7y); Sertraline (OCD ≥6y).
  • ⚠️ BBW: ↑ Suicidal ideation risk (<25 yrs).
• Atypical Antipsychotics: Risperidone (ASD irritability ≥5y); Aripiprazole (ASD irritability ≥6y).
  • S/E: Weight gain, metabolic syndrome (monitor lipids, glucose).

⭐ Fluoxetine is the only SSRI FDA-approved for MDD in children (≥8 yrs). oka

Geriatric Psychopharm - Golden Year Drugs

• Principle: "Start Low, Go Slow, But Go!"
• Pharmacokinetics (PK):
  • ↓ Renal & hepatic clearance → ↑ Drug half-life
  • ↑ Body fat → ↑ Volume of distribution (lipid-soluble drugs)
  • ↓ Serum albumin → ↑ Free drug fraction (protein-bound drugs)
• Pharmacodynamics (PD): ↑ Sensitivity to CNS effects (sedation, confusion), anticholinergic burden, orthostasis, Extrapyramidal Symptoms (EPS).
• Polypharmacy: High risk of Drug-Drug Interactions (DDIs). Regular medication review is crucial.
• Key Drug Considerations:
  • SSRIs (e.g., Sertraline, Escitalopram) often first-line for depression. Citalopram max dose 20mg/day (QTc risk).
  • Benzodiazepines: Prefer short-acting (📌 LOT: Lorazepam, Oxazepam, Temazepam). Use with extreme caution (fall/confusion risk).
  • Antipsychotics: ↑ Mortality risk in dementia-related psychosis. Use lowest effective dose for shortest duration.
  • Lithium: Narrow therapeutic index. Monitor renal function closely.

⭐ Avoid long-acting benzodiazepines (e.g., Diazepam, Chlordiazepoxide) in elderly due to prolonged sedation, cognitive impairment, and ↑ fall risk. Prefer agents from the LOT mnemonic (Lorazepam, Oxazepam, Temazepam).

Pregnancy & Lactation - Bump & Beyond Meds

• Risk-benefit key. Monotherapy, lowest dose. Folic acid vital.
• Antidepressants:
  • SSRIs (Sertraline, Escitalopram) preferred.
  • Avoid Paroxetine (cardiac defects 📌 Paroxetine = Problems with heart).
• Mood Stabilizers:
  • Lithium: Ebstein's anomaly (📌 Lithium = Low-set tricuspid). Monitor levels. Safer in lactation (monitor infant serum).
  • Lamotrigine: Safer option; dose adjustment needed.

⭐ Valproate: Contraindicated. High risk Neural Tube Defects (NTDs) & neurodevelopmental disorders.

• Antipsychotics: Atypicals (Olanzapine, Risperidone) if essential; monitor GDM.
• Benzodiazepines: Floppy infant syndrome, withdrawal. Short-acting (Lorazepam) sparingly.
• ECT: Safe & effective throughout pregnancy.
• Lactation: Most drugs in milk. Sertraline preferred. Monitor infant. Clozapine contraindicated.

Medically Comorbid - Tricky Treatments

• General: "Start low, go slow." Prioritize safety; monitor closely.
• Hepatic Impairment:
  • Prefer drugs with less hepatic metabolism (e.g., Lorazepam, Oxazepam, Temazepam 📌 LOT BZDs).
  • Avoid/Caution: Valproate (hepatotoxicity risk), Duloxetine, TCAs.
• Renal Impairment:
  • Lithium: Dose adjust by CrCl; monitor levels. Contraindicated if CrCl < 30 ml/min.
  • Adjust dose: Paliperidone, Amisulpride, Gabapentin, Pregabalin.
• Cardiovascular Disease (CVD):
  • QTc Risk: Antipsychotics (Ziprasidone, IV Haloperidol), TCAs, Citalopram (>40mg; >20mg if >60yrs/hepatic/CYP2C19 poor metabolizer).
  • Orthostatic Hypotension: Clozapine, Risperidone, TCAs.
  • Post-MI: Sertraline often preferred SSRI.
• Epilepsy:
  • ↓Seizure threshold: Bupropion, Clozapine, Chlorpromazine, Maprotiline.
  • Safer options: Most SSRIs, Valproate, Lamotrigine.

⭐ Sertraline is generally the safest SSRI in patients with recent myocardial infarction or unstable angina.

High‑Yield Points - ⚡ Biggest Takeaways

• Elderly: Lower doses, slower titration; increased risk of anticholinergic effects, falls.
• Pregnancy: SSRIs (sertraline, fluoxetine) preferred; valproate (NTDs), paroxetine (cardiac defects) contraindicated.
• Lactation: Sertraline, paroxetine generally safer; avoid lithium, clozapine.
• Children: SSRIs for depression (monitor suicidality); stimulants for ADHD (monitor growth).
• Hepatic Impairment: LOT BZDs (Lorazepam, Oxazepam, Temazepam) are safer options.
• Renal Impairment: Adjust lithium, gabapentin doses; high lithium toxicity risk.
• CYP450 Interactions: Crucial in polypharmacy; be aware of inducers and inhibitors.