treatment guidelines

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twinkienic
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40056
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treatment guidelines
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2010-10-05 21:46:07
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psychiatry canadian treatment guidelines
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psychiatry canadian treatment guidelines
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  1. What are the treatment guidelines for schizophrenia?
    1. start medications early

    2. 1st-line: AAPs (except clozapine)

    3. optimize; trial of 4-8wks at max tolerable dose

    4. switch to different 1st-line agent, or augment

    5. clozapine trial (or another 1st-line first)

    • 6. augment
    • - Li, anticonvulsants, ADs, benzos
    • - ECT
    • - AAP (last strategy)

    6. oral typical neuroleptic ok if prev effective

    7. consider depot
  2. What are the first-line treatments for MDD?
    Combination medications + psychotherapy best

    • 1st-line medications
    • - all SSRIs
    • - all SNRIs
    • - bupropion
    • - mirtazapine
    • - moclobemide

    • 1st-line psychotherapy
    • - CBT
    • - IPT
  3. What is the medication treatment algorithm for MDD?
    1. Start 1st-line medication

    2. Optimize dose

    3. Switch to other 1st-line medication

    4. Augment with Li or AAP

    5. Augment/combine with bupropion, mirtazapine, seroquel or cytomel

    6. Add-on other agent or switch or consider 2nd-/3rd-line agents (TCAs, MAOIs, selegiline, trazodone)
  4. How long should medications be maintained in MDD? What are risk factors for recurrence?
    Maintain at least 6-9 months after remission.

    • At least 2 years to lifetime if risk of recurrence:
    • - 3+ episodes
    • - chronic episodes
    • - psychotic episodes
    • - severe episodes
    • - harder to treat episodes
    • - hx of relapse with AD discontinuation
    • - older age
    • - psychiatric/medical comorbidities
    • - residual symptoms in current episode
  5. What are the 1st-line medications for Bipolar I acute mania?
    PRN antipsychotic + benzodiazepines for agitation

    • 1st-line medications:
    • - Lithium
    • - Epival
    • - AAP
    • - Li/DVP + AAP
  6. What is the medication treatment algorithm for Bipolar I acute mania/mixed episode?
    Trial each step for 2 weeks at adequate medication dose before moving on.

    1. Start 1st-line medication(s) and optimize

    • 2. Switch to or combine with different 1st-line agent
    • - Li/DVP -> switch/add AAP
    • - AAP -> switch/add Li or DVP
    • - combination Li/DVP + AAP -> switch one or both agents

    3. Switch to or combine with different 1st-line agent

    • 4. Switch to or add 2nd- or 3rd-line agents
    • - Li + DVP
    • - CBZ
    • - ECT
    • - Clozapine
    • - Haldol
    • - Asenapine
    • - Paliperidone
    • - Oxcarbamazepine
    • - Tamoxifen

    • 5. Try add-on or experimental agents
    • - Tryptophan
    • - Allopurinol
    • - Amisupride
  7. What are the 1st-line medications for Bipolar I MDE?
    • 1st-line medications:
    • - Lithium
    • - Lamotrigine
    • - Seroquel (IR/XR)
    • - Li + DVP
    • - Li/DVP + SSRI/bupropion
    • - Olanzapine + SSRI
  8. What is the medication treatment algorithm for Bipolar I MDE?
    1. Start 1st-line treatment and optimize

    • 2. Switch or add-on alternate 1st-line agent or consider 2nd-line agents
    • - DVP monotx
    • - Seroquel + SSRI
    • - Li/DVP + lamotrigine
    • - adjunc modafanil

    3. Switch or add-on alternate 1st-line agent, or consider 2nd-line

    • 4. Switch to or add-on 3rd-line agents, or novel agents
    • - other mood stabilizers (CBZ, topiramate)
    • - other ADs (venlafaxine, MAOIs, TCAs)
    • - n-acetylcysteine
    • - other combinations
  9. What are the 1st-line medications for Bipolar I maintenance treatment?
    • monotherapy:
    • - mood stabilizer: Lithium, Lamotrigine, Epival
    • - AAP: Olanzapine, Seroquel, Aripiprazole, Risperidone Consta
  10. combination:
    • - Li/DVP + Seroquel
    • - adjunctive Risperidone
    • - adjunctive Ziprasidone
  11. What are the 1st-, 2nd- and 3rd-line medications for treatment of Bipolar II MDE?
    • 1st-line medications:
    • - Quetiapine IR/XR

    • 2nd-line medications:
    • - Lithium
    • - Lamotrigine
    • - Epival
    • - Li + DVP
    • - Li/DVP/AAP + antidepressant

    • 3rd-line medications:
    • - Ziprasidone
    • - antidepressant monotherapy
  12. What are the 1st-line treatment recommendations for Panic Disorder?
    • Psychological:
    • - CBT

    • Medications:
    • - all SSRIs
    • - Venlafaxine
    • - short-term benzodiazepine PRNs
  13. What are the treatment recommendations for Social Anxiety Disorder?
    • Psychotherapy:
    • - CBT: exposure, cognitive restructuring, social skills training, relaxation

    • Medications;
    • - SSRIs (not fluoxetine or citalopram)
    • - Venlafaxine
    • - optimize dose and trial two 1st-line agents before switch to 2nd-line
    • - 2nd-line: citalopram, gabapentin, pregabalin, phenelzine
    • - 3rd-line: adjunc AD (fluoxetine, wellbutrin, remeron, clomipramine, moclobemide), mood stabilizers (epival, topiramate), AAP
  14. What are the treatment recommendations for OCD?
    • Psychotherapy:
    • - Exposure-Response Prevention
    • - CBT

    • Medication algorithm:
    • 1. 1st-line: SSRIs (not es/citalopram)
    • 2. optimize (may need higher than usual doses)
    • 3. switch to different 1st-line agent
    • 4. consider augmentation with 2nd- or 3rd-line agent early if partial response
    • 5. switch to Clomipramine
    • 6. 2nd-line:
    • - celexa, effexor, remeron
    • - risperidone
    • 7. trial combinations of 1st- and 2nd-line agents
    • 8. add-on adjunctive 3rd-line agents:
    • - IV Clomipramine
    • - Seroquel, Olanzapine, Haldol, Phenelzine
    • - Gabapentin, Topiramate
    • 9. Continue medications 1-2y post-remission or lifetime

    • Consider neurosurgical tx if no response:
    • - anterior cingulotomy, anterior capsulotomy, subcaudate tractotomy, limbic leucotomy
    • - DBS
  15. What are the treatment recommendations for Generalized Anxiety Disorder?
    • Psychotherapy:
    • - CBT

    • Medications:
    • 1. 1st-line: Effexor, Paroxetine, Escitalopram, Sertraline
    • 2. optimize; trial 8-12wks at adequate dose
    • 3. switch to different 1st-line agent
    • 4. 2nd-line: Bupropion, Imipramine, Buspirone, Pregabalin
    • 5. switch or combine 1st- and 2nd-line agents
    • 6. add-on 3rd-line as adjunct:
    • - Risperidone, Olanzapine
    • - Hydroxyzine
    • - Remeron, Trazodone
    • 7. continue tx at least 1y after remission
  16. What are the treatment recommendations for PTSD?
    • Psychotherapy:
    • - CBT
    • - EMDR

    • Medications:
    • 1. 1st-line: fluoxetine, paroxetine, sertraline. venlafaxine
    • 2. optimize, trial up to 8wks
    • 3. switch to different 1st-line agent, OR
    • 4. switch to or add 2nd-line:
    • - fluvoxamine, mirtazapine, moclobemide, phenelzine
    • - adjunctive risperidone or olanzapine
    • 5. consider adjunctive 2nd- or 3rd-line agents early to preserve gains
    • 6. 3rd-line adjuncts:
    • - TCAs (monotx)
    • - citalopram, trazodone, bupropion
    • - CBZ, gabapentin, DVP, lamotrigine, topiramate
    • -quetiapine
    • - prazosin, clonidine (nightmares)
    • 7. continue medications at least 1y if chronic PTSD
  17. What baseline investigations and monitoring are recommended for Lithium treatment?
    • Baseline studies:
    • - CBC, lytes, BUN, Cr, TSH, glucose, bHCG
    • - ECG
    • - weight

    • Monitor:
    • - q1y: renal fn, TSH
    • - weight
    • - Li level: q3-6mo after 2 consec levels in therapeutic range (on stable dose)
    • - target Li levels 0.8-1.1 mEq/L (0.4-0.7 for elderly)
  18. What baseline investigations and monitoring are recommended for Epival?
    • Baseline:
    • - CBC, LFTs, bHCG
    • - weight

    • Monitor:
    • - q1mo x6mo, then q6mo: CBC (plts), INR/PTT, LFTs,
    • - weight and signs of PCOS
    • - Epival level: q3-6mo after 2 consec levels in therapeutic range (on stable dose)
    • - target Epival level 400-800 mmol/L
  19. What baseline investigations and monitoring are recommended for Carbamazepine?
    • Baseline:
    • - CBC, diff, bHCG

    • Monitor:
    • - CBC at 1wk, 3 wk, then q1mo x6mo, then q6mo x2y, then q1y

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