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Stimulant Use for ADHD in a Cardiac Transplant Recipient: A Case Report
- Olivia Iverson, Shirshendu Sinha, Terry Schneekloth, Brian Hardaway, Kari Martin
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- Journal:
- CNS Spectrums / Volume 28 / Issue 2 / April 2023
- Published online by Cambridge University Press:
- 14 April 2023, p. 254
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Introduction
Methylphenidate is a central nervous system stimulant used as first-line treatment for attention-deficit/hyperactivity disorder (ADHD). CNS stimulant use is associated with increased risk of cardiovascular events such as increased resting heart rate and blood pressure, sudden cardiac death, arrhythmia, and stroke. Its safety profile in recipients of cardiovascular transplants is unknown, and more research is warranted to determine the risk of adverse cardiac events due to stimulant medication in this population.
MethodsClinical case report, n=1
Results/Clinical CaseA 19-year-old female with a history of restrictive cardiomyopathy, cardiac arrest, and orthotopic cardiac transplant has been treated with methylphenidate for ADHD for approximately 2 years without incident. The patient was diagnosed with ADHD between the ages of 8 and 10 and historically was treated with stimulant medication. At age 13, she experienced a cardiac arrest after a volleyball game with 4–6 minutes of pulselessness. She was successfully resuscitated and underwent defibrillator placement. It was concluded that the patient had restrictive cardiomyopathy undetected at birth, leading to the need for orthotopic cardiac transplantation at age 16. After her cardiac arrest, the patient’s memory and cognition worsened, and approximately 1 year after her transplant, she was prescribed amantadine. The patient remained untreated for her ADHD until approximately 1.5 years after her cardiac transplant, at which time she underwent neuropsychological testing that showed findings consistent with attention deficit disorder, and was restarted on stimulant medication. Her transplant cardiologist and psychiatrist have collaborated in her ongoing treatment with methylphenidate 40 mg daily and monitoring symptom response and cardiac stability. Because the patient had previously been stable on stimulant medication for many years, it is reasonable to conclude that stimulant medication did not lead to her cardiac arrest. The patient reports that methylphenidate has been helpful in improving her functioning as a college student, through reduction of her ADHD symptoms. The patient’s blood pressure and heart rate remain within an acceptable range and she has not experienced any adverse cardiac events to date while taking methylphenidate.
ConclusionThis case sheds light on the potential to treat cardiac transplant recipients with stimulant medication for ADHD. Although a careful evaluation of risk factors must be undertaken in cooperation with cardiology and other specialists, a role exists for the safe use of stimulant medications in the cardiac transplant population.
FundingNo Funding
110 Implementation of Personalized Medicine in a Community Psychiatry Practice
- Audrey Umbreit, Shirshendu Sinha, Emily Holm
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- Journal:
- CNS Spectrums / Volume 25 / Issue 2 / April 2020
- Published online by Cambridge University Press:
- 24 April 2020, p. 271
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Objective:
To describe the initial results of implementing pharmacogenomics testing in a community-based psychiatry practice and potential impacts on medication management.
Method:Retrospective chart review of prospectively maintained medical records of all adult patients with pharmacogenomics results from 9/01/2017 to 6/30/2019 under the care of psychiatrist and clinical pharmacist.
Results:A total of 51 patients met inclusion criteria. A total of 7 pharmacokinetic genes and, due to changes in the test report over time, a range of 6-10 pharmacodynamic genes relevant to psychotropic medications were evaluated per patient. Every patient had genetic variations, with an average of 6.1 per patient (range 3-9; SD= 1.5). Patients were taking an average of 3.6 (range 1-8; SD=1.7) psychiatric medications at the time of the genetic test, to treat an average of 5 psychiatric conditions (range 1-9; SD=2.2). An average of 1.2 (range 0-4; SD=1.0) gene-drug interactions were uncovered per patient. Following review by psychiatrist and pharmacist, medication adjustments resulted in patients remaining on an average of 3.6 psychiatric medications, but decreasing the average number of gene-drug interactions per patient to 0.8 (range 0-3, SD=0.8).
Discussion:The large number of genetic variations observed per patient is consistent with previous findings 1-2. The decrease in number of gene-drug interactions following testing demonstrates the practical utility of pharmacogenomics information to guide medication therapy. This study did not examine outcomes such as improvement in psychiatric condition or reduction in medication adverse effects; however, these endpoints have been evaluated in other trials 3-4.
Conclusions:Pharmacogenomics testing presents an opportunity for a personalized medicine approach in a community-based psychiatry practice.
98 Dronabinol-Induced Hypomania: A Case Report and Literature Review
- Shirshendu Sinha, Audrey Umbreit, Charles Sieberg
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- Journal:
- CNS Spectrums / Volume 24 / Issue 1 / February 2019
- Published online by Cambridge University Press:
- 12 March 2019, pp. 223-224
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Purpose
Present a case of dronabinol-induced hypomania.
BackgroundDronabinol is a synthetic derivative of cannabis that is commonly prescribed for chemotherapy-induced nausea and vomiting or cachexia due to HIV/AIDS. The safety in those with bipolar disorder warrants further investigation as previous studies suggest that the use of cannabis may be associated with exacerbation of manic symptoms. The risk of developing manic symptoms in patients with bipolar disorder who use dronabinol is largely unknown. Clinical Case: A 55-year-old Caucasian male, following with psychiatry since July of 2016 for substance use disorder (alcohol, cocaine and cannabis), bipolar I disorder, generalized anxiety, PTSD, and intermittent sleep disturbances, was prescribed dronabinol 2.5mg twice daily on 5/19/17 to treat wasting syndrome and significant weight loss due to underlying HIV. He has been abstinent from alcohol, tobacco, and illicit substances for more than a year. The patient’s relevant medication list includes: bupropion XL 150mg daily, quetiapine 300mg daily at bedtime, and trazodone 50–100mg at bedtime. At psychiatrist visit on 7/10/17, his bipolar disorder was noted to be stable. But, after his dose of dronabinol was increased on 7/21/17 to 5mg twice daily, the patient presented to psychiatrist on 8/1/2017 in a state of hypomania, with symptoms including: increased interest in sex, insomnia and increased animation. His judgment and impulse control were slightly impaired. Excluding the dronabinol dose increase, no other medication changes had taken place and the patient was not using alcohol or other substances. Quetiapine was discontinued and olanzapine 10mg at bedtime was started. Bupropion was discontinued, trazodone was tapered off, and dronabinol was discontinued. Upon follow up within a month, our patient’s hypomania symptoms resolved. He was also gaining weight with the olanzapine and reported improved sleep. He was continued on olanzapine 10mg at bedtime and continued off the trazodone, bupropion and dronabinol. He continues to remain abstinent from alcohol and illicit drugs.
DiscussionThe underlying mechanism of dronabinol-induced manic symptoms in those with bipolar disorder remains unclear but may involve dopamine. Sensitization of the dopaminergic system by THC is thought to be associated with the development of manic symptoms in those that use cannabis. THC is associated with increased dopaminergic cell firing, dopamine synthesis, and dopamine release when used acutely.
Other medications associated with causing manic symptoms include bupropion and trazodone, as relevant to our case. However, our patient was stable on these medications before the addition of dronabinol. Thus, it is reasonable to conclude that the dronabinol likely caused our patient’s hypomania symptoms.
ConclusionThis case emphasizes the need to evaluate mental health conditions before prescribing cannabis derivatives such as dronabinol.