December 13, 2023 • 13 mins
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In this episode, Dr. Handratta and Dr. Amayo explore the importance of the kidney in psychiatry and discuss the impact of renal disease on medication management. They provide insights on dosing adjustments for various medications and highlight the role of the kidney in drug excretion. Tune in to unlock the mysteries of the human psyche on The Y in Psychiatry.
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Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
Dr. Handratta (00:00):
So why is cytochrome P450 called
cytochrome P450?
Dr. Amayo (00:05):
What?
That
Dr. Handratta (00:05):
Enzymes are so named because.
There are bound to memorieswithin a cell and contain a heme
pigment.
Yeah, and because of heme itgets chrome, the name, and
because of the pigment.
The first letter is p.
that absorbs light at awavelength of 450 nano more when
exposed to carbon monoxide.
Dr. Amayo (00:23):
That's a weird reason to give an enzyme name.
You must be fun at parties.
I will.
Thanh (00:30):
Welcome to the Y in Psychiatry!
Dr. Amayo (00:32):
Hi, this is Dr.
Amayo C/L fellow.
Thanh (00:35):
Where we delve into the intricate nuances of psychiatric
topics.
Dr. Handratta (00:39):
My name is Dr.
Handratta attendingpsychiatrist.
I did my residency fromUniversity of Connecticut and
then I did my fellowship fromGeorgetown University in
consultation and liaison.
Thanh (00:49):
Each episode features interview style discussions that
explore the intersection of themind medicine and the human
experience.
Together we'll uncover thehidden why and the
groundbreaking discovery shapingthe psychiatric landscape.
So grab a seat, warm beverage,tune in, and let's embark on
this journey to unlock themysteries of the human psyche.
(01:12):
Only on The Y in Psychiatry.
Dr. Amayo (01:16):
Welcome back to the Y in psychiatry.
Today we'll be continuing ourseries depression in special
population, and we'll befocusing on renal disease as
usual.
I'm your host, Dr.
Amayo, consult and liaisonfellow.
And I have Dr.
Dr. Handratta (01:31):
Hi.
And this is Dr.
Handratta attendingpsychiatrist.
Dr. Amayo (01:36):
And so today, last time we talked about the liver.
Today we're talking about thekidney.
And the question is, why is thekidney important in psychiatry?
Yeah.
Why should we talk about thekidney?
Dr. Handratta (01:48):
So now for psychiatrists, brain is the
primary organ.
Dr. Amayo (01:54):
What is life?
Dr. Handratta (01:55):
Yes.
And cardiologists will say,heart is life.
I didn't.
Yeah.
So we all like, actually, likethere will be a tough war on
this.
But we need to know about kidneybecause as we talked about in
the previous episode, how liverplays an important role in drug
metabolism.
Kidney also plays a veryimportant role, especially in
excretion of the drugs, right?
(02:16):
Majority of our medications, notall after they are metabolized
in the liver, are conjugated andmade water soluble and excreted
through the kidney, right?
So the drug can be excretedeither in the feces or in the,
your right.
So patients who have renaldisease, there will be a problem
in the way our body handles thedrug.
(02:37):
And plus patients with renaldisease also have increased
comorbidity with depression.
Again, actually the incidencerate actually of depression is,
it's a huge range actually, butit's usually like around 30 to
40%, especially patients who areon dialysis.
Dr. Amayo (02:53):
Okay.
So the kidney is important forexcretion.
And again, we see there's a lotof comorbidities with depression
and kidney failure and treatingthe depression improves outcome.
And so what specific role orwhat specific way does the
kidney excrete our medications?
Dr. Handratta (03:09):
So kidney plays an important role with the
medication excretion.
We know that, right?
So when in renal disease,there's a decrease in the urine
output and there's a decrease inthe glomerular filtration rate.
So the medications, which goesthrough the kidney, is going to
accumulate in a systemiccirculation causing toxicity,
right?
Patients with renal disease,they also excrete a large amount
(03:30):
of albumin so patients can havehypoalbuminemia.
And we know that a lot of ourpsychiatric medication bounds to
albumin
Dr. Amayo (03:36):
By the last time.
Dr. Handratta (03:37):
Exactly.
And then it's a pre form of themedication that is active.
Yeah.
And then patients with renaldisease, there is also an
increase in the level of ureaand urea will now compete with
albumin with the medication.
So further increasing the freeform of the medication causing
more toxicity.
So these are the three reasonswhy people with renal disease
(04:01):
can experience toxicity whenantidepressants are not dosed in
a proper way.
Dr. Amayo (04:06):
Okay.
And I know there's anomenclature for grading kidney
failure or kidney disease usingthe creatinine clearance.
Can you.
Can you remind me of thosenumber of questions and are
those important for us?
Let knowing like when should weprescribe this medication?
Dr. Handratta (04:24):
Yes so there is an app where you can calculate
the estimated creatinineclearance.
Don't ask me the formula.
Yeah.
So you put in the, you punch inthe numbers actually in the,
prelbuadmin clearance calculatorand based on the number they
didivide into when is normalfunction, so we have to talk
about normal, right?
Yeah.
So normal estimated creatinineclearance is more than or equal
(04:46):
to 80 ml per minute, okay?
Mild is in the range of 51 to 80ml per minute.
Okay?
Moderate is from 31 to 50 ml perminute.
Severe is less than or equal to30 ml per minute.
And end stage renal disease iswhen you require dialysis is
less than 10 ml per minute.
Basically for simplicity, we saynormal functioning, mild,
(05:07):
moderate, severe kidney diseaseor end stage renal disease.
Dr. Amayo (05:10):
Yeah.
Okay.
And what medications should we,what medications can we give or
should we stay away from towardsthe severe and ESRD?
Dr. Handratta (05:20):
Umm, there are a lot of medications that we can
talk about, but the ones that Iwant to stress about in this
particular podcast.
Some of them I'm gonna name.
So Venlafaxine, vex, right?
Metabolic of venlafaxine.
That is desvenlafaxine.
Then we have duloxetine, uh, wehave Bupropion and we have
levomilnacipram.
I hardly use it levomilnacipram,but there are psychiatrists who
(05:43):
do use levomilnacipram.
So we have to be careful withthese four medications in
patients with renal disease.
So let's look at venlafaxine.
Like how do we dose venlafaxinein patients with renal disease?
So it's not like renal toxic,but it's excreted by the kidney.
More than 80% of venlafaxinegoes through the kidney and
(06:05):
excreted out, right?
So in patients who are mild,moderate, and severe renal
disease, we decrease the dose ofvenlafaxine by 25 to 50%.
So you can still use it, but youdecrease the dose to prevent the
toxicity and accumulation, andin patients with stage renal
disease, you drop down the doseof 50% and wait till the
(06:25):
dialysis,
Dr. Amayo (06:26):
So you dose after the dialysis.
Dr. Handratta (06:28):
Okay.
You give one time dose, waittill the dialysis is done, and
then give the second dose, whichis 50% or before the renal
toxicity.
Okay?
Then you have desvenlafaxine,which is a metabolite of
venlafaxine.
Again, more than 80% is excretedby the kidney.
So with desvenlafaxine, you canget away with mild renal
disease, you can dose it exactlythe way you dose it, right?
(06:50):
Whereas in patients withmoderate renal disease, you
don't go above 50 milligramevery day, right?
And in patients with severe andend stage renal disease, you
dose it at 50 milligram everyother day, right?
So you can still use thismedication, but you have to be
careful how you dose them.
Dr. Amayo (07:09):
And for the desvenlafaxine, does it matter
when they have the dialysis alldone?
Do you It doesn't matter.
Okay.
It doesn't matter.
Dr. Handratta (07:15):
Yeah.
As long as you give it 50milligram every other day.
Yeah.
Okay.
And then you all got duloxetine.
So this is a medication thatwill be used actually by
physicians, even if the patientis in severe or end stage renal
disease.
And there's a common mistakethat I see again and again while
I do consultation/ liaisonpsychiatry.
(07:37):
So duloxetine, once yourestimated clearing creatinine
clearance is less than 30 ml perminute, you stay away from
duloxetine.
Interesting.
The reason being is that themetabolite of duloxetine, the
area under the curve, that isthe amount of medication is
about seven to nine times higherin patients with renal diseases
compared to healthy control.
(07:58):
And that itself can be toxic.
Plus it can also causehepatotoxicity.
Yeah.
So you have to be careful withduloxetine.
Dr. Amayo (08:05):
So once they reach severe stop duloxetine.
Yes.
And do a different medication.
Dr. Handratta (08:11):
Exactly.
And again, I'll say, don't stopit cold Turkey.
Yeah.
Because duloxetine has a veryshort half-life and is one of
the medication which has reallybad serotonin withdrawal.
So whenever I'm prescribingpatients duloxetine or
venlafaxine or desvenlafaxine, Itell the patient, keep at least
a week supply in your office sothat if you forget it at home,
(08:33):
at least you have a medicationin your office which you can
take because the withdrawal isbad.
You feel the withdrawal by theend of the day.
Yeah.
Okay.
Then you got bupropion.
Bupropion.
So Bupropion is a medication weextensively use in psychiatry.
Yeah.
Because it's one of themedication which does not cause
sexual side effects.
Yeah.
Plus it's one of the medicationthat does not cause
hyponatremia.
(08:53):
So people feel comfortable usingit.
Plus it gives you the boost ofenergy because in depression you
have a decrease in the energylevel.
So with Bupropion you canactually improve it
Dr. Amayo (09:03):
And it helps with apathy.
Dr. Handratta (09:05):
Exactly.
And it helps with apathy helpswith smoking cessation.
Oh, wow.
It helps with ADHD.
Yeah.
Yeah.
So it does though it's all notFDA approved.
Yeah.
So with Bupropion, it's brokendown into a metabolite called
hydroxy-bupropion, which hasapproximately 50% of the
activity of bupropion.
In a healthy individual, theconcentration of the metabolite
(09:28):
is 10 times that of a parentcompound.
Just imagine patients with renaldisease, plus patients with
renal disease will have problemwith sodium if they have
hyponatremia.
You give bupropion, you'redecreasing the seizure
threshold, and you're increasingthe risk of seizures, right?
So Bupropion, you have to becareful.
In mild and moderate bupropionextended release, you can dose
(09:52):
normally.
Okay?
But in severe and end stagerenal disease, you give them 150
milligram every third day,right?
So you have, be careful.
And if you're using an immediaterelease, bupropion mild, you're
fine.
Be a little careful.
Start low, go slow.
Yeah.
And then in moderate severe, atend stage, 75 milligram per day.
So you have to be careful withBupropion because you don't want
(10:13):
to induce seizure in thesepatients, right?
Levomilnacipram, I don't use it,but that does not mean that it's
not a good medication.
I do not have too muchexperience with it.
buT it has a relativecontraindication in in patients
with end stage renal disease.
So when you're using it, becareful in end stage renal
disease.
Dr. Amayo (10:31):
iS there any medication that has your
approval?
No, it seems like we, we hit allthe SNRI.
How about the SSRIs is itrelatively good in renal
disease.
Dr. Handratta (10:41):
So most there are two SSRI which are, relatively
safe It says safer in patientswith renal disease, which we
commonly use.
One is sertraline and there isone, one property of sertraline
in that makes it actually themedication of choice is because
it prevents post dialysishypotension.
Do not ask me why.
I do not know.
I tried to look up for that andI could not find anything.
Dr. Amayo (11:05):
Post dialysis apathy.
Prevents that.
Dr. Handratta (11:07):
Yes, it prevents that.
And we do not know how does itdo it.
And then the other medicationthat is safer in patient renal
disease fluoxetine flux.
But one caution with fluoxetineis that it has a lot of drug
interaction.
Yeah.
Please look up the druginteraction before you prescribe
fluoxetine because patients withrenal disease will be on
polypharmacy.
Dr. Amayo (11:25):
And fluoxetine has a long half-life.
Dr. Handratta (11:27):
Yes.
Dr. Amayo (11:28):
Is it cleared renally or
Dr. Handratta (11:29):
Fluoxetine it's metabolized in the liver and
then it does actually but itdoes not accumulate in the
system does.
Dr. Amayo (11:35):
Yeah.
Okay.
Okay.
And so just to recap so kidneysare very important.
They help with excretion and thebiggest way that we can lead to
toxicity is toxicity, is becauseof the reduced albumin in
nephrotic syndromes.
The increase in urea, whichfights with, which reduces the
plasma protein binding capacityof medications leading to high.
(11:58):
Free medications and so this, soin kidney disease there's a
higher risk of toxicity in thesepatients.
We estimate creatinine clearanceusing the mild, moderate, severe
method.
And we talked about this.
Five medications,desvenlafaxine, bupropion,
levomilnacipram.
And, and in venlafaxine, it'sokay to reduce the dose by 25 or
(12:22):
to 50% in mild, moderate,severe.
And then in ESRD you give 50% ofwhat you normally give and you
give it after dialysis.
In does venlafaxine, it's okayto reduce the dose around mild
and moderate by severe.
And ESRD give 50 milligramsevery other day.
Duloxetine, I would say stayaway from.
Because you accumulate a lot ofthe metabolites and increases,
(12:45):
increases chance for both liverdamage and as well as just as
toxicity for bupropion.
There's an increase in themetabolite as well and increases
risk for seizures.
So stay away with severe or ESRDand levomilnacipram has a
relative contraindication inESRD.
Yeah.
Sertraline and fluoxetine isrelatively safe in this patient
(13:08):
population.
But be careful for fluoxetinedrug-drug-interactions.
Sertraline helps with postdialysis hypotension Yes, but
our guru doesn't know why.
So that's all we have on todayfor the Y Psychiatry.
Dr. Handratta (13:25):
Thank you.
Thank you.
Katrina (13:31):
Thank you for joining us on today's episode.
Our tireless team is alreadyhard at work, cobbling together
another potpourri of fascinatingdiscussion for next week, so be
sure to tune in, visit ourwebsite and our podcast feed and
let us know your thoughts on theepisode.
Subscribe so you don't miss ourreleases every Wednesday.
Until next time, keep smiling,keep shining, and stay curious.
So why is cytochrome P450 called
cytochrome P450?
Dr. Amayo (00:05):
What?
That
Dr. Handratta (00:05):
Enzymes are so named because.
There are bound to memorieswithin a cell and contain a heme
pigment.
Yeah, and because of heme itgets chrome, the name, and
because of the pigment.
The first letter is p.
that absorbs light at awavelength of 450 nano more when
exposed to carbon monoxide.
Dr. Amayo (00:23):
That's a weird reason to give an enzyme name.
You must be fun at parties.
I will.
Thanh (00:30):
Welcome to the Y in Psychiatry!
Dr. Amayo (00:32):
Hi, this is Dr.
Amayo C/L fellow.
Thanh (00:35):
Where we delve into the intricate nuances of psychiatric
topics.
Dr. Handratta (00:39):
My name is Dr.
Handratta attendingpsychiatrist.
I did my residency fromUniversity of Connecticut and
then I did my fellowship fromGeorgetown University in
consultation and liaison.
Thanh (00:49):
Each episode features interview style discussions that
explore the intersection of themind medicine and the human
experience.
Together we'll uncover thehidden why and the
groundbreaking discovery shapingthe psychiatric landscape.
So grab a seat, warm beverage,tune in, and let's embark on
this journey to unlock themysteries of the human psyche.
(01:12):
Only on The Y in Psychiatry.
Dr. Amayo (01:16):
Welcome back to the Y in psychiatry.
Today we'll be continuing ourseries depression in special
population, and we'll befocusing on renal disease as
usual.
I'm your host, Dr.
Amayo, consult and liaisonfellow.
And I have Dr.
Dr. Handratta (01:31):
Hi.
And this is Dr.
Handratta attendingpsychiatrist.
Dr. Amayo (01:36):
And so today, last time we talked about the liver.
Today we're talking about thekidney.
And the question is, why is thekidney important in psychiatry?
Yeah.
Why should we talk about thekidney?
Dr. Handratta (01:48):
So now for psychiatrists, brain is the
primary organ.
Dr. Amayo (01:54):
What is life?
Dr. Handratta (01:55):
Yes.
And cardiologists will say,heart is life.
I didn't.
Yeah.
So we all like, actually, likethere will be a tough war on
this.
But we need to know about kidneybecause as we talked about in
the previous episode, how liverplays an important role in drug
metabolism.
Kidney also plays a veryimportant role, especially in
excretion of the drugs, right?
(02:16):
Majority of our medications, notall after they are metabolized
in the liver, are conjugated andmade water soluble and excreted
through the kidney, right?
So the drug can be excretedeither in the feces or in the,
your right.
So patients who have renaldisease, there will be a problem
in the way our body handles thedrug.
(02:37):
And plus patients with renaldisease also have increased
comorbidity with depression.
Again, actually the incidencerate actually of depression is,
it's a huge range actually, butit's usually like around 30 to
40%, especially patients who areon dialysis.
Dr. Amayo (02:53):
Okay.
So the kidney is important forexcretion.
And again, we see there's a lotof comorbidities with depression
and kidney failure and treatingthe depression improves outcome.
And so what specific role orwhat specific way does the
kidney excrete our medications?
Dr. Handratta (03:09):
So kidney plays an important role with the
medication excretion.
We know that, right?
So when in renal disease,there's a decrease in the urine
output and there's a decrease inthe glomerular filtration rate.
So the medications, which goesthrough the kidney, is going to
accumulate in a systemiccirculation causing toxicity,
right?
Patients with renal disease,they also excrete a large amount
(03:30):
of albumin so patients can havehypoalbuminemia.
And we know that a lot of ourpsychiatric medication bounds to
albumin
Dr. Amayo (03:36):
By the last time.
Dr. Handratta (03:37):
Exactly.
And then it's a pre form of themedication that is active.
Yeah.
And then patients with renaldisease, there is also an
increase in the level of ureaand urea will now compete with
albumin with the medication.
So further increasing the freeform of the medication causing
more toxicity.
So these are the three reasonswhy people with renal disease
(04:01):
can experience toxicity whenantidepressants are not dosed in
a proper way.
Dr. Amayo (04:06):
Okay.
And I know there's anomenclature for grading kidney
failure or kidney disease usingthe creatinine clearance.
Can you.
Can you remind me of thosenumber of questions and are
those important for us?
Let knowing like when should weprescribe this medication?
Dr. Handratta (04:24):
Yes so there is an app where you can calculate
the estimated creatinineclearance.
Don't ask me the formula.
Yeah.
So you put in the, you punch inthe numbers actually in the,
prelbuadmin clearance calculatorand based on the number they
didivide into when is normalfunction, so we have to talk
about normal, right?
Yeah.
So normal estimated creatinineclearance is more than or equal
(04:46):
to 80 ml per minute, okay?
Mild is in the range of 51 to 80ml per minute.
Okay?
Moderate is from 31 to 50 ml perminute.
Severe is less than or equal to30 ml per minute.
And end stage renal disease iswhen you require dialysis is
less than 10 ml per minute.
Basically for simplicity, we saynormal functioning, mild,
(05:07):
moderate, severe kidney diseaseor end stage renal disease.
Dr. Amayo (05:10):
Yeah.
Okay.
And what medications should we,what medications can we give or
should we stay away from towardsthe severe and ESRD?
Dr. Handratta (05:20):
Umm, there are a lot of medications that we can
talk about, but the ones that Iwant to stress about in this
particular podcast.
Some of them I'm gonna name.
So Venlafaxine, vex, right?
Metabolic of venlafaxine.
That is desvenlafaxine.
Then we have duloxetine, uh, wehave Bupropion and we have
levomilnacipram.
I hardly use it levomilnacipram,but there are psychiatrists who
(05:43):
do use levomilnacipram.
So we have to be careful withthese four medications in
patients with renal disease.
So let's look at venlafaxine.
Like how do we dose venlafaxinein patients with renal disease?
So it's not like renal toxic,but it's excreted by the kidney.
More than 80% of venlafaxinegoes through the kidney and
(06:05):
excreted out, right?
So in patients who are mild,moderate, and severe renal
disease, we decrease the dose ofvenlafaxine by 25 to 50%.
So you can still use it, but youdecrease the dose to prevent the
toxicity and accumulation, andin patients with stage renal
disease, you drop down the doseof 50% and wait till the
(06:25):
dialysis,
Dr. Amayo (06:26):
So you dose after the dialysis.
Dr. Handratta (06:28):
Okay.
You give one time dose, waittill the dialysis is done, and
then give the second dose, whichis 50% or before the renal
toxicity.
Okay?
Then you have desvenlafaxine,which is a metabolite of
venlafaxine.
Again, more than 80% is excretedby the kidney.
So with desvenlafaxine, you canget away with mild renal
disease, you can dose it exactlythe way you dose it, right?
(06:50):
Whereas in patients withmoderate renal disease, you
don't go above 50 milligramevery day, right?
And in patients with severe andend stage renal disease, you
dose it at 50 milligram everyother day, right?
So you can still use thismedication, but you have to be
careful how you dose them.
Dr. Amayo (07:09):
And for the desvenlafaxine, does it matter
when they have the dialysis alldone?
Do you It doesn't matter.
Okay.
It doesn't matter.
Dr. Handratta (07:15):
Yeah.
As long as you give it 50milligram every other day.
Yeah.
Okay.
And then you all got duloxetine.
So this is a medication thatwill be used actually by
physicians, even if the patientis in severe or end stage renal
disease.
And there's a common mistakethat I see again and again while
I do consultation/ liaisonpsychiatry.
(07:37):
So duloxetine, once yourestimated clearing creatinine
clearance is less than 30 ml perminute, you stay away from
duloxetine.
Interesting.
The reason being is that themetabolite of duloxetine, the
area under the curve, that isthe amount of medication is
about seven to nine times higherin patients with renal diseases
compared to healthy control.
(07:58):
And that itself can be toxic.
Plus it can also causehepatotoxicity.
Yeah.
So you have to be careful withduloxetine.
Dr. Amayo (08:05):
So once they reach severe stop duloxetine.
Yes.
And do a different medication.
Dr. Handratta (08:11):
Exactly.
And again, I'll say, don't stopit cold Turkey.
Yeah.
Because duloxetine has a veryshort half-life and is one of
the medication which has reallybad serotonin withdrawal.
So whenever I'm prescribingpatients duloxetine or
venlafaxine or desvenlafaxine, Itell the patient, keep at least
a week supply in your office sothat if you forget it at home,
(08:33):
at least you have a medicationin your office which you can
take because the withdrawal isbad.
You feel the withdrawal by theend of the day.
Yeah.
Okay.
Then you got bupropion.
Bupropion.
So Bupropion is a medication weextensively use in psychiatry.
Yeah.
Because it's one of themedication which does not cause
sexual side effects.
Yeah.
Plus it's one of the medicationthat does not cause
hyponatremia.
(08:53):
So people feel comfortable usingit.
Plus it gives you the boost ofenergy because in depression you
have a decrease in the energylevel.
So with Bupropion you canactually improve it
Dr. Amayo (09:03):
And it helps with apathy.
Dr. Handratta (09:05):
Exactly.
And it helps with apathy helpswith smoking cessation.
Oh, wow.
It helps with ADHD.
Yeah.
Yeah.
So it does though it's all notFDA approved.
Yeah.
So with Bupropion, it's brokendown into a metabolite called
hydroxy-bupropion, which hasapproximately 50% of the
activity of bupropion.
In a healthy individual, theconcentration of the metabolite
(09:28):
is 10 times that of a parentcompound.
Just imagine patients with renaldisease, plus patients with
renal disease will have problemwith sodium if they have
hyponatremia.
You give bupropion, you'redecreasing the seizure
threshold, and you're increasingthe risk of seizures, right?
So Bupropion, you have to becareful.
In mild and moderate bupropionextended release, you can dose
(09:52):
normally.
Okay?
But in severe and end stagerenal disease, you give them 150
milligram every third day,right?
So you have, be careful.
And if you're using an immediaterelease, bupropion mild, you're
fine.
Be a little careful.
Start low, go slow.
Yeah.
And then in moderate severe, atend stage, 75 milligram per day.
So you have to be careful withBupropion because you don't want
(10:13):
to induce seizure in thesepatients, right?
Levomilnacipram, I don't use it,but that does not mean that it's
not a good medication.
I do not have too muchexperience with it.
buT it has a relativecontraindication in in patients
with end stage renal disease.
So when you're using it, becareful in end stage renal
disease.
Dr. Amayo (10:31):
iS there any medication that has your
approval?
No, it seems like we, we hit allthe SNRI.
How about the SSRIs is itrelatively good in renal
disease.
Dr. Handratta (10:41):
So most there are two SSRI which are, relatively
safe It says safer in patientswith renal disease, which we
commonly use.
One is sertraline and there isone, one property of sertraline
in that makes it actually themedication of choice is because
it prevents post dialysishypotension.
Do not ask me why.
I do not know.
I tried to look up for that andI could not find anything.
Dr. Amayo (11:05):
Post dialysis apathy.
Prevents that.
Dr. Handratta (11:07):
Yes, it prevents that.
And we do not know how does itdo it.
And then the other medicationthat is safer in patient renal
disease fluoxetine flux.
But one caution with fluoxetineis that it has a lot of drug
interaction.
Yeah.
Please look up the druginteraction before you prescribe
fluoxetine because patients withrenal disease will be on
polypharmacy.
Dr. Amayo (11:25):
And fluoxetine has a long half-life.
Dr. Handratta (11:27):
Yes.
Dr. Amayo (11:28):
Is it cleared renally or
Dr. Handratta (11:29):
Fluoxetine it's metabolized in the liver and
then it does actually but itdoes not accumulate in the
system does.
Dr. Amayo (11:35):
Yeah.
Okay.
Okay.
And so just to recap so kidneysare very important.
They help with excretion and thebiggest way that we can lead to
toxicity is toxicity, is becauseof the reduced albumin in
nephrotic syndromes.
The increase in urea, whichfights with, which reduces the
plasma protein binding capacityof medications leading to high.
(11:58):
Free medications and so this, soin kidney disease there's a
higher risk of toxicity in thesepatients.
We estimate creatinine clearanceusing the mild, moderate, severe
method.
And we talked about this.
Five medications,desvenlafaxine, bupropion,
levomilnacipram.
And, and in venlafaxine, it'sokay to reduce the dose by 25 or
(12:22):
to 50% in mild, moderate,severe.
And then in ESRD you give 50% ofwhat you normally give and you
give it after dialysis.
In does venlafaxine, it's okayto reduce the dose around mild
and moderate by severe.
And ESRD give 50 milligramsevery other day.
Duloxetine, I would say stayaway from.
Because you accumulate a lot ofthe metabolites and increases,
(12:45):
increases chance for both liverdamage and as well as just as
toxicity for bupropion.
There's an increase in themetabolite as well and increases
risk for seizures.
So stay away with severe or ESRDand levomilnacipram has a
relative contraindication inESRD.
Yeah.
Sertraline and fluoxetine isrelatively safe in this patient
(13:08):
population.
But be careful for fluoxetinedrug-drug-interactions.
Sertraline helps with postdialysis hypotension Yes, but
our guru doesn't know why.
So that's all we have on todayfor the Y Psychiatry.
Dr. Handratta (13:25):
Thank you.
Thank you.
Katrina (13:31):
Thank you for joining us on today's episode.
Our tireless team is alreadyhard at work, cobbling together
another potpourri of fascinatingdiscussion for next week, so be
sure to tune in, visit ourwebsite and our podcast feed and
let us know your thoughts on theepisode.
Subscribe so you don't miss ourreleases every Wednesday.
Until next time, keep smiling,keep shining, and stay curious.
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