PSYCHOSOMATIC MEDICINE: PART 1
Psychiatric Issues for Patients With Renal Disease
by John H. Fanton, MD, Roger S. McIntyre, MD, FRCPC, and Lewis M. Cohen, MD |
November 16, 2011
Dr Fanton is Assistant Professor of Psychiatry at Tufts University School of Medicine in Boston, and Director, Children’s Partial Hospital Program, Baystate Medical Center in Springfield, Mass; Dr McIntyre is Associate Professor of Psychiatry and Pharmacology at the University of Toronto, and Head, Mood Disorders Psychopharmacology Unit; Dr Cohen is Professor of Psychiatry at Tufts University School of Medicine and Consultation Psychiatrist at Baystate Medical Center. Drs Fanton and Cohen report no conflicts of interest concerning the subject matter of this article. Dr McIntyre reports that he is on the advisory board for AstraZeneca, Biovail, Bristol-Myers Squibb, France Foundation, GlaxoSmithKline, Janssen-Ortho, Eli Lilly, Lundbeck, Organon, Pfizer, Schering-Plough, Shire, and Solvay/Wyeth; he is on the speakers bureau of AstraZeneca, Biovail, Janssen-Ortho, Eli Lilly, Lundbeck, and Wyeth; has taken part in CME activities for AstraZeneca, Bristol-Myers Squibb, France Foundation, CME Outfitters, I3CME, Eli Lilly, Optum Health, Physicians’ Postgraduate Press, Schering-Plough, and Solvay/Wyeth; has received research grants from AstraZeneca, Janssen-Ortho, Eli Lilly, and Shire; and has received travel funds from Bristol-Myers Squibb.
Acknowledgments—The authors are grateful to Edward G. Tessier, Adam M. Mirot, and Michael J. Germain for their help with this article.
Sizable numbers of patients have compromised renal function, and it is highly likely that psychiatrists will need to collaborate with primary care providers and nephrologists when prescribing psychotropic medications. There are unfortunately few formal pharmacological research studies that have investigated this subject, and clinicians must rely on basic knowledge of the factors that influence the effects and metabolism of psychoactive substances. This requires an appreciation of pharmacokinetics, including absorption, volume of distribution, metabolism, and excretion of the parent drug and metabolites.
Most psychotropic medications are not metabolized or excreted by the kidneys. In the absence of systematic data, caution is always necessary, but most of these medications are well tolerated and produce their accustomed beneficial effects. Renal dysfunction should not theoretically be associated with any unusual drug interactions.
Serum levels of medications such as the anticonvulsants/mood stabilizers should be monitored, especially if patients receive a renal transplant and immunosuppressants. Lithium(Drug information on lithium) is the only psychotropic medication associated with nephrotoxicity with long-term use.
Caution is especially required in the treatment of the pediatric population, but this group should also not be neglected because of the absence of research. Lastly, this review underscores the need for psychiatrists and primary care physicians to urge the pharmaceutical industry and other organizations to cease ignoring this subject and to begin sponsoring empirical research.
Also in this Special Report
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