USE OF STIMULANTS IN THE MEDICALLY ILL
Section snippets
CHEMISTRY AND PHARMACOLOGY OF THE PSYCHOSTIMULANTS
β-Phenylethylamine is the parent compound of sympathomimetic amines, including the psychostimulant amphetamine (Fig. 1). Substitutions on the aromatic ring, the α- and β-carbons, and the terminal amino group contribute to a variety of sympathomimetic compounds with a range of physiologic activities.51 In general, substitution on the α-carbon prolongs physiologic activity by inhibiting the oxidating potential of monoamine oxidase (MAO), and hydroxy substitution on the β-carbon decreases central
Patients with General Medical Illness
Although the first major review of amphetamine therapy was published in 1939, it was not until the mid- to late 1970s that their use for the depressed medically ill was advocated. At the 1978 annual meeting of the American Psychiatric Association, Dr. Thomas Hackett outlined 10 important indications for amphetamine use. In addition to their previously reported use in narcolepsy, as an antidote to amobarbital during the Amytal interview, for enhancement of verbal communication in psychotherapy,
DOSING OF PSYCHOSTIMULANTS
Recommended starting doses, peak doses, and dosage schedules are listed in Table 6. Because the half-life of MPD is 2 to 7 hours,21 most patients need at least twice-a-day dosing (at 8 am and 12 noon). We recommend starting with 5 mg at 8 am and observing how the patient does 1 hour after the first dose. We usually check the pulse and the blood pressure prior to and 1 hour after the first dose to determine if the patient shows evidence of sinus tachycardia or hypertension (pulse > 100
CONTRAINDICATIONS TO PSYCHOSTIMULANTS
Relative contraindications to the use of psychostimulants in the medically ill include: a history of hypersensitivity to stimulants; history of psychosis or tics; pregnancy; uncontrolled hypertension or arrhythmias; a history of abusing stimulants; or concomitant use of monoamine oxidase inhibitors (MAOIs) (even though there have been case reports describing the safe combination of MAOIs and psychostimulants with good success).33, 35
DRUG INTERACTIONS
The important interactions of psychostimulants with other drugs can be divided into four categories: (1) drug effects inhibited by psychostimulants, (2) drug effects potentiated by psychostimulants, (3) drugs that inhibit psychostimulant effects, and (4) drugs that potentiate psychostimulant effects (Table 7). Interference with hepatic metabolism, delayed absorption, intensified urinary excretion, and additive adrenergic effects are the mechanisms by which these interactions occur. Most of the
SIDE EFFECTS
Psychostimulants are capable of producing a range of central nervous system, cardiovascular, and GI disturbances that are generally dose-related and reversible (Table 8). Their use in the medically ill, however, has been associated with few adverse effects and they have been used safely even in the presence of underlying cardiovascular or central nervous system disease. Their comparative safety is probably a function of the low doses and brief courses of treatment used in the depressed
TOLERANCE, ABUSE, AND ADDICTION
All agents labeled as psychostimulants, central nervous stimulants, or amphetamine-based appetite suppressants have abuse potential. Their capacity to produce euphoria and a sense of well-being can lead to craving and compulsive use. In animals, a variety of different experimental techniques have demonstrated that the psychostimulants activate mesolimbic and mesocortical “pleasure pathways” in the brain.47 Electrical stimulation of these areas produces behavior similar to that elicited by
FUTURE DIRECTIONS FOR RESEARCH
Future directions for research include the following:
- 1
Placebo-controlled trials of stimulants for depression in the medically ill including patients with stroke, AIDS, Parkinson's disease, head injury, and cardiac problems.
- 2
Studies of stimulants should evaluate efficacy at 24 to 72 hours rather than after 1 to 2 weeks (which is the traditional period for follow-up in controlled clinical trials) to demonstrate quick onset of action.
- 3
Systematic long-term follow-up studies of medically ill
ACKNOWLEDGMENT
The authors wish to thank Theodore Stern, MD, for his helpful suggestions and critical review of the manuscript.
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What Treatments Are Effective for Depression in Palliative Care Settings?
2023, Evidence-Based Practice of Palliative Medicine, Second EditionMethylphenidate as Needed for Fatigue in Patients With Advanced Cancer. A Prospective, Double-Blind, and Placebo-Controlled Study
2020, Journal of Pain and Symptom ManagementCitation Excerpt :Furthermore, an improvement in activity was found after two hours. These observations correlate well with the described pharmacology for methylphenidate where peak plasma level occurs after one to two hours and half-life is two to seven hours.32 Looking at the baseline scores on ESAS and the two additional VAS concerning tiredness and problems with concentration, there were no significant differences between methylphenidate and placebo, that is, there was no indication of unequal baseline score differences influencing the results.
What Treatments Are Effective for Depression in the Palliative Care Setting?
2012, Evidence-Based Practice of Palliative MedicineDepression and anxiety in the older patient with cancer: A case-based approach
2012, Management of Cancer in the Older PatientStimulant Abuse: Pharmacology, Cocaine, Methamphetamine, Treatment, Attempts at Pharmacotherapy
2011, Primary Care - Clinics in Office PracticeCitation Excerpt :Indications include attention-deficit/hyperactivity disorder (ADHD), weight control, and narcolepsy. OTC stimulants include aerosolized or ingested forms of decongestants as well as caffeine in multifarious forms.29 There has been a recent boom of highly caffeinated beverages, aka “energy” drinks.30
Psychostimulants
2010, Journal of Pain and Symptom ManagementCitation Excerpt :A consensus panel concluded that they were the drugs of choice for treating depression in patients with a prognosis of <3 months.17 If daily review is practical, it is often possible to achieve a response in a few days, increasing the dose every 1–2 days until a response is obtained or undesirable effects prevent further escalation (Box 1).11,17 However, published trials are generally of poor quality, short duration, and with outcome measures of uncertain clinical significance.
Address reprint requests to Prakash S. Masand, MD, Psychiatry Consultation Service, SUNY Health Science Center, 750 East Adams Street, Syracuse, NY 13210