E251 - (CME) Prescribing Potentially Unsafe Drug Combinations in Treatment-Resistant Cases

Mar 26, 2025

Dr. Roger S. McIntyre, a leading expert in treatment-resistant depression and bipolar disorder, joins Dr. Andrew Cutler to discuss the complexities of prescribing potentially unsafe drug combinations. They explore the intricacies of pharmacokinetics and pharmacodynamics, emphasizing the risks of polypharmacy. Key topics include the importance of monitoring drug interactions, the implications of anticholinergic medications, and the safety of stimulants in mood disorders. The conversation highlights guidelines for responsible prescribing and the challenges of managing treatment-resistant cases.

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ADVICE

Drug Interaction Types

Consider pharmacokinetic and pharmacodynamic interactions when evaluating drug combinations.
Pharmacokinetics is the body on the drug; pharmacodynamics is the drug on the body.

ANECDOTE

Serotonin Syndrome Example

Dr. Cutler shared causing serotonin syndrome once, with a patient on high fluoxetine and trazodone doses.
He highlighted it's difficult to induce and requires high serotonergic drug doses.

ADVICE

Ketamine and Stimulants

Hold stimulants on ketamine treatment days to mitigate potential blood pressure increases.
Monitor blood pressure, and consider holding benzodiazepines due to theoretical efficacy concerns.

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In this CME podcast, Dr. Andrew Cutler and Dr. Roger McIntyre discuss the use of potentially unsafe drug combinations in patients with treatment-resistant psychiatric conditions. They review situations where complex medication regimens may be necessary and how clinicians may proceed in these instances. By addressing these topics, the podcast offers guidance on balancing the potential benefits of combination therapies with the risks associated with polypharmacy in psychiatric care.

Target Audience: This activity has been developed for the healthcare team or individual prescriber specializing in mental health. All other healthcare team members interested in psychopharmacology are welcome for advanced study.

Learning Objectives: After completing this educational activity, you should be better able to:

Identify common potentially unsafe drug combinations that may be considered in treatment-resistant cases
Evaluate the risks and benefits of prescribing potentially unsafe drug combinations for treatment-resistant patients, considering factors such as efficacy, adverse effects, and patient-specific characteristics
Develop strategies to monitor and manage patients prescribed potentially unsafe drug combinations

Accreditation: In support of improving patient care, this activity has been planned and implemented by HMP Education and Neuroscience Education Institute (NEI). HMP Education is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.

Activity Overview: This activity is available with synchronized audio and is best supported via a computer or device with current versions of the following browsers: Mozilla Firefox, Google Chrome, or Safari. A PDF reader is required for print publications. A post-test score of 70% or higher is required to receive CME/CE credit. Estimated Time to Complete: 1 hour. Released: March 26, 2025* Expiration: March 25, 2028 *NEI maintains a record of participation for six (6) years.

CME/CE Credits and Certificate Instructions: After listening to the podcast, to take the optional posttest and receive CME/CE credit, click: https://nei.global/POD25-01 Credit Designations: The following are being offered for this activity:

Physician: ACCME AMA PRA Category 1 Credits™

HMP Education designates this enduring material for a maximum of 1.00 AMA PRA Category 1 Credit™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Nurse: ANCC contact hours

This continuing nursing education activity awards 1.00 contact hour. Provider approved by the California Board of Registered Nursing, Provider #18006 for 1.00 contact hour.

Nurse Practitioner: ACCME AMA PRA Category 1 Credit™

American Academy of Nurse Practitioners National Certification Program accepts AMA PRA Category 1 Credits™ from organizations accredited by the ACCME.
The content in this activity pertaining to pharmacology is worth 1.00 continuing education hour of pharmacotherapeutics.

Pharmacy: ACPE application-based contact hours

This internet enduring, knowledge-based activity has been approved for a maximum of 1.00 contact hour (.10 CEU).
The official record of credit will be in the CPE Monitor system. Following ACPE Policy, NEI and HMP Education must transmit your claim to CPE Monitor within 60 days from the date you complete this CPE activity and are unable to report your claimed credit after this 60-day period. Ensure your profile includes your DOB and NABP ID.

Physician Associate/Assistant: AAPA Category 1 CME credits

HMP Education has been authorized by the American Academy of PAs (AAPA) to award AAPA Category 1 CME credits for activities planned in accordance with the AAPA CME Criteria. This internet enduring activity is designated for 1.00 AAPA Category 1 credit. Approval is valid until March 25, 2028. PAs should only claim credit commensurate with the extent of their participation.

Psychology: APA CE credits

Continuing Education (CE) credits for psychologists are provided through the co-sponsorship of the American Psychological Association (APA) Office of Continuing Education in Psychology (CEP). The APA CEP Office maintains responsibility for the content of the programs. This activity awards 1.00 CE Credit.

Social Work: ASWB-ACE CE credits

As a Jointly Accredited Organization, HMP Education is approved to offer social work continuing education by the Association of Social Work Boards (ASWB) Approved Continuing Education (ACE) program. Organizations, not individual courses, are approved under this program. Regulatory boards are the final authority on courses accepted for continuing education credit. Social workers completing this internet enduring course receive 1.00 general continuing education credit.

Non-Physician Member of the Healthcare Team: Certificate of Participation

HMP Education awards hours of participation (consistent with the designated number of AMA PRA Category 1 Credit™) to a participant who successfully completes this educational activity.

Interprofessional Continuing Education: IPCE credit for learning and change

This activity was planned by and for the healthcare team, and learners will receive 1.00 Interprofessional Continuing Education (IPCE) credit for learning and change.

Peer Review: The content was peer-reviewed by an MD, MPH specializing in forensics, psychosis, schizophrenia, mood disorders, anxiety, and cognitive disorders — to ensure the scientific accuracy and medical relevance of information presented and its independence from commercial bias. NEI and HMP Education take responsibility for the content, quality, and scientific integrity of this CME/CE activity.

Disclosures: All individuals in a position to influence or control content are required to disclose any relevant financial relationships. Any relevant financial relationships were mitigated prior to the activity being planned, developed, or presented.

Faculty Author / Presenter Andrew J. Cutler, MD Clinical Associate Professor, Department of Psychiatry and Behavioral Sciences, Norton College of Medicine, State University of New York Upstate Medical University, Syracuse, New York Chief Medical Officer, Neuroscience Education Institute, Malvern, Pennsylvania Consultant/Advisor: AbbVie, Acadia, Alfasigma, Alkermes, Axsome, Biogen, BioXcel, Boehringer Ingelheim, Brii Biosciences, Cerevel, Corium, Delpor, Evolution Research, Idorsia, Intra-Cellular, Ironshore, Janssen, Jazz, Karuna, Lundbeck, LivaNova, Luye, MapLight Therapeutics, Neumora, Neurocrine, NeuroSigma, Noven, Otsuka, Relmada, Reviva, Sage Therapeutics, Sumitomo (Sunovion), Supernus, Takeda, Teva, Tris Pharma, VistaGen Therapeutics Speakers Bureau: AbbVie, Acadia, Alfasigma, Alkermes, Axsome, BioXcel, Corium, Idorsia, Intra-Cellular, Ironshore, Janssen, Lundbeck, Neurocrine, Noven, Otsuka, Sumitomot (Sunovion), Supernus, Takeda, Teva, Tris Pharma, Vanda Data Safety Monitoring Board (DSMB): COMPASS Pathways, Freedom Biosciences Faculty Author / Presenter Roger S. McIntyre, MD, FRCPC Professor, Departments of Psychiatry and of Pharmacology, University of Toronto, Toronto, Ontario, Canada CEO, Braxia Scientific Corp, Toronto, ON, Canada Grant/Research: Canadian Institutes of Health Research, China National Natural Research Foundation, Global Alliance for Chronic Diseases, Milken Institute Consultant/Advisor: Alkermes, Atai Life Sciences, Axsome, Bausch Health, Biogen, Eisai, Intra-Cellular, Janssen, Kris, Lundbeck, Mitsubishi Tanabe, Neumora Therapeutics, Neurocrine, NewBridge Pharmaceuticals, Novo Nordisk, Otsuka, Pfizer, Purdue, Sage, Sanofi, Sunovion, Takeda, Viatris The remaining Planning Committee members, Content Editors, Peer Reviewer, NEI and HMP planners/staff have no financial relationships to disclose. NEI and HMP Education planners and staff include Gabriela Alarcón, PhD, Ali Holladay, Andrea Zimmerman, EdD, CHCP, Brielle Calleo, and Steven S. Simring, MD, MPH.

Disclosure of Off-Label Use: This educational activity may include discussion of unlabeled and/or investigational uses of agents that are not currently labeled for such use by the FDA. Please consult the product prescribing information for full disclosure of labeled uses.

Cultural Linguistic Competency and Implicit Bias: A variety of resources addressing cultural and linguistic competencies and strategies for understanding and reducing implicit bias can be found in this handout—download me.

Accessibility Statement

For questions regarding this educational activity, or to cancel your account, please email customerservice@neiglobal.com.

Support: This activity is supported solely by the provider, NEI.