ECT + Phamacotherapy

Dr. Dandaithapani Thyagarajan

Psychiatrist,
Hospital Kuala Lumpur
Drug interactions

• Interactions with medications used during ECT procedures

• Interactions that affect the efficacy of ECT (e.g., suppressing seizure

activities)

• Interaction that increases risk associated with ECT (e.g., prolong

seizure)
General rule

• Avoid/reduce dose of medications that raise seizure threshold or

impede seizure propagation.

• Cardiac medications, antihypertensives and anti-gastric medications

can be continued.
Medications during ECT procedures
Anesthetic inductions agents
• Methohexital, Thiopental, Propofol, Ketamine, Etomidate

Neuromuscular blocking agents

• Succinylcholine, Rocuronium, Atracurium, Mivacurium

Antihypertensives
• Beta blockers, Calcium channel blockers

Anticholinergic agents
• Glycopyrrolate

Narcotics
• Fentanyl, Remifentanyl, Alfentanyl
Lithium
• Evidence
 Risk of delirium, prolong seizures, toxic level, prolong
neuromuscular blockade.
 Elderly, withholding within 24 hours can cause delirium post ECT.

• Possible effect
 Delirium, postictal confusion, prolong seizure, increase levels.
 Prolonged action of neuromuscular blocking agents (e.g.
succinylcholine)
 Potential serotonin syndrome
Lithium
• Management strategies
 Avoid if possible
 Maintain at lowest therapeutic level
 Withhold a day before ECT
 Close monitoring for adverse effect
 Substitute with other mood stabilizers (e.g. atypical antipsychotics)
Valporic acid (VPA)
• Evidence
 Difficulty in eliciting seizures
 Lower doses of Propofol is required to induce anesthesia

• Possible effect
 Seizure inhibition or difficult to elicit adequate seizure
 Affects the efficacy of ECT
Valporic acid (VPA)
• Management strategies
 Dose reduction
 Withholding doses (e.g.: morning prior to ECT procedure)
Carbamazepine
• Evidence
 Mixed evidence
 Shorter duration of seizure
 Higher stimulus for unilateral ECT
 Prolongs action of succinylcholine
 Long term usage shows resistance to nondepolarizing
neuromuscular blockers

• Possible effect
 Seizure inhibition
 Fast recovery, need increase doses to achieve compete
neuromuscular block
Carbamazepine
• Management strategies
 Dose reduction
 Withholding doses (e.g.: morning prior to ECT procedure)
 Mivacurium preferred for neuromuscular blockade
Lamotrigine / Gabapentin / Topiramate
• Evidence
 Minimal or no influence of seizure

• Possible effect
 Minimal effect
 Theoretically causes seizure inhibition
Lamotrigine / Gabapentin / Topiramate
• Management strategies
 No recommendations
MAOI
• Evidence
 No evidence of interaction
 Use with ketamine causes sympathetic stimulation

• Possible effect
 Theoretically, risk of hypertensive crisis if used with
sympathomimetics
MAOI
• Management strategies
 Continue through ECT course
 Inform anest team prior to ECT
TCA
• Evidence
 Combination of TCA+ECT has better outcome
 Some studies shows shorter seizure time

• Possible effect
 Theoretically, reduces seizure threshold and increase risk of
cardiotoxicity
TCA
• Management strategies
 Continue through ECT course
 Avoid in elderly and those with cardiac problems
SSRI / SNRI
• Evidence
 Minimal effect

• Possible effect
 Minimal effect
SSRI / SNRI
• Management strategies
 Continue through ECT course
Benzodiazepines
• Evidence
 Impact may be low if patient is on long term usage
 Acts as an anticonvulsant

• Possible effect
 Increases seizure threshold, decreases seizure duration, and
decreases efficacy of ECT
 Possibly increases cognitive side effects if combine ECT
Benzodiazepines

• Management strategies
 Stop before ECT
 If long acting Benzodiazepine, should be discontinued several days prior to
ECT
 If cannot be discontinued, use higher stimulus
 Use Zolpidem
First Generation Antipsychotics
• Evidence
 Causes prolong seizure

• Possible effect
 Reduces seizure threshold
First Generation Antipsychotics

• Management strategies
 Continue through ECT course
Second Generation Antipsychotics
• Evidence
 Beneficial and additive efficacy

• Possible effect
 Clozapine decreases seizure threshold in dose dependent manner
(usually >600mg/day)
Second Generation Antipsychotics

• Management strategies
 Continue through ECT course
Cholinesterase inhibitors
• Evidence
 No evidence of adverse incidents
 Donepezil has been used in treating cognitive deficits associated
with maintenance ECT

• Possible effect
 Theoretically may cause synergistic effect with neuromuscular
blocking agents
Cholinesterase inhibitors

• Management strategies
 Continue through ECT course
 Caution when using with neuromuscular blocking agents
CNS Stimulants (Methylphenidate)
• Evidence
 Reduces sedation and improves respiratory function in patients
given halothane

• Possible effect
 Increase risk of potentiating seizure activities
 May cause dysrhythmias and elevate blood pressure during
anesthesia.
CNS Stimulants (Methylphenidate)

• Management strategies
 No specific recommendations
Thank you