Steroid-induced psychosis: Difference between revisions
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==Background== | ==Background== | ||
*In 718 hospitalized patients, 4.6% of patients on 40 mg or higher per day of prednisone had psychiatric symptoms<ref>Acute adverse reactions to prednisone in relation to dosage. Clin Pharmacol Ther. 1972;13:694-698.</ref> | *In 718 hospitalized patients, 4.6% of patients on 40 mg or higher per day of [[prednisone]] had psychiatric symptoms<ref>Acute adverse reactions to [[prednisone]] in relation to dosage. Clin Pharmacol Ther. 1972;13:694-698.</ref> | ||
**Incidence rises to 18.4% for patients receiving more than 80 mg per day | **Incidence rises to 18.4% for patients receiving more than 80 mg per day | ||
*Mechanism unproven but thought to be increased dopamine due to induction of tyrosin hydroxylase by corticosteroids<ref>J Pharm Technol. 2021 Apr; 37(2): 120–126. Published online 2020 Dec 2.</ref> | *Mechanism unproven but thought to be increased dopamine due to induction of tyrosin hydroxylase by corticosteroids<ref>J Pharm Technol. 2021 Apr; 37(2): 120–126. Published online 2020 Dec 2.</ref> | ||
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==Management== | ==Management== | ||
*Cease offending agent or taper depending on clinical need for corticosteroids vs psychiatric complications | *Cease offending agent or taper depending on clinical need for [[corticosteroids]] vs psychiatric complications | ||
**Onset of relief of symptoms vary widely, with some improving within 24 hours or as long as 8 weeks at the longest | **Onset of relief of symptoms vary widely, with some improving within 24 hours or as long as 8 weeks at the longest | ||
**Discontinuing immediately, as opposed to tapering, contributed to quicker resolution of symptoms | **Discontinuing immediately, as opposed to tapering, contributed to quicker resolution of symptoms | ||
*Antipsychotics mediate dopamine D2 receptor, correlating with possible mechanism of steroid induced psychosis | *Antipsychotics mediate dopamine D2 receptor, correlating with possible mechanism of steroid induced psychosis | ||
**2nd generation antipsychotics, low-moderate dosage - [[risperdone]], [[olanzapine]], [[quetiapine]]<ref>Huhn M, Nikolakopoulou A, Schneider-Thoma J, et al. Comparative efficacy and tolerability of 32 oral antipsychotics for the acute treatment of adults with multi-episode schizophrenia: a systematic review and network meta-analysis. Lancet. 2019;394:939-951.</ref> | **2nd generation [[antipsychotics]], low-moderate dosage - [[risperdone]], [[olanzapine]], [[quetiapine]]<ref>Huhn M, Nikolakopoulou A, Schneider-Thoma J, et al. Comparative efficacy and tolerability of 32 oral antipsychotics for the acute treatment of adults with multi-episode schizophrenia: a systematic review and network meta-analysis. Lancet. 2019;394:939-951.</ref> | ||
**Severe may require IM/IV doses | **Severe may require IM/IV doses | ||
*Consult psychiatry for duration of medication treatment | *Consult psychiatry for duration of medication treatment | ||
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==Disposition== | ==Disposition== | ||
*Admission for severe cases | *Admission for severe cases | ||
*Possible discharge for mild cases, consider short supply atypical antipsychotics and close follow up | *Possible discharge for mild cases, consider short supply atypical [[antipsychotics]] and close follow up | ||
==See Also== | ==See Also== | ||
Revision as of 22:38, 20 March 2024
Background
- In 718 hospitalized patients, 4.6% of patients on 40 mg or higher per day of prednisone had psychiatric symptoms[1]
- Incidence rises to 18.4% for patients receiving more than 80 mg per day
- Mechanism unproven but thought to be increased dopamine due to induction of tyrosin hydroxylase by corticosteroids[2]
Clinical Features
- Time of onset variable
- Wide range of possible psychiatric symptoms
- Delusions or hallucinations
- Euphoria
- Mania, depression, anxiety
- Severe cases may present with suicidal ideation, violence, aggression
Differential Diagnosis
Altered mental status
Diffuse brain dysfunction
- Hypoxic encephalopathy
- Acute toxic-metabolic encephalopathy (Delirium)
- Hypoglycemia
- Hyperosmolar state (e.g., hyperglycemia)
- Electrolyte Abnormalities (hypernatremia or hyponatremia, hypercalcemia)
- Organ system failure
- Hepatic Encephalopathy
- Uremia/Renal Failure
- Endocrine (Addison's disease, Cushing syndrome, hypothyroidism, myxedema coma, thyroid storm)
- Hypoxia
- CO2 narcosis
- Hypertensive Encephalopathy
- Toxins
- TTP / Thrombotic thrombocytopenic purpura
- Alcohol withdrawal
- Drug reactions (NMS, Serotonin Syndrome)
- Environmental causes
- Deficiency state
- Wernicke encephalopathy
- Subacute Combined Degeneration of Spinal Cord (B12 deficiency)
- Vitamin D Deficiency
- Zinc Deficiency
- Sepsis
- Osmotic demyelination syndrome (central pontine myelinolysis)
- Limbic encephalitis
Primary CNS disease or trauma
- Direct CNS trauma
- Diffuse axonal injury
- Subdural/epidural hematoma
- Vascular disease
- SAH
- Stroke
- Hemispheric, brainstem
- CNS infections
- Neoplasms
- Paraneoplastic Limbic encephalitis
- Malignant Meningitis
- Pancreatic Insulinoma
- Seizures
- Nonconvulsive status epilepticus
- Postictal state
- Dementia
Psychiatric
Evaluation
Workup
- Diagnosis of exclusion
- DSM 5 diagnostic criteria
- Must include hallucinations or delusions after steroid exposure[5]
- Other causes cannot explain symptoms
Diagnosis
- Consider AMS workup
Management
- Cease offending agent or taper depending on clinical need for corticosteroids vs psychiatric complications
- Onset of relief of symptoms vary widely, with some improving within 24 hours or as long as 8 weeks at the longest
- Discontinuing immediately, as opposed to tapering, contributed to quicker resolution of symptoms
- Antipsychotics mediate dopamine D2 receptor, correlating with possible mechanism of steroid induced psychosis
- 2nd generation antipsychotics, low-moderate dosage - risperdone, olanzapine, quetiapine[6]
- Severe may require IM/IV doses
- Consult psychiatry for duration of medication treatment
Disposition
- Admission for severe cases
- Possible discharge for mild cases, consider short supply atypical antipsychotics and close follow up
See Also
External Links
References
- ↑ Acute adverse reactions to prednisone in relation to dosage. Clin Pharmacol Ther. 1972;13:694-698.
- ↑ J Pharm Technol. 2021 Apr; 37(2): 120–126. Published online 2020 Dec 2.
- ↑ Lewis DA, Smith RE. Steroid-Induced Psychiatric Syndromes. J Affect Disord. 1983;5(4):319-332.
- ↑ Nishimura K, Harigai M, Omori M, Sato E, Hara M. Blood-Brain Barrier Damage as a Risk Factor for Corticosteroid-Induced Psychiatric Disorders in Systemic Lupus Erythematosus. Psychoneuroendocrinology. 2008;33(3):395-403.
- ↑ American Psychiatric Association. Schizophrenia Spectrum and Other Psychotic Disorders: Substance/Medication-Induced Psychotic Disorder. DSM-5-TR. Published 2022.
- ↑ Huhn M, Nikolakopoulou A, Schneider-Thoma J, et al. Comparative efficacy and tolerability of 32 oral antipsychotics for the acute treatment of adults with multi-episode schizophrenia: a systematic review and network meta-analysis. Lancet. 2019;394:939-951.