The Necessary Evil: Balancing the risks and benefits of fluvoxamine in a patient with treatment refractory depression on warfarin:A Case Report

Warfarin, a commonly prescribed anticoagulant, has a narrow therapeutic index; and is metabolised by a number of cytochrome P-450 isoenzymes. Fluvoxamine is an effective antidepressant. It is a potent SSRI, with proven efficacy on obsessive-compulsive symptoms, anxiety, and psychotic depression. It is also a potent inhibitor of a number of cytochrome P-450 isoenzymes and has the potential to cause pharmacokinetic interactions with warfarin, resulting in elevated International Normalised Ratio (INR). We report a case of an elderly man, who was on warfarin for atrial fibrillation. He also suffered from severe and complex depressive episodes, with marked anxiety, and obsessive-compulsive symptoms which at times were impervious to reassurance and rational explanations. The depression responded inadequately to a number of trial of antidepressants, including a combination of antidepressants. Hence a decision was taken to commence Fluvoxamine. Co-administration resulted in the marked and rapid elevation of INR, necessitating adjustment in the dose of Warfarin. Although Fluvoxamine, by dint of its pharmacokinetic profile as a Selective Serotonin Reuptake Inhibitor (SSRI) has a high likelihood of interaction with Warfarin, there are very clinical few case-reports of such an interaction. Over the years, the use of Fluvoxamine in clinical practice has declined following the availability of other SSRIs that have less effect on the cytochrome enzyme system. However, in certain clinical situations where the use of Fluvoxamine is warranted, careful consideration of the drug interactions is highly recommended The case demonstrates the necessity of close monitoring when Fluvoxamine is co-administered with Warfarin, as the INR is elevated and the risk of haemorrhage increases even at small doses of Fluvoxamine. This close monitoring becomes even more relevant in the elderly because of prolonged half-life of Fluvoxamine in this population

Using mentoring to improve the foundation placement in psychiatry: review of literature and a practical example

In the past few years, mentoring in clinical settings has attracted the attention of medical educators, clinicians, managers, and policy makers. Most of the Royal Colleges of medical and surgical specialities have some form of mentoring schemes and various regional divisions of Health Education England support mentoring and coaching in the workplace. Despite the importance of this topic and the great need to provide more support to doctors in recent times, there is a paucity of literature on examples of mentoring schemes in clinical settings and practicalities of setting up such schemes in hospitals. This paper describes the implementation of a mentoring scheme in a large mental health trust in the UK to support junior doctors and the issues involved in creating such scheme. We hope that this article will be useful to clinicians who would like to start similar schemes in their workplace

Differential in vitro activity of the DNA topoisomerase inhibitor idarubicin against Trypanosoma rangeli and Trypanosoma cruzi

In this study the effect of eight DNA topoisomerase inhibitors on the growth Trypanosoma rangeli epimastigotes in cell culture was investigated. Among the eight compounds tested, idarubicin was the only compound that displayed promising trypanocidal activity with a half-maximal growth inhibition (GI(50)) value in the sub-micromolar range. Fluorescence-activated cell sorting analysis showed a reduction in DNA content in T. rangeli epimastigotes when treated with idarubicin. In contrast to T. rangeli, against Trypanosoma cruzi epimastigotes idarubicin was much less effective exhibiting a GI(50) value in the mid-micromolar range. This result indicates that idarubicin displays differential toxic effects in T. rangeli and T. cruzi. Compared with African trypanosomes, it seems that American trypanosomes are generally less susceptible to DNA topoisomerase inhibitors