Medications to Discontinue 24 Hours Before ECT
Leukotriene antagonists (montelukast, zafirlukast) should be discontinued 24 hours before ECT, though this recommendation comes from oral food challenge testing guidelines rather than ECT-specific literature 1.
High-Priority Medications Requiring Discontinuation Before ECT
The following medications pose significant risks when administered concurrently with ECT and should be discontinued when clinically feasible:
Medications That Must Be Stopped
Lithium should be discontinued during ECT due to reports of acute brain syndrome and prolonged/severe post-ECT confusion when used concurrently 2, 3. Studies show significantly longer post-ECT hospital stays and increased confusion in patients receiving lithium within 24 hours before or 48 hours after ECT 3.
Theophylline must be discontinued as it prolongs seizure duration at both therapeutic and toxic levels 2. While theophylline can be used therapeutically to reverse seizure inhibition in patients with inadequate seizure duration 4, 5, its uncontrolled presence increases risk of prolonged seizures (>180 seconds) requiring termination with additional anesthetics 1.
Carbamazepine should be stopped as it has been associated with failure to induce seizures during ECT 2. Additionally, carbamazepine may prolong the action of succinylcholine (the muscle relaxant used during ECT) 6.
Trazodone requires discontinuation due to reported adverse effects, specifically prolonged seizures during ECT 2.
Benzodiazepines should be discontinued as they increase seizure threshold through anticonvulsant properties, potentially making it difficult to induce therapeutic seizures 2, 6.
Clinical Algorithm for Medication Management
Pre-ECT Assessment
- Review all current medications for potential interactions with ECT 7.
- Prioritize discontinuation of lithium, trazodone, carbamazepine, theophylline, and benzodiazepines as highest-risk medications 2.
- Obtain anesthesiology consultation, preferably with someone experienced in ECT 7.
When Medications Cannot Be Discontinued
- If medications cannot be stopped due to clinical necessity, they may be administered with appropriate monitoring 2.
- Increased vigilance is required for prolonged seizures (>180 seconds on EEG), which should be treated with additional methohexital, diazepam, or lorazepam 1.
- Monitor for tardive seizures (late-onset seizures occurring 24-48 hours after ECT despite full recovery from anesthesia) 1.
Post-ECT Monitoring
- Provide close monitoring for at least 24 hours after each ECT procedure for tardive seizures 1, 2.
- If recurrent prolonged seizures or tardive seizures occur, obtain neurology consultation before resuming ECT 1, 2.
Important Caveats
Adolescents may have lower seizure thresholds and more prolonged seizures with ECT compared to adults, requiring extra caution with seizure-modifying medications 2.
Monoamine oxidase inhibitors (MAOIs) require more care, especially older irreversible varieties and in patients recently started on MAOI therapy 6.
Tricyclic antidepressants (TCAs) and selective serotonin reuptake inhibitors (SSRIs) can be combined safely with ECT without significant effects on seizure duration 6, 8.
Antipsychotics are well tolerated with ECT and may be beneficial 6.