Antidepressant meds Flashcards
Antidepressants
General
Most antidepressants have similar efficacy in treating depression so your choice of antidepressant should be based on side effect profile and comorbidities
Lots of antidepressants work on multiple neurotransmitters
Start low and go slow
Peds patients typically start at ½ starting dose for 7 days then increase
All antidepressants have a BLACK BOX WARNING for increase suicidal ideation in patients under 25yo
Follow up closely with these patients
neurotransmitters
Serotonin Side Effects
Nausea, vomiting, diarrhea
Headaches, dizziness
Inducing mania/hypomania
Increased bleeding risk (serotonin receptors on platelets)
Typically presents as easy bruising
No need to hold medications prior to surgery
Bone fractures (up to 76% increased risk with SSRIs)
Seuxal Dysfunction - decfreased libido, delayed or inability to climax (F>M)
Serotonin Syndrome
And possible meds
EMERGENCY - potentially fatal
2+ serotonergic medications simultaneously
Serotonin Syndrome “Shivers”
S - Shivering
H - Hyperreflexia and Myoclonus
I - Increased Temperature
V- Vital Sign instability( increase BP, HR, RR)
E- Encephalopathy (altered LOC)
R - Restlessness
S - Sweating
Discontinuation Syndrome
Best and worst offender
Advise patients to never abruptly stop medications
NOT medically dangerous but uncomfortable
Typically will taper off medications over several weeks OR cross taper onto new medication
Reduce dose by 25% per week over 4 weeks
Paxil = WORST
Prozac = LEAST
Discontinuation syndrome
Sx
F - Flu-like symptoms
I - Insomnia
N - Nausea
I - Imbalance
S - Sensory Disturbances
H - Hyperarousal
SSRI
Fluoxetine (Prozac)
SSRI
Dose - 10mg - 60mg, weekly form 90mg
FDA indications- MDD (age 8+), OCD (age 7+), panic disorder, bulimia, PMDD
Off label- PTSD, social anxiety
Monitoring-no routine monitoring
Side Effects- general SSRI SE, SSRI most likely to cause insomnia and anxiety
Has longest half live (active metabolite T1/2 is 2+ weeks) of any SSRI which can make it self-tapering (no discontinuation syndrome)
Can be stimulating (cause insomnia, anxiety, and decreased appetite) so is a good option for someone who needs activation (fatigue, concentration issues, etc)
Paroxetine (Paxil)
SSRI
Dose: 10mg - 40mg
FDA indications- MDD, OCD, panic disorder, social anxiety, GAD, PTSD, PMDD, menopausal hot flashes
Off label- premature ejaculation
Monitoring- no routine monitoring
Side Effects- general SSRI SE, SSRI most likely to cause weight gain, sexual side effects, sedation
Pregnancy category D, so avoid if possible in women of child-bearing age
Half live of less than 24 hours, bad rebounds symptoms if stopped abruptly
Sertraline (Zoloft)
SSRI
Dose: 50mg - 300mg
FDA indications- MDD, OCD (age 6+), panic disorder, PTSD, PMDD, social anxiety
Off label- GAD
Monitoring- no routine monitoring
Side Effects- general SSRI SE, SSRI most likely to cause nausea
Sometimes called squirt-raline due to GI SE
Escitalopram (Lexapro)
SSRI
Dose: 10mg - 20mg
FDA indications- MDD (age 12+), GAD
Off label- OCD, PTSD, social anxiety, panic disorder, PMDD
Monitoring- no routine monitoring
Side Effects- general SSRI SE
Enantiomer of citalopram (S enantiomer is the pure active form and R en antiomer has anticholinergic properties which causes more side effects)
Considered the cleanest SSRI meaning it has the fewest SE
Selective Norepinephrine Reuptake Inhibitors
Blocks serotonin and norepinephrine reuptake transports to increase both in synaptic cleft
Venlafaxine (Effexor)
SNRI
Dose: 37.5mg - 225mg
FDA indications- MDD, social anxiety disorder, GAD, panic disorder
Off label- PTSD, PMDD, vasomotor symptoms of menopause, diabetic peripheral neuropathy
Monitoring- periodic BP
Cost- cheap
Side Effects- anorexia, dizziness, dry mouth, sweating, sexual side effects, nervousness, hypertension, hyponatremia (in volume depleted)
Has significant discontinuation syndrome even with the XR formulation, titrate off very slowly or consider using fluoxetine taper
Desvenlafaxine (Pristiq)
SNRI
Dose: 50mg - 200mg
FDA indications- MDD
Off label- fibromyalgia, vasomotor symptoms of menopause, GAD, social anxiety disorder, panic disorder, PTSD, PMDD
Monitoring- periodic BP
Cost- not as cheap as other antidepressants
Side Effects- hypertension, nausea, dizziness, insomnia, excessive sweating, sexual side effects
No clear advantage of using desvenlafaxine over venlafaxine