Antidepressants

Question 1

Citalopram (Celexa) (SSRI) Clinical

Answer 1

2C19 substrate (major)
QTc prolongation warning: EKG for doses ove/equal to 40mg QD or pts with CV risk, lower dose with strong 2C19 inhibitors

Question 2

Escitalopram (Lexapro) (SSRI) Clinical

Answer 2

Lower doses for patients taking strong 2C19 or 3A4 inhibitors

Question 3

Fluoxetine (Prozac, Prozac Weekly, Serafem) (SSRI) Clinical

Answer 3

2C19 inhibitor (moderate), 2D6 inhibitor (strong)
Norfluoxetine: inhibitor 3A4 (strong)
Long T1/2 7-9 days for metabolite

Question 4

Fluvoxamine (Luvox) (SSRI) Clinical

Answer 4

1A2 inhibitor (strong), usual use for obsessive-compulsive disorder

Question 5

Paroxetine hydrochloride (Paxil), Paroxetine mesylate (Brisdelle, Pexeva) (SSRI) Clinical

Answer 5

2D6 inhibitor (strong), anticholinergic effects require a dose taper to discontinue regardless of switch to new antidepressant to avoid cholinergic rebound, Pregnancy D (septal wall defects)

Question 6

Sertraline (Zoloft) (SSRI) Clinical

Answer 6

Moderate inhibitor of several CYPs

Question 7

Vilazodone (Viibryd) (SSRI) Clinical

Answer 7

3A4 substrate (major), reduce target dose to 20mg once daily when given with strong 3A4 inhibitors, avoid use with strong 3A4 inducers, give with food to increase absorption

Question 8

Vortioxetine (Brintellix) (SSRI) Dosing

Answer 8

Reduce target dose to 10mg once daily with strong 2D6 inhibitors or in patients that are 2D6 poor metabolizers

Question 9

Vortioxetine (Brintellix) (SSRI) Clinical

Answer 9

2D6 substrate (major), may need to increase dose if patient is taking strong CYP inducer

Question 10

Desvenlafaxine (Pristiq) (SNRI) Clinical

Answer 10

No sig CYP interactions, nausea limits dose tolerability, many pts can only tolerate 100mg QD
Renal dosing: CrCl less than 30ml/min: 50mg QOD

Question 11

Duloxetine (Cymbalta) (SNRI) Clinical

Answer 11

1A2 substrate (major), 2D6 substrate (major), 2D6 inhibitor (moderate)
Nausea can be prominent side effect

Question 12

Levomilnacipran (Fetzima) (SNRI) Clinical

Answer 12

3A4 substrate (major), don’t exceed 80mg QD in patients with moderate renal impairment or those taking strong 3A4 inhibitors, give MAX: 40mg/day in severe renal impairment

Question 13

Milnacipran (Savella) (SNRI) Clinical

Answer 13

No dosing for depression, indicated for fibromyalgia

Question 14

Venlafaxine (Effexor®) (SNRI) Clinical

Answer 14

2D6 substrate (major), 3A4 substrate (major)
Consider dose reduction if given with strong 2D6/3A4 inhibitors, need to get dose greater than 150mg/day to have NE reuptake inhibitor effects

Question 15

Bupropion hydrochloride (Budeprion, Buproban, Forfivo, Wellbutrin) 
Bupropion hydrobromide (Aplenzin) (NOVEL) Clinical

Answer 15

2B6 substrate (major)
CI’d in active seizure disorder and eating disorders
Aplenzin approved for SAD

Question 16

Mirtazapine (Remeron) (NOVEL) Clinical

Answer 16

Sedation and appetite increase occur with doses LESS THAN 15mg/day

Question 17

Trazodone (Desyrel) (NOVEL) Clinical

Answer 17

3A4 substrate (major), 2D6 inhibitor (moderate), clinically used for insomnia (dose range 50-150mg QHS)

Question 18

Amitriptyline (Elavil) (TCA) Clinical

Answer 18

Clinically used at lower doses (25-100mg QHS) for neuropathic pain

Question 19

Desipramine (Norpramin) (TCA) Clinical

Answer 19

Not commonly used clinically for depression

Question 20

Imipramine (Tofranil) (TCA) Clinical

Answer 20

Most often used clinically for children with ADHD or nocturnal enuresis at lower doses (10-25mg QD)

Question 21

Nortriptyline (Pamelor) (TCA) Clinical

Answer 21

Can be used for smoking cessation

Question 22

Isocarboxazid (Marplan) (MAOI) Clinical

Answer 22

Indicated for monotherapy only, must have 2 week washout of other antidepressants (4-5 for fluoxetine)

Question 23

Phenelzine (Nardil) (MAOI) Clinical

Answer 23

Indicated for monotherapy only, most commonly used MAOI, must have 2 week washout of other antidepressants (4-5 for fluoxetine)

Question 24

Selegiline (Emsam) (MAOI) Clinical

Answer 24

Indicated for monotherapy only, must have a 2 week washout of other antidepressants (4-5 for fluoxetine), 6mg/24hr patch doesn’t require tyramine diet, other patch strengths do require it

Question 25

Tranylcypromine (Parnate) (MAOI) Clinical

Answer 25

Indicated for monotherapy only, must have a 2 week washout of other antidepressants (4-5 for fluoxetine)