DEPRESSION: SSRIs Flashcards
Why are SSRIs first line in depression?
Better tolerated and safer in overdose
MoA
Selectively inhibit the reuptake of 5-HT from the synaptic cleft
Commonly used SSRIs
Sertraline
Fluoxetine
Fluoxetine
citalopram
escitalopram
fluvoxamine
Side effects - SSRIs
- GI
- Hyponatraemia
- QT prolongation
- Suicidal tendencies
- Seizures
- SS
Interactions - increased risk of hyponatraemia
Diuretics - loop/thiazides
Desmopressin
Carbamazepine
NSAIDs
initial dose of sertraline in depression, OCD and panic disorder/PTSD/social anxiety disorder
depression and OCD: 50mg
panic disorder, PTSD, social anxiety disorder: 25mg
max dose sertraline per day
200mg
Which SSRI is safe in stable angina + MI
Sertraline
is chest pain a common symptom of sertraline
Yes
Which antidepressant in licensed for children?
Under 17
Fluoxetine
Which SSRIs cause QT prolongation
Citalopram
Escitalopram
Which SSRI has higher risk of withdrawal reactions?
Paroxetine
Other SSRIs
Escitalopram
Fluvoxamine
Paroxetine
Benefit of SSRIs over TCAs
o less cardiotoxic
o less sedating
o less antimuscarinic than TCAs
o SSRis safer in unstable angina and myocardial infarction and in overdose
T or F - symptoms of sexual dysfunction will stop on treatment discontinuation
false. they can persist even after treatment has stopped
SSRIs interactions
o CYP enzyme inhibitors (Avoid grapefruit, increases plasma conc)
o CYP enzyme inducers e.g. St John’s Wart (reducers effectiveness)
o Drugs that cause QT prolongation
o Drugs increasing risk of bleed
o Hyponatraemia (carbamazepine and diuretics)
o Serotonin syndrome
SSRIs in pregnancy
Risk vs benefits
Use lowest effective dose
Small increased risk of persistent pulmonary hypertension in newborns with use beyond 20 weeks
Use in later stages = neonatal withdrawal symptoms
Small increased risk of PP haemorrhage when used in month before delivery
Using SSRIs in later stages of pregnancy may result in neonatal withdrawal symptoms. What do we monitor?
Associated CNS, motor, respiratory, and GI symptoms
You know that a patient is due to give birth in a couple of weeks. You see that she has just had an rx for sertraline 50mg OD come in. You know there was recent MHRA safety info published about the use of SSRIs in the month before delivery having a possible increased risk of PP haemorrhage. What do you do?
- contact prescriber and tell them this is contraindicated
- dispense it
dispense it. there MIGHT be a small increased risk of PP haemorrhage when used in month before delivery. but specialist sources indicate SSRIs may be suitable for use in pregnancy, but risks and benefits of use may be considered, and lowest effective dose to be used
SSRIs in BF
- sertraline and paroxetine preferred
- however all can be used with caution
- risks with switching SSRIs so may be more clinically appropriate to continue treatment with SSRI that has been effective, or restart with one that has previously been effective
What should you monitor the infant for when BF?
Monitor infant for drowsiness, poor feeding, adequate weight gain, GI disturbances, irritability, restlessness
Although all SSRIs can be used in BF women with caution, the following two are preferred based on passage into milk, half-life, published evidence of safety
paroxetine
sertraline
use of sertraline in BF
can be used (preferred in BF, along with paroxetine)
long half life increase risk of accumulation in infant
monitor infant for drowsiness, poor feeding, irritability, GI disturbance, restlessness, adequate weight gain
important safety info for all SSRIs - small increased risk of PP haemorrhage when used in month before delivery
increased bleeding risk due to effect on platelet function
using in last month before delivery may increase risk of PP haemorrhage
consider benefits and risks of AD during pregnancy, and risks of untreated depression in pregnancy
Overdose
N + V
Agitation
Tremor
Nystagmus
Drowsiness
Sinus tachycardia
Convulsion
Interactions - increased plasma concentrations
Grapefruit juice (enzyme inhibitor)
Interactions - increased risk of bleeding
NSAIDs/Aspirin (GI bleeding)
Anticoagulant
Antiplatelets e.g. warfarin
Interactions - increased risk of QT prolongations
Erythromycin (macrolides)
TCAs
Sotalol
Amiodarone
Chloroquine
Mefloquine
Lithium
Quinine
Antipyschotics
Interactions - increased risk of QT prolongation due to hypokalaemia
These cause hypokalaemia, which in turn can lead to QT prolongation increases risk of torsade de pointes
- Theophylline
- Beta 2 agonists
- Loop/thiazide diuretics
- Corticosteroids
Interactions - increased risk of serotonergic effects/serotonin syndrome
St. Johns wort (serotonergic antidepressant)
Amfetamines
Sumatriptan (5-HT1a agonist)
Selegiline (MAO-B inhibitor)
Tramadol (opioid that also inhibits reuptake of 5-HT + NA)
TCAs/MAOIs (serotonergic drugs)
Ondansetron (5-HT3 antagonists)
Under 18s
Citalopram, escitalopram, paroxetine, sertraline, mirtazapine + venlafaxine are NOT recommended in under 18s.
ONLY fluoxetine effective in children + adolescents.
Monitor carefully for suicidal behaviour, self-harm or hostility esp @ the start.
Cautions
Epilepsy (poorly controlled/if seizures develop = discontinue)
Cardiac disease
Diabetes
Susceptibility to angle-closure glaucoma
History of mania
Bleeding disorders
Overdose (poisoning)
N + V
Agitation
Tremor
Nystagmus
Drowsiness
Sinus tachycardia
Treatment cessation
GI disturbances
Headache
Anxiety
Electric shock sensation in head, neck + spine
Tinnitus
Sleep disturbances
Fatigue
Flu-like symptoms
Sweating
Palpitations + visual disturbances (less common)
withdrawal effects may occur within the following timeframe of stopping treatment with AD
usually mild and self limiting but sometimes severe
within 5 days
risk of withdrawal symptoms is increased if AD stopped suddenly after regular administration for ….. weeks or more
8 weeks or more
how to withdraw sertraline
withdraw dose gradually over about 4 weeks or longer if withdrawal symptoms occur
6 months in pt who have been on long term maintenance
labels for sertraline
do not drink grapefruit juice (increases amount of sertraline in body, it is a inhibitor!)
this electrolyte imbalance has been associated with all types of AD, but more freq with SSRIs
hyponatraemia
is vortioxetine an SSRI
no but inhibits the re-uptake of serotonin (5-HT) and is an antagonist at 5-HT3 and an agonist at 5-HT1A receptors
when to consider hyponatramia
Drowsiness
Confusion
Convulsions
pt has drowsiness, confusion and convulsions. what is this
consider hyponatraemia
main interactions with sertraline - increasing bleeding risk, sedation, hyponatramia
bleeding: aspirin, NSAIDs, dalteparin, heparin, DOACs, warfarin, other ADs
hyponatraemia: desmopressin, TCAs, diuretics, antipsychotics, NSAIDs
max dose citalopram in elderly (drops vs tabs)
20mg tabs
16mg drops
3 contraindications for citalopram (2 of them are for all SSRIs)
all SSRIs: poorly controlled epilepsy, do not use if enters manic phase
other: QT interval prolongation
interactions citalopram - hypokalaemia
hypokalaemia potentially increases risk of TDP: aminophylline, theophylline, amphotericin B, CCs, thiazides, diuretics (NOT K sparing SEAT),
interactions citalopram - QT interval and
QT: amiodarone, dronedarone, antipsychotics, apomorphine, clomipramine, erythromycin, fluconazole, hydroxyzine, methadone
how to withdraw citalopram
The dose should preferably be reduced gradually over about 4 weeks, or longer if withdrawal symptoms emerge (6 months in patients who have been on long-term maintenance treatment).
max dose escitalopram in elderly
10mg
3 contraindications for escitalopram
all SSRIs: poorly controlled epilepsy, pt enters manic phase
escital: qt interval prolongation
max dose paroxetine in elderly
40mg
this SSRI can be given for menopausal symptoms, particularly hot flushes, in women with breast cancer (except those taking tamoxifen) at a dose of 10mg OD - UNLICENSED
paroxetine
withdrawing paroxetine
higher risk of withdrawal reations
dose should preferably be reduced gradually over about 4 weeks, or longer if withdrawal symptoms emerge (6 months in patients who have been on long-term maintenance treatment)
this SSRI can be used for menopausal symptoms, particularly hot flushes, in women with breast cancer (except those taking tamoxifen) at a dose of 20mg OD. UNLICENSED
fluoxetine
This OTC supplement commonly used increases the risk of bleeding. Therefore they interact with other drugs including SSRIs
omega 3
can you use vortioxetine in BF
avoid
can you use vortioxetine in pregnancy
Avoid unless benefit outweighs risk—toxicity in animal studies.
If used during the later stages of pregnancy, there is a risk of neonatal withdrawal symptoms and persistent pulmonary hypertension in the newborn.
can vortioxetine be stopped abruptly
Manufacturer advises treatment can be stopped abruptly, without need for gradual dose reduction.
