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Child Psychiatry > Fluoxetine > Flashcards

Fluoxetine Flashcards

1
Q

Fluoxetine - Mechanism of action

A
  • SSRI - increases serotonergic neurotransmission which results in desensitisation of serotonin receptors (1A)
  • has an antagonist effect a serotonin 2C-R which increases norepinephrine/dopamin neurotransmission
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2
Q

FDA and OGYEI approved use in pediatric population

A

FDA:

  • MDD (8+)
  • OCD (7+)
  • Bipolar depression (in combination with olanzapine)

OGYEI:
- MDD (8+)

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3
Q

How long does it take for fluoxetine to work?

A

2-8 weeks

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4
Q

Notable side effects of fluoxetine:

A
  1. CNS (insomnia/sedation/agitation/tremor/headache/dizziness)
  2. TEAS
  3. GI (dry mouth/decreases appetite/nauseaconstipation/diarrhea/weight loss)
  4. Sexual dysfunction (delayed ejaculation/erectile dysfunction/decreased sexual desire/anorgasmia)
  5. Sweating
  6. Bruising/rare bleeding (in combination with NSAID/aspirin/anticouagulants)
  7. SIADH
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5
Q

Dangerous side effects of fluoxetine

A
  1. Rare seizures
  2. Rare induction of mania
  3. Rare activation of suicidality
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6
Q

What is TEAS?

A

Treatment-emergent activation syndrome:

  • hypomania
  • agitation
  • anxiety
  • panic attacks
  • hostility/aggression
  • impulsivity
  • insomnia
  • suicidality
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7
Q

What can TEAS represent?

A

bipolar mania or the onset of suicidality

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8
Q

What to do upon detecting TEAS?

A
  1. decreasing the dose
  2. discontinuation (and switching)
  3. adding of another agent
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9
Q

Fluoxetine may be one of the […] activating agents in its class.

A

most

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10
Q

What to do if fluoxetine causes activation?

A
  1. administer dose in the morning
  2. consider temporary dose reduction (or a more gradual up-titration)
  3. consider adding a 5HT2A antagonist (trazodone or mirtazapine)
  4. consider adding a benzodiazepine short-term
  5. consider switching to another antidepressant
  6. optimize behavioral interventions
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11
Q

What is the rule of thump in augmentation vs. mono-therapy (antidepressants)?

A

Often best to try another mono-therapy prior resorting to augmentation strategies to treat side effects.

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12
Q

For insomnia (fluoxetine):

A
  1. consider adding melatonin

2. consider addig trazodone/mirtazapine

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13
Q

For GI upset (fluoxetine):

A
  • try giving medication with a meal (or after the meal)
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14
Q

For sexual dysfunction (fluoxetine):

A
  1. reduce dose or try another agent
  2. daytime exercise
  3. (bupropion/buspirone)
  4. (cyproheptadine/mirtazapine)
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15
Q

For emotional flattening, apathy (fluoxetine)

A
  • try adding bupropion with caution
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16
Q

When side effects are expected? (fluoxetine)

A
  • In the first 2-3 weeks of starting or increasing the dose.
  • They go away about the same time that therapeutic effects start.
17
Q

How does fluoxetine cause side effects?

A
  • increases serotonin concentrations in unwanted areas (e.g. sleep center, gut)
  • increased serotonin cc. cause diminished dopamine release which contribute to emotional flattening, cognitive slowing, and apathy
  • fluoxetine’s 5HT2C antagonist properties could contribute to agitation, anxiety, activation
18
Q

Contraindications of fluoxetine:

A

Patient is taking:

  1. MAO inhibitor
  2. thioridazine
  3. pimozide
  4. tamoxifen
  5. has proven allergy to fluoxetine
19
Q

Overdose of fluoxetine:

A
  • rarely lethal in monotherapy overdose

- causes resp. depression/ataxia/sedation/seizures

20
Q

Usual dose range and how to dose (fluoxetine):

A
  • usual dose range: 10-80 mg/day

- doses higher than 20 mg/day may best administered in divided doses twice daily (morning and noon).

21
Q

Pharmacokinetics of fluoxetine:

A
  • norfluoxetine is the active metabolite (2 week half life)
  • parent drug has 2-3 day half-life
  • Inhibits CYP450 2D6/3A4/2C19
22
Q

Drug interactions (fluoxetine):

A
  1. tramadol increases seizures in patients taking antidepressants
  2. can increase TCA levels
  3. may displace highly protein bound drugs (e.g. warfarin)
  4. in combination with sumatriptan (or other triptans) can rarely cause weakness, hyperreflexia, incoordination
  5. increased risk of bleeding when combined with anticoagulants (NSAID!!!)
  6. NSAID may impair the effectiveness of SSRIs
  7. CYP450 2D6 inhibition: can interfere with codein analgesic action/increase the plasma levels of beta blockers and atomoxetine/increase the cc. of thioridazine/may increase aripiprazole levels (!!!)
  8. may reduce the clearance of trazodone/diazepam
  9. CYP450 3A4 inhibition: could theoretically increase the cc. of HMG COA reductase inhibitors/pimozide

Child Psychiatry (3 decks)

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