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SSRIs > Sertraline (Zoloft) > Flashcards

Sertraline (Zoloft) Flashcards

1
Q

Brand name

A

Zoloft

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2
Q

Class, receptors

A

SSRI - Serotonin 1A, sigma 1 (anxiolytic)

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3
Q

Onset of action

A

2-4 weeks to start action; increase dose or switch if no effect in 6-8 weeks.

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4
Q

common S/E

A
  1. Sexual dysfunction (dose dependent; men - delayed ejactulation, erectile dysfunction.
    men and women - decreased sexual desire, anorgasmia)
  2. GI - Decreased appetite, nausea, diarrhea, constipation, dry mouth
  3. CNS - Insomnia, but maybe sedation, agitation, headache, dizziness
  4. Sweating, bruising, rare hyponatremia, rare hypotension, SIADH
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5
Q

Dangerous S/E

A
  • seizures
  • mania induction
  • increased suicidal ideation before age 24
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6
Q

what to do about S/E?

A
  • wait, wait, wait
  • Take in morning to reduce insomnia
  • Reduce dose to 25 or 12.5 until S/Es abate, and then increase dose to 50
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7
Q

Dose for depression

A

start with 50 PO daily, can increase after a week, max 200 PO daily. Wait a few weeks before increasing though.

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8
Q

Dose for panic, PTSD, social anxiety

A

25 daily, increase to 50 after 1 week, max 200. Wait a few weeks before increasing though.

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9
Q

Dose for PMDD

A

50 daily through menstrual cycle or limit to luteal phase

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10
Q

Oral solution dose

A

Mix with 4 oz water, ginger ale, lemon/lime soda, lemonade or orange juice. Drink immediately after mixing.

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11
Q

Dosing tips

A
  • 50 and 100 mg cost the same, so give 50 as half of 100 tablet
  • Once a day dosing, in morning to reduce insomnia
  • More agitated and anxious patient - Start with lower dose, titrate slower, may need more concomitant agents like trazodone, BZP
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12
Q

OD symptoms

A
  • Rarely lethal
  • vomiting
  • sedation
  • heart rhythm disturbance
  • dilated pupils
  • agitation
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13
Q

Addictive?

A

No

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14
Q

How to stop?

A
  • taper slowly
  • reduce to half for 3 days, then half the next 3 days, then stop
  • if withdrawal symptoms appear, raise dose and then taper again slowly
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15
Q

Withdrawal effects

A

Dizziness, Nausea, stomach cramps, sweating, tingling, dysesthesias

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16
Q

Parent half life

A

22-36 hours

17
Q

Metabolic half life

A

62-104 hours

18
Q

Cytochrome action

A

inhibits CYP450 2D6 and 3A4 (weakly at low doses)

19
Q

DI with Tramadol

A

Inc risk of seizures

20
Q

DI with MAOIs

A

Fatal serotonin syndrome - don’t use for 14 days after MAOIs stopped.

21
Q

DI with anticoagulants (warfarin)

A

Displace protein bound drugs like warfarin, NSAIDs - inc bleeding risk

22
Q

DI with BZPs

A

Inhibit CYP450 3A4 - may inc levels of alprazolam, triazolam; and also buspirone

23
Q

DI with statins

A

Inhibit CYP450 3A4 - Could increase conc. of simvastatin, atorvastatin, lovastatin, but not pravastatin and fluvastatin - inc risk of rhabdomyolysis

24
Q

May cause false positive urine tox for

A

BZPs (even after stopping sertraline for many days)

25
Q

Warning/Caution

A
  • Don’t start another antidepressant until 2 weeks after stopping
  • Caution in seizure history patients
  • Caution in bipolar
  • Monitor patients for suicidal ideation, esp children and adolescents
26
Q

C/I with

A
  • MAOIs
  • Pimozide
  • Thioridazine
  • disulfiram (only the oral sertraline concentrate, because it contains alcohol)
  • Allergy to sertraline
27
Q

DI with Pimozide

A

CYP450 3A4 inhibition - QTc prolongation - cardiac arrhythmia

28
Q

DI with Thioridazine

A

CYP450 2D6 inhibition - cardiac arrhythmia

29
Q

Renal, Hepatic, Cardiac impaired pts

A
  • R - no change
  • H - half the dose
  • C - Proven safe in pts with recent MI/angina, may even reduce cardiac events in future and improve survival and mood - BEST cardiovascular safety out of all antidepressants
30
Q

Elderly pt

A
  • start lower dose, slow titration
  • higher risk of SIADH
  • Reduces risk of suicidality in 65 and older as compared to placebo
  • Maybe used to treat hot flushes in perimenopausal females
  • may add estrogen to sertraline for some post menopausal women for better response
  • non response - may want to consider mild cognitive impairment or Alzheimer disease
31
Q

Children and adolescents

A
  • Be cautious
  • Follow up regularly
  • Observe for bipolar symptoms and suicidal ideation, and inform parents to observe
  • 6-12 year old - Start at 25 mg/day
  • 13 onwards - adult dose
32
Q

Pregnant patients

A
  • no controlled studies conducted
  • Not recommended, esp in 1st trim, but no proven risk to fetus (may be very rare septal heart defects)
  • After 20th week - May inc risk of Pulm HTN in newborn
  • Late pregnancy - Gestational HTN, preeclampsia risk
  • At delivery - may be more bleeding in mother and transient sedation in newborn
  • Newborn may need prolonged hospitalization, rest support, tube feeding; may cause seizures, N/V, cyanosis, apnea, irritability, crying, feeding problems.
  • Weigh risks and benefits
  • NOTHING PROVEN THO
33
Q

Breastfeeding pt

A
  • Trace amt in breast milk and in nursing child
  • Stop breastfeeding if child irritable or sedated
  • Immediate postpartum period is high risk, esp in pts with history of depression, so may wanna start sertraline in 3rd trim or after birth to prevent recurrence
  • Weigh benefits and risks
34
Q

Primary target symptoms

A
  • depressed mood
  • anxiety
  • sleep disturbance (both insomnia and hypersomnia)
  • panic attacks, avoidant behavior, hyper arousal, re-experiencing
35
Q

Potential advantages

A
  • Atypical depression (hypersomnia, increased appetite)
  • Fatigue and low energy pts
  • Pts who want to avoid hyperprolactemia or are hypersensitive to prolactin elevation caused by some other SSRIs
36
Q

Potential disadvantages

A
  • dosage titration
  • IBD pts (can cause diarrhea)
  • anxious pts with insomnia (can worsen insomnia in beginning)
37
Q

Compared to other antidepressants

A
  • better cardiovascular safety
  • more chances of diarrhea
  • not as well tolerated as others in panic disorder, especially in the beginning, unless given with BZPs or trazodone
  • no effect on prolactin
38
Q

PMDD

A

Sertraline during luteal phase only maybe more effective that continuous treatment

SSRIs (6 decks)

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