SSRIs Flashcards
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
what drug would you give in pt with unstable angina or recent MI
sertraline
max dose sertraline per day
200mg
2 contraindications for all SSRIs
poorly controlled epilepsy
do not use if pt enters manic phase
is QT interval prolongation a common SE of all SSRIs
yes
T or F - symptoms of sexual dysfunction will stop on treatment discontinuation
false. they can persist even after treatment has stopped
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
symptoms of poisoning by SSRIs include
nausea, vomiting, agitation, tremor, nystagmus, drowsiness, and sinus tachycardia; convulsions may occur.
rarely severe poisoning with SSRI results in serotonin syndrome with the following
marked neuropsychiatric effects, neuromuscular hyperactivity, and autonomic instability; hyperthermia, rhabdomyolysis, renal failure, and coagulopathies may develop.
is chest pain a common symptom of sertraline
yes
SSRIs in pregnancy
- specialist sources indicate they may be suitable for us win pregnancy but consider risks and benefits
- use lowest effective dose
- may be small increased risk of persistent pulmonary hypertension in newborn with use of SSRIs beyond 20 weeks gestation
- use in later stages of pregnancy may result in neonatal withdrawal syndrome - monitor them for associated CNS, motor, respiratory, and GI symptoms
- small increased risk of PP haemorrhage when used in month before delivery
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
Use of 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
- 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
most common features of withdrawal of SSRI or marked reduction of dose
GI disturbance, headache, anxiety, dizziness, paraesthesia, electric shock sensation in head, neck and spine, tinnitus, sleep disturbance, fatigue, flu like symptoms, sweating
do palpitations and visual disturbances occur with withdrawal or abrupt reduction in dosage of SSRIs
less commonly
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!)
name the SSRIs
sertraline
paroxetine
fluoxetine
citalopram
escitalopram
fluvoxamine
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
this electrolyte imbalance has been associated with all types of AD, but more freq with SSRIs
hyponatraemia
when to consider hyponatramia
in all patients who develop drowsiness, confusion, or convulsions while taking an antidepressant.
pt has drowsiness, confusion and convulsions. what is this
consider hyponatraemia
main interactions with sertraline - increasing bleeding risk , serotonin syndrome, sedation, hyponatramia
bleeding: aspirin, NSAIDs, dalteparin, heparin, DOACs, warfarin, other ADs
serotonin syndrome: methadone, other ADs, triptans
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 - QT interval and hypokalaemia
hypokalaemia potentially increases risk of TDP: aminophylline, theophylline, amphotericin B, CCs, thiazides, diuretics (NOT K sparing SEAT),
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
This SSRI is associated with higher risk of withdrawal reactions
paroxetine
withdrawing paroxetine
higher risk of withdrawal reactions
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
Manufacturer advises avoid unless potential 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.
this AD is used for major depression and does not require gradual dose reduction; it can be stopped abruptly
vortioxetine
