SSRIs

Question 1

Name all available selective serotonin re-uptake inhibitors?

Answer 1

Citalopram, Escitalopram, Fluoxetine, Paroxetine, Fluvoxamine, Sertraline :)

Question 2

SSRI’s contraindications ?

Answer 2

poorly controlled epilepsy, should be stopped when patient enters manic phase

Question 3

SSRI’s cautions ?

Answer 3

Cardiac disease
Concurrent electroconvulsive therapy
DM
Epilepsy ( discontinue if convulsions develop)
History of GI bleeding / bleeding disorders
History of mania
Susceptibility to angle closure glaucoma

Question 4

When would prescription for elderly patients for SSRI’s would be deemed inappropriate to continue/prescribe?
( Hint: STOPP criteria)

Answer 4

Current or recent significant hyponatraemia, serum sodium less than 130 mmol/l

Question 5

Common/very common SIDE EFFECTS of SSRI/s?

Answer 5

Anxiety
appetite abnormal
arrhythmias
arthralgia
asthenia
concentration impaired
confusion 
constipation
depersonalisation 
diarrhoea
dizziness
 drowsiness 
dry mouth 
fever 
gastrointestinal discomfort;
 haemorrhage;
 headache; 
hyperhidrosis;
 malaise; 
memory loss; 
menstrual cycle irregularities; 
myalgia; 
mydriasis; 
nausea (dose-related); 
palpitations; paraesthesia; 
QT interval prolongation; 
sexual dysfunction; 
skin reactions; 
sleep disorders; 
taste altered;
 tinnitus; 
tremor; 
urinary disorders; 
visual impairment; 
vomiting; 
weight changes; 
yawning

Question 6

Uncommon SIDE EFFECTS of SSRI’s?

Answer 6

Alopecia; 
angioedema; 
behaviour abnormal;
 hallucination;
 mania; 
movement disorders; 
photosensitivity reaction;
 postural hypotension; 
seizure; 
suicidal tendencies; 
syncope

Question 7

Rare or very rare SIDE EFFECTS of SSRI’s?

Answer 7

Galactorrhoea;
 hepatitis; 
hyperprolactinaemia;
 hyponatraemia; 
serotonin syndrome; 
severe cutaneous adverse reactions (SCARs); 
SIADH; 
thrombocytopenia

Question 8

What are the symptoms of poisoning by SSRI’S ?

Answer 8

Nausea
Vomiting
Agitation
Tremor
Nystagmus
Drowsiness
Sinus tachycardia
Convulsions may occur

Question 9

Describe symptoms of serotonin syndrome ?

Answer 9

marked neuropsychiatric effects
neuromuscular hyperactivity
autonomic instability; hyperthermia, rhabdomyolysis, renal failure, and coagulopathies may develop.

Question 10

What are the risks of using SSRI’s during pregnancy?

Answer 10

There is a small increased risk of congenital heart defects when taken during early pregnancy. If used during the third trimester there is a risk of neonatal withdrawal symptoms, and persistent pulmonary hypertension in the newborn has been reported.

Question 11

What are the most common symptoms of abrupt withdrawal of SSRI’s or marked reduction in dose?

Answer 11

Gastro-intestinal disturbances, 
headache, 
anxiety, 
dizziness,
 paraesthesia, 
electric shock sensation in the head, neck, and spine, tinnitus, 
sleep disturbances, 
fatigue, influenza-like symptoms 
sweating

Question 12

After how long withdrawal effects may occur?

Answer 12

Within 5 days of stopping

Question 13

When is the risk of withdrawal symptoms increased?

Answer 13

If antidepressant is stopped abruptly after regular administration for eight weeks or more.

Question 14

Which SSRIs are associated with higher propensity for drug interactions?

Answer 14

Fluoxetine, fluvoxamine and paroxetine

Question 15

Which SSRI is associated with higher incidence of discontinuanion symptoms?

Answer 15

Paroxetine, it has shorter half life

Question 16

Which SSRI has been shown to be safe in patients with unstable angina or who have had a recent myocardial infarction ?

Answer 16

Sertraline

Question 17

To what electrolyte disturbances use of SSRI may lead and what symptoms would indicate it?

Answer 17

Hyponatraemia. Hyponatraemia should be considered in all patients who develop drowsiness, confusion, or convulsions while taking an antidepressant.

Question 18

What are the characteristic symptoms of serotonin syndrome?

Answer 18

The characteristic symptoms of serotonin syndrome fall into 3 main areas, although features from each group may not be seen in all patients—neuromuscular hyperactivity (such as tremor, hyperreflexia, clonus, myoclonus, rigidity), autonomic dysfunction (tachycardia, blood pressure changes, hyperthermia, diaphoresis, shivering, diarrhoea), and altered mental state (agitation, confusion, mania).

Question 19

Maximum sertraline dose?

Answer 19

200mg

Question 20

Which two SSRIs cause QT prolongation ?

Answer 20

Citalopram, Escitalopram

Question 21

Which SSRI is used in children?

Answer 21

Fluoxetine

Question 22

Why are SSRIs preferred over TCA’s?

Answer 22

Less sedating, less antimuscarinic, less cardiotoxic

Question 23

Explain interaction: Grapefruit Juice + SSRIs

Answer 23

Grapefruit juice increases SSRI conc

Question 24

Explain interaction: SSRIs + NSAIDS/ASPIRIN/Anticoagulants

Answer 24

Increased risk of bleeding

Question 25

Explain interaction: Citalopram/escitalopram + macrolides
Citalopram/escitalopram+ TCA’s
Citalopram/escitalopram + sotalol
Citalopram/escitalopram + amiodarone
Citalopram/escitalopram + chloroquine, mefloquine, quinine
Citalopram/escitalopram + Lithium
Citalopram/escitalopram + Antipsychotics

Answer 25

QT prolongation

Question 26

Explain interaction: SSRIs + loop thiazide diuretics/ desmopressin/carbamazepine/ NSAIDs

Answer 26

increased risk of hyponatraemia

Question 27

Explain interaction: SSRIs + St Johns wort/ amfetamines/ Sumatriptan/ Selegiline/ Tramadol/ TCAs/ MAOI/ Ondasetron

Answer 27

Increased risk of serotonergic effects/ serotonin syndrome

Question 28

When is best to take paroxetine?

Answer 28

In the morning

Question 29

When changing to MAOIs from fluoxetine, how long should patient be advised to wait before taking their new prescribed MAOI?

Answer 29

Five weeks after fluoxetine. At least a week after an SSRI or related antidepressant (at least 5 weeks in the case of fluoxetine) has been stopped.