Antidepressants

SSRI antidepressant medications

• citalopram (Celexa)

• escitalopram (Lexapro)

• fluoxetine (Prozac)

• Fluvoxamine (Luvox)

• paroxetine (Paxil)

• sertraline (Zoloft)

SSRI side effects

Common side effects include sexual dysfunction, GI issues, sweating, bruising, sedation or activation, hyponatremia in elderly, SIADH

Citalopram (Celexa) dosing and special considerations

• 20-40mg

• Do not take with a CYP450 2C19 inhibitor due to risk of QT prolongation

Escitalopram (Lexapro) dosing and special considerations

• 10-20mg

• Very well tolerative, with minimal side effects.

Fluoxetine (Prozac) dosing and special considerations

• 20-80mg

• Long half-life of 2-3 days, weekly formulation May increase levels of Xanax, Buspar, Halcion and some cholesterol meds. May reduce clearance of Trazodone and Valium

Fluvoxamine (Luvox) dosing and special considerations

• 100-300mg

• May reduce clearance of Theophylline and Clozapine, may increase levels of benzos, Tegretol, and cholesterol meds

• can dose at night as more likely to be sedating

Paroxetine (Paxil) dosing and special considerations

• 20-50mg

• Can be sedating, dose at night Watch for other drugs that can inhibit breakdown such as beta blockers, Strattera, Codeine, and Thioridazine.

Sertraline (Zoloft) dosing and special considerations

• 50-200mg

• Watch for other drugs that can inhibit breakdown such as beta blockers, Straterra, Codeine, and Thioridazine. May increase levels of Xanax, Buspar, Halcion and some cholesterol meds.

Citalopram (Celexa) FDA indications

Depression

Escitalopram (Lexapro) FDA indications

MDD and GAD

Fluoxetine (Prozac) FDA indications

MDD (8 and older), OCD (7 and older), PMDD, Bulimia Nervosa, Panic Disorder, bipolar depression and the treatment of resistant depression in combination of Zyprexa (Symbyax)

Fluvoxamine (Luvox) FDA indications

OCD and social anxiety disorder

NOT FDA approved for depression

Paroxetine (Paxil) FDA indications

MDD, OCD, panic disorder, social anxiety disorder, PTSD, GAD, PMDD

Sertraline (Zoloft) FDA indications

MDD, PMDD, panic disorder, PTSD, social anxiety disorder, OCD

Vortioxetine (Trintellix) drug class and MOA

S-MM

Inhibits serotonin reuptake/5-HT1A partial agonist to 5HT1B, and antagonist to 5HT(3)(D) and (7), reduces the release of GABA

Vortioxetine (Trintellix) Dosing, special considerations, and side effects

• 5-+20mg

• Many studies show pro-cognitive effects. Effective in the elderly with depression.

• GI side effects, sexual dysfunction.

SNRI antidepressant medications

• Desvenlafaxine (Pristiq)

• Duloxetine (Cymbalta)

• Venlafaxine (Effexor)

• Levomilnacipran (Fetzima)

SNRI Side effects and special considerations

• Insomnia, sedation, anxiety, dizziness, GI side effects, sexual dysfunction, sweating, hyponatremia with the elderly, increased blood pressure, SIADH

• Monitor BP, do not use in those with angle-closure glaucoma.

Levomilnacipran (Fetzima) FDA indications, dosing and unique side effects

• MDD

• 40-120mg

• GI side effects, hyperhidrosis, tachycardia, palpitations, erectile dysfunction, urinary hesitancy or retention

Desvenlafaxine (Pristiq) FDA indications and dosing

• MDD

• 50-100mg

Withdrawal effects more common SLOW taper off

Duloxetine (Cymbalta) FDA indication and dosing

• MDD, GAD, musculoskeletal pain, fibro, diabetic peripheral neuropathy,

• 30-120mg

Venlafaxine (Effexor) FDA indications and dosing

• Depression, GAD, social anxiety, panic disorder

• 37.5-375mg

Withdrawal effects are more common and severe - need SLOW taper

NDRI antidepressant and side effects

• Bupropion (Wellbutrin)

• Dry mouth, constipation, nausea, weight loss, anorexia, myalgia, insomnia, dizziness, headaches, agitation, anxiety, tremor, abdominal pain, tinnitus, sweating, hypertension

Bupropion (Wellbutrin) FDA indications, dosing, special considerations

• MDD and seasonal affective disorder

• 75-450mg

• Reduces fatigue Monitor BP. Do not use in those with history of seizures or eating disorders. Watch for other drugs that can inhibit breakdown such as beta blockers, Strattera, Codeine, and Thioridazine.

Comes in 3 forms: R, SR, XL

TCA antidepressant medications

• Amitriptyline (Elavil)

• Clomipramine (Anafranil)

• Doxepin (Sinequan)

• Imipramine (Tofranil)

• Nortriptyline (Pamelor)

TCA side effects and special considerations

• Blurred vision, constipation, urinary retention, increased appetite, dry mouth, nausea, diarrhea, heartburn, unusual taste in mouth, weight gain, fatigue, weakness, dizziness, sedation, headache, anxiety, nervousness, restlessness, sexual dysfunction, sweating

• Risk for electrolyte disturbances Baseline ECG rec for those over 50 yo. Do not use in those recovering from MI. Monitor weight and BMI Use with extreme caution in suicidal clients.

• Dose at night

Amitriptyline (Elavil) FDA indications, dosing

• Depression and endogenous depression

• 25-300mg

Clomipramine (Anafranil) FDA indications and dosing

• OCD (10 and older)

• 25-250mg

Doxepin (Sinequan) FDA indications and dosing

• Psychoneurotic patient with depression/anxiety, Depression/anxiety associated with alcoholism, depression/anxiety associated with organic disease, psychotic depressive disorders with associated anxiety, involutional depression, manic-depressive disorder, insomnia

• 75-300mg

This is the only TCA available in a topical formulation.

Imipramine (Tofranil) FDA indications and dosing

• Depression

• 50-150mg

Nortriptyline (Pamelor) FDA indications and dosing

• MDD

• 75-300mg

MAOI antidepressant medications and special considerations

• Phenelzine (Nardil)

• Selegiline (EMSAM)

• Tranylcypromine (Parnate)

• Risk for hypertensive crisis, dietary restrictions Monitor BP, weight, BMI, glucose, cholesterol, and hepatic function. Do not use in those with cardiovascular disease or frequent severe headaches.

• DIETARY restrictions!!! Dairy, cheese, red wine, fermented food, pickled food, some grains, some fruits.

Phenelzine (Nardil) FDA indications and dosing

• atypical nonendogenous or neurotic depression

• 45-90mg

Phenelzine (Nardil) side effects

• Dizziness, sedation, headache, sleep disturbances, fatigue, weakness, tremor, movement problems, blurred vision, increase sweating, constipation, dry mouth, nausea, change in appetite, weight gain, sexual dysfunction, orthostatic hypotension

• Do not use in those with cardiovascular disease or frequent severe headaches.

Selegiline (EMSAM) FDA indications and dosing and considerations

• MDD (transdermal) Parkinson’s (oral)

• Patch 6-12mg, oral 30-60mg daily

• Transdermal- site reaction, headache, insomnia, diarrhea, dry mouth Oral-nausea, dizziness, abdominal pain, dry mouth, headache, dyskinesia, confusion, hallucinations, vivid dreams

Tranylcypromine (Parnate) FDA indications and dosing

• MDD without melancholia

• 30-60mg

Tranylcypromine (Parnate) side effects and considerations

• Agitation, anxiety, insomnia, weakness, sedation, dizziness, constipation, dry mouth, nausea, diarrhea, change in appetite, weight gain, sexual dysfunction, orthostatic hypotension

• Do not use in those with cardiovascular disease or frequent severe headaches, or liver impairment

MAOI drug -drug interactions that can be fatal

• Amphetamines

• Ephedrine

• fenfluramine

• isoproterenol

• meperidine

• phenylephrine

• phenylpropanolamine

• pseudoephedrine

• SSRIs

• TCAs

• Tyramine

When changing from other antidepressants must have 2 weeks of no drugs between MAOIs and other classes

Mirtazapine (Remeron) drug class and MOA

• Alpha 2 antagonist

• Blocks alpha 2 adrenergic presynaptic receptor increasing norepinephrine and serotonin neurotransmission

Mirtazapine (Remeron) FDA indication and dosage

• MDD

• 15-45mg nightly

Mirtazapine (Remeron) side effects and considerations

• Agitation, anxiety, insomnia, weakness, sedation, dizziness, constipation, dry mouth, nausea, diarrhea, change in appetite, weight gain, sexual dysfunction, orthostatic hypotension

• Sedation may not increase with dosage Monitor weight, BMI, cholesterol and glucose.

SARIs antidepressant medications and MOA

• Nefazodone (Dutonin)

• Trazodone (Desyrel)

• Blocks serotonin 2A receptors potently, blocks serotonin and norepinephrine reuptake less potently

Nefazodone (Dutonin) FDA indications and dosing

• Depression and relapse prevention in MDD

• 300-600mg

Nefazodone (Dutonin) Side effects and considerations

• Nausea, dry mouth, constipation, dyspepsia, increase appetite, headache, dizziness, vision changes, sedation, insomnia, agitation, confusion, memory impairment, ataxia, paresthesia, asthenia, cough increased, postural hypotension

• Monitor LFT’s Contraindicated in hepatic impairment

Trazodone (Desyrel) FDA indications and dosing

• Depression (often used off label for insomnia)

• 150-600mg (can be dosed at 25mg effectively for insomnia)

Trazodone (Desyrel) Side effects and special considerations

• Nausea, vomiting, edema, blurred vision, constipation, dry mouth, dizziness, sedation, fatigue, headache, incoordination, tremor, hypotension, syncope, bradycardia, rash

• Dose at night-sedation Can cause priapism.

Vilazodone (Viibryd) class and MOA

• SPARI

• Serotonin reuptake inhibitor plus 5HT1A partial agonist

Vilazodone (Viibryd) FDA indications and dosing

• MDD

• 20-40mg

Vilazodone (Viibryd) side effects and considerations

• Nausea, diarrhea, vomiting, insomnia, dizziness, bruising, hyponatremia in the elderly, sexual dysfunction, SIAD

• If taken on an empty stomach drug absorption can be reduced to 50%. Must be taken with food. Tegretol may increase clearance, causing lower plasma levels. Nefazodone, fluoxetine, fluvoxamine raise drug levels and dose should not exceed 20mg daily.

Esketamine (Spravato) Class and MOA

• NMDA receptor antagonist

• Noncompetitive open channel inhibitor of the NMDA receptor

Esketamine (Spravato) FDA indications and dosing

• Treatment resistant depression in adults (adjunct), depressive symptoms in adults with MDD with acute suicidal ideation or behavior (adjunct)

• 56-84mg bi-weekly inhalation

Esketamine (Spravato) Side effects and special considerations

• Dissociation, dizziness, sedation, vertigo, anxiety, lethargy, feeling drunk, numbness, hypoesthesia, nausea, vomiting, lower urinary tract symptoms including increase frequency of urination.

• Must give with antidepressant, Assess BP, do not administer if increased blood pressure or intercranial pressure. Each device delivers 2 sprays (one for each nostril), must monitor for 2 hours post inhalation, use with caution with NMDA antagonist (amantadine, memantine, dextromethorphan), not recommended in those with severe hepatic impairment, contraindicated in those with aneurysmal vascular disease, must be in REMS

Brexanolone (Zulresso) class, MOA, FDA indications

• Neuroactive steroid

• GABA binding, exact mechanism unknown, potentially effects progesterone

• Postpartum depression

Brexanolone (Zulresso) dosing/administration, Side effects, considerations

• 100mg infusion over 60hrs, must be inpatient and be monitored

• Sedation, dizziness, dry mouth, flushing/hot flash

• Clinical improvement may be as early as 12-24 hours. Should use with antidepressants, must be in REMS, effects may last a month, infused over 60 hours, avoid use with ESRD, monitor for hypoxia with pulse oximetry, pill form is under investigation.

FDA approved antidepressants for children

• Escitalopram (Lexapro) - 12 and older

  • children 5-20mg/day, adolescents 10-20mg/day

• Fluoxetine - 8 and older

  • Children 10-80mg, adolescents 20-80mg

Off label medications used for depression in children and adolescents

• bupropion, citalopram (Celexa), Clomipramine (Anafranil), Duloxetine (Cymbalta), Fluvoxamine (Luvox), Paroxetine (Paxil), Sertraline (Zoloft), Trazodone (Desyrel), Venlafaxine (Effexor)

Antidepressants and elderly considerations

• Escitalopram (Lexapro), Sertraline (Zoloft) - cleaner medications with fewer side effects

• SSRIs most commonly used

• Use medications with limited sedative effects

• Be aware of polypharmacy

• Watch for increased bleeding and hyponatremia

Serotonin syndrome

SHIVERS

• Shivering

• Hyperflexia + myoclonus

• Increased temp (>41 C)

• Vital sign instability ( ^HR, ^RR, BP up or down)

• Encephalopathy (Alt LOC)

• Restlessness

• Sweating (Diaphoresis)