SSRIs Flashcards
(190 cards)
1
Q
What class of drugs does Celexa belong to?
A
serotonin reuptake inhibitor (S-RI) and SSRI (selective serotonin reuptake inhibitor)
Often classified as an antidepressant, but it has broader uses.
2
Q
citalopram is commonly prescribed for:
A
- Depression
- Premenstrual dysphoric disorder (PMDD)
- Obsessive–compulsive disorder (OCD)
- Panic disorder
- Generalized anxiety disorder
- Posttraumatic stress disorder (PTSD)
- Social anxiety disorder (social phobia)
Conditions listed are FDA approved uses.
3
Q
How does Celexa work?
A
Boosts neurotransmitter serotonin
Blocks serotonin reuptake pump
Desensitizes serotonin receptors, especially serotonin 1A autoreceptors
Presumably increases serotonergic neurotransmission
Citalopram has mild antagonist actions at H1 histamine receptors.
4
Q
What effect does Citalopram’s inactive R enantiomer have?
A
It may interfere with the therapeutic actions of the active S enantiomer at serotonin reuptake pumps
This could potentially impact the overall effectiveness of the drug.
5
Q
How long does it typically take for Celexa to show therapeutic effects?
A
Onset of therapeutic actions usually not immediate, often delayed 2–4 weeks
Patients may need to wait several weeks to experience the full benefits.
6
Q
What is the primary goal of treatment for psychiatric disorders?
A
Complete remission of current symptoms and prevention of future relapses
Treatment aims to reduce or eliminate symptoms but does not guarantee a cure; symptoms can recur after stopping medication.
7
Q
How long should treatment continue after symptoms are gone for the first episode of depression?
A
1 year
This is to prevent relapse after the first episode.
8
Q
What may be necessary for second and subsequent episodes of depression?
A
Indefinite treatment
This applies to both depression and anxiety disorders.
9
Q
What is a common issue faced by many patients in treatment?
A
Partial response
Some symptoms improve while others persist, particularly insomnia, fatigue, and concentration problems.
10
Q
What term is used for patients who do not respond to treatment?
A
Treatment-resistant or treatment-refractory
These patients may have limited improvement from standard therapies.
11
Q
What is ‘poop-out’ in the context of psychiatric treatment?
A
Relapse despite continued treatment
This can occur even if the patient initially responded to the medication.
12
Q
What should be considered if a patient has only a partial response?
A
- Increasing dose
- Switching to another agent
- Adding an appropriate augmenting agent
- Considering psychotherapy
- Evaluating for another diagnosis or comorbid condition
Comorbid conditions may include medical illness or substance abuse.
13
Q
What may require the discontinuation of antidepressants?
A
Activation of latent or underlying bipolar disorder
In such cases, a switch to a mood stabilizer may be necessary.
14
Q
What is a recommended augmenting agent for insomnia?
A
Trazodone
Trazodone is particularly effective for insomnia in patients with partial response.
15
Q
Name some augmenting agents that can be added to celexa with caution for partial response.
A
- Bupropion
- Mirtazapine
- Reboxetine
- Atomoxetine
These should be used at lower doses due to potential interactions.
16
Q
What is Modafinil used for in psychiatric treatment?
A
Fatigue, sleepiness, and lack of concentration
It is especially useful for improving energy levels.
17
Q
Which classes of medications are indicated for bipolar depression?
A
- Mood stabilizers
- Atypical antipsychotics
These are also used for treatment-resistant depression and anxiety disorders.
18
Q
What should be considered for anxiety disorders if all else fails?
A
Gabapentin or tiagabine
These may be alternatives when standard treatments are ineffective.
19
Q
What class of medication is recommended for insomnia?
A
Hypnotics
Hypnotics can help manage sleep issues in patients.
20
Q
Which medications are classically used in treatment-resistant cases?
A
- Lithium
- Buspirone
- Thyroid hormone
These agents may help in managing treatment-resistant depression or anxiety.
21
Q
What is the theoretical cause of side effects from drugs like citalopram?
A
Increases in serotonin concentrations at serotonin receptors in parts of the brain and body other than those that cause therapeutic actions
Examples include unwanted actions of serotonin in sleep centers causing insomnia and in the gut causing diarrhea.
22
Q
What are some potential consequences of increased serotonin levels?
A
Diminished dopamine release, emotional flattening, cognitive slowing, and apathy in some patients
These effects may vary among individuals.
23
Q
How do the timing of side effects compare to therapeutic effects?
A
Most side effects are immediate but often go away with time, while most therapeutic effects are delayed and enhanced over time.
24
Q
What unique properties of citalopram may contribute to side effects?
A
Citalopram’s unique mild antihistamine properties may contribute to sedation and fatigue in some patients.
25
List notable side effects of citalopram.
* Sexual dysfunction (dose-dependent: delayed ejaculation, erectile dysfunction, decreased sexual desire, anorgasmia)
* Gastrointestinal (decreased appetite, nausea, diarrhea, constipation, dry mouth)
* CNS (insomnia, sedation, agitation, tremors, headache, dizziness)
* Activation (short-term)
* Sweating (dose-dependent)
* Bruising and rare bleeding
* Rare hyponatremia
* Syndrome of inappropriate antidiuretic hormone secretion (SIADH)
26
What are some life-threatening or dangerous side effects of citalopram?
* Rare seizures
* Rare induction of mania
* Rare activation of suicidal ideation and behavior
* Weight gain reported but not expected
27
What should be done about side effects experienced from citalopram?
* Wait
* Take in the morning if nighttime insomnia
* Take at night if daytime sedation
* In a few weeks, switch to another agent or add other drugs
28
What are some best augmenting agents for managing side effects?
* Another SSRI or another antidepressant monotherapy
* Trazodone or a hypnotic for insomnia
* Bupropion, sildenafil, vardenafil, or tadalafil for sexual dysfunction
* Bupropion for emotional flattening, cognitive slowing, or apathy
* Mirtazapine for insomnia, agitation, and gastrointestinal side effects
* Benzodiazepines for jitteriness and anxiety
29
True or False: Many side effects of citalopram are dose-dependent.
True
30
Fill in the blank: Activation and agitation may represent the induction of a ______ state.
[bipolar]
31
What additional treatments may be required for activation and agitation associated with citalopram?
* Addition of lithium
* A mood stabilizer
* An atypical antipsychotic
* Discontinuation of citalopram
32
What is the usual dosage range for citalopram?
20–40 mg/day
33
What are the available dosage forms of citalopram?
* Tablet 10 mg
* Tablet 20 mg scored
* Tablet 40 mg scored
* Solution 10 mg/5 mL
34
What is the initial dosing recommendation for citalopram?
20 mg/day
35
How should the dosage of citalopram be increased?
Increase by 20 mg/day after 1 or more weeks
36
What is the maximum daily dose of citalopram?
40 mg/day
37
When can citalopram be administered?
Single-dose administration, morning or evening
38
What should be considered if intolerable anxiety occurs upon dosing initiation?
Possibility of activated bipolar disorder; consider switching to a mood stabilizer or atypical antipsychotic
39
True or False: Citalopram can be prescribed at doses greater than 40 mg/day.
False
40
What are the potential overdose symptoms of citalopram?
* Vomiting
* Sedation
* Heart rhythm disturbances
* Dizziness
* Sweating
* Nausea
* Tremor
* Rarely amnesia, confusion, coma, convulsions
41
Is tapering necessary when stopping citalopram?
Not usually necessary, but generally prudent to taper
42
What is a common tapering strategy for citalopram?
50% dose reduction for 3 days, then another 50% reduction for 3 days, then discontinuation
43
What should be done if withdrawal symptoms emerge during discontinuation of citalopram?
Raise dose to stop symptoms and then restart withdrawal more slowly
44
What is the half-life of the parent drug citalopram?
23–45 hours
45
What type of inhibitor is citalopram regarding CYP2D6?
Weak inhibitor
46
Which enzymes metabolize citalopram?
* CYP3A4
* CYP2C19
47
Is tapering usually necessary when discontinuing citalopram?
Not usually necessary, but tapering to avoid potential withdrawal reactions is generally prudent
48
What is a common tapering schedule for citalopram?
50% dose reduction for 3 days, then another 50% reduction for 3 days, then discontinuation
49
What should be done if withdrawal symptoms emerge during citalopram discontinuation?
Raise dose to stop symptoms and then restart withdrawal much more slowly
50
What is the half-life of the parent drug citalopram?
23–45 hours
51
What enzymes metabolize citalopram?
CYP3A4 and CYP2C19
52
What is the risk associated with tramadol when taken with antidepressants?
Increases the risk of seizures
53
What serious condition can occur when citalopram is combined with MAOIs?
Fatal serotonin syndrome
54
What should be done after stopping MAOIs before starting citalopram?
Do not start an MAOI for at least 5 half-lives (5 to 7 days for most drugs) after discontinuing citalopram
55
What is a warning regarding citalopram and highly protein-bound drugs?
Citalopram may displace highly protein-bound drugs (e.g., warfarin)
56
What is a potential risk when citalopram is combined with sumatriptan?
Can cause weakness, hyperreflexia, and incoordination
57
What should be monitored when citalopram is used with anticoagulants?
Possible increased risk of bleeding
58
What is the maximum recommended dose of citalopram for patients taking a CYP2C19 inhibitor?
Should not be dosed above 20 mg/day
59
What populations should use citalopram with caution?
Patients with history of seizures, bipolar disorder, and children
60
What should be documented when treating children with antidepressants?
Weigh the risks and benefits of pharmacological treatment against nontreatment
61
Is citalopram generally recommended for use during pregnancy?
Not generally recommended, especially during the first trimester
62
What are the potential risks associated with SSRI exposure late in pregnancy?
Increased risk of gestational hypertension and preeclampsia
63
What complications have been reported in neonates exposed to SSRIs late in the third trimester?
Respiratory distress, cyanosis, apnea, seizures, temperature instability, feeding difficulty, vomiting, hypoglycemia, hypotonia, hypertonia, hyperreflexia, tremor, jitteriness, irritability, and constant crying
64
What should be considered when weighing the risks of antidepressant treatment versus nontreatment during pregnancy?
Risks to child from treatment versus risks of recurrence of depression to mother
65
What is a potential advantage of citalopram for elderly patients?
May be more tolerable than some other antidepressants
66
What are common primary target symptoms for citalopram treatment?
Depressed mood, anxiety, panic attacks, sleep disturbance
67
True or False: Citalopram can cause cognitive and affective flattening.
True
68
What is a potential disadvantage of citalopram in terms of dosage?
May require dosage titration to attain optimal efficacy
69
What is a special consideration for using citalopram in elderly patients?
Risk of SIADH is higher in the elderly
70
List three conditions for which SSRIs are commonly prescribed.
* Major depressive disorder
* Generalized anxiety disorder (GAD)
* Panic disorder
71
How do SSRIs work?
Boost neurotransmitter serotonin and block serotonin reuptake pump
## Footnote
This increases serotonergic neurotransmission.
72
What is the typical onset time for SSRIs to show therapeutic effects?
2–4 weeks
73
What should be done if SSRIs are not effective within 6–8 weeks?
Consider a dosage increase or switch to another treatment.
74
What is the goal of SSRI treatment?
Complete remission of current symptoms and prevention of future relapses.
75
For how long should treatment continue after symptoms have significantly reduced?
At least 1 year for the first episode of depression.
76
What are possible outcomes if SSRIs do not work?
* Partial response with some symptoms improved
* Nonresponders (treatment-resistant)
* Patients may relapse
77
Name two augmenting agents that can be used for SSRIs.
* Trazodone
* Bupropion
78
What is a class of medications that may be considered for anxiety disorders if all else fails?
Gabapentin or tiagabine
79
Fill in the blank: SSRIs desensitize serotonin receptors, especially _______.
serotonin 1A autoreceptors
80
What class of medication does escitalopram belong to?
Serotonin reuptake inhibitor (S-RI), selective serotonin reuptake inhibitor (SSRI)
81
List three conditions for which escitalopram is commonly prescribed.
* Major depressive disorder
* Generalized anxiety disorder (GAD)
* Panic disorder
82
How does escitalopram work?
Boosts neurotransmitter serotonin, blocks serotonin reuptake pump, desensitizes serotonin receptors
83
What is the typical onset time for escitalopram's therapeutic effects?
2–4 weeks
84
What should be done if escitalopram is not effective after 6–8 weeks?
Consider dosage increase or switch medication
85
What should be done if a patient has a partial response to escitalopram?
Consider increasing dose, switching agents, or adding an augmenting agent
86
Name two common side effects of escitalopram.
* Sexual dysfunction
* Gastrointestinal issues (nausea, diarrhea)
87
What is a rare but life-threatening side effect of escitalopram?
Seizures
88
What is the usual dosage range for escitalopram?
10–20 mg/day
89
Fill in the blank: The initial dose of escitalopram is _______.
10 mg/day
90
What are the recommended dosing forms of escitalopram?
* Tablets (5 mg, 10 mg, 20 mg)
* Oral solution (5 mg/5 mL)
91
How long is the mean terminal half-life of escitalopram?
27–32 hours
92
What should be monitored in patients taking escitalopram?
Activation of suicidal ideation
93
What is a precaution for using escitalopram in patients with a history of seizures?
Use with caution
94
Why is escitalopram not generally recommended during pregnancy?
Potential risks to fetal development
95
What should be done if withdrawal symptoms occur when discontinuing escitalopram?
Raise dose to stop symptoms and then restart withdrawal more slowly
96
What is the risk of using escitalopram in elderly patients?
Higher risk of SIADH and suicidality
97
What may escitalopram exposure during late pregnancy lead to?
Increased risk of gestational hypertension and complications in neonates
98
What are the potential advantages of escitalopram?
* Fewer drug interactions
* Faster onset of action
99
What may be a reason for nonresponse to escitalopram in elderly patients?
Mild cognitive impairment or Alzheimer disease
100
Name an augmenting agent for treating insomnia associated with escitalopram.
Trazodone
101
Fill in the blank: Escitalopram may increase _______ in adolescents.
visceral fat mass
102
What are the brand names for fluoxetine?
Prozac, Prozac weekly, Sarafem
## Footnote
These are the marketed names for fluoxetine.
103
For which conditions is fluoxetine FDA approved?
* Major depressive disorder (ages 8 and older)
* Obsessive–compulsive disorder (OCD) (ages 7 and older)
* Premenstrual dysphoric disorder
* Bulimia nervosa
* Panic disorder
* Bipolar depression (in combination with olanzapine)
* Treatment-resistant depression (in combination with olanzapine)
* Social anxiety disorder
* Posttraumatic stress disorder (PTSD)
## Footnote
These are the conditions for which fluoxetine is commonly prescribed.
104
How does fluoxetine work?
* Boosts neurotransmitter serotonin
* Blocks serotonin reuptake pump
* Desensitizes serotonin receptors
## Footnote
Fluoxetine also has antagonist properties at serotonin 2C receptors, potentially increasing norepinephrine and dopamine neurotransmission.
105
What is the typical onset time for fluoxetine's therapeutic effects?
2–4 weeks
## Footnote
Some patients may experience increased energy or activation earlier.
106
What is the goal of fluoxetine treatment?
Complete remission of current symptoms and prevention of future relapses
## Footnote
Treatment often reduces or eliminates symptoms but is not a cure.
107
What should be done if fluoxetine does not seem effective?
* Consider increasing the dose
* Switch to another agent
* Add an appropriate augmenting agent
* Consider psychotherapy
* Evaluate for another diagnosis or comorbid condition
## Footnote
Some patients may experience a partial response or relapse even while continuing treatment.
108
What are common side effects of fluoxetine?
* Sexual dysfunction
* Gastrointestinal issues (nausea, diarrhea)
* Central nervous system effects (insomnia, agitation)
* Autonomic effects (sweating)
* Bruising and rare bleeding
## Footnote
Patients with bipolar or psychotic disorders may be more vulnerable to CNS-activating actions.
109
What are some life-threatening side effects of fluoxetine?
* Rare seizures
* Rare induction of mania
* Activation of suicidal ideation and behavior
## Footnote
Short-term studies did not show an increase in suicidality risk beyond age 24.
110
What is the usual dosage range for fluoxetine in treating depression?
20–80 mg
## Footnote
Higher doses may be used for bulimia (60–80 mg).
111
What should be done if side effects occur with fluoxetine?
* Wait for effects to stabilize
* Adjust the dose
* Consider adding another medication
## Footnote
Many side effects are dose-dependent and may improve with time.
112
What are the pharmacokinetics of fluoxetine?
* Active metabolite (norfluoxetine) has a 2-week half-life
* Parent drug has a 2–3-day half-life
* Inhibits CYP2D6 and CYP3A4
## Footnote
The long half-lives affect how quickly dose changes are reflected in plasma levels.
113
What precautions should be taken when prescribing fluoxetine?
* Caution in patients with a history of seizure
* Caution in patients with bipolar disorder
* Monitor for activation of suicidal ideation, especially in children and adolescents
## Footnote
It is important to document the risks and benefits of treatment.
114
What are the considerations for using fluoxetine in pregnancy?
* Not generally recommended, especially in the first trimester
* Weigh risks of treatment against risks of no treatment
* Continuous treatment during pregnancy may be necessary
## Footnote
Exposure to SSRIs in pregnancy may carry certain risks, including potential heart defects.
115
Is fluoxetine safe for breastfeeding mothers?
Trace amounts may be present in breast milk
## Footnote
If the child becomes irritable or sedated, breastfeeding or the drug may need to be discontinued.
116
What should be considered if a child becomes irritable or sedated while breastfeeding from a mother on fluoxetine?
Breastfeeding or the drug may need to be discontinued
## Footnote
This highlights the importance of monitoring the infant's response to maternal medication.
117
Why is the immediate postpartum period a high-risk time for depression?
Especially in women who have had prior depressive episodes
## Footnote
This necessitates careful management of antidepressant treatment during this time.
118
What must be weighed when considering breastfeeding while on antidepressants?
Benefits of breastfeeding with risks and benefits of antidepressant treatment versus nontreatment to both the infant and the mother
## Footnote
This includes evaluating the impact of medication on both mother and child.
119
For which patients may fluoxetine be a first-line choice?
Patients with atypical depression (e.g., hypersomnia, hyperphagia, low energy, mood reactivity)
## Footnote
Atypical depression presents with distinct symptoms that may respond well to fluoxetine.
120
What are potential advantages of using fluoxetine?
* Patients with atypical depression
* Patients with fatigue and low energy
* Patients with comorbid eating and affective disorders
* Generic is less expensive than brand name where available
* Patients for whom weekly administration is desired
* Children with OCD or depression
## Footnote
These advantages cater to specific patient needs and economic considerations.
121
What are potential disadvantages of using fluoxetine?
* Patients with anorexia
* Initiating treatment in anxious, agitated patients
* Initiating treatment in severe insomnia
## Footnote
These disadvantages must be carefully considered when prescribing fluoxetine.
122
What are the primary target symptoms of fluoxetine treatment?
* Depressed mood
* Energy, motivation, and interest
* Anxiety
* Sleep disturbance (both insomnia and hypersomnia)
## Footnote
Addressing these symptoms is crucial for effective treatment outcomes.
123
What may fluoxetine cause in agitated insomniacs?
Cognitive and affective 'flattening'
## Footnote
This effect can hinder the overall therapeutic outcomes for these patients.
124
What is a notable pharmacokinetic feature of fluoxetine?
Long half-life; even longer-lasting active metabolite
## Footnote
This characteristic affects dosing and frequency of administration.
125
How can sexual dysfunction caused by fluoxetine be managed?
* Augment with bupropion, sildenafil, vardenafil, or tadalafil
* Switch to a non-SSRI such as bupropion or mirtazapine
## Footnote
These strategies can improve patient adherence and quality of life.
126
Which demographic may show reduced effectiveness of SSRIs like fluoxetine?
Women over 50, especially if they are not taking estrogen
## Footnote
This necessitates a tailored approach for older women experiencing depression.
127
What may enhance the response of postmenopausal women’s depression to fluoxetine?
Fluoxetine plus estrogen augmentation
## Footnote
This combination may provide a more effective treatment strategy.
128
What must be considered if there is nonresponse to fluoxetine in the elderly?
Possible mild cognitive impairment or Alzheimer disease
## Footnote
This consideration is crucial for accurate diagnosis and treatment.
129
What is available for the treatment of bipolar depression, psychotic depression, and treatment-resistant unipolar depression?
A single pill containing both fluoxetine and olanzapine
## Footnote
This combination therapy can streamline treatment for complex cases.
130
Which agent can be used for insomnia?
Trazodone or a hypnotic
## Footnote
These medications are commonly prescribed to help with sleep disturbances.
131
Name three agents that can be used for sexual dysfunction.
* Bupropion
* Sildenafil
* Vardenafil
* Tadalafil
## Footnote
These medications target various aspects of sexual dysfunction.
132
What can Bupropion be used for?
Emotional flattening, cognitive slowing, or apathy
## Footnote
Bupropion is effective in addressing mood-related symptoms.
133
Which agent is indicated for insomnia, agitation, and gastrointestinal side effects?
Mirtazapine
## Footnote
Mirtazapine is often used to manage multiple side effects.
134
What type of medication can be used for jitteriness and anxiety at treatment initiation?
Benzodiazepines
## Footnote
These are particularly useful for anxious patients during the start of treatment.
135
What are two types of dependence related to side effects?
* Dose-dependent
* Time-dependent
## Footnote
Understanding these dependencies helps in managing side effects effectively.
136
What does activation and agitation potentially indicate in a patient?
Induction of a bipolar state
## Footnote
This situation may require careful management and possibly the addition of mood stabilizers.
137
Which conditions may require the addition of lithium or an atypical antipsychotic?
Mixed dysphoric bipolar II condition
## Footnote
This condition can sometimes be associated with suicidal ideation and needs careful treatment.
138
What is the brand name for fluvoxamine?
Luvox and Luvox CR
## Footnote
Luvox CR is the controlled-release formulation of fluvoxamine.
139
Is fluvoxamine available in generic form?
Yes, but not for fluvoxamine CR
## Footnote
Generic formulations may vary in release formulation.
140
What class of medication is fluvoxamine categorized under?
Serotonin reuptake inhibitor (S-RI) and SSRI (selective serotonin reuptake inhibitor)
## Footnote
It is often classified as an antidepressant.
141
What are the FDA approved indications for fluvoxamine?
* Obsessive–compulsive disorder (OCD)
* Social anxiety disorder
* Depression
* Panic disorder
* Generalized anxiety disorder
* Posttraumatic stress disorder
## Footnote
Fluvoxamine is approved for OCD and its CR formulation for social anxiety disorder.
142
How does fluvoxamine work?
Boosts serotonin neurotransmitter, blocks serotonin reuptake pump, desensitizes serotonin receptors
## Footnote
It particularly affects serotonin 1A receptors and also binds at sigma 1 receptors.
143
How long does it typically take for fluvoxamine to show therapeutic effects?
2–4 weeks for onset, with some immediate relief possible
## Footnote
If no improvement is seen in 6–8 weeks, dosage may need adjustment.
144
What is the goal of fluvoxamine treatment?
Complete remission of symptoms and prevention of future relapses
## Footnote
Treatment aims to reduce or eliminate symptoms, but it is not a cure.
145
When should fluvoxamine treatment be continued after symptoms are gone?
For 1 year after the first episode of depression
## Footnote
Subsequent episodes may require indefinite treatment.
146
What are potential outcomes if fluvoxamine does not work?
* Partial response
* Nonresponders
* Relapse in initially responsive patients
## Footnote
Treatment-resistant cases may require a change in strategy.
147
What should be considered if a patient experiences a partial response to fluvoxamine?
* Increasing the dose
* Switching to another agent
* Adding an augmenting agent
* Psychotherapy
* Evaluation for another diagnosis
## Footnote
This may include checking for comorbid conditions like medical illness or substance abuse.
148
What augmenting agents may be considered for treatment-resistant OCD?
Clomipramine
## Footnote
This should be done cautiously and under expert guidance.
149
Which medications may help with insomnia in partial response cases?
Trazodone
## Footnote
Trazodone is often used specifically for insomnia.
150
Name some medications that can be used cautiously as augmenting agents in depression.
* Bupropion
* Mirtazapine
* Reboxetine
* Atomoxetine
## Footnote
Caution is advised as combinations can activate bipolar disorder.
151
What are some additional treatments for fatigue and lack of concentration?
Modafinil
## Footnote
It is particularly noted for treating sleepiness and fatigue.
152
What medications may be used for bipolar depression or treatment-resistant conditions?
* Mood stabilizers
* Atypical antipsychotics
## Footnote
These may be necessary for patients with treatment-resistant depression or anxiety disorders.
153
What should be considered for anxiety disorders if all else fails?
Gabapentin or tiagabine
## Footnote
Hypnotics may also be considered for insomnia.
154
In which regions is augmentation more commonly administered for depression and anxiety disorders?
Europe and Japan
## Footnote
In these regions, benzodiazepines and lithium are more frequently used.
155
What are the theoretical causes of side effects from drugs that increase serotonin concentrations?
Increases in serotonin concentrations at serotonin receptors in parts of the brain and body other than those that cause therapeutic actions
## Footnote
Unwanted actions of serotonin can lead to issues such as insomnia and diarrhea.
156
How might increasing serotonin affect dopamine release?
It can cause diminished dopamine release, contributing to emotional flattening, cognitive slowing, and apathy in some patients.
157
What properties of fluvoxamine may contribute to sedation and fatigue?
Fluvoxamine’s sigma 1 agonist properties.
158
What are notable side effects of drugs that increase serotonin?
Sexual dysfunction, gastrointestinal issues, central nervous system effects, autonomic issues, bruising, rare bleeding, and rare hyponatremia.
159
What sexual dysfunctions can occur due to serotonin-increasing drugs?
* Delayed ejaculation (men)
* Erectile dysfunction (men)
* Decreased sexual desire (men and women)
* Anorgasmia (men and women)
160
What gastrointestinal side effects are associated with serotonin-increasing drugs?
* Decreased appetite
* Nausea
* Diarrhea
* Constipation
* Dry mouth
161
What are the central nervous system side effects of serotonin-increasing drugs?
* Insomnia
* Sedation
* Agitation
* Tremors
* Headache
* Dizziness
162
True or False: Patients with bipolar or psychotic disorders may be more vulnerable to CNS-activating actions of SSRIs.
True
163
What are some life-threatening or dangerous side effects of serotonin-increasing drugs?
* Rare seizures
* Rare induction of mania
* Rare activation of suicidal ideation and behavior
* Weight gain
164
What should patients do if they experience side effects from fluvoxamine?
* Wait
* If sedating, take at night
* Reduce dose
* Switch or add other drugs in a few weeks
165
What are some augmenting agents for side effects of serotonin-increasing drugs?
* Trazodone or a hypnotic for insomnia
* Bupropion, sildenafil, vardenafil, or tadalafil for sexual dysfunction
* Bupropion for emotional flattening, cognitive slowing, or apathy
* Mirtazapine for insomnia, agitation, and gastrointestinal side effects
* Benzodiazepines for jitteriness and anxiety
166
What factors can influence the side effects of serotonin-increasing drugs?
* Dose-dependent factors
* Time-dependent factors
167
What is the usual dosage range of fluvoxamine for OCD?
100–300 mg/day
168
What is the usual dosage range of fluvoxamine for depression?
100–200 mg/day
169
What is the usual dosage range of fluvoxamine for social anxiety disorder?
100–300 mg/day
170
What is the initial dosage for immediate-release fluvoxamine?
50 mg/day
## Footnote
Increase by 50 mg/day in 4–7 days
171
What is the maximum dosage for immediate-release fluvoxamine?
300 mg/day
172
How should doses below 100 mg/day be administered for immediate-release fluvoxamine?
As a single dose at bedtime
173
For fluvoxamine doses above 100 mg/day, how can they be divided?
Into 2 doses to enhance tolerability, with the larger dose at night
174
What is the initial dosage for controlled-release fluvoxamine?
100 mg/day
175
How should dosing be adjusted for controlled-release fluvoxamine?
Increase by 50 mg/day each week until desired efficacy is reached
176
What can be done to improve tolerability of immediate-release formulation? (fluvoxamine)
Dosing can be given once a day at night or split symmetrically or asymmetrically
177
What should be done if intolerable anxiety or agitation occurs during dosing initiation ? (fluvoxamine)
Consider the possibility of activated bipolar disorder and switch to a mood stabilizer or atypical antipsychotic
178
What are the possible effects of overdose?(fluvoxamine)
Sedation, dizziness, vomiting, diarrhea, irregular heartbeat, seizures, coma, breathing difficulty
179
How should dosage be tapered to avoid withdrawal effects?(fluvoxamine)
Many patients tolerate 50% dose reduction for 3 days, then another 50% reduction for 3 days, then discontinuation
180
What is the half-life of the parent drug?(fluvoxamine)
9–28 hours
181
Which CYP enzymes does the drug inhibit?(fluvoxamine)
* CYP3A4
* CYP1A2
* CYP2C9/2C19
182
What risk does tramadol pose when taken with an antidepressant?
Increases the risk of seizures
183
When should an MAOI not be started after discontinuing fluvoxamine?
For at least 5 half-lives (5 to 7 days for most drugs)
184
What effect can fluvoxamine have on theophylline and clozapine?
It may reduce their clearance, raising their levels
185
What should be monitored when combining fluvoxamine with sumatriptan or other triptans?
Weakness, hyperreflexia, and incoordination
186
What should be done with caution when administering fluvoxamine with anticoagulants?
Monitor for possible increased risk of bleeding
187
What may happen when fluvoxamine is taken with NSAIDs?
May impair effectiveness of SSRIs
188
What can enhance the metabolism of fluvoxamine?
Smoking
189
What should patients and caregivers be warned about regarding side effects?
Possibility of activating side effects
190
List medications that should not be used if a patient is taking fluvoxamine.
* pimozide
* tizanidine
* alosetron
* ramelteon
* thioridazine
## Footnote
These medications can interact negatively with thioridazine.
