SSRIs

Question 1

Citalopram

Answer 1

(CELEXA) – Start 10 -20mg QD. (target 20-40mg); FDA warning long QT: maximum dose 40mg in most adults. Maximum 20mg in elderly (>60), those with hepatic impairment, and patients taking a CYP2C19 inhibitor (eg. Cimetidine, omeprazole)

Question 2

Sertraline

Answer 2

(ZOLOFT) – start 50mg QD, then 100mg (target 150-200mg) Down side is that it needs titrating (eg increments of 25mg per week in the elderly population)

Question 3

Escitalopram

Answer 3

(CIPRALEX) – Start 5-10mg QD (target 10-20mg) Not covered by RAMQ insurance

Question 4

Fluoxetine

Answer 4

(PROZAC) – Start 10-20mg QD(target 20-40mg) – the first SSRI (lots of studies!). Often used in pediatrics. Long half life.

Question 5

Fluvoxamine

Answer 5

(LUVOX) – start 50mg QD (target 100-300mg)

Question 6

Paroxetine

Answer 6

(PAXIL) – Start 10-20mg QD (target 20-40mg) the only SSRI with significant anticholinergic action (ie more side effects). Short half life (withdrawal symptoms).

Question 7

SSRI side FX

Answer 7

Acute: improve over 1 week: Headaches, GI symptoms, anxiety, somnolence
Sub acute: ↓libido, ejaculation dysfunction (♂), anorgasmia (♀), vivid dreams
Possible physical complications: osteopenia, hyponatremia, long QT.

There is much controversy over a possible increase in suicidal ideation caused by SSRIs. Especially in teens and young adults (under 25 years old) there may be an increase in suicidal ideation but there is no clear evidence of increase in completed suicide. Make sure to educate and screen for suicidal ideation at follow up visits after starting an SSRI with young people especially.

Question 8

SSRIs preferentially used in elderly (2-3)

Answer 8

Celexa and Zoloft (and Cipralex) have less effect on CYP450 enzymes than the other SSRIs and are commonly used in the elderly population because they are less likely to interact.

Question 9

SSRI side FX (more complete list)

Answer 9

Nausea
    Nervousness, agitation or restlessness
    Dizziness
    Reduced sexual desire or difficulty reaching orgasm or inability to maintain an erection (erectile dysfunction)
    Drowsiness
    Insomnia
    Weight gain or loss
    Headache
    Dry mouth
    Vomiting
    Diarrhea