Strategies to Switch Antidepressants Brittany Parmentier, PharmD PGY2 Behavioral Care Resident Butler University/Community Health Network This speaker has no actual or potential conflicts of interest to disclose in relation to this presentation.
Dec 29, 2015
Strategies to Switch Antidepressants
Brittany Parmentier, PharmDPGY2 Behavioral Care ResidentButler University/Community Health Network
This speaker has no actual or potential conflicts of interest to disclose in relation to this presentation.
AD – antidepressant SSRI – selective serotonin reuptake inhibitorSNRI – serotonin norepinephrine reuptake inhibitor TCA – tricyclic antidepressantMAOI – monoamine oxidase inhibitor
Abbreviations
27.5% of STAR*D patients achieved remission with 1st treatment
50% of depression patients respond to 1st treatment
35-50% of responders still have residual symptoms
Intolerance to side effects
Need for Switch
Trivedi MH e al. Am J Psychiatry. 2006;163:28-40. Fava M et al. Psychiatr Clin N Am. 2003;26:457-494.
Optimize dose
Adequate duration
Key Points before Switching
American Psychiatric Association. Practice guideline for the treatment of patients with major depressive disorder (3 rd ed). Oct 2010. Available at: http://psychiatryonline.org/pb/assets/raw/sitewide/practice_guidelines/guidelines/mdd.pdf. Accessed July 30, 2015.
Individualized therapy for each patient
Variations in acute and ambulatory practice
Limited data comparing one strategy to another
General Considerations
Jefferson JW. J Clin Psychiatry. 2008;69(Suppl E1):14-18.
Switching Effects
Serotonin Syndrome• Sweating• Insomnia• Tremor• Akathisia
Antidepressant Discontinuation
Zerumsky K et al. P&T. 2005;30(12):740-747.
• Flu-like symptoms• Insomnia• Nausea• Imbalance• Sensory disturbances• Hyperarousal (anxiety/agitation)
Between SSRIs
SSRI (except fluoxetine) SSRI • Direct switch to equivalent dose• Direct switch to lower new dose of new SSRI
Fluoxetine Other SSRI • Stop fluoxetine, 4-7 day washout with no
antidepressant, start new SSRI at low dose
Marangell. J Clin Psychiatry. 2001;62(Suppl 18):12-7.Zerumsky K et al. P&T. 2005;30(12):740-747.
SSRI Dose Fluoxetine 20 mg Paroxetine 20 mg Citalopram 20 mg Escitalopram 10 mg Sertraline 50 mg Fluvoxamine 50 mg
SSRI Dose Equivalency
Hayasaka Y et al. J Affect Disord. 2015;180:179-184.
SSRI duloxetine • Direct switch to duloxetine 60mg daily • Start duloxetine 60mg and taper SSRI down
SSRI venlafaxine • Direct switch to low dose venlafaxine (37.5 mg –
75mg) • Cross-taper
SSRI to SNRI
Marangell. J Clin Psychiatry. 2001;62(Suppl 18):12-7.Jefferson JW. J Clin Psychiatry. 2008;69(Suppl E1):14-18.
Venlafaxine SSRI• Direct switch to therapeutic SSRI dose• Cross-taper
Duloxetine SSRI• Direct switch to therapeutic SSRI dose• Cross-taper
SNRI to SSRI
Marangell. J Clin Psychiatry. 2001;62(Suppl 18):12-7.Jefferson JW. J Clin Psychiatry. 2008;69(Suppl E1):14-18.
To/from another agent Cross-taper
Bupropion, Mirtazapine, and TCAs
Marangell. J Clin Psychiatry. 2001;62(Suppl 18):12-7.Jefferson JW. J Clin Psychiatry. 2008;69(Suppl E1):14-18.
MAOI MAOIMAOI Other antidepressant Other antidepressant (except fluoxetine) MAOI
• Stop medication, 2 week washout with no AD, start new AD
Fluoxetine MAOI
• Stop fluoxetine, 5 week washout with no AD, start MAOI
MAOIs – High Risk for Toxicity
Marangell. J Clin Psychiatry. 2001;62(Suppl 18):12-7.Jefferson JW. J Clin Psychiatry. 2008;69(Suppl E1):14-18.
When would it be most appropriate to do a direct switch from a therapeutic dose of old AD to a therapeutic dose of new AD?
A. Imipramine tranylcypromine B. Escitalopram nortriptyline C. Citalopram sertraline D. Venlafaxine phenelzine
Assessment Question
When would it be most appropriate to do a direct switch from a therapeutic dose of old AD to a therapeutic dose of new AD?
A. Imipramine tranylcypromine B. Escitalopram nortriptyline C. Citalopram sertraline D. Venlafaxine phenelzine
Assessment Question
Strategies to Switch Antidepressants
Brittany Parmentier, PharmDPGY2 Behavioral Care ResidentButler University/Community Health [email protected]