| Medication | Advantages | Disadvantages |
|
Citalopram Sertraline
|
SSRI Firstline Reduced risk of toxicity in overdose Better tolerated than other ADs; better compliance Fewer interactions; due to shorter half lives; better in those on multiple medications Effective in the treatment of depression with anxiety |
Increased risk of bleeding; consider a PPI in older people and in patients on NSAIDs or aspirin SSRIs can exacerbate hyponatraemia; especially in the elderly Citalopram and escitalopram increase the QT interval - avoid with these drugs Sertraline may result in higher rates of diarrhea
|
| Fluoxetine Paroxetine |
SSRI Fluoxetine is more commonly used in younger adults; start with 10mg daily for several days Fluoxetine; lower rates of withdrawal symptoms and suicidal thoughts or behavior Paroxetine can be used for pain treatment in patients with depression |
High propensity for interactions
Increased likelihood of the person stopping treatment because of side effects Monitor the elderly more closely for side-effects and start on low dose Paroxetine; higher rate of withdrawal symptoms such as suicide, higher risk of weight gain an sexual symptoms Fluoxetine; longer half life and more potential interactions Avoid in women on tamoxifen |
|
Duloxetine |
SNRI Used in chronic pain (fibromyalgia, chronic musculoskeletal pain, peripheral neuropathy) as well as depression |
Increased likelihood of stopping treatment because of side effects; need to increase the dose more gradually May increase blood pressure |
|
Propranolol |
Licensed for anxiety with symptoms such as palpitation, sweating and tremor |
Side effects
| Drug | Anticho-linergic | Cardiac | Postural Hypo-tension | Nausea | Sedation | Insomnia | Procon- vulsant | Sexual Dysfunction | Weight Gain | Withdrawal Symptoms | Inhibition of Hepatic | QT Interval Prolon-gation | Toxicity in Over-dose | Specific Problems |
| Sertraline | * | * | ** | *** | * | *** | * | *** | ** | *** | ** | * | * | All SSRIs Can: a. Increase nervouseness in first three days of treatment b. Possibly increase risk of suicide attempts in depressed chldren and adolescents c. increased risk of gastrointestinal bleeding. |
| Citalopram | * | * | ** | **** | * | *** | * | *** | ** | *** | ** | ** | * | |
| Fluoxetine | * | * | ** | *** | * | *** | * | *** | ** | U | **** | * | * | |
| Escitalopram | * | * | ** | *** | * | *** | * | *** | ** | *** | ** | ** | * | |
| Paroxetine | * | * | ** | *** | * | *** | * | **** | *** | **** | **** | * | * | |
| Duloxetine | * | * | ** | **** | ** | *** | U | *** | ** | U | ** | * | U | |
| Propranolol | * | *** |
Dosages
Antianxiety medication |
Start dose Adults <65y |
Max dose Adults <65y |
Start dose Adults >65y |
Max dose Adults >65y |
Hepatic impairment |
Renal Impairment |
|
Citalopram |
20mg |
40mg |
10mg |
20mg |
20mg |
No information available for eGFR less than 20 mL/min; start at reduced dose and titrate slowly |
|
Escitalopram |
10mg |
20mg |
5mg |
10mg |
10mg |
Caution if eGFR less than 30 mL/ min: Start at reduced dose and titrate slowly |
|
Sertraline |
50mg |
200mg |
50mg |
200mg |
Reduce dose or increase dose interval in mild to moderate impairment. |
Use with caution |
| Fluoxetine | 20mg | 60mg | 20mg | 40mg | Caution due to prolonged half-life | No adjustment needed |
| Paroxetine | 20mg | 50mg | 20mg | 40mg | Caution due to prolonged half-life | In severe impairment: initial dose 10mg max dose 40mg |
| Duloxetine | 60mg | 120mg | 60mg | 120mg | Avoid | Avoid if eGFR less than 30 mL/minute/1.73 m2 |
| Propranolol | 40 mg od | 40 mg tds |
References
-
- https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2674796/
- https://www.drugs.com/article/antidepressants.html
- https://www.intechopen.com/books/pharmacokinetics-and-adverse-effects-of-drugs-mechanisms-and-risks-factors/new-antidepressant-medication-benefits-versus-adverse-effects
- https://www.uspharmacist.com/article/qtc-prolongation-with-antidepressants-and-antipsychotics
- https://www.ncbi.nlm.nih.gov/pubmed/27121934
- https://www.scielo.br/scielo.php?script=sci_arttext&pid=S0004-282X2019000600412
- https://www.tandfonline.com/doi/abs/10.1586/14737175.2014.908709?src=recsys&journalCode=iern20
- NICE
- https://www.ncbi.nlm.nih.gov/pubmed/27121934
check all this
- The DTB reports a study that tried to work out how many people who had not responded to an antidepressant at 4 weeks would get a benefit if the same one was continued until 8 weeks.
- Always ask about alcohol history, and take this into account when considering treatment options, particularly drug options
- The importance of continuing once remission achieved.
- The risk and nature of discontinuation symptoms (especially with paroxetine and venlafaxine).
- Review the patient after 2w, and then 2–4 weekly for the first 3m. See review section
- If <30y or risk of suicide, see more often (e.g. after 1w).
- If significant side-effects early in treatment:
- Continue with close monitoring if acceptable to patient.
- Stop/change antidepressant.
- Offer short-term (2w) benzodiazepine to help anxiety/agitation, but not in those with chronic anxiety ( or previous drug dependence or alcohol dependence issues) as they are more likely to develop dependence
- Expect initial improvement after 2–4w. If no/minimal response after 3–4w, increase support and consider:
- If inadequate response after 6–8w, consider switching to an alternative antidepressant
- Remember that a single antidepressant usually gives fewer side-effects than combinations of antidepressants.
- When switching antidepressants:
- If one SSRI has been ineffective, try an alternative SSRI.
- If that is ineffective, try an alternative class of antidepressants (venlafaxine, tricyclic, MAOI).
SSRI
SNRI
Pregabalin
benzo = Do not offer a benzodiazepine for the treatment of GAD in primary or secondary care except as a short-term measure during crises.
antipsychotic - Do not offer an antipsychotic for the treatment of GAD in primary care
propranolol
gastroprotective drug
Benzodiazepine
