Things To Consider When Taking Antidepressants

 

Antidepressants are widely used in the general population, primarily to treat depression but also commonly in conditions such as anxiety disorders and neuropathic pain. There are many things to be considered when taking antidepressants.

1)   Drug interations:

1.    Some important drug interactions with SSRI

SSRI	Interacting Drug	Possible Effect(s)	Importance and Management
All	Alcohol	Increased CNS sedation	Advise vigilance in early stages of treatment
All	Benzodiazepines	Increased sedation possible. Fluoxetine and paroxetine may reduce metabolism of some benzodiazepines	Warn that increased sedation is possible
All	Warfarin	Increased INR and increased bleeding risk due to antiplatelet effect	Monitor INR and advise patients to report signs of bleeding
Fluoxetine & paroxetine	Metoprolol and propranolol	Increased beta-blocking effects, bradycardia	Monitor heart rate. Interaction not reported with citalopram
All	Buspirone	Serotonin syndrome and lowering of seizure threshold theoretically possible	Monitor concurrent use
All	Antiepileptics	SSRIs may lower the seizure threshold	Unlikely to be a problem if epilepsy well controlled. Observe seizure frequency
Fluoxetine	Antiepileptics, carbamazepine and phenytoin	Increased plasma concentrations of carbamazepine and phenytoin with fluoxetine	Monitor plasma concentrations of carbamazepine and phenytoin. Adjust dose if necessary. No similar reports with paroxetine and an interaction appears unlikely with citalopram.
Paroxetine	Antiepileptics, carbamazepine and phenytoin	Reported to decrease plasma concentration of paroxetine	Clinical significance not clear. Monitor clinical response
All	NSAIDs including aspirin	Increased risk of GI bleeding	Concurrent use not contraindicated but be aware of increased risk of bleeding especially in those with additional risk factors
All	Monoamaine oxidase inhibitors (MAOIs), including moclobemide	Hypertensive crisis	Avoid concurrent use. Washout periods essential when switching. Refer to product prescribing information and reference texts
Fluoxetine & paroxetine (possibly citalopram)	Clozapine, haloperidol and risperidone	Increased plasma concentrations of antipsychotics	Monitor for dose related adverse effects and reduce dose of antipsychotic if necessary
All	Tramadol	Both tramadol and SSRIs lower seizure threshold. Serotonin syndrome reported with concurrent use	Use the combination of tramadol and an SSRI very cautiously especially at high doses. Alternative analgesic may be preferable
All	Tricyclic antidepressants	Increased plasma concentrations of TCA and increased adverse effects. Risk of serotonin syndrome especially with clomipramine Increases are variable but can be in the order of 3–4 times and more.	Increases usually less significant or negligible with citalopram. If the combination is judged necessary, start with the lowest dose of TCA and monitor for dose related adverse effects, e.g sedation, or anticholinergic symptoms
All	Sibutramine	Increased risk of CNS toxicity	Avoid
All (especially fluoxetine & paroxetine)	Perhexilene, flecainide and other antiarrhythmic drugs	Plasma concentrations can be increased leading to toxicity.	Refer to individual product prescribing information and reference texts
Fluoxetine & paroxetine	Protease inhibitors (ritonavir)	Fluoxetine increases ritonavir concentrations and ritonavir may increase fluoxetine and paroxetine concentrations. Cases of serotonin syndrome with fluoxetine reported	Monitor for symptoms of serotonin syndrome. Reduce dose if necessary
All	Lithium	Neurotoxic symptoms and serotonin like syndrome occasionally reported	Addition of lithium to an SSRI can be beneficial and is usually uneventful. Observe for adverse effects
All	Selegiline	Hypertension, CNS excitation, serotonin syndrome	Avoid this combination as serious interactions have been reported. Manufacturers advise to avoid. N.B. apparent safe use of this combination has also been reported in the literature
All	St John’s Wort	Serotonin syndrome	Avoid this combination
All	Sumatriptan	A few cases of dyskinesias with fluoxetine. Occasional reports of serotonin syndrome	Concurrent use of sumatriptan and SSRIs not usually a problem but monitor for any adverse effects when the combination is started

 

2.    Some important drug interactions with tricyclic antidepressants.

Interacting drugs(s)	Possible effect(s)	Importance and management
SSRIs	Increased plasma concentrations of TCA causing increased adverse effects. Serotonin syndrome possible, especially with clomipramine	Increases are variable but can be in the order of 3 – 4 times and more. Increases usually less significant or negligible with citalopram. If the combination is judged necessary, start with the lowest dose of TCA and monitor for dose related adverse effects, e.g. sedation, or anticholinergic symptoms
Alcohol	Increased CNS depression, sedation	Warn patient about increased drowsiness. Limit alcohol intake
Antiarrhythmic drugs, e.g. amiodarone, flecainide, quinidine	Increased risk of ventricular arrhythmias	Avoid concurrent use. Refer to specialised texts.
CNS depressants e.g. Benzodiazepines Antihistamines Antipsychotics	Increased CNS depression, sedation	Warn patient about increased drowsiness
Clonidine	Antihypertensive effects of clonidine are reduced or abolished	Avoid concurrent use
Warfarin	Occasional reports of changes in INR	Evidence for an interaction is poor and inconclusive. Monitor INR as normal
Lithium	Neurotoxic symptoms and serotonin-like syndrome occasionally reported	Concurrent use can be beneficial and is usually uneventful. Observe for adverse effects
Antipsychotics	Increased sedation, additive anticholinergic effects Plasma concentrations of phenothiazines and/or the TCA may be increased	Often used together in clinical practice but be aware of the possibility of additive pharmacological and adverse effects
Selegiline	CNS excitation, serotonin syndrome	Interaction appears less likely than with an SSRI Caution and awareness of possible symptoms advised
Ritonavir	Plasma concentrations of TCAs may be increased.	Monitor for increased dose related adverse effects. Reduce dose of TCA if necessary.
Tramadol	Increased risk of seizures. Possibility of serotonin syndrome especially with clomipramine	Adverse effects unlikely but be aware of symptom

 

 

Pregnancy : Taking medications during pregnancy can have risks and benefits. know facts about antidepressant use during pregnancy.

Antidepressants are a primary treatment option for most types of depression. But there are benefits and risks to consider when taking antidepressants during pregnancy.

Is it necessary to get treated for depression during pregnancy?

If you have untreated depression, you might not seek optimal prenatal care or eat the healthy foods you and your baby need. Experiencing major depression during pregnancy is associated with an increased risk of premature birth, low birth weight, decreased fetal growth or other problems for the baby. Unstable depression during pregnancy also increases the risk of postpartum depression and difficulty bonding with your baby.

A decision to use antidepressants during pregnancy, in addition to counseling, is based on the balance between risks and benefits. The biggest concern is typically the risk of birth defects from exposure to antidepressants. Overall, the risk of birth defects and other problems for babies of mothers who take antidepressants during pregnancy is very low. However, some antidepressants are associated with a higher risk of complications for your baby. Talking to your health care provider about your symptoms and medication options can help you make an informed decision.

If you use antidepressants during pregnancy, your health care provider will try to minimize your baby's exposure to the medication. This can be done by prescribing a single medication (monotherapy) at the lowest effective dose, particularly during the first trimester.

Keep in mind that psychotherapy is also an effective treatment for mild to moderate depression.

Which antidepressants are safe in pregnancy?

Ø Certain selective serotonin reuptake inhibitors (SSRIs): SSRIs are generally considered an option during pregnancy, including citalopram (Celexa) and sertraline (Zoloft). Potential complications include maternal weight changes and premature birth. Most studies show that SSRIs aren't associated with birth defects. However, paroxetine (Paxil) might be associated with a small increased risk of a fetal heart defect and is generally discouraged during pregnancy.

Ø Serotonin and norepinephrine reuptake inhibitors (SNRIs): SNRIs also are considered an option during pregnancy, including duloxetine (Cymbalta) and venlafaxine (Effexor XR).

Ø Bupropion (Wellbutrin): Although bupropion isn't generally considered a first line treatment for depression during pregnancy, it might be an option for women who haven't responded to other medications. Research suggests that taking bupropion during pregnancy might be associated with miscarriage or heart defects.

Ø Tricyclic antidepressants: This class of medications includes nortriptyline (Pamelor) and desipramine (Norpramin). Although tricyclic antidepressants aren't generally considered a first line or second line treatment, they might be an option for women who haven't responded to other medications. The tricyclic antidepressant clomipramine (Anafranil) might be associated with fetal birth defects, including heart defects.

Risks associated with use of antidepressants in pregnancy: Treatment of depression during pregnancy and breastfeeding is a controversial issue, as antidepressants can negatively affect the developing fetus. According to epidemiological studies, the effects of treated depression in pregnancy are related to premature birth, decreased body weight of the child, intrauterine growth retardation, neonatal adaptive syndrome, and persistent pulmonary hypertension. However, untreated depression can adversely affect maternal health and increase the risk of preeclampsia and eclampsia, as well as of subsequent postnatal depression, which can lead to disruption of the mother-child relationship. Based on the above mentioned facts, the basic question arises as to whether or not to treat depression during pregnancy and lactation. Treatment should be given if the benefits overweigh the risks.