Guidelines on Choice and Selection of Antidepressants for

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3 Recommended Pharmacological Treatment for Depression. Patients under 18 years,Fluoxetine is the recommended first line. Pharmacological Treatment of 7,treatment in patients under 18 years It is. licensed for the treatment of moderate to severe, Depression in Adults depression from 8 years onwards See section. Older Adults 65 years,Recommend monitoring for antidepressant. SSRIs potentially interact with,concomitant medication or physical.
FIRST LINE induced hyponatraemia Increased risk of GI. illness see section 5 below SSRI Citalopram Fluoxetine or Sertraline bleeding See section 6 1 5 6. Antenatal and Postnatal Prescribing, There is a risk of a dose dependant QT SSRIs have low known risk most experience with. prolongation with citalopram do NOT SECOND LINE fluoxetine and sertraline TCAs also have low. prescribe in patients with known QTc, prolongation congenital long QT syndrome or Alternative SSRI or Venlafaxine or Mirtazapine teratogenic risk. in those with medications that are known to Imipramine nortriptyline and sertraline. prolong QTc considered safest in breastfeeding See section. 6 3 5 8 10,THIRD LINE,Alternative 2nd line agent see above. Consider vortioxetine or other options MAOI TCA,Consider a combination of two different. antidepressants For specialist initiation only, Consider augmentation with an antipsychotic or lithium.
With appropriate physical health monitoring,Refer to prescribing notes page 8. Guidelines for the Pharmacological Management of Depression Review date Sept 2018 2. 4 Pharmacological Treatment for Depression,Basic principles of prescribing in depression5. Discuss with the patient choice of drug and availability of other non pharmacological. treatments, Discuss with the patient likely outcomes such as gradual relief from depressive symptoms. over several weeks, Prescribe a dose of antidepressant after titration if necessary that is likely to be effective. For a single episode continue treatment for at least 6 9 months after resolution of. symptoms those at risk of relapse should continue for at least 2 years. Withdraw antidepressants gradually always inform patients on the risk and nature of. discontinuation symptoms,Choice of antidepressant5 6.
Consider a baseline assessment for severity of depression and regularly review symptoms both. clinically and using a standard severity rating scales Initially normally choose a generic SSRI whilst. taking the following into account, Fluoxetine fluvoxamine and paroxetine have the higher propensity for drug interactions. fluvoxamine and paroxetine are the least preferred SSRI s It may be appropriate to. consider sertraline and citalopram in patients who have chronic health problems as. these have a lower propensity for interactions with medications for physical health. SSRI s are associated with an increased risk of bleeding consider prescribing a gastro. protective drug e g omeprazole in older adults who are taking NSAIDs and or aspirin. Discuss choice of antidepressant covering, Patient choice the perception of the efficacy and tolerability. Existing co morbid psychiatric disorders such as obsessive compulsive disorder anxiety etc. through accurate history taking, Anticipated adverse events e g agitation nausea and vomiting with SSRIs and. discontinuation symptoms See appendix 1 for table of relative side effects of. antidepressants, Potential interactions with concomitant medication or physical illness5 11. Medication for physical Recommended antidepressant s. health problem, NSAIDs non steroidal anti Try to avoid SSRI s but if no suitable alternatives can be identified offer.
inflammatory drugs gastro protective medicines e g omeprazole together with the SSRI5 11. Consider mirtazapine moclobemide or trazodone, Warfarin or heparin Do not normally offer SSRI s Consider mirtazapine. Theophylline or methadone Offer citalopram or sertraline sertraline may increase methadone levels. Clozapine Consider citalopram or sertraline small to modest increases in plasma. clozapine levels may occur particularly with sertraline 2 16. Triptan drugs for migraine Do not offer SSRI s offer mirtazapine or trazodone. Aspirin Use SSRI s with caution if no suitable alternatives can be identified offer. gastro protective medicines together with the SSRI Consider trazodone when. aspirin is used as a single agent alternatively consider mirtazapine. Monoamine oxidase B Do not normally offer SSRI s offer mirtazapine or trazodone. inhibitors e g selegiline or,rasagiline, Flecainide or propafenone Offer sertraline as the preferred antidepressant mirtazapine or moclobemide. may also be used, Guidelines for the Pharmacological Management of Depression Review date Sept 2018 3. Switch treatments early e g after 1 2 weeks if adverse effects are intolerable or if no. improvement at all is seen by 3 4 weeks Antidepressants have a fairly prompt onset of. action and non response at 2 6 weeks is a good predictor of overall response See Appendix. 2 for table of swapping and stopping advice taken directly from the Maudsley Prescribing. Guidelines 12th Edition5, The absence of any improvement at all at 3 4 weeks should normally provoke a change in. treatment If there is some improvement at this time continue and assess for a further 2. For advice on switching treatments please refer to the Psychotropic Drug Directory4 The. Maudsley Prescribing Guidelines5 or contact the pharmacy team for advice. Guidelines for the Pharmacological Management of Depression Review date Sept 2018 4. 5 HPFT Formulary Drugs for the treatment of Depression in Adults1 5. Drug Drug Class Formulation Additional Prescribing Information. Amitriptyline Tricyclic 10mg 25mg and 50mg tablets Consider TCAs in patients presenting with pain and physical. antidepressant TCA 25mg 5ml and 50mg 5ml oral solution symptoms. Avoid in patients at risk of arrhythmias, Consider ECG at higher dose or when co administered with.
other drugs that may increase the risk e g fluoxetine. Increased cholinergic burden especially when co prescribed. with other anticholinergic drugs, Citalopram Selective serotonin 10mg 20mg 40mg tablets SSRI with lowest propensity for drug interactions. reuptake inhibitor 40mg ml oral drops 1 drop 2mg Suitable choice in renal impairment. SSRI 4 drops 8mg 10mg tablet Citalopram QT interval prolongation new maximum daily. dose restrictions including in elderly patients,contraindications and warnings. Citalopram most toxic of SSRI s in overdose coma seizures. arrhythmia 5, Contraindicated with other QT prolonging medications. Baseline ECG advised in patients with cardiac disease. Clomipramine TCA 10mg 25mg and 50mg capsules As for amitriptyline. Duloxetine Serotonin and 30mg and 60mg capsules Second line SNRI only after venlafaxine. noradrenaline,reuptake inhibitor, Fluoxetine SSRI 20mg capsules 60mg capsules NOT approved. 20mg 5ml oral liquid can also be used Good option for patents with poor medication compliance due. sublingually to its long half life, Imipramine TCA 10mg and 25mg tablets As for amitriptyline.
25mg 5ml oral solution,Lofepramine TCA 70mg tablets As for amitriptyline. 70mg 5ml oral suspension Lower incidence of side effects and less dangerous in. overdose Less cardiotoxic than other TCAs,It is an option in SSRI induced hyponatraemia. Guidelines for the Pharmacological Management of Depression Review date Sept 2018 5. Can cause raised liver function tests, Mianserin Tetracyclic 10mg tablets and 30mg tablets For specialist initiation only in line with NICE CG 90 for. antidepressant combining with an another antidepressant. Mirtazapine Noradrenaline and 15mg 30mg and 45mg tablets and Oral solution should only be used when orodispersible tablets. specific serotonin orodispersible tablets are unsuitable. antidepressant 5mg ml oral solution Safer option in patients at high risk of GI bleed e g older. NaSSa adults NSAIDs, Consider if SSRI has not benefited or SSRI not appropriate. Good choice if sedation required, Moclobemide Reversible 150mg and 300mg tablets For specialist initiation only Reversible MAOI.
Monoamine oxidase Reduced risk of major food and drug interactions however. inhibitor MAOI patients should still be advised to avoid large quantities of. tyramine rich foods and sympathomimetic drugs, See BNF for details on initiating treatment after another. antidepressant has been stopped,MAOIs not recommended in cardiovascular disease. Nortriptyline TCA 10mg and 25mg tablets As for amitriptyline. Paroxetine SSRI 20mg and 30mg tablets Less preferred choice SSRI with greatest risk of withdrawal. 10mg 5ml oral suspension reactions, Phenelzine MAOI 15mg tablets For specialist initiation only. As for moclobemide,Preferred MAOI probably the most safest. Reboxetine Selective inhibitor of 4mg tablets Reboxetine should be used with caution in patients with renal. noradrenaline re or hepatic impairment It should also be used under close. uptake supervision in patients with bipolar disorder urinary. retention benign prostatic hyperplasia glaucoma or a history. of epilepsy or cardiac disorders, Sertraline SSRI 50mg and 100mg tablets Drug of choice for those with cardiovascular disease recent.
MI or unstable angina or renal impairment,Reduced propensity for drug interactions. Trazodone Tricyclic related 50mg and 100mg capsules Oral liquid significantly more expensive than tabs caps. Antidepressant 150mg tablets Restricted to those unable to swallow solid dose forms. 50mg 5ml sugar free oral solution, Guidelines for the Pharmacological Management of Depression Review date Sept 2018 6. Venlafaxine SNRI 37 5mg and 75mg tablets Immediate release venlafaxine BD dosage is considerably. 37 5mg 75mg 150mg and 225mg MR tablets less expensive than once daily MR formulations The MR. formulation should only be used if the immediate release. formulation is not tolerated or if concordance with a twice. daily regimen is difficult, If MR preparation is required then MR tablets should be. prescribed rather than MR capsules as these are more cost. effective Existing patients on MR preparations must not be. switched to IR tablets without involvement agreement of. psychiatrist, Avoid use in patients with high risk of cardiac arrhythmia. Monitor blood pressure in doses above 150mg,Consider ECG at higher dose.
Do not prescribe venlafaxine for patients with11,Uncontrolled hypertension. Recent myocardial infarction,High risk of cardiac arrhythmia. Monitor BP at initiation and regularly during treatment. particularly during dose titration, Monitor for signs and symptoms of cardiac dysfunction. Doses of 300 mg daily or more should only be prescribed. under the supervision or advice of a specialist mental. health practitioner, Vortioxetine Serotonin modulator 5mg 10mg and 20mg tablets GPs can initiate once specialist advice has been sought from. and stimulator SMS a HPFT Consultant Psychiatrist, NICE recommends that vortioxetine is an option for treating.
major depression in adults who have responded inadequately. to two antidepressants within the current episode of. depression9 However NICE considered that there was no. convincing evidence that vortioxetine was more or less. effective than other antidepressants9,Low toxicity in overdose. Dose adjustment not required in renal impairment although. Guidelines for the Pharmacological Management of Depression Review date Sept 2018 7. caution in severe renal impairment and in severe hepatic. impairment as data is limited15, Trial data suggest no effect on QTc or on coagulation. parameters, Treatment can be stopped abruptly as it has a long half life. 66hours and there is no evidence of clinically important. discontinuation symptoms15, Escitalopram and Agomelatine are non formulary within HPFT Requests to use these drugs will need to be made via a named patient request form. Dosulepin DO NOT SWITCH TO OR START dosulepin because evidence supporting its tolerability relative to other antidepressants is outweighed by the. increased cardiac risk and toxicity in overdose NICE CG901 6. Trimipramine Non formulary DTC decision May 2018 to remove from HPFT medicines formulary. Guidelines for the Pharmacological Management of Depression Review date Sept 2018 8. 6 Prescribing antidepressants in specialist groups. 6 1 Older Adults 65 years 5 6, SSRIs are generally used first line they offer considerable advantages over TCAs including potentially.
fewer side effects safety in overdose less dosage titration once a day administration and greater. patient adherence Fluoxetine may not be considered first line in this patient group due to its longer. duration of action risk of accumulation and multiple drug interactions Potential side effects such as. sedation and consequent risk of falls should be taken into account when selecting an antidepressant. TCAs except lofepramine may be less suitable due to the antimuscarinic adverse effects. Due to changes in pharmacodynamic sensitivity and pharmacokinetics older adults usually take. longer to respond to antidepressants and are more sensitive to their side effects Therefore a. minimum of six weeks treatment should be given before considering the treatment to be ineffective. SSRIs increase the risk of gastrointestinal GI bleeds particularly in the very elderly and those with. established risk factors such as history of bleeds or treatment with non steroidal anti inflammatory. section 6 2 Further guidance on prescribing for older adults and for antenatal postnatal service users can be found in section 6 1 and section 6 3 respectively These guidelines act as a guide only they are to be used alongside the following reference sources and NICE Maudsley Prescribing Guidelines Psychotropic Drug Directory BNF

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