Antidepressant precautions

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antidepressant precautions

ANTIDEPRESSANTS COMMONLY USED IN PRIMARY CARE:
NEWER ANTIDEPRESSANTS
Drug Name Recommended Dosage General Dosing Comments
Fluxoetine
PROZAC
**GENEREIC
AVAILABLE

20 mg/day administered in the A.M. is sufficient to obtain a
satisfactory antidepressant
response. A
dose increase may be considered after several weeks if no clinical improvement
is observed. Doses above 20 mg/day may be administered on a
once a
day (
morning) or b.i.d.
schedule (
ie, morning and noon) and should not exceed a
maximum dose of 80 mg/day.

As with other antidepressants, the full antidepressant effect may be delayed until 4
weeks of
treatment or longer.

As with many other medications, a
lower or less frequent dosage should be used in
patients with hepatic impairment

Elderly: 10 mg initial dose with maintenance of 10-20mg.
Citalopram
CELEXA

Initial dose of 20 mg once daily, generally with an increase to a
dose of 40 mg/day. Dose
increases should usually occur in increments of 20 mg at intervals of no less than one week.

Celexa should be administered once daily, in the morning or evening, with or without food.

10-20 mg/day is the recommended dose for most elderly patients and patients with
hepatic impairment with titration to 40 mg/day only for non-responding patients.

No dosage adjustment is necessary for patients with mild or moderate renal impairment
though caution should be used in patients with severe renal impairment.

At least 14 days should elapse between discontinuation of an MAOI &
initiation of Celexa
therapy. At least 14 days should be allowed after stopping Celexa before starting a
MAOI .
Fluvoxamine
LUVOX
**GENEREIC
AVAILABLE

50 mg, administered as a
single daily dose at bedtime. Titration of the dose should be
increased in 50 mg increments every 4
to 7
days, as tolerated, not to exceed 300 mg per day.
The total daily dose of more than 100 mg should be given in two divided doses. If the doses are
not equal, the larger dose should be given at bedtime.

Elderly patients and those with hepatic impairment have been observed to have a
decreased clearance of fluvoxamine maleate. It may be appropriate to modify the initial
dose and the dose titration.
Paroxetine
PAXIL

Administered as a
single initial daily dose of 20mg with or without food, usually in the AM.
Range of 20 to 50mg/day demonstrated antidepressant effectiveness. Some patients that do
not respond to a
20mg daily dose may benefit from dose increases, in 10 mg/day increments,
at intervals of at least 1
week, up to a
maximum of 50 mg/day.

10 mg initial dose in elderly.

Paxil has shown that efficacy is maintained for periods of up to 1
year with doses that
averaged about 30 mg.
Sertraline
ZOLOFT

Initial dose of 50mg once daily, with a range of 50mg to a
maximum of 200mg/day. Given the
24 hour elimination half-life of Zoloft, dose changes should occur at intervals of at least 1
week.

Initial elderly dose of 25mg q
AM, maintenance of 50-75mg q
AM with a
maximum of
75mg BID.
Mitazapine
REMERON

Initial dose of 15mg/day (
7.5 mg in elderly), preferably in the evening prior to sleep. Patients
not responding to the initial 15 mg dose may benefit from dose increases up to a
maximum of
45 mg/day. Dose range is 15mg-45mg. Remeron has an elimination half-life of approximately
20-40 hours; therefore dose changes should be made at 1-2
weeks to allow sufficient time for
therapeutic response.

At least 14 days should elapse between discontinuation of an MAOI &
initiation of
Remeron therapy. At least 14 days should be allowed after stopping Remeron before
starting a
MAOI ..

Clearance of mirtazapine is reduced in elderly patients and in patients with moderate to
severe renal or hepatic impairment. Consequently, the plasma levels may be increased in
these patient groups.
Nefazodone
SERZONE

Initial dose is 200mg (
100mg BID) with an effective dose range of 300-600mg/day. Dose
increases should occur in increments of 100 mg/day to 200 mg/day (
again, on a
BID schedule)
at intervals of no less than 1
week.

Elderly recommended initial dose is 100 mg/day BID. These patients often have reduced
nefazodone clearance and/or increased sensitivity to the side effects of CNS-active
drugs. It may also be appropriate to modify the rate of subsequent dose titration.

At least 14 days should elapse between discontinuation of an MAOI and initiation of
Serzone therapy. Similarly, at least 14 days should be allowed after stopping Serzone
before starting a
MAOI
Venlafaxine
EFFEXOR XR

Initial single dose of 75mg with food either in the AM or PM at approximately the same time
each day. For some patients, it may be desirable to start at 37.5 mg/day for 4
to 7 days, to
allow new patients to adjust to 75 mg/day. Patients not responding to the initial 75 mg/day
dose may benefit from dose increases to a
maximum of approximately 225 mg/day. Dose
increases should be in increments of up to 75 mg/day, as needed, and should be made at
intervals of not less than 4
days.

Recommendation in moderate renal impairment to reduce by 50%, and 25% in moderate
renal impairment.

Elderly: No dose adjustment is recommended on the basis of age. However, caution
should be exercised in treating the elderly. When individualizing the dosage, extra care
should be taken when increasing the dose

At least 14 days should elapse between discontinuation of an MAOI and initiation of
therapy with Effexor. In addition, at least 7
days should be allowed after stopping Effexor
before starting an MA
Venlafaxine
EFFEXOR

Initial starting dose for Effexor is 75 mg/day, administered in two or three divided doses, taken
with food. Depending on tolerability and the need for further clinical effect, the dose may be
increased to 150 mg/day, maximum of 225mg. Increases should be done at increments of up
to 75 mg/day and made at intervals of no less than 7
days.
• It is recommended that the total daily dose be reduced by 50% in patients with moderate
hepatic impairment.

It is recommended that the total daily dose be reduced by 25% in patients with mild to
moderate renal impairment.

No dose adjustment is recommended for elderly patients on the basis of age.

At least 14 days should elapse between discontinuation of an MAOI and initiation of
therapy with Effexor. In addition, at least 7
days should be allowed after stopping Effexor
before starting an MAOI
Information provided is assumed to be correct; however, the provider retains final responsibility for appropriate prescribing. Data Source: 2001 PDR
ANTIDEPRESSANTS COMMONLY USED IN PRIMARY CARE:
NEWER ANTIDEPRESSANTS continued
Drug Name Recommended Dosage General Dosing Comments
Bupropion
WELLBUTRIN SR

Initial adult starting dose is 150mg mg/day, given in the AM. Adult target dose is 150 mg twice
daily, may be made as early as day 4
of dosing. There should be an interval of at least 8
hours
between successive doses.

As with other antidepressants, the full antidepressant effect of WELLBUTRIN SR Tablets may
not be evident until 4
weeks of treatment or longer. An increase in dosage to a
maximum of
400 mg/day, given as 200 mg twice daily, may be considered for patients in whom no clinical
improvement is noted after several weeks of treatment at 300 mg/day.
• Maintenance: the lowest dose that maintains remission is recommended.

It is particularly important to administer WELLBUTRIN SR Tablets in a
manner most likely
to minimize the risk of seizure. Gradual escalation in dosage is also important if
agitation, motor restlessness, and insomnia, often seen during the initial days of
treatment, are to be minimized. If necessary, these effects may be managed by
temporary reduction of dose or the short-term administration of an intermediate to longacting
sedative hypnotic. A
sedative hypnotic usually is not required beyond the first
week of treatment. If distressing, untoward effects supervene, dose escalation should be
stopped
Bupropion
WELLBUTRIN

Initial dosing should begin at200mg/day, given as 100mg BID. The usual adult dose is 300 mg/
day, given three times daily. Based on clinical response, this dose may be increased to 300
mg/day, given as 100 mg three times daily, no sooner than 3
days after beginning therapy.

The full antidepressant effect of WELLBUTRIN may not be evident until 4
weeks of treatment
or longer. An increase in dosage, given in divided dose of 150mg increments, up to a
maximum
of 450 mg/day.

WELLBUTRIN should be discontinued in patients who do not demonstrate an adequate
response after an appropriate period of treatment at 450 mg/day.

It is particularly important to administer WELLBUTRIN in a
manner most likely to
minimize the risk of seizure. Increases in dose should not exceed 100 mg/day in a
3-
day period.
TRICYCLIC ANTIDEPRESSANTS
AMITRIPTYLINE

Initial Dose (
Adults): 75 mg of amitriptyline HCl a
day in divided doses is usually satisfactory.
May be increased to a
total of 150 mg per day. Increases are made preferably in the late
afternoon and/or bedtime doses. A
sedative effect may be apparent before the antidepressant
effect is noted. An adequate therapeutic effect may take as along as 30 days to develop. The
usual maintenance dose is 50 to 100 mg per day

An alternate method of initiating therapy in outpatients is to begin with 50 to 100mg
amitriptyline HCl at bedtime. This may be increased by 25 or 50 mg as necessary in the
bedtime dose to a
total of 150mg per day. The usual maintenance dose is 50 to 100 mg per
day

Elderly: lower dosages are recommended. 10mg three times a
day with 20 mg at bedtime
may be satisfactory.

Dosage should be initiated at a
low level and increased gradually, noting carefully the
clinical response and any evidence of intolerance. High sedation and anticohlinergic
activity.

Death may occur from overdosage with this class of drug
DOXEPIN

For mild to moderate severity, a
starting daily dose of 75 mg is recommended. The usual
optimum dose range is 75 mg/day to 150 mg/day. May be given on a
divided or once-a-day
dosage schedule. In more severely ill patients higher doses may be required with subsequent
gradual increase to 300 mg/day if necessary. Additional therapeutic effect is rarely to be
obtained by exceeding a
dose of 300 mg/day.

Death may occur from overdosage with this class of drug
NORTRIPTYLINE

Initiate dosages at a
low level and increase it gradually, checking the clinical response carefully
and noting any evidence of intolerance. Adults: 25 mg 3
or 4
times daily; dosage should begin
at a
low level and be increased as required. As an alternate regimen, the total daily dose may
be given once a
day at bedtime. When doses above 100 mg daily are administered, plasma
levels of nortriptyline should be monitored and maintained in the optimum range of 50 to 150
ng/mL. Doses above 150 mg/day are not recommended.

Elderly: 30 to 50 mg/day, in divided doses.

Nortriptyline is not recommended for children
TRAZODONE

Usual adult dosage: The recommended initial dose is 150 daily, in 2
or 3
divided doses.
Trazodone should be taken shortly after a
meal or light snack in order to reduce the incidence
of adverse reactions. The initial dose may be increased according to tolerance and response
by increments of 50 mg every 3-4
days, usually up to 300 mg daily in divided doses. ,
not to
exceed 400 mg daily. Elderly: one-half the recommended adult dosage should be used.

Occurrence of drowsiness may require the administration of a
major portion of the daily
dose at bedtime or a
reduction of dosage. Once an adequate response has been
achieved, the dosage may be gradually reduced, with adjustment depending on
therapeutic response. During prolonged maintenance therapy the dosage should be kept
at the lowest effective level.
IMIPRAMINE

Adults: Initial Dosage: 25 mg 3
times daily. This should be increased gradually as required and
tolerated up to 150 mg/day. Dosages over 200 mg/day are not recommended. Maintenance :
50-150mg daily

Elderly and Debilitated Patients: 30 to 40 mg/day, in divided doses, gradually increasing
dosage if necessary, and tolerated; it is generally not necessary to exceed 100 mg/day.
DESIPRAMINE

Adult Dose: 100 to 200 mg per day. Dosages above 300 mg/day are not recommended. Initiate
dosage at lower level and increased according to tolerance and clinical response. Initial
therapy may be administered in divided doses or a
single daily dose. Maintenance therapy may
be given on a
once-daily schedule.

Elderly: lower dosages, 25-100mg daily, are recommended. Doses above 150mg are not
recommended.

Not recommended for use in children

Clinical symptoms of intolerance, especially drowsiness, dizziness, and postural
hypotension should alert the need for reduction in dosage..
Information provided is assumed to be correct; however, the provider retains final responsibility for appropriate prescribing. Data Source: 2001 PDR pdr 2001



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