Download Strategies to Switch Antidepressants

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.
Abbreviations
AD – antidepressant
SSRI – selective serotonin reuptake inhibitor
SNRI – serotonin norepinephrine reuptake inhibitor
TCA – tricyclic antidepressant
MAOI – monoamine oxidase inhibitor
Need for Switch
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
Trivedi MH e al. Am J Psychiatry. 2006;163:28-40.
Fava M et al. Psychiatr Clin N Am. 2003;26:457-494.
Key Points before Switching
Optimize
dose
Adequate
duration
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.
General Considerations
Individualized therapy for each patient
Variations in acute and ambulatory practice
Limited data comparing one strategy to
another
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.
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•
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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 Equivalency
SSRI
Fluoxetine
Paroxetine
Citalopram
Escitalopram
Sertraline
Fluvoxamine
Hayasaka Y et al. J Affect Disord. 2015;180:179-184.
Dose
20 mg
20 mg
20 mg
10 mg
50 mg
50 mg
SSRI to SNRI
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
Marangell. J Clin Psychiatry. 2001;62(Suppl 18):12-7.
Jefferson JW. J Clin Psychiatry. 2008;69(Suppl E1):14-18.
SNRI to SSRI
Venlafaxine  SSRI
• Direct switch to therapeutic SSRI dose
• Cross-taper
Duloxetine  SSRI
• Direct switch to therapeutic SSRI dose
• Cross-taper
Marangell. J Clin Psychiatry. 2001;62(Suppl 18):12-7.
Jefferson JW. J Clin Psychiatry. 2008;69(Suppl E1):14-18.
Bupropion, Mirtazapine, and TCAs
To/from
another agent
Marangell. J Clin Psychiatry. 2001;62(Suppl 18):12-7.
Jefferson JW. J Clin Psychiatry. 2008;69(Suppl E1):14-18.
Cross-taper
MAOIs – High Risk for Toxicity
MAOI  MAOI
MAOI  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
Marangell. J Clin Psychiatry. 2001;62(Suppl 18):12-7.
Jefferson JW. J Clin Psychiatry. 2008;69(Suppl E1):14-18.
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
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
Strategies to Switch
Antidepressants
Brittany Parmentier, PharmD
PGY2 Behavioral Care Resident
Butler University/Community Health Network
[email protected]