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Strategies to Switch Antidepressants
Brittany Parmentier, PharmDPGY2 Behavioral Care ResidentButler University/Community Health Network
This speaker has no actual or potential conflicts of interest to disclose in relation to this presentation.
AD – antidepressant SSRI – selective serotonin reuptake inhibitorSNRI – serotonin norepinephrine reuptake inhibitor TCA – tricyclic antidepressantMAOI – monoamine oxidase inhibitor
Abbreviations
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
Need for Switch
Trivedi MH e al. Am J Psychiatry. 2006;163:28-40. Fava M et al. Psychiatr Clin N Am. 2003;26:457-494.
Optimize dose
Adequate duration
Key Points before Switching
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.
Individualized therapy for each patient
Variations in acute and ambulatory practice
Limited data comparing one strategy to another
General Considerations
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.
• 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 Fluoxetine 20 mg Paroxetine 20 mg Citalopram 20 mg Escitalopram 10 mg Sertraline 50 mg Fluvoxamine 50 mg
SSRI Dose Equivalency
Hayasaka Y et al. J Affect Disord. 2015;180:179-184.
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
SSRI to SNRI
Marangell. J Clin Psychiatry. 2001;62(Suppl 18):12-7.Jefferson JW. J Clin Psychiatry. 2008;69(Suppl E1):14-18.
Venlafaxine SSRI• Direct switch to therapeutic SSRI dose• Cross-taper
Duloxetine SSRI• Direct switch to therapeutic SSRI dose• Cross-taper
SNRI to SSRI
Marangell. J Clin Psychiatry. 2001;62(Suppl 18):12-7.Jefferson JW. J Clin Psychiatry. 2008;69(Suppl E1):14-18.
To/from another agent Cross-taper
Bupropion, Mirtazapine, and TCAs
Marangell. J Clin Psychiatry. 2001;62(Suppl 18):12-7.Jefferson JW. J Clin Psychiatry. 2008;69(Suppl E1):14-18.
MAOI MAOIMAOI 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
MAOIs – High Risk for Toxicity
Marangell. J Clin Psychiatry. 2001;62(Suppl 18):12-7.Jefferson JW. J Clin Psychiatry. 2008;69(Suppl E1):14-18.
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
Assessment Question
Strategies to Switch Antidepressants
Brittany Parmentier, PharmDPGY2 Behavioral Care ResidentButler University/Community Health [email protected]
