strategies to switch antidepressants brittany parmentier, pharmd pgy2 behavioral care resident...

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 Networkbparmentier@ecommunity.com