ANTIDEPRESSANTS

All dosing is for ADULTS unless otherwise specified. P = drugs with pediatric dosing recommendations.

PRICING INFO

$ = 0 - $50
$$ = $51 - $100
$$$ = $101 - $150
$$$$ = > $151

Pricing based on one month of therapy at standard dosing in an adult
Pricing based on information from GoodRX.com®
Pricing may vary by region and availability

References:

1 - Manufacturer's Package Insert for each drug listed

PREGNANCY SAFETY STUDIES

Association Between Serotonergic Antidepressant Use During Pregnancy and Autism Spectrum Disorder in Children - JAMA (2017) [PMID 28418480]

DESIGN: Retrospective cohort study (N=35,906 pregnancies)
EXPOSURE: Serotonergic antidepressant exposure defined as 2 or more consecutive maternal prescriptions for a SSRI or SNRI between conception and delivery
PRIMARY OUTCOME: Child autism spectrum disorder identified after the age of 2 years
FINDINGS: In children born to mothers receiving public drug coverage in Ontario, Canada, in utero serotonergic antidepressant exposure compared with no exposure was not associated with autism spectrum disorder in the child. Although a causal relationship cannot be ruled out, the previously observed association may be explained by other factors.

Associations of Maternal Antidepressant Use During the First Trimester of Pregnancy With Preterm Birth, Small for Gestational Age, Autism Spectrum Disorder, and Attention-Deficit/Hyperactivity Disorder in Offspring - JAMA (2017) [PMID 28418479]

DESIGN: Retrospective cohort study (N=1,508,629 offspring)
EXPOSURE: Maternal self-reported first-trimester antidepressant use and first-trimester antidepressant dispensations
PRIMARY OUTCOME: Preterm birth (<37 gestational weeks), small for gestational age (birth weight <2 SDs below the mean for gestational age), and first inpatient or outpatient clinical diagnosis of autism spectrum disorder and attention-deficit/hyperactivity disorder in offspring
FINDINGS: Among offspring born in Sweden, after accounting for confounding factors, first-trimester exposure to antidepressants, compared with no exposure, was associated with a small increased risk of preterm birth but no increased risk of small for gestational age, autism spectrum disorder, or attention-deficit/hyperactivity disorder

Neonatal Morbidity After Maternal Use of Antidepressant Drugs During Pregnancy. (Pediatrics 2016) [PubMed abstract]

Design: Cohort registry study
Results: Maternal use of antidepressants during pregnancy was associated with increased neonatal morbidity and a higher rate of admissions to the NICU. The absolute risk for severe disease was low, however.

Association of SSRI Exposure During Pregnancy With Speech, Scholastic, and Motor Disorders in Offspring. (JAMA Psychiatry 2016) [PubMed abstract]

Design: Cohort registry study
Results: Exposure to SSRIs during pregnancy was associated with an increased risk of speech/language disorders. This finding may have implications for understanding associations between SSRIs and child development.

Pregnancy Complications Following Prenatal Exposure to SSRIs or Maternal Psychiatric Disorders (Am J Psychiatry 2015) [PubMed abstract]

Design: Cohort registry study
Results: In a large national birth cohort, treatment of maternal psychiatric disorders with SSRIs during pregnancy was related to a lower risk of preterm birth and cesarean section but a higher risk of neonatal maladaptation. The findings provide novel evidence for a protective role of SSRIs on some deleterious reproductive outcomes, possibly by reducing maternal depressive symptoms. The divergent findings suggest that clinical decisions on SSRI use during pregnancy should be individualized, taking into account the mother's psychiatric and reproductive history.

Specific SSRIs and birth defects: bayesian analysis to interpret new data in the context of previous reports. (BMJ 2015) [PubMed abstract]

Design: Bayesian case-control study
Results: These data provide reassuring evidence for some SSRIs but suggest that some birth defects occur 2 - 3.5 times more frequently among the infants of women treated with paroxetine or fluoxetine early in pregnancy.

Antidepressant use late in pregnancy and risk of Persistent Pulmonary Hypertension of the Newborn (PPHN) (JAMA 2015) [PubMed abstract]

Design: Cohort registry study
Results: Evidence from this large study of publicly insured pregnant women may be consistent with a potential increased risk of PPHN associated with maternal use of SSRIs in late pregnancy. However, the absolute risk was small, and the risk increase appears more modest than suggested in previous studies.

SSRIs and venlafaxine in early pregnancy and risk of birth defects (BMJ 2015) [PubMed abstract]

Design: Cohort registry study
Results: In this large Nordic study no substantial increase was found in prevalence of overall cardiac birth defects among infants exposed to SSRIs or venlafaxine in utero. Although the prevalence of septal defects and right ventricular outflow tract defects was higher in exposed infants, the lack of an association in the sibling controlled analyses points against a teratogenic effect of these drugs.

ADDING ANTIPSYCHOTIC IN RESISTANT MDD

Efficacy, safety, and tolerability of augmentation pharmacotherapy with aripiprazole for treatment-resistant depression in late life (Lancet 2015) [PubMed abstract]

Design: Randomized controlled trial
Results: In adults aged 60 years or older who do not achieve remission from depression with a first-line antidepressant, the addition of aripiprazole is effective in achieving and sustaining remission. Tolerability concerns include the potential for akathisia and Parkinsonism.

TAMOXIFEN INTERACTION STUDIES

Risk of mortality with concomitant use of tamoxifen and SSRIs: multi-database cohort study. (BMJ 2016) [PubMed abstract]

Design: Cohort study
Results: Concomitant use of tamoxifen and potent CYP2D6 inhibiting SSRIs versus other SSRIs was not associated with an increased risk of death

Tamoxifen and Antidepressant Drug Interaction in a Cohort of 16,887 Breast Cancer Survivors (J Natl Cancer Inst 2015) [PubMed abstract]

Design: Cohort registry study
Results: Using the comprehensive electronic health records of insured patients, we did not observe an increased risk of subsequent breast cancer in women who concurrently used tamoxifen and antidepressants, including paroxetine.

BUPROPION AND SMOKING CESSATION

Neuropsychiatric safety and efficacy of varenicline, bupropion, and nicotine patch in smokers with and without psychiatric disorders, Lancet (2016) [PubMed abstract]

DESIGN: Randomized placebo-controlled trial (N=8144, length=24 weeks)
TREATMENT: Nicotine patch vs Varenicline vs Bupropion vs Placebo
PRIMARY OUTCOME: 1. Incidence of a composite measure of moderate and severe neuropsychiatric adverse events 2. Biochemically confirmed continuous abstinence for weeks 9-12
RESULTS:The study did not show a significant increase in neuropsychiatric adverse events attributable to varenicline or bupropion relative to nicotine patch or placebo. Varenicline was more effective than placebo, nicotine patch, and bupropion in helping smokers achieve abstinence, whereas bupropion and nicotine patch were more effective than placebo.

LEXAPRO IN HEART FAILURE STUDY

Effect of Escitalopram on All-Cause Mortality and Hospitalization in Patients With Heart Failure and Depression: The MOOD-HF Randomized Clinical Trial, JAMA (2016) [PubMed abstract]

DESIGN: Randomized placebo-controlled trial (N=372, length=24 months)
TREATMENT: Lexapro 10 - 20 mg vs Placebo
PRIMARY OUTCOME: The composite primary outcome was time to all-cause death or hospitalization
RESULTS: In patients with chronic heart failure with reduced ejection fraction and depression, 18 months of treatment with escitalopram compared with placebo did not significantly reduce all-cause mortality or hospitalization, and there was no significant improvement in depression. These findings do not support the use of escitalopram in patients with chronic systolic heart failure and depression.

Drug	Dosage form	Dosage	Generic/Price	Other	Class/Mechanism of Action	Indications (FDA-approved)	Side Effects	Drug Interactions	Precautions/ Contraindications
Citalopram (Celexa®)	Citalopram tablet 10 mg 20 mg 40 mg	Depression Starting: 20 mg a day Maintenance: 20 - 40 mg a day Max: 40 mg a day Max dose of 20 mg a day recommended for patients > 60 years old, and patients with liver disease For patients who are poor CYP2C19 metabolizers, and patients taking CYP2C19 inhibitors, the maximum daily dose is 20 mg. See CYP2C19 for more.	Citalopram YES/$	May take without regard to food	SSRI Inhibits serotonin reuptake by neurons	Depression	NOTE: P = % of patients on placebo who reported side effect Nausea - 21%, P - 14% Dry mouth - 20%, P - 14% Somnolence - 18%, P - 10% Insomnia - 15%, P - 14% Increased sweating - 11%, P - 9% Ejaculation disorder - 6%, P - 1%	MAO inhibitors - DO NOT COMBINE Pimozide (Orap®) - DO NOT COMBINE Drugs that prolong the QT interval - DO NOT COMBINE Serotonergic drugs - may increase risk of serotonin syndrome Anticoagulant/Antiplatelet meds - may increase bleeding risk CYP2C19 inhibitors - may increase citalopram levels. Maximum citalopram dose is 20 mg a day.	Prolonged QT syndrome - citalopram should be stopped in patients with persistent QT_c longer than 500 ms Serotonin syndrome Abnormal bleeding - through platelet inhibition Glaucoma - may cause pupil dilation that precipitates angle-closure glaucoma Suicide - possible increase in risk when starting therapy in patients ≤ 24 years old Bipolar - may precipitate mania in bipolar patients Seizure - possible increase risk Low sodium (hyponatremia) - may cause SIADH Abrupt discontinuation - anxiety, confusion, paresthesias, etc. Poor CYP2C19 metabolizers - max dose 20 mg a day Liver disease - maximum dose is 20 mg a day Kidney disease CrCl ≥ 30 ml/min: no dose adjustment necessary CrCl < 30 ml/min: use caution

Drug

Dosage form

Dosage

Generic/Price

Other

Class/Mechanism of Action

Indications
(FDA-approved)

Side Effects

Drug Interactions

Precautions/
Contraindications

Citalopram

(Celexa®)

Citalopram tablet

10 mg
20 mg
40 mg

Depression

Starting: 20 mg a day
Maintenance: 20 - 40 mg a day
Max: 40 mg a day
Max dose of 20 mg a day recommended for patients > 60 years old, and patients with liver disease
For patients who are poor CYP2C19 metabolizers, and patients taking CYP2C19 inhibitors, the maximum daily dose is 20 mg. See CYP2C19 for more.

Citalopram
YES/$

May take without regard to food

SSRI
Inhibits serotonin reuptake by neurons

Depression

NOTE: P = % of patients on placebo who reported side effect

Nausea - 21%, P - 14%
Dry mouth - 20%, P - 14%
Somnolence - 18%, P - 10%
Insomnia - 15%, P - 14%
Increased sweating - 11%, P - 9%
Ejaculation disorder - 6%, P - 1%

MAO inhibitors - DO NOT COMBINE
Pimozide (Orap®) - DO NOT COMBINE
Drugs that prolong the QT interval - DO NOT COMBINE
Serotonergic drugs - may increase risk of serotonin syndrome
Anticoagulant/Antiplatelet meds - may increase bleeding risk
CYP2C19 inhibitors - may increase citalopram levels. Maximum citalopram dose is 20 mg a day.

Prolonged QT syndrome - citalopram should be stopped in patients with persistent QT_c longer than 500 ms
Serotonin syndrome
Abnormal bleeding - through platelet inhibition
Glaucoma - may cause pupil dilation that precipitates angle-closure glaucoma
Suicide - possible increase in risk when starting therapy in patients ≤ 24 years old
Bipolar - may precipitate mania in bipolar patients
Seizure - possible increase risk
Low sodium (hyponatremia) - may cause SIADH
Abrupt discontinuation - anxiety, confusion, paresthesias, etc.
Poor CYP2C19 metabolizers - max dose 20 mg a day
Liver disease - maximum dose is 20 mg a day
Kidney disease

CrCl ≥ 30 ml/min: no dose adjustment necessary
CrCl < 30 ml/min: use caution

Drug	Dosage form	Dosage	Generic/Price	Other / Studies	Class/Mechanism of Action	Indications (FDA-approved)	Side Effects	Drug Interactions	Precautions/ Contraindications
Escitalopram (Lexapro®)	Escitalopram tablet 5 mg 10 mg 20 mg	Depression Adults Starting: 10 mg once daily Maintenance: 10 - 20 mg once daily Max: 20 mg once daily Liver disease: 10 mg once daily Elderly: 10 mg once daily Increase dose after a minimum of one week Adolescents (12 - 17 years) Starting: 10 mg once daily Maintenance: 10 - 20 mg once daily Max: 20 mg once daily Increase dose after a minimum of three weeks Generalized anxiety disorder Starting: 10 mg once daily Maintenance: 10 - 20 mg once daily Max: 20 mg once daily Liver disease: 10 mg once daily Elderly: 10 mg once daily Increase dose after a minimum of one week	Escitalopram YES/$	Other May take without regard to food Studies Lexapro vs Placebo in patients with heart failure and depression	SSRI Inhibits serotonin reuptake by neurons	Depression Generalized anxiety disorder	NOTE: P = % of patients on placebo who reported side effect Nausea - 15%, P - 7% Insomnia - 9%, P - 4% Ejaculation disorder (delay) - 9%, P - <1% Diarrhea - 8%, P - 5% Somnolence - 6%, P - 2%	MAO inhibitors - DO NOT COMBINE Pimozide (Orap®) - DO NOT COMBINE Drugs that prolong the QT interval Serotonergic drugs - may increase risk of serotonin syndrome Anticoagulant/Antiplatelet meds - may increase bleeding risk CYP2D6 substrates - escitalopram is a weak CYP2D6 inhibitor	Serotonin syndrome Seizure - possible increase risk Glaucoma - may cause pupil dilation that precipitates angle-closure glaucoma Suicide - possible increase in risk when starting therapy in patients ≤ 24 years old Bipolar - may precipitate mania in bipolar patients Abnormal bleeding - through platelet inhibition Low sodium (hyponatremia) - may cause SIADH Prolonged QT syndrome - may worsen QT prolongation Abrupt discontinuation - anxiety, confusion, paresthesias, etc. Liver disease - recommended dose is 10 mg a day Kidney disease CrCl ≥ 30 ml/min: no dose adjustment necessary CrCl < 30 ml/min: use caution

Drug

Dosage form

Dosage

Generic/Price

Other / Studies

Class/Mechanism of Action

Indications
(FDA-approved)

Side Effects

Drug Interactions

Precautions/
Contraindications

Escitalopram

(Lexapro®)

Escitalopram tablet

5 mg
10 mg
20 mg

Depression

Adults

Starting: 10 mg once daily
Maintenance: 10 - 20 mg once daily
Max: 20 mg once daily
Liver disease: 10 mg once daily
Elderly: 10 mg once daily
Increase dose after a minimum of one week

Adolescents (12 - 17 years)

Starting: 10 mg once daily
Maintenance: 10 - 20 mg once daily
Max: 20 mg once daily
Increase dose after a minimum of three weeks

Generalized anxiety disorder

Starting: 10 mg once daily
Maintenance: 10 - 20 mg once daily
Max: 20 mg once daily
Liver disease: 10 mg once daily
Elderly: 10 mg once daily
Increase dose after a minimum of one week

Escitalopram
YES/$

Other

May take without regard to food

Studies

Lexapro vs Placebo in patients with heart failure and depression

SSRI
Inhibits serotonin reuptake by neurons

Depression
Generalized anxiety disorder

NOTE: P = % of patients on placebo who reported side effect

Nausea - 15%, P - 7%
Insomnia - 9%, P - 4%
Ejaculation disorder (delay) - 9%, P - <1%
Diarrhea - 8%, P - 5%
Somnolence - 6%, P - 2%

MAO inhibitors - DO NOT COMBINE
Pimozide (Orap®) - DO NOT COMBINE
Drugs that prolong the QT interval
Serotonergic drugs - may increase risk of serotonin syndrome
Anticoagulant/Antiplatelet meds - may increase bleeding risk
CYP2D6 substrates - escitalopram is a weak CYP2D6 inhibitor

Serotonin syndrome
Seizure - possible increase risk
Glaucoma - may cause pupil dilation that precipitates angle-closure glaucoma
Suicide - possible increase in risk when starting therapy in patients ≤ 24 years old
Bipolar - may precipitate mania in bipolar patients
Abnormal bleeding - through platelet inhibition
Low sodium (hyponatremia) - may cause SIADH
Prolonged QT syndrome - may worsen QT prolongation
Abrupt discontinuation - anxiety, confusion, paresthesias, etc.
Liver disease - recommended dose is 10 mg a day
Kidney disease

CrCl ≥ 30 ml/min: no dose adjustment necessary
CrCl < 30 ml/min: use caution

Drug	Dosage form	Dosage	Generic/Price	Other	Mechanism of Action	FDA-approved indications	Side Effects	Drug Interactions	Precautions / Contraindications
Fluoxetine (Prozac®) (Prozac weekly™) (Sarafem®) Fluoxetine + olanzapine (Symbyax®)	Fluoxetine capsule 10 mg 20 mg 40 mg Fluoxetine tablet 10 mg 20 mg 60 mg Prozac Weekly® 90 mg capsule Sarafem® tablet 10 mg 15 mg 20 mg Symbyax® capsule Olanzapine(mg):Fluoxetine(mg) 3 : 25 6 : 25 6 : 50 12 : 25 12 : 50	Fluoxetine (Prozac®) Depression (Adults) Starting: 20 mg once daily Maintenance: 20 - 40 mg once daily Max: 80 mg once daily Depression (Children and adolescents) Starting: 10 - 20 mg once daily Maintenance: 10 - 20 mg once daily Max: 20 mg once daily Lower weight children may only require 10 mg/day In trials, children as young as 8 years old were included Obsessive compulsive disorder (Adults) Starting: 20 mg once daily Maintenance: 20 - 60 mg once daily Max: 80 mg once daily Obsessive compulsive disorder (Adolescents and higher weight children) Starting: 10 mg once daily for 2 weeks, then 20 mg once daily Maintenance: 20 - 60 mg once daily Max: 60 mg once daily In trials, children as young as 7 years old were included Obsessive compulsive disorder (Lower weight children) Starting: 10 mg once daily Maintenance: 20 - 30 mg once daily Max: 30 mg once daily In trials, children as young as 7 years old were included Bulimia nervosa (Adults) Target dose: 60 mg once daily Max: 60 mg once daily In trials, only the 60 mg dose was superior to placebo Panic disorder (Adults) Starting: 10 mg once daily Maintenance: 10 - 60 mg once daily Max: 60 mg once daily Prozac weekly® Depression (Adults) 90 mg once a week Sarafem® Premenstrual dysphoric disorder (Adults) Continuous dosing: 20 mg once daily Intermittent dosing: 20 mg once daily starting 14 days before menstruation through first full day of menses Olanzapine + fluoxetine (Symbyax®) Depression with Bipolar I and treatment-resistant depression (Adults) Starting: 6/25 mg once daily in the evening Maintenance: 6/25 mg - 12/50 mg once daily Max: 18/75 mg once daily See olanzapine for more Depression with Bipolar I (10 - 17 years) Starting: 3/25 mg once daily in the evening Maintenance: 6/25 mg - 12/50 mg once daily Max: 12/50 mg once daily See olanzapine for more	Prozac® YES/$ Prozac weekly™ YES/$$-$$$ Sarafem NO/$$$$ Symbyax™ YES/$$$$	May take without regard to food Switching from daily Prozac to Prozac weekly - start Prozac weekly 7 days after last daily dose Full effect of medication may not be seen for 4 weeks	SSRI Inhibits serotonin reuptake by neurons	Prozac® Depression Obsessive-Compulsive Disorder (OCD) Bulimia Nervosa Panic disorder Premenstrual dysphoric disorder Sarafem® Premenstrual dysphoric disorder Symbyax® Depression associated with Bipolar 1 Treatment resistant depression	NOTE: P = % of patients on placebo who reported side effect Nausea - 22%, P - 9% Headache - 21%, P - 19% Insomnia - 19%, P - 10% Nervousness - 13%, P - 8% Fatigue - 11%, P - 6% Diarrhea - 11%, P - 7% Decreased appetite - 10%, P - 3% Abnormal ejaculation - 7%, P - 1%	Thioridazine - DO NOT COMBINE Pimozide (Orap®) - DO NOT COMBINE MAO inhibitors - DO NOT COMBINE Serotonergic drugs - may increase risk of serotonin syndrome Drugs that prolong the QT interval - fluoxetine may prolong the QT interval. Use caution with other drugs that prolong the QT interval. Anticoagulant/Antiplatelet meds - may increase bleeding risk CYP2D6 substrates - fluoxetine is a strong CYP2D6 inhibitor Tamoxifen - tamoxifen is metabolized by CYP2D6 to its active form. Some studies have found that tamoxifen is not as effective when taken with CYP2D6 strong inhibitors. Other studies have found no effect. See tamoxifen studies for more.	Serotonin syndrome Seizure - possible increase risk Glaucoma - may cause pupil dilation that precipitates angle-closure glaucoma Suicide - possible increase in risk when starting therapy in patients ≤ 24 years old Bipolar - may precipitate mania in bipolar patients Abnormal bleeding - through platelet inhibition Low sodium (hyponatremia) - may cause SIADH Prolonged QT syndrome - may worsen QT prolongation Abrupt discontinuation - anxiety, confusion, paresthesias, etc. Liver disease - use lower or less frequent dose. Manufacturer makes no specific dosage recommendations. Kidney disease - no dose adjustment necessary

Drug

Dosage form

Dosage

Generic/Price

Other

Mechanism of Action

FDA-approved indications

Side Effects

Drug Interactions

Precautions / Contraindications

Fluoxetine

(Prozac®)
(Prozac weekly™)
(Sarafem®)

Fluoxetine + olanzapine

(Symbyax®)

Fluoxetine capsule

10 mg
20 mg
40 mg

Fluoxetine tablet

10 mg
20 mg
60 mg

Prozac Weekly®

90 mg capsule

Sarafem® tablet

10 mg
15 mg
20 mg

Symbyax® capsule
Olanzapine(mg):Fluoxetine(mg)

3 : 25
6 : 25
6 : 50
12 : 25
12 : 50

Fluoxetine (Prozac®)

Depression (Adults)

Starting: 20 mg once daily
Maintenance: 20 - 40 mg once daily
Max: 80 mg once daily

Depression (Children and adolescents)

Starting: 10 - 20 mg once daily
Maintenance: 10 - 20 mg once daily
Max: 20 mg once daily
Lower weight children may only require 10 mg/day
In trials, children as young as 8 years old were included

Obsessive compulsive disorder (Adults)

Starting: 20 mg once daily
Maintenance: 20 - 60 mg once daily
Max: 80 mg once daily

Obsessive compulsive disorder (Adolescents and higher weight children)

Starting: 10 mg once daily for 2 weeks, then 20 mg once daily
Maintenance: 20 - 60 mg once daily
Max: 60 mg once daily
In trials, children as young as 7 years old were included

Obsessive compulsive disorder (Lower weight children)

Starting: 10 mg once daily
Maintenance: 20 - 30 mg once daily
Max: 30 mg once daily
In trials, children as young as 7 years old were included

Bulimia nervosa (Adults)

Target dose: 60 mg once daily
Max: 60 mg once daily
In trials, only the 60 mg dose was superior to placebo

Panic disorder (Adults)

Starting: 10 mg once daily
Maintenance: 10 - 60 mg once daily
Max: 60 mg once daily

Prozac weekly®

Depression (Adults)

90 mg once a week

Sarafem®

Premenstrual dysphoric disorder (Adults)

Continuous dosing: 20 mg once daily
Intermittent dosing: 20 mg once daily starting 14 days before menstruation through first full day of menses

Olanzapine + fluoxetine (Symbyax®)

Depression with Bipolar I and treatment-resistant depression (Adults)

Starting: 6/25 mg once daily in the evening
Maintenance: 6/25 mg - 12/50 mg once daily
Max: 18/75 mg once daily
See olanzapine for more

Depression with Bipolar I (10 - 17 years)

Starting: 3/25 mg once daily in the evening
Maintenance: 6/25 mg - 12/50 mg once daily
Max: 12/50 mg once daily
See olanzapine for more

Prozac®
YES/$

Prozac weekly™
YES/$$-$$$

Sarafem
NO/$$$$

Symbyax™
YES/$$$$

May take without regard to food
Switching from daily Prozac to Prozac weekly - start Prozac weekly 7 days after last daily dose
Full effect of medication may not be seen for 4 weeks

SSRI
Inhibits serotonin reuptake by neurons

Prozac®

Depression
Obsessive-Compulsive Disorder (OCD)
Bulimia Nervosa
Panic disorder
Premenstrual dysphoric disorder

Sarafem®

Premenstrual dysphoric disorder

Symbyax®

Depression associated with Bipolar 1
Treatment resistant depression

NOTE: P = % of patients on placebo who reported side effect

Nausea - 22%, P - 9%
Headache - 21%, P - 19%
Insomnia - 19%, P - 10%
Nervousness - 13%, P - 8%
Fatigue - 11%, P - 6%
Diarrhea - 11%, P - 7%
Decreased appetite - 10%, P - 3%
Abnormal ejaculation - 7%, P - 1%

Thioridazine - DO NOT COMBINE
Pimozide (Orap®) - DO NOT COMBINE
MAO inhibitors - DO NOT COMBINE
Serotonergic drugs - may increase risk of serotonin syndrome
Drugs that prolong the QT interval - fluoxetine may prolong the QT interval. Use caution with other drugs that prolong the QT interval.
Anticoagulant/Antiplatelet meds - may increase bleeding risk
CYP2D6 substrates - fluoxetine is a strong CYP2D6 inhibitor
Tamoxifen - tamoxifen is metabolized by CYP2D6 to its active form. Some studies have found that tamoxifen is not as effective when taken with CYP2D6 strong inhibitors. Other studies have found no effect. See
tamoxifen studies
for more.

Serotonin syndrome
Seizure - possible increase risk
Glaucoma - may cause pupil dilation that precipitates angle-closure glaucoma
Suicide - possible increase in risk when starting therapy in patients ≤ 24 years old
Bipolar - may precipitate mania in bipolar patients
Abnormal bleeding - through platelet inhibition
Low sodium (hyponatremia) - may cause SIADH
Prolonged QT syndrome - may worsen QT prolongation
Abrupt discontinuation - anxiety, confusion, paresthesias, etc.
Liver disease - use lower or less frequent dose. Manufacturer makes no specific dosage recommendations.
Kidney disease - no dose adjustment necessary

Drug	Dosage form	Dosage	Generic/Price	Other	Class/Mechanism of Action	Indications (FDA-approved)	Side Effects	Drug Interactions	Precautions/ Contraindications
Fluvoxamine (Luvox®) (Luvox® CR)	Luvox® tablet 25 mg 50 mg 100 mg Luvox CR® capsule 100 mg 150 mg	Obsessive compulsive disorder Luvox® (Adults) Starting: 50 mg once daily at bedtime Maintenance: 100 - 300 mg/day Max: 300 mg/day Doses > 100 mg should be given in 2 divided doses Increase in increments of 50 mg/day every 4 - 7 days Luvox® (Children and adolescents 8 - 17 years) Starting: 25 mg once daily at bedtime Maintenance: 50 - 200 mg/day Max: 300 mg/day Doses > 50 mg should be given in 2 divided doses Increase dose in increments of 25 mg/day every 4 - 7 days Luvox® CR Starting: 100 mg once daily at bedtime Maintenance: 100 - 300 mg once daily Max: 300 mg once daily Increase in increments of 50 mg/day every 7 days	Luvox® YES/$ Luvox® CR YES/$$$-$$$$	May take without regard to food Because of the potential for drug interactions, fluvoxamine is not widely used	SSRI Inhibits serotonin reuptake by neurons	Obsessive-Compulsive Disorder (OCD)	NOTE: P = % of patients on placebo who reported side effect Nausea - 40%, P - 14% Somnolence - 22%, P - 8% Headache - 22%, P - 20% Insomnia - 21%, P - 10% Fatigue - 14%, P - 6% Dry mouth - 14%, P - 10% Nervousness - 12%, P - 5% Dizziness - 11%, P - 6% Diarrhea - 11%, P - 7% Delayed ejaculation - 8%, P - 1%	Alosetron (Lotronex®) - DO NOT COMBINE MAO inhibitors - DO NOT COMBINE Pimozide (Orap®) - DO NOT COMBINE Thioridazine - DO NOT COMBINE Tizanidine (Zanaflex®) - DO NOT COMBINE Drugs that prolong the QT interval Serotonergic drugs - may increase risk of serotonin syndrome Anticoagulant/Antiplatelet meds - may increase bleeding risk Zolpidem (Ambien®) - fluvoxamine may inhibit zolpidem metabolism and increase zolpidem blood levels CYP1A2 substrates - fluvoxamine is a strong CYP1A2 inhibitor CYP3A4 substrates - fluvoxamine is a strong CYP3A4 inhibitor CYP2C19 substrates - fluvoxamine is a strong CYP2C19 inhibitor CYP2C9 substrates - fluvoxamine is a moderate CYP2C9 inhibitor	Serotonin syndrome Seizure - possible increase risk Glaucoma - may cause pupil dilation that precipitates angle-closure glaucoma Suicide - possible increase in risk when starting therapy in patients ≤ 24 years old Bipolar - may precipitate mania in bipolar patients Abnormal bleeding - through platelet inhibition Low sodium (hyponatremia) - may cause SIADH Prolonged QT syndrome - may worsen QT prolongation Abrupt discontinuation - anxiety, confusion, paresthesias, etc. Liver disease - clearance is decreased. Dose may need to be decreased. Manufacturer makes no specific dosage recommendations. Kidney disease - kidney disease does not appear to affect clearance

Drug

Dosage form

Dosage

Generic/Price

Other

Class/Mechanism of Action

Indications
(FDA-approved)

Side Effects

Drug Interactions

Precautions/
Contraindications

Fluvoxamine

(Luvox®)
(Luvox® CR)

Luvox® tablet

25 mg
50 mg
100 mg

Luvox CR® capsule

100 mg
150 mg

Obsessive compulsive disorder

Luvox® (Adults)

Starting: 50 mg once daily at bedtime
Maintenance: 100 - 300 mg/day
Max: 300 mg/day
Doses > 100 mg should be given in 2 divided doses
Increase in increments of 50 mg/day every 4 - 7 days

Luvox® (Children and adolescents 8 - 17 years)

Starting: 25 mg once daily at bedtime
Maintenance: 50 - 200 mg/day
Max: 300 mg/day
Doses > 50 mg should be given in 2 divided doses
Increase dose in increments of 25 mg/day every 4 - 7 days

Luvox® CR

Starting: 100 mg once daily at bedtime
Maintenance: 100 - 300 mg once daily
Max: 300 mg once daily
Increase in increments of 50 mg/day every 7 days

Luvox®
YES/$

Luvox® CR
YES/$$$-$$$$

May take without regard to food
Because of the potential for drug interactions, fluvoxamine is not widely used

SSRI
Inhibits serotonin reuptake by neurons

Obsessive-Compulsive Disorder (OCD)

NOTE: P = % of patients on placebo who reported side effect

Nausea - 40%, P - 14%
Somnolence - 22%, P - 8%
Headache - 22%, P - 20%
Insomnia - 21%, P - 10%
Fatigue - 14%, P - 6%
Dry mouth - 14%, P - 10%
Nervousness - 12%, P - 5%
Dizziness - 11%, P - 6%
Diarrhea - 11%, P - 7%
Delayed ejaculation - 8%, P - 1%

Alosetron (Lotronex®) - DO NOT COMBINE
MAO inhibitors - DO NOT COMBINE
Pimozide (Orap®) - DO NOT COMBINE
Thioridazine - DO NOT COMBINE
Tizanidine (Zanaflex®) - DO NOT COMBINE
Drugs that prolong the QT interval
Serotonergic drugs - may increase risk of serotonin syndrome
Anticoagulant/Antiplatelet meds - may increase bleeding risk
Zolpidem (Ambien®) - fluvoxamine may inhibit zolpidem metabolism and increase zolpidem blood levels
CYP1A2 substrates - fluvoxamine is a strong CYP1A2 inhibitor
CYP3A4 substrates - fluvoxamine is a strong CYP3A4 inhibitor
CYP2C19 substrates - fluvoxamine is a strong CYP2C19 inhibitor
CYP2C9 substrates - fluvoxamine is a moderate CYP2C9 inhibitor

Serotonin syndrome
Seizure - possible increase risk
Glaucoma - may cause pupil dilation that precipitates angle-closure glaucoma
Suicide - possible increase in risk when starting therapy in patients ≤ 24 years old
Bipolar - may precipitate mania in bipolar patients
Abnormal bleeding - through platelet inhibition
Low sodium (hyponatremia) - may cause SIADH
Prolonged QT syndrome - may worsen QT prolongation
Abrupt discontinuation - anxiety, confusion, paresthesias, etc.
Liver disease - clearance is decreased. Dose may need to be decreased. Manufacturer makes no specific dosage recommendations.
Kidney disease - kidney disease does not appear to affect clearance

Drug	Dosage form	Dosage	Generic/Price	Other	Class/Mechanism of Action	Indications (FDA-approved)	Side Effects	Drug Interactions	Precautions/ Contraindications
Paroxetine (Paxil®) (Paxil CR®) (Brisdelle™) (Pexeva®)	Paxil® (paroxetine HCL) tablet 10 mg 20 mg 30 mg 40 mg Paxil CR® (paroxetine HCL) tablet 12.5 mg 25 mg 37.5 mg Pexeva® (paroxetine mesylate) tablet 10 mg 20 mg 30 mg 40 mg Brisdelle™ (paroxetine mesylate) 7.5 mg	Depression Paxil®, Pexeva® Starting: 20 mg once daily Maintenance: 20 - 50 mg once daily Max: 50 mg once daily Increase in increments of 10 mg/day every 7 days Liver and kidney disease - initial dose 10 mg a day. Do not exceed 40 mg a day. Paxil CR® Starting: 25 mg once daily Maintenance: 25 - 62.5 mg once daily Max: 62.5 mg once daily Increase in increments of 12.5 mg/day every 7 days Liver and kidney disease - initial dose 12.5 mg a day. Do not exceed 50 mg a day. Obsessive compulsive disorder (OCD) Paxil®, Pexeva® Starting: 20 mg once daily Target: 40 mg once daily Max: 60 mg once daily Increase in increments of 10 mg/day every 7 days Panic disorder Paxil®, Pexeva® Starting: 10 mg once daily Target: 40 mg once daily Max: 60 mg once daily Increase in increments of 10 mg/day every 7 days Paxil CR® Starting: 12.5 mg once daily Maintenance: 12.5 - 75 mg once daily Max: 75 mg once daily Increase in increments of 12.5 mg/day every 7 days Social anxiety disorder Paxil® Starting: 20 mg once daily Maintenance: 20 - 60 mg once daily Max: 60 mg once daily Increase in increments of 10 mg/day every 7 days Paxil CR® Starting: 12.5 mg once daily Maintenance: 12.5 - 37.5 mg once daily Max: 37.5 mg once daily Increase in increments of 12.5 mg/day every 7 days Generalized anxiety disorder Paxil®, Pexeva® Starting: 20 mg once daily Target: 20 once daily Max: 50 mg once daily Increase in increments of 10 mg/day every 7 days Posttraumatic stress disorder Paxil® Starting: 20 mg once daily Target: 20 mg once daily Max: 50 mg once daily Increase in increments of 10 mg/day every 7 days Premenstrual dysphoric disorder Paxil CR® Continuous: 12.5 - 25 mg once daily Intermittent: 12.5 - 25 mg once daily during the luteal phase (days 14 - 28 of the menstrual cycle with day 1 being the first day of menses) Vasomotor symptoms associated with menopause Brisdelle™ 7.5 mg once daily at bedtime	Paxil® YES/$ Paxil® CR YES/$$-$$$ Pexeva® NO/$$$$ Brisdelle™ NO/$$$-$$$$	All May take without regard to food Paxil® CR Do not crush or chew tablet	SSRI Inhibits serotonin reuptake by neurons	Paxil® Depression Panic disorder Social anxiety disorder Generalized anxiety disorder Posttraumatic stress disorder (PTSD) Paxil® CR Depression Panic disorder Social anxiety disorder Premenstrual dysphoric disorder Pexeva® Depression Obsessive-Compulsive Disorder (OCD) Panic disorder Generalized anxiety disorder Brisdelle™ Vasomotor symptoms in menopause	NOTE: P = % of patients on placebo who reported side effect Nausea - 26%, P - 9% Somnolence - 23%, P - 9% Headache - 18%, P - 17% Dry Mouth - 18%, P - 12% Fatigue - 15%, P - 6% Constipation - 14%, P - 9% Dizziness - 13%, P - 6% Insomnia - 13%, P - 6% Ejaculatory delay - 13%, P - 0% Diarrhea - 12%, P - 8% Sweating - 11%, P - 2% Other male sexual dysfunction - 10%, P - 0%	MAO inhibitors - DO NOT COMBINE Pimozide (Orap®) - DO NOT COMBINE Thioridazine - DO NOT COMBINE Cimetidine (Tagamet®) - may increase paroxetine levels Risperidone (Risperdal®) - may increase risperidone levels Tricyclic antidepressants (TCA) - may increase TCA levels Fosamprenavir/Ritonavir - may decrease paroxetine levels Drugs that prolong the QT interval Serotonergic drugs - may increase risk of serotonin syndrome Anticoagulant/Antiplatelet meds - may increase bleeding risk CYP2D6 substrates - paroxetine is a strong CYP2D6 inhibitor Tamoxifen - tamoxifen is metabolized by CYP2D6 to its active form. Some studies have found that tamoxifen is not as effective when taken with CYP2D6 strong inhibitors. Other studies have found no effect. See tamoxifen studies for more.	Serotonin syndrome Seizure - possible increase risk Glaucoma - may cause pupil dilation that precipitates angle-closure glaucoma Suicide - possible increase in risk when starting therapy in patients ≤ 24 years old Bipolar - may precipitate mania in bipolar patients Abnormal bleeding - through platelet inhibition Low sodium (hyponatremia) - may cause SIADH Prolonged QT syndrome - may worsen QT prolongation Abrupt discontinuation - anxiety, confusion, paresthesias, etc. Liver disease Paxil, Pexeva Severe (Child-Pugh C): starting - 10 mg/day; do not exceed 40 mg/day Paxil CR Severe (Child-Pugh C): starting - 12.5 mg/day; do not exceed 50 mg/day Brisdelle No dose adjustment necessary Kidney disease Paxil, Pexeva CrCl 30 - 60 ml/min: paroxetine levels increase 2-fold; use caution CrCl < 30 ml/min: starting - 10 mg/day; do not exceed 40 mg/day Paxil CR CrCl 30 - 60 ml/min: paroxetine levels increase 2-fold; use caution CrCl < 30 ml/min: starting - 12.5 mg/day; do not exceed 50 mg/day Brisdelle No dose adjustment necessary

Drug

Dosage form

Dosage

Generic/Price

Other

Class/Mechanism of Action

Indications
(FDA-approved)

Side Effects

Drug Interactions

Precautions/
Contraindications

Paroxetine

(Paxil®)
(Paxil CR®)
(Brisdelle™)
(Pexeva®)

Paxil® (paroxetine HCL) tablet

10 mg
20 mg
30 mg
40 mg

Paxil CR® (paroxetine HCL) tablet

12.5 mg
25 mg
37.5 mg

Pexeva® (paroxetine mesylate) tablet

10 mg
20 mg
30 mg
40 mg

Brisdelle™ (paroxetine mesylate)

7.5 mg

Depression

Paxil®, Pexeva®

Starting: 20 mg once daily
Maintenance: 20 - 50 mg once daily
Max: 50 mg once daily
Increase in increments of 10 mg/day every 7 days
Liver and kidney disease - initial dose 10 mg a day. Do not exceed 40 mg a day.

Paxil CR®

Starting: 25 mg once daily
Maintenance: 25 - 62.5 mg once daily
Max: 62.5 mg once daily
Increase in increments of 12.5 mg/day every 7 days
Liver and kidney disease - initial dose 12.5 mg a day. Do not exceed 50 mg a day.

Obsessive compulsive disorder (OCD)

Paxil®, Pexeva®

Starting: 20 mg once daily
Target: 40 mg once daily
Max: 60 mg once daily
Increase in increments of 10 mg/day every 7 days

Panic disorder

Paxil®, Pexeva®

Starting: 10 mg once daily
Target: 40 mg once daily
Max: 60 mg once daily
Increase in increments of 10 mg/day every 7 days

Paxil CR®

Starting: 12.5 mg once daily
Maintenance: 12.5 - 75 mg once daily
Max: 75 mg once daily
Increase in increments of 12.5 mg/day every 7 days

Social anxiety disorder

Paxil®

Starting: 20 mg once daily
Maintenance: 20 - 60 mg once daily
Max: 60 mg once daily
Increase in increments of 10 mg/day every 7 days

Paxil CR®

Starting: 12.5 mg once daily
Maintenance: 12.5 - 37.5 mg once daily
Max: 37.5 mg once daily
Increase in increments of 12.5 mg/day every 7 days

Generalized anxiety disorder

Paxil®, Pexeva®

Starting: 20 mg once daily
Target: 20 once daily
Max: 50 mg once daily
Increase in increments of 10 mg/day every 7 days

Posttraumatic stress disorder

Paxil®

Starting: 20 mg once daily
Target: 20 mg once daily
Max: 50 mg once daily
Increase in increments of 10 mg/day every 7 days

Premenstrual dysphoric disorder

Paxil CR®

Continuous: 12.5 - 25 mg once daily
Intermittent: 12.5 - 25 mg once daily during the luteal phase (days 14 - 28 of the menstrual cycle with day 1 being the first day of menses)

Vasomotor symptoms associated with menopause

Brisdelle™

7.5 mg once daily at bedtime

Paxil®
YES/$

Paxil® CR
YES/$$-$$$

Pexeva®
NO/$$$$

Brisdelle™
NO/$$$-$$$$

All

May take without regard to food

Paxil® CR

Do not crush or chew tablet

SSRI
Inhibits serotonin reuptake by neurons

Paxil®

Depression
Panic disorder
Social anxiety disorder
Generalized anxiety disorder
Posttraumatic stress disorder (PTSD)

Paxil® CR

Depression
Panic disorder
Social anxiety disorder
Premenstrual dysphoric disorder

Pexeva®

Depression
Obsessive-Compulsive Disorder (OCD)
Panic disorder
Generalized anxiety disorder

Brisdelle™

Vasomotor symptoms in menopause

NOTE: P = % of patients on placebo who reported side effect

Nausea - 26%, P - 9%
Somnolence - 23%, P - 9%
Headache - 18%, P - 17%
Dry Mouth - 18%, P - 12%
Fatigue - 15%, P - 6%
Constipation - 14%, P - 9%
Dizziness - 13%, P - 6%
Insomnia - 13%, P - 6%
Ejaculatory delay - 13%, P - 0%
Diarrhea - 12%, P - 8%
Sweating - 11%, P - 2%
Other male sexual dysfunction - 10%, P - 0%

MAO inhibitors - DO NOT COMBINE
Pimozide (Orap®) - DO NOT COMBINE
Thioridazine - DO NOT COMBINE
Cimetidine (Tagamet®) - may increase paroxetine levels
Risperidone (Risperdal®) - may increase risperidone levels
Tricyclic antidepressants (TCA) - may increase TCA levels
Fosamprenavir/Ritonavir - may decrease paroxetine levels
Drugs that prolong the QT interval
Serotonergic drugs - may increase risk of serotonin syndrome
Anticoagulant/Antiplatelet meds - may increase bleeding risk
CYP2D6 substrates - paroxetine is a strong CYP2D6 inhibitor
Tamoxifen - tamoxifen is metabolized by CYP2D6 to its active form. Some studies have found that tamoxifen is not as effective when taken with CYP2D6 strong inhibitors. Other studies have found no effect. See
tamoxifen studies
for more.

Serotonin syndrome
Seizure - possible increase risk
Glaucoma - may cause pupil dilation that precipitates angle-closure glaucoma
Suicide - possible increase in risk when starting therapy in patients ≤ 24 years old
Bipolar - may precipitate mania in bipolar patients
Abnormal bleeding - through platelet inhibition
Low sodium (hyponatremia) - may cause SIADH
Prolonged QT syndrome - may worsen QT prolongation
Abrupt discontinuation - anxiety, confusion, paresthesias, etc.
Liver disease

Paxil, Pexeva

Severe (Child-Pugh C): starting - 10 mg/day; do not exceed 40 mg/day

Paxil CR

Severe (Child-Pugh C): starting - 12.5 mg/day; do not exceed 50 mg/day

Brisdelle

No dose adjustment necessary

Kidney disease

Paxil, Pexeva

CrCl 30 - 60 ml/min: paroxetine levels increase 2-fold; use caution
CrCl < 30 ml/min: starting - 10 mg/day; do not exceed 40 mg/day

Paxil CR

CrCl 30 - 60 ml/min: paroxetine levels increase 2-fold; use caution
CrCl < 30 ml/min: starting - 12.5 mg/day; do not exceed 50 mg/day

Brisdelle

No dose adjustment necessary

Drug	Dosage form	Dosage	Generic/Price	Other	Class/Mechanism of Action	Indications (FDA-approved)	Side Effects	Drug Interactions	Precautions/ Contraindications
Sertraline (Zoloft®)	Zoloft® 25 mg 50 mg 100 mg	Depression Starting: 50 mg once daily Maintenance: 50 - 200 mg once daily Max: 200 mg once daily Increase dose at intervals of ≥ 1 week Obsessive compulsive disorder Adults Starting: 50 mg once daily Maintenance: 50 - 200 mg once daily Max: 200 mg once daily Increase dose at intervals of ≥ 1 week Children and adolescents Starting (6 - 12 years old): 25 mg once daily Starting (13 - 17 years old): 50 mg once daily Maintenance: 50 - 200 mg once daily Max: 200 mg once daily Increase dose at intervals of ≥ 1 week Panic disorder, Posttraumatic stress disorder (PTSD), Social anxiety disorder Starting: 25 mg once daily Maintenance: 50 - 200 mg once daily Max: 200 mg a day Increase dose at intervals of ≥ 1 week Premenstrual dysphoric disorder Continuous: 50 - 150 mg once daily Intermittent: 50 - 100 mg once daily during the luteal phase (days 14 - 28 of the menstrual cycle with day 1 being the first day of menses) Increase dose at the onset of each new cycle For 100 mg/day intermittent dosing, use 50 mg/day for first 3 days of each new cycle	Zoloft® YES/$	May take without regard to food	Selective Serotonin Reuptake Inhibitor (SSRI) Inhibits serotonin reuptake by neurons	Depression Obsessive-Compulsive Disorder (OCD) Panic disorder Posttraumatic Stress Disorder (PTSD) Premenstrual Dysphoric Disorder Social Anxiety Disorder	NOTE: P = % of patients on placebo who reported side effect Nausea - 25%, P - 11% Headache - 25%, P - 23% Insomnia - 21%, P - 11% Diarrhea - 20%, P - 10% Ejaculation failure - 14%, P - 1% Dry Mouth - 14%, P - 8% Somnolence - 13%, P - 7% Dizziness - 12%, P - 7% Fatigue - 12%, P - 7%	MAO inhibitors - DO NOT COMBINE Pimozide (Orap®) - DO NOT COMBINE Drugs that prolong the QT interval Warfarin (Coumadin®) - may increase effect of warfarin Carbamazepine (Tegretol®) - may reduce sertraline levels Cimetidine (Tagamet®) - may increase sertraline levels Serotonergic drugs - may increase risk of serotonin syndrome Anticoagulant/Antiplatelet meds - may increase bleeding risk CYP2D6 substrates - sertraline is a weak CYP2D6 inhibitor	Serotonin syndrome Seizure - possible increase risk Glaucoma - may cause pupil dilation that precipitates angle-closure glaucoma Suicide - possible increase in risk when starting therapy in patients ≤ 24 years old Bipolar - may precipitate mania in bipolar patients Abnormal bleeding - through platelet inhibition Low sodium (hyponatremia) - may cause SIADH Prolonged QT syndrome - may worsen QT prolongation Abrupt discontinuation - anxiety, confusion, paresthesias, etc. Liver disease - clearance is decreased. Use caution. Decrease dose or frequency. Kidney disease - no dose adjustment necessary

Drug

Dosage form

Dosage

Generic/Price

Other

Class/Mechanism of Action

Indications
(FDA-approved)

Side Effects

Drug Interactions

Precautions/
Contraindications

Sertraline

(Zoloft®)

Zoloft®

25 mg
50 mg
100 mg

Depression

Starting: 50 mg once daily
Maintenance: 50 - 200 mg once daily
Max: 200 mg once daily
Increase dose at intervals of ≥ 1 week

Obsessive compulsive disorder

Adults

Starting: 50 mg once daily
Maintenance: 50 - 200 mg once daily
Max: 200 mg once daily
Increase dose at intervals of ≥ 1 week

Children and adolescents

Starting (6 - 12 years old): 25 mg once daily
Starting (13 - 17 years old): 50 mg once daily
Maintenance: 50 - 200 mg once daily
Max: 200 mg once daily
Increase dose at intervals of ≥ 1 week

Panic disorder,
Posttraumatic stress disorder (PTSD),
Social anxiety disorder

Starting: 25 mg once daily
Maintenance: 50 - 200 mg once daily
Max: 200 mg a day
Increase dose at intervals of ≥ 1 week

Premenstrual dysphoric disorder

Continuous: 50 - 150 mg once daily
Intermittent: 50 - 100 mg once daily during the luteal phase (days 14 - 28 of the menstrual cycle with day 1 being the first day of menses)
Increase dose at the onset of each new cycle
For 100 mg/day intermittent dosing, use 50 mg/day for first 3 days of each new cycle

Zoloft®
YES/$

May take without regard to food

Selective Serotonin Reuptake Inhibitor (SSRI)
Inhibits serotonin reuptake by neurons

Depression
Obsessive-Compulsive Disorder (OCD)
Panic disorder
Posttraumatic Stress Disorder (PTSD)
Premenstrual Dysphoric Disorder
Social Anxiety Disorder

NOTE: P = % of patients on placebo who reported side effect

Nausea - 25%, P - 11%
Headache - 25%, P - 23%
Insomnia - 21%, P - 11%
Diarrhea - 20%, P - 10%
Ejaculation failure - 14%, P - 1%
Dry Mouth - 14%, P - 8%
Somnolence - 13%, P - 7%
Dizziness - 12%, P - 7%
Fatigue - 12%, P - 7%

MAO inhibitors - DO NOT COMBINE
Pimozide (Orap®) - DO NOT COMBINE
Drugs that prolong the QT interval
Warfarin (Coumadin®) - may increase effect of warfarin
Carbamazepine (Tegretol®) - may reduce sertraline levels
Cimetidine (Tagamet®) - may increase sertraline levels
Serotonergic drugs - may increase risk of serotonin syndrome
Anticoagulant/Antiplatelet meds - may increase bleeding risk
CYP2D6 substrates - sertraline is a weak CYP2D6 inhibitor

Serotonin syndrome
Seizure - possible increase risk
Glaucoma - may cause pupil dilation that precipitates angle-closure glaucoma
Suicide - possible increase in risk when starting therapy in patients ≤ 24 years old
Bipolar - may precipitate mania in bipolar patients
Abnormal bleeding - through platelet inhibition
Low sodium (hyponatremia) - may cause SIADH
Prolonged QT syndrome - may worsen QT prolongation
Abrupt discontinuation - anxiety, confusion, paresthesias, etc.
Liver disease - clearance is decreased. Use caution. Decrease dose or frequency.
Kidney disease - no dose adjustment necessary

Drug	Dosage form	Dosage	Generic/Price	Other	Class/Mechanism of Action	Indications (FDA-approved)	Side Effects	Drug Interactions	Precautions/ Contraindications
Desvenlafaxine Succinate (Pristiq®) Desvenlafaxine (Khedezla™)	Pristiq® extended-release tablet 25 mg 50 mg 100 mg Khedezla™ extended-release tablet 50 mg 100 mg	Depression Pristiq®, Khedezla™ Starting: 50 mg once daily Maintenance: 50 - 400 mg once daily Max: 400 mg once daily Pristiq and Khedezla are not considered therapeutically equivalent and cannot be substituted for each other	Pristiq® YES/$$-$$$ Khedezla™ YES/$$$-$$$$	Pristiq®, Khedezla™ May take without regard to food Take at approximately the same time every day Do not cut, crush, or chew tablet In trials, no additional benefit was seen at doses greater than 50 mg a day	Serotonin-Norepinephrine Reuptake Inhibitor (SNRI) Inhibits serotonin and norepinephrine reuptake by neurons	Depression	NOTE: P = % of patients on placebo who reported side effect. Side effects presented here are for 100 mg/day dosing. Nausea - 26%, P - 10% Dry Mouth - 17%, P - 9% Insomnia - 12%, P - 6% Sweating - 11%, P - 4% Dizziness - 10%, P - 5% Constipation - 9%, P - 4% Ejaculation delay - 5%, P - < 1% Erectile dysfunction - 6%, P - 1% Orthostatic hypotension - 8% of patients ≥ 65 years Elevated blood pressure - desvenlafaxine may cause an increase in blood pressure. Effect is typically small. Average SBP increase 2 - 4 mmHg. Elevated cholesterol - desvenlafaxine may raise cholesterol levels (4 - 10% of patients)	MAO inhibitors - DO NOT COMBINE. Do not start a MAO inhibitor within 7 days of stopping desvenlafaxine . Do not start desvenlafaxine within 14 days of stopping a MAO inhibitor. Serotonergic drugs - may increase risk of serotonin syndrome Anticoagulant/Antiplatelet meds - desvenlafaxine may increase bleeding risk when taken with drugs that affect hemostasis CYP2D6 substrates - desvenlafaxine is a weak CYP2D6 inhibitor. When taking desvenlafaxine 400 mg a day, may need to half dose of sensitive CYP2D6 substrates. CYP3A4 strong inhibitors - desvenlafaxine is a minor substrate of CYP3A4. Strong CYP3A4 inhibitors may increase desvenlafaxine levels.	Serotonin syndrome Seizure - possible increase risk Hypertension - may raise blood pressure Glaucoma - may cause pupil dilation that precipitates angle-closure glaucoma Suicide - possible increase in risk when starting therapy in patients ≤ 24 years old Bipolar - may precipitate mania in bipolar patients Abnormal bleeding - serotonin is involved in platelet activation. Desvenlafaxine may inhibit serotonin uptake by platelets and increase the risk of bleeding. Low sodium (hyponatremia) - may cause SIADH Abrupt discontinuation - anxiety, confusion, paresthesias, etc. Liver disease Moderate-severe disease (Child-Pugh B and C): recommended dose is 50 mg/day; do not exceed 100 mg/day Kidney disease CrCl 30 - 50 ml/min: max dose is 50 mg a day CrCl < 30 ml/min: max dose is 25 mg every day or 50 mg every other day

Drug

Dosage form

Dosage

Generic/Price

Other

Class/Mechanism of Action

Indications
(FDA-approved)

Side Effects

Drug Interactions

Precautions/
Contraindications

Desvenlafaxine Succinate

(Pristiq®)

Desvenlafaxine

(Khedezla™)

Pristiq®
extended-release tablet

25 mg
50 mg
100 mg

Khedezla™
extended-release tablet

50 mg
100 mg

Depression

Pristiq®, Khedezla™

Starting: 50 mg once daily
Maintenance: 50 - 400 mg once daily
Max: 400 mg once daily
Pristiq and Khedezla are not considered therapeutically equivalent and cannot be substituted for each other

Pristiq®
YES/$$-$$$

Khedezla™
YES/$$$-$$$$

Pristiq®, Khedezla™

May take without regard to food
Take at approximately the same time every day
Do not cut, crush, or chew tablet
In trials, no additional benefit was seen at doses greater than 50 mg a day

Serotonin-Norepinephrine Reuptake Inhibitor (SNRI)
Inhibits serotonin and norepinephrine reuptake by neurons

Depression

NOTE: P = % of patients on placebo who reported side effect. Side effects presented here are for 100 mg/day dosing.

Nausea - 26%, P - 10%
Dry Mouth - 17%, P - 9%
Insomnia - 12%, P - 6%
Sweating - 11%, P - 4%
Dizziness - 10%, P - 5%
Constipation - 9%, P - 4%
Ejaculation delay - 5%, P - < 1%
Erectile dysfunction - 6%, P - 1%
Orthostatic hypotension - 8% of patients ≥ 65 years
Elevated blood pressure - desvenlafaxine may cause an increase in blood pressure. Effect is typically small. Average SBP increase 2 - 4 mmHg.
Elevated cholesterol - desvenlafaxine may raise cholesterol levels (4 - 10% of patients)

MAO inhibitors - DO NOT COMBINE. Do not start a MAO inhibitor within 7 days of stopping desvenlafaxine . Do not start desvenlafaxine within 14 days of stopping a MAO inhibitor.
Serotonergic drugs - may increase risk of serotonin syndrome
Anticoagulant/Antiplatelet meds - desvenlafaxine may increase bleeding risk when taken with drugs that affect hemostasis
CYP2D6 substrates - desvenlafaxine is a weak CYP2D6 inhibitor. When taking desvenlafaxine 400 mg a day, may need to half dose of sensitive CYP2D6 substrates.
CYP3A4 strong inhibitors - desvenlafaxine is a minor substrate of CYP3A4. Strong CYP3A4 inhibitors may increase desvenlafaxine levels.

Serotonin syndrome
Seizure - possible increase risk
Hypertension - may raise blood pressure
Glaucoma - may cause pupil dilation that precipitates angle-closure glaucoma
Suicide - possible increase in risk when starting therapy in patients ≤ 24 years old
Bipolar - may precipitate mania in bipolar patients
Abnormal bleeding - serotonin is involved in platelet activation. Desvenlafaxine may inhibit serotonin uptake by platelets and increase the risk of bleeding.
Low sodium (hyponatremia) - may cause SIADH
Abrupt discontinuation - anxiety, confusion, paresthesias, etc.
Liver disease

Moderate-severe disease (Child-Pugh B and C): recommended dose is 50 mg/day; do not exceed 100 mg/day

Kidney disease

CrCl 30 - 50 ml/min: max dose is 50 mg a day
CrCl < 30 ml/min: max dose is 25 mg every day or 50 mg every other day

Drug	Dosage form	Dosage	Generic/Price	Other	Class/Mechanism of Action	Indications (FDA-approved)	Side Effects	Drug Interactions	Precautions/ Contraindications
Duloxetine (Cymbalta®)	Cymbalta® capsule 20 mg 30 mg 60 mg	Depression Starting: 30 - 60 mg/day Maintenance: 40 - 60 mg/day Max: 120 mg/day May be given once daily or in two divided doses Generalized anxiety disorder Adults Starting: 30 - 60 mg once daily Maintenance: 60 - 120 mg once daily Max: 120 mg once daily For elderly patients, starting dose should be 30 mg once daily. Increase to 60 mg once daily after 2 weeks. Children and adolescents (7 - 17 years) Starting: 30 mg once daily Maintenance: 30 - 60 mg once daily Max: 120 mg/day Increase dose in increments of 30 mg/day at intervals of ≥ 2 weeks Diabetic peripheral neuropathy Starting: 30 - 60 mg once daily Target: 60 mg once daily Max: 60 mg once daily Fibromyalgia Starting: 30 - 60 mg once daily Target: 60 mg once daily Max: 60 mg once daily Chronic musculoskeletal pain Starting: 30 - 60 mg once daily Target: 60 mg once daily Max: 60 mg once daily	Cymbalta® YES/$	May take without regard to food Do not open, crush, or chew capsule In most studies, doses > 60 mg a day have not shown additional benefit	Serotonin-Norepinephrine Reuptake Inhibitor (SNRI) Inhibits serotonin and norepinephrine reuptake by neurons	Depression Generalized anxiety disorder Diabetic peripheral neuropathy Fibromyalgia Chronic musculoskeletal pain	NOTE: P = % of patients on placebo who reported side effect Nausea - 23%, P - 8% Dry Mouth - 14%, P - 6% Headache - 14%, P - 14% Constipation - 9%, P - 4% Diarrhea - 9%, P - 6% Fatigue - 9%, P - 5% Somnolence - 9%, P - 3% Insomnia - 9%, P - 5% Erectile dysfunction - 4%, P - 1% Ejaculation delay - 2%, P - 1% Elevated liver enzymes (> 3X upper limit of normal) - 1.25%, P - 0.45% Elevated blood pressure - duloxetine may cause an increase in blood pressure. Effect is typically small. Average SBP increase 1 - 2 mmHg at typical dosing. Orthostatic hypotension - may occur in some patients	MAO inhibitors - DO NOT COMBINE Thioridazine - DO NOT COMBINE CYP1A2 strong inhibitors - DO NOT COMBINE Serotonergic drugs - may increase risk of serotonin syndrome CYP2D6 strong inhibitors - may increase duloxetine levels CYP2D6 substrates - duloxetine is a moderate CYP2D6 inhibitor. It may increase CYP2D6 substrate levels. Anticoagulant/Antiplatelet meds - may increase bleeding risk	Serotonin syndrome Seizure - possible increase risk Hypertension - may raise blood pressure Glaucoma - may cause pupil dilation that precipitates angle-closure glaucoma Suicide - possible increase in risk when starting therapy in patients ≤ 24 years old Bipolar - may precipitate mania in bipolar patients Abnormal bleeding - through platelet inhibition Decreased gastric motility - may affect absorption Low sodium (hyponatremia) - may cause SIADH Abrupt discontinuation - anxiety, confusion, paresthesias, etc. Liver disease - do not use in patients with significant liver disease Kidney disease CrCl ≥ 30 ml/min: no dose adjustment necessary CrCl < 30 ml/min: DO NOT USE

Drug

Dosage form

Dosage

Generic/Price

Other

Class/Mechanism of Action

Indications
(FDA-approved)

Side Effects

Drug Interactions

Precautions/
Contraindications

Duloxetine

(Cymbalta®)

Cymbalta® capsule

20 mg
30 mg
60 mg

Depression

Starting: 30 - 60 mg/day
Maintenance: 40 - 60 mg/day
Max: 120 mg/day
May be given once daily or in two divided doses

Generalized anxiety disorder

Adults

Starting: 30 - 60 mg once daily
Maintenance: 60 - 120 mg once daily
Max: 120 mg once daily
For elderly patients, starting dose should be 30 mg once daily. Increase to 60 mg once daily after 2 weeks.

Children and adolescents (7 - 17 years)

Starting: 30 mg once daily
Maintenance: 30 - 60 mg once daily
Max: 120 mg/day
Increase dose in increments of 30 mg/day at intervals of ≥ 2 weeks

Diabetic peripheral neuropathy

Starting: 30 - 60 mg once daily
Target: 60 mg once daily
Max: 60 mg once daily

Fibromyalgia

Starting: 30 - 60 mg once daily
Target: 60 mg once daily
Max: 60 mg once daily

Chronic musculoskeletal pain

Starting: 30 - 60 mg once daily
Target: 60 mg once daily
Max: 60 mg once daily

Cymbalta®
YES/$

May take without regard to food

Do not open, crush, or chew capsule

In most studies, doses > 60 mg a day have not shown additional benefit

Serotonin-Norepinephrine Reuptake Inhibitor (SNRI)
Inhibits serotonin and norepinephrine reuptake by neurons

Depression
Generalized anxiety disorder
Diabetic peripheral neuropathy
Fibromyalgia
Chronic musculoskeletal pain

NOTE: P = % of patients on placebo who reported side effect

Nausea - 23%, P - 8%
Dry Mouth - 14%, P - 6%
Headache - 14%, P - 14%
Constipation - 9%, P - 4%
Diarrhea - 9%, P - 6%
Fatigue - 9%, P - 5%
Somnolence - 9%, P - 3%
Insomnia - 9%, P - 5%
Erectile dysfunction - 4%, P - 1%
Ejaculation delay - 2%, P - 1%
Elevated liver enzymes (> 3X upper limit of normal) - 1.25%, P - 0.45%
Elevated blood pressure - duloxetine may cause an increase in blood pressure. Effect is typically small. Average SBP increase 1 - 2 mmHg at typical dosing.
Orthostatic hypotension - may occur in some patients

MAO inhibitors - DO NOT COMBINE
Thioridazine - DO NOT COMBINE
CYP1A2 strong inhibitors - DO NOT COMBINE
Serotonergic drugs - may increase risk of serotonin syndrome
CYP2D6 strong inhibitors - may increase duloxetine levels
CYP2D6 substrates - duloxetine is a moderate CYP2D6 inhibitor. It may increase CYP2D6 substrate levels.
Anticoagulant/Antiplatelet meds - may increase bleeding risk

Serotonin syndrome
Seizure - possible increase risk
Hypertension - may raise blood pressure
Glaucoma - may cause pupil dilation that precipitates angle-closure glaucoma
Suicide - possible increase in risk when starting therapy in patients ≤ 24 years old
Bipolar - may precipitate mania in bipolar patients
Abnormal bleeding - through platelet inhibition
Decreased gastric motility - may affect absorption
Low sodium (hyponatremia) - may cause SIADH
Abrupt discontinuation - anxiety, confusion, paresthesias, etc.
Liver disease - do not use in patients with significant liver disease
Kidney disease

CrCl ≥ 30 ml/min: no dose adjustment necessary
CrCl < 30 ml/min: DO NOT USE

Drug	Dosage form	Dosage	Generic/Price	Other	Class/Mechanism of Action	Indications (FDA-approved)	Side Effects	Drug Interactions	Precautions/ Contraindications
Levomilnacipran (Fetzima™)	Fetzima™ extended-release capsule 20 mg 40 mg 80 mg 120 mg Titration pack: 20 mg capsule X 2 40 mg capsule X 26	Depression Starting: 20 mg once daily for 2 days, then 40 mg once daily Maintenance: 40 - 120 mg once daily Max: 120 mg once daily Increase in increments of 40 mg/day at intervals of ≥ 2 days Dosing in kidney disease CrCl ≥ 60 ml/min: no dose adjustment necessary CrCl 30 - 59 ml/min: do not exceed 80 mg a day CrCl 15 - 29 ml/min: do not exceed 40 mg/day CrCl < 15 ml/min: not recommended Dosing with strong CYP3A4 inhibitors Do not exceed 80 mg a day See CYP3A4 for more	Fetzima™ NO/$$$$	May take without regard to food Do not open, chew, or crush capsule	Serotonin-Norepinephrine Reuptake Inhibitor (SNRI) Inhibits serotonin and norepinephrine reuptake by neurons	Depression	NOTE: P = % of patients on placebo who reported side effect Nausea - 17%, P - 6% Constipation - 9%, P - 3% Excessive sweating - 9%, P - 2% Erectile dysfunction - 6%, P - 1% Rapid heart beat - 6%, P - 2% Urinary hesitancy/retention - 5%, P - 0% Ejaculation disorder - 5%, P - <1% Vomiting - 5%, P - 1% Palpitations - 5%, P - 1% Testicular pain - 4%, P - <1% Hot flush - 3%, P - 1% Orthostatic hypotension - 3%, P - 1% Decreased appetite - 3%, P - 1% Elevated blood pressure - levomilnacipran may cause an increase in blood pressure. Effect is typically small. Average SBP increase 3 - 4 mmHg, average DBP increase 3 mmHg. Increase in heart rate - levomilnacipran may cause an increase in heart rate. Average increase of 7-9 bpm in studies	MAO inhibitors - DO NOT COMBINE Alcohol - alcohol may accelerate drug release from the levomilnacipran capsule. It is recommended that it not be taken with alcohol. CYP3A4 strong inhibitors - levomilnacipran is a CYP3A4 sensitive substrate. The dose of levomilnacipran should not exceed 80 mg a day when taken with CYP3A4 strong inhibitors Serotonergic drugs - may increase risk of serotonin syndrome Anticoagulant/Antiplatelet meds - may increase bleeding risk	Uncontrolled narrow-angle glaucoma - DO NOT USE Glaucoma - may cause pupil dilation that precipitates angle-closure glaucoma Urinary retention (e.g. BPH) - levomilnacipran may worsen urinary retention in certain conditions Serotonin syndrome Seizure - possible increase risk Hypertension - may raise blood pressure Suicide - possible increase in risk when starting therapy in patients ≤ 24 years old Bipolar - may precipitate mania in bipolar patients Abnormal bleeding - through platelet inhibition Low sodium (hyponatremia) - may cause SIADH Abrupt discontinuation - anxiety, confusion, paresthesias, etc. Liver disease - no dose adjustment necessary Kidney disease CrCl ≥ 60 ml/min: no dose adjustment necessary CrCl 30 - 59 ml/min: do not exceed 80 mg a day CrCl 15 - 29 ml/min: do not exceed 40 mg/day CrCl < 15 ml/min: not recommended

Drug

Dosage form

Dosage

Generic/Price

Other

Class/Mechanism of Action

Indications
(FDA-approved)

Side Effects

Drug Interactions

Precautions/
Contraindications

Levomilnacipran

(Fetzima™)

Fetzima™
extended-release capsule

20 mg
40 mg
80 mg
120 mg

Titration pack:
20 mg capsule X 2
40 mg capsule X 26

Depression

Starting: 20 mg once daily for 2 days, then 40 mg once daily
Maintenance: 40 - 120 mg once daily
Max: 120 mg once daily
Increase in increments of 40 mg/day at intervals of ≥ 2 days

Dosing in kidney disease

CrCl ≥ 60 ml/min: no dose adjustment necessary
CrCl 30 - 59 ml/min: do not exceed 80 mg a day
CrCl 15 - 29 ml/min: do not exceed 40 mg/day
CrCl < 15 ml/min: not recommended

Dosing with strong CYP3A4 inhibitors

Do not exceed 80 mg a day
See CYP3A4 for more

Fetzima™
NO/$$$$

May take without regard to food
Do not open, chew, or crush capsule

Serotonin-Norepinephrine Reuptake Inhibitor (SNRI)
Inhibits serotonin and norepinephrine reuptake by neurons

Depression

NOTE: P = % of patients on placebo who reported side effect

Nausea - 17%, P - 6%
Constipation - 9%, P - 3%
Excessive sweating - 9%, P - 2%
Erectile dysfunction - 6%, P - 1%
Rapid heart beat - 6%, P - 2%
Urinary hesitancy/retention - 5%, P - 0%
Ejaculation disorder - 5%, P - <1%
Vomiting - 5%, P - 1%
Palpitations - 5%, P - 1%
Testicular pain - 4%, P - <1%
Hot flush - 3%, P - 1%
Orthostatic hypotension - 3%, P - 1%
Decreased appetite - 3%, P - 1%
Elevated blood pressure - levomilnacipran may cause an increase in blood pressure. Effect is typically small. Average SBP increase 3 - 4 mmHg, average DBP increase 3 mmHg.
Increase in heart rate - levomilnacipran may cause an increase in heart rate. Average increase of 7-9 bpm in studies

MAO inhibitors - DO NOT COMBINE
Alcohol - alcohol may accelerate drug release from the levomilnacipran capsule. It is recommended that it not be taken with alcohol.
CYP3A4 strong inhibitors - levomilnacipran is a CYP3A4 sensitive substrate. The dose of levomilnacipran should not exceed 80 mg a day when taken with CYP3A4 strong inhibitors
Serotonergic drugs - may increase risk of serotonin syndrome
Anticoagulant/Antiplatelet meds - may increase bleeding risk

Uncontrolled narrow-angle glaucoma - DO NOT USE
Glaucoma - may cause pupil dilation that precipitates angle-closure glaucoma
Urinary retention (e.g. BPH) - levomilnacipran may worsen urinary retention in certain conditions
Serotonin syndrome
Seizure - possible increase risk
Hypertension - may raise blood pressure
Suicide - possible increase in risk when starting therapy in patients ≤ 24 years old
Bipolar - may precipitate mania in bipolar patients
Abnormal bleeding - through platelet inhibition
Low sodium (hyponatremia) - may cause SIADH
Abrupt discontinuation - anxiety, confusion, paresthesias, etc.
Liver disease - no dose adjustment necessary
Kidney disease

CrCl ≥ 60 ml/min: no dose adjustment necessary
CrCl 30 - 59 ml/min: do not exceed 80 mg a day
CrCl 15 - 29 ml/min: do not exceed 40 mg/day
CrCl < 15 ml/min: not recommended

Drug	Dosage form	Dosage	Generic/Price	Other	Class/Mechanism of Action	Indications (FDA-approved)	Side Effects	Drug Interactions	Precautions/ Contraindications
Venlafaxine (Effexor®) (Effexor XR®)	Effexor® tablet 25 mg 37.5 mg 50 mg 75 mg 100 mg Effexor XR® extended-release capsule 37.5 mg 75 mg 150 mg Effexor XR® extended-release tablet 37.5 mg 75 mg 150 mg 225 mg	Depression Effexor® Starting: 75 mg a day Maintenance: 75 - 225 mg a day Max: 375 mg a day Give in 2 to 3 divided doses Increase dose in increments of up to 75 mg/day at intervals of ≥ 4 days Doses higher than 225 mg a day have not been extensively studied Effexor XR® Starting: 37.5 - 75 mg once daily Maintenance: 75 - 225 mg once daily Max: 225 mg once daily Increase dose in increments of up to 75 mg/day at intervals of ≥ 4 days Generalized anxiety disorder Effexor XR® Starting: 37.5 - 75 mg once daily Maintenance: 75 - 225 mg once daily Max: 225 mg once daily Increase dose in increments of up to 75 mg/day at intervals of ≥ 4 days Social anxiety disorder Effexor XR® Target: 75 mg once daily There is no evidence that higher doses are beneficial Panic disorder Effexor XR® Starting: 37.5 once daily Maintenance: 75 - 225 mg once daily Max: 225 mg once daily Increase dose in increments of up to 75 mg/day at intervals of ≥ 7 days Migraine prevention (off-label) Effexor XR® 75 - 150 mg/day Diabetic neuropathy (off-label) Starting: 37.5 mg once daily Target: 75 - 225 mg/day See diabetic neuropathy for more	Effexor® YES/$ Effexor XR® YES/ capsule - $ tablet - $$-$$$	Effexor® Take with food to help reduce nausea May cause false-positive urine drug tests for phencyclidine (PCP) and amphetamines Effexor XR® Take with food to help reduce nausea May cause false-positive urine drug tests for phencyclidine (PCP) and amphetamines Capsules may be opened and sprinkled on applesauce. Do not chew contents. Do not crush, cut, or chew tablet Switching brands When switching between Effexor® and Effexor XR®, keep total daily dose the same	Serotonin-Norepinephrine Reuptake Inhibitor (SNRI) Inhibits serotonin and norepinephrine reuptake by neurons Weak dopamine reuptake inhibitor	Depression Generalized anxiety disorder Social anxiety disorder Panic disorder	NOTE: P = % of patients on placebo who reported side effect Nausea - 35%, P - 12% Dizziness - 16%, P - 11% Dry Mouth - 16%, P - 6% Insomnia - 15%, P - 10% Somnolence - 14%, P - 8% Fatigue - 12%, P - 8% Ejaculation delay/abnormal - 11%, P - < 1% Constipation - 10%, P - 4% Sweating - 10%, P - 3% Elevated blood pressure - venlafaxine may cause an increase in blood pressure. The effect increases with higher doses. Elevated cholesterol - venlafaxine may raise cholesterol levels (5.3% of patients)	MAO inhibitors - DO NOT COMBINE Cimetidine (Tagamet®) - may increase venlafaxine levels Haloperidol (Haldol®) - may increase haloperidol levels Desipramine - may increase desipramine levels Metoprolol - may increase metoprolol levels Risperidone (Risperdal®) - may increase risperidone levels Indinavir (Crixivan®) - may decrease indinavir levels Drugs that prolong the QT interval Serotonergic drugs - may increase risk of serotonin syndrome Anticoagulant/Antiplatelet meds - may increase bleeding risk CYP2D6 inhibitors and substrates - venlafaxine is a CYP2D6 sensitive substrate and CYP2D6 weak inhibitor CYP3A4 inhibitors - may increase venlafaxine levels	Serotonin syndrome Seizure - possible increase risk Hypertension - may raise blood pressure Glaucoma - may cause pupil dilation that precipitates angle-closure glaucoma Suicide - possible increase in risk when starting therapy in patients ≤ 24 years old Bipolar - may precipitate mania in bipolar patients Abnormal bleeding - through platelet inhibition Low sodium (hyponatremia) - may cause SIADH Prolonged QT syndrome - may worsen QT prolongation Abrupt discontinuation - anxiety, confusion, paresthesias, etc. Liver disease Effexor, Effexor XR Mild-moderate disease (Child-Pugh A/B): reduce dose by 50% Severe (Child-Pugh C): reduce dose by 50% or more Kidney disease Effexor CrCl 30 - 90 ml/min: reduce dose by 25% CrCl < 30 ml/min: reduce dose by 50% Effexor XR CrCl 30 - 90 ml/min: reduce dose by 25% - 50% CrCl < 30 ml/min: reduce dose by 50% or more

Drug

Dosage form

Dosage

Generic/Price

Other

Class/Mechanism of Action

Indications
(FDA-approved)

Side Effects

Drug Interactions

Precautions/
Contraindications

Venlafaxine

(Effexor®)
(Effexor XR®)

Effexor® tablet

25 mg
37.5 mg
50 mg
75 mg
100 mg

Effexor XR®
extended-release capsule

37.5 mg
75 mg
150 mg

Effexor XR®
extended-release tablet

37.5 mg
75 mg
150 mg
225 mg

Depression

Effexor®

Starting: 75 mg a day
Maintenance: 75 - 225 mg a day
Max: 375 mg a day
Give in 2 to 3 divided doses
Increase dose in increments of up to 75 mg/day at intervals of ≥ 4 days
Doses higher than 225 mg a day have not been extensively studied

Effexor XR®

Starting: 37.5 - 75 mg once daily
Maintenance: 75 - 225 mg once daily
Max: 225 mg once daily
Increase dose in increments of up to 75 mg/day at intervals of ≥ 4 days

Generalized anxiety disorder

Effexor XR®

Starting: 37.5 - 75 mg once daily
Maintenance: 75 - 225 mg once daily
Max: 225 mg once daily
Increase dose in increments of up to 75 mg/day at intervals of ≥ 4 days

Social anxiety disorder

Effexor XR®

Target: 75 mg once daily
There is no evidence that higher doses are beneficial

Panic disorder

Effexor XR®

Starting: 37.5 once daily
Maintenance: 75 - 225 mg once daily
Max: 225 mg once daily
Increase dose in increments of up to 75 mg/day at intervals of ≥ 7 days

Migraine prevention (off-label)

Effexor XR®

75 - 150 mg/day

Diabetic neuropathy (off-label)

Starting: 37.5 mg once daily
Target: 75 - 225 mg/day
See diabetic neuropathy for more

Effexor®
YES/$

Effexor XR®
YES/
capsule - $
tablet - $$-$$$

Effexor®

Take with food to help reduce nausea
May cause false-positive urine drug tests for phencyclidine (PCP) and amphetamines

Effexor XR®

Take with food to help reduce nausea
May cause false-positive urine drug tests for phencyclidine (PCP) and amphetamines
Capsules may be opened and sprinkled on applesauce. Do not chew contents.
Do not crush, cut, or chew tablet

Switching brands

When switching between Effexor® and Effexor XR®, keep total daily dose the same

Serotonin-Norepinephrine Reuptake Inhibitor (SNRI)
Inhibits serotonin and norepinephrine reuptake by neurons
Weak dopamine reuptake inhibitor

Depression
Generalized anxiety disorder
Social anxiety disorder
Panic disorder

NOTE: P = % of patients on placebo who reported side effect

Nausea - 35%, P - 12%
Dizziness - 16%, P - 11%
Dry Mouth - 16%, P - 6%
Insomnia - 15%, P - 10%
Somnolence - 14%, P - 8%
Fatigue - 12%, P - 8%
Ejaculation delay/abnormal - 11%, P - < 1%
Constipation - 10%, P - 4%
Sweating - 10%, P - 3%
Elevated blood pressure - venlafaxine may cause an increase in blood pressure. The effect increases with higher doses.
Elevated cholesterol - venlafaxine may raise cholesterol levels (5.3% of patients)

MAO inhibitors - DO NOT COMBINE
Cimetidine (Tagamet®) - may increase venlafaxine levels
Haloperidol (Haldol®) - may increase haloperidol levels
Desipramine - may increase desipramine levels
Metoprolol - may increase metoprolol levels
Risperidone (Risperdal®) - may increase risperidone levels
Indinavir (Crixivan®) - may decrease indinavir levels
Drugs that prolong the QT interval
Serotonergic drugs - may increase risk of serotonin syndrome
Anticoagulant/Antiplatelet meds - may increase bleeding risk
CYP2D6 inhibitors and substrates - venlafaxine is a CYP2D6 sensitive substrate and CYP2D6 weak inhibitor
CYP3A4 inhibitors - may increase venlafaxine levels

Serotonin syndrome
Seizure - possible increase risk
Hypertension - may raise blood pressure
Glaucoma - may cause pupil dilation that precipitates angle-closure glaucoma
Suicide - possible increase in risk when starting therapy in patients ≤ 24 years old
Bipolar - may precipitate mania in bipolar patients
Abnormal bleeding - through platelet inhibition
Low sodium (hyponatremia) - may cause SIADH
Prolonged QT syndrome - may worsen QT prolongation
Abrupt discontinuation - anxiety, confusion, paresthesias, etc.
Liver disease

Effexor, Effexor XR

Mild-moderate disease (Child-Pugh A/B): reduce dose by 50%
Severe (Child-Pugh C): reduce dose by 50% or more

Kidney disease

Effexor

CrCl 30 - 90 ml/min: reduce dose by 25%
CrCl < 30 ml/min: reduce dose by 50%

Effexor XR

CrCl 30 - 90 ml/min: reduce dose by 25% - 50%
CrCl < 30 ml/min: reduce dose by 50% or more

Drug	Dosage form	Dosage	Generic/Price	Other / Studies	Class/Mechanism of Action	Indications (FDA-approved)	Side Effects	Drug Interactions	Precautions/ Contraindications
Bupropion (Wellbutrin®) (Wellbutrin SR®) (Wellbutrin XL®) (Zyban®) (Aplenzin®) (Forfivo XL™) (Contrave®)	Wellbutrin® tablet 75 mg 100 mg Wellbutrin SR® tablet 100 mg 150 mg 200 mg Wellbutrin XL® tablet 150 mg 300 mg Forfivo XL™ tablet 450 mg Zyban® tablet 150 mg Aplenzin® (Bupropion hydrobromide) tablet 174 mg 348 mg 522 mg Contrave® (naltrexone + bupropion) see Contrave®	Depression Wellbutrin® Starting: 100 mg twice a day for 3 days Maintenance: 100 mg three times a day Max: 450 mg a day Wellbutrin SR® Starting: 150 mg once a day for 3 days Maintenance: 150 mg twice a day Max: 200 mg twice a day Wellbutrin XL® Starting: 150 mg once daily Maintenance: 300 mg once daily Max: 450 mg once daily Increase dose at intervals ≥ 4 days Aplenzin® Starting: 174 mg once daily for 4 days Maintenance: 348 mg once daily Max: 522 mg once daily Aplenzin-Wellbutrin XL equivalence: 174 mg = 150 mg, 348 mg = 300 mg, 522 = 450 mg Forfivo XL™ Starting: use another form of bupropion to initiate therapy Maintenance: 450 mg once daily Max: 450 mg once daily Seasonal affective disorder Wellbutrin XL® Starting: 150 mg once daily Target: 300 mg once daily Max: 300 mg once daily Increase dose at intervals ≥ 7 days Aplenzin® Starting: 174mg once daily Target: 348mg once daily Max: 348mg once daily Increase dose at intervals ≥ 7 days Aplenzin-Wellbutrin XL equivalence: 174mg = 150 mg, 348mg = 300 mg, 522 = 450 mg Smoking cessation Zyban® Starting: 150 mg once daily for 3 days Maintenance: 150 mg twice a day Max: 150 mg twice a day Weight loss Contrave® (naltrexone + bupropion) See Contrave®	Wellbutrin® YES/$ Wellbutrin SR® YES/$ Wellbutrin XL® YES/$ Forfivo XL™ NO/$$$$ Aplenzin® NO/$$$$ Zyban® YES/$-$$	Other All May take without regard to food Do not crush, cut, or chew tablets May cause false-positive urine drug tests for amphetamines Switching brands When switching between Wellbutrin®, Wellbutrin SR®, and Wellbutrin XL® - keep total daily dose the same Studies Bupropion vs Chantix vs Nicotine patch vs Placebo in smoking cessation	Norepinephrine-Dopamine Reuptake Inhibitor Inhibits norepinephrine and dopamine reuptake by neurons	Depression Seasonal affective disorder Smoking cessation	NOTE: P = % of patients on placebo who reported side effect Agitation - 32%, P - 22% Dry mouth - 28%, P - 18% Constipation - 26%, P - 17% Headache - 26%, P - 22% Nausea - 23%, P - 19% Excessive sweating - 22%, P - 15% Dizziness - 22%, P - 16% Tremor - 21%, P - 8% Insomnia - 19%, P - 16% Blurred vision - 15%, P - 10% Rapid heart beat - 11%, P - 9% Increased blood pressure - may increase blood pressure. Incidence is unknown.	MAO inhibitors - DO NOT COMBINE CYP2B6 inhibitors and inducers - bupropion is a CYP2B6 sensitive substrate CYP2D6 substrates - bupropion is a CYP2D6 strong inhibitor OCT2 substrates - bupropion is an OCT2 inhibitor Amantadine - may increase side effects Clopidogrel (Plavix®) - clopidogrel is a CYP2B6 inhibitor and may raise bupropion levels. Bupropion doses may need to be decreased when taken with clopidogrel. Digoxin - bupropion may decrease digoxin levels. Monitor digoxin levels when taking together. Levodopa (Sinemet®) - may increase side effects Drugs that increase dopaminergic or noradrenergic activity - may increase risk of hypertension Ritonavir, Lopinavir, and Efavirenz - ritonavir, lopinavir, and efavirenz are CYP2B6 inducers and may lower bupropion levels to subtherapeutic levels Tamoxifen - tamoxifen is metabolized by CYP2D6 to its active form. Some studies have found that tamoxifen is not as effective when taken with CYP2D6 strong inhibitors. Other studies have found no effect. See tamoxifen studies for more.	Seizure disorder - DO NOT USE. Bupropion carries the highest seizure risk of all the antidepressants. Bulimia or anorexia nervosa - DO NOT USE. These patients have higher risk of seizure. Alcohol/benzodiazepine/barbiturate withdrawal - DO NOT USE. These patients have higher risk of seizure. Antiepileptic drug withdrawal - DO NOT USE. These patients have higher risk of seizure. Suicide - possible increase in risk when starting therapy in patients ≤ 24 years old Bipolar - may precipitate mania in bipolar patients Glaucoma - may cause pupil dilation that precipitates angle-closure glaucoma Abrupt discontinuation - anxiety, confusion, paresthesias, etc. Liver disease Wellbutrin Mild (Child-Pugh A): consider dose/frequency reduction Moderate-severe (Child-Pugh B/C): do not exceed 75 mg a day Wellbutrin SR Mild (Child-Pugh A): consider dose/frequency reduction Moderate-severe (Child-Pugh B/C): max dose is 100 mg a day or 150 mg every other day Wellbutrin XL, Zyban Mild (Child-Pugh A): consider dose/frequency reduction Moderate-severe (Child-Pugh B/C): max dose is 150 mg every other day Aplenzin Severe (Child-Pugh C): max dose is 174mg every other day Forfivo XL Liver disease not recommended since only one dose Kidney disease CrCl < 90 ml/min: consider dose/frequency reduction Forfivo XL is not recommended since only one dose

Drug

Dosage form

Dosage

Generic/Price

Other / Studies

Class/Mechanism of Action

Indications
(FDA-approved)

Side Effects

Drug Interactions

Precautions/
Contraindications

Bupropion

(Wellbutrin®)
(Wellbutrin SR®)
(Wellbutrin XL®)
(Zyban®)
(Aplenzin®)
(Forfivo XL™)
(Contrave®)

Wellbutrin® tablet

75 mg
100 mg

Wellbutrin SR® tablet

100 mg
150 mg
200 mg

Wellbutrin XL® tablet

150 mg
300 mg

Forfivo XL™ tablet

450 mg

Zyban® tablet

150 mg

Aplenzin®
(Bupropion hydrobromide) tablet

174 mg
348 mg
522 mg

Contrave®
(naltrexone + bupropion)
see Contrave®

Depression

Wellbutrin®

Starting: 100 mg twice a day for 3 days
Maintenance: 100 mg three times a day
Max: 450 mg a day

Wellbutrin SR®

Starting: 150 mg once a day for 3 days
Maintenance: 150 mg twice a day
Max: 200 mg twice a day

Wellbutrin XL®

Starting: 150 mg once daily
Maintenance: 300 mg once daily
Max: 450 mg once daily
Increase dose at intervals ≥ 4 days

Aplenzin®

Starting: 174 mg once daily for 4 days
Maintenance: 348 mg once daily
Max: 522 mg once daily
Aplenzin-Wellbutrin XL equivalence:
174 mg = 150 mg, 348 mg = 300 mg, 522 = 450 mg

Forfivo XL™

Starting: use another form of bupropion to initiate therapy
Maintenance: 450 mg once daily
Max: 450 mg once daily

Seasonal affective disorder

Wellbutrin XL®

Starting: 150 mg once daily
Target: 300 mg once daily
Max: 300 mg once daily
Increase dose at intervals ≥ 7 days

Aplenzin®

Starting: 174mg once daily
Target: 348mg once daily
Max: 348mg once daily
Increase dose at intervals ≥ 7 days
Aplenzin-Wellbutrin XL equivalence:
174mg = 150 mg, 348mg = 300 mg, 522 = 450 mg

Smoking cessation

Zyban®

Starting: 150 mg once daily for 3 days
Maintenance: 150 mg twice a day
Max: 150 mg twice a day

Weight loss

Contrave® (naltrexone + bupropion)

See Contrave®

Wellbutrin®
YES/$

Wellbutrin SR®
YES/$

Wellbutrin XL®
YES/$

Forfivo XL™
NO/$$$$

Aplenzin®
NO/$$$$

Zyban®
YES/$-$$

Other

All

May take without regard to food
Do not crush, cut, or chew tablets
May cause false-positive urine drug tests for amphetamines

Switching brands

When switching between Wellbutrin®, Wellbutrin SR®, and Wellbutrin XL® - keep total daily dose the same

Studies

Bupropion vs Chantix vs Nicotine patch vs Placebo in smoking cessation

Norepinephrine-Dopamine Reuptake Inhibitor
Inhibits norepinephrine and dopamine reuptake by neurons

Depression
Seasonal affective disorder
Smoking cessation

NOTE: P = % of patients on placebo who reported side effect

Agitation - 32%, P - 22%
Dry mouth - 28%, P - 18%
Constipation - 26%, P - 17%
Headache - 26%, P - 22%
Nausea - 23%, P - 19%
Excessive sweating - 22%, P - 15%
Dizziness - 22%, P - 16%
Tremor - 21%, P - 8%
Insomnia - 19%, P - 16%
Blurred vision - 15%, P - 10%
Rapid heart beat - 11%, P - 9%
Increased blood pressure - may increase blood pressure. Incidence is unknown.

MAO inhibitors - DO NOT COMBINE
CYP2B6 inhibitors and inducers - bupropion is a CYP2B6 sensitive substrate
CYP2D6 substrates - bupropion is a CYP2D6 strong inhibitor
OCT2 substrates - bupropion is an OCT2 inhibitor
Amantadine - may increase side effects
Clopidogrel (Plavix®) - clopidogrel is a CYP2B6 inhibitor and may raise bupropion levels. Bupropion doses may need to be decreased when taken with clopidogrel.
Digoxin - bupropion may decrease digoxin levels. Monitor digoxin levels when taking together.
Levodopa (Sinemet®) - may increase side effects
Drugs that increase dopaminergic or noradrenergic activity - may increase risk of hypertension
Ritonavir, Lopinavir, and Efavirenz - ritonavir, lopinavir, and efavirenz are CYP2B6 inducers and may lower bupropion levels to subtherapeutic levels
Tamoxifen - tamoxifen is metabolized by CYP2D6 to its active form. Some studies have found that tamoxifen is not as effective when taken with CYP2D6 strong inhibitors. Other studies have found no effect. See
tamoxifen studies
for more.

Seizure disorder - DO NOT USE. Bupropion carries the highest seizure risk of all the antidepressants.
Bulimia or anorexia nervosa - DO NOT USE. These patients have higher risk of seizure.
Alcohol/benzodiazepine/barbiturate withdrawal - DO NOT USE. These patients have higher risk of seizure.
Antiepileptic drug withdrawal - DO NOT USE. These patients have higher risk of seizure.
Suicide - possible increase in risk when starting therapy in patients ≤ 24 years old
Bipolar - may precipitate mania in bipolar patients
Glaucoma - may cause pupil dilation that precipitates angle-closure glaucoma
Abrupt discontinuation - anxiety, confusion, paresthesias, etc.
Liver disease

Wellbutrin

Mild (Child-Pugh A): consider dose/frequency reduction
Moderate-severe (Child-Pugh B/C): do not exceed 75 mg a day

Wellbutrin SR

Mild (Child-Pugh A): consider dose/frequency reduction
Moderate-severe (Child-Pugh B/C): max dose is 100 mg a day or 150 mg every other day

Wellbutrin XL, Zyban

Mild (Child-Pugh A): consider dose/frequency reduction
Moderate-severe (Child-Pugh B/C): max dose is 150 mg every other day

Aplenzin

Severe (Child-Pugh C): max dose is 174mg every other day

Forfivo XL

Liver disease not recommended since only one dose

Kidney disease

CrCl < 90 ml/min: consider dose/frequency reduction
Forfivo XL is not recommended since only one dose

Drug	Dosage form	Dosage	Generic/Price	Other	Class/Mechanism of Action	Indications (FDA-approved)	Side Effects	Drug Interactions	Precautions/ Contraindications
Amitriptyline (Elavil®)	Amitriptyline tablet 10 mg 25 mg 50 mg 75 mg 100 mg 150 mg	Depression Starting: 25- 50 mg once daily Maintenance: 50 - 100 mg once daily Max: 150 mg once daily Migraine prevention (off-label) 25 - 150 mg/day Diabetic neuropathy (off-label) Starting: 10 - 25 mg once daily Target: 25 - 100 mg/day See diabetic neuropathy for more	Amitriptyline YES/$	May take without regard to food	Tricyclic antidepressant Inhibits norepinephrine and serotonin reuptake by neurons	Depression	NOTE: Side effect profile not well-defined. Clomipramine is another TCA. It has the most extensive side effect information available. (see clomipramine for more) Dry mouth - > 50% of patients in some trials Drowsiness - common Blurred vision Constipation Urinary retention Postural hypotension	MAO inhibitors - DO NOT COMBINE Anticholinergic medications - may potentiate side effects Serotonergic drugs - may increase risk of serotonin syndrome Anticoagulant/Antiplatelet meds - may increase bleeding risk CYP2D6 inhibitors - may increase levels of amitriptyline CYP1A2 substrates - amitriptyline is a moderate CYP1A2 inhibitor CYP2C19 substrates - amitriptyline is a strong CYP2C19 inhibitor Topiramate - topiramate may increase amitriptyline levels Valproic acid - valproic acid may increase amitriptyline levels Clonidine - amitriptyline may decrease the effectiveness of clonidine Drugs that prolong the QT interval	Seizure - may increase risk Serotonin syndrome Glaucoma - may cause pupil dilation that precipitates angle-closure glaucoma Urinary retention - may worsen Prolonged QT syndrome - may worsen QT prolongation Abnormal bleeding - through platelet inhibition Suicide - possible increase in risk when starting therapy in patients ≤ 24 years old Bipolar - may precipitate mania in bipolar patients Abrupt discontinuation - anxiety, confusion, paresthesias, etc. Liver disease - use caution Kidney disease - use caution

Drug

Dosage form

Dosage

Generic/Price

Other

Class/Mechanism of Action

Indications
(FDA-approved)

Side Effects

Drug Interactions

Precautions/
Contraindications

Amitriptyline

(Elavil®)

Amitriptyline tablet

10 mg
25 mg
50 mg
75 mg
100 mg
150 mg

Depression

Starting: 25- 50 mg once daily
Maintenance: 50 - 100 mg once daily
Max: 150 mg once daily

Migraine prevention (off-label)

25 - 150 mg/day

Diabetic neuropathy (off-label)

Starting: 10 - 25 mg once daily
Target: 25 - 100 mg/day
See diabetic neuropathy for more

Amitriptyline
YES/$

May take without regard to food

Tricyclic antidepressant
Inhibits norepinephrine and serotonin reuptake by neurons

Depression

NOTE: Side effect profile not well-defined. Clomipramine is another TCA. It has the most extensive side effect information available. (see clomipramine for more)

Dry mouth - > 50% of patients in some trials
Drowsiness - common
Blurred vision
Constipation
Urinary retention
Postural hypotension

MAO inhibitors - DO NOT COMBINE
Anticholinergic medications - may potentiate side effects
Serotonergic drugs - may increase risk of serotonin syndrome
Anticoagulant/Antiplatelet meds - may increase bleeding risk
CYP2D6 inhibitors - may increase levels of amitriptyline
CYP1A2 substrates - amitriptyline is a moderate CYP1A2 inhibitor
CYP2C19 substrates - amitriptyline is a strong CYP2C19 inhibitor
Topiramate - topiramate may increase amitriptyline levels
Valproic acid - valproic acid may increase amitriptyline levels
Clonidine - amitriptyline may decrease the effectiveness of clonidine
Drugs that prolong the QT interval

Seizure - may increase risk
Serotonin syndrome
Glaucoma - may cause pupil dilation that precipitates angle-closure glaucoma
Urinary retention - may worsen
Prolonged QT syndrome - may worsen QT prolongation
Abnormal bleeding - through platelet inhibition
Suicide - possible increase in risk when starting therapy in patients ≤ 24 years old
Bipolar - may precipitate mania in bipolar patients
Abrupt discontinuation - anxiety, confusion, paresthesias, etc.
Liver disease - use caution
Kidney disease - use caution

Drug	Dosage form	Dosage	Generic/Price	Other	Class/Mechanism of Action	Indications (FDA-approved)	Side Effects	Drug Interactions	Precautions/ Contraindications
Clomipramine (Anafranil™)	Clomipramine capsule 25 mg 50 mg 75 mg	Obsessive compulsive disorder Starting: 25 mg a day Maintenance: 100 mg a day Max: 250 mg a day When initiating, increase to 100 mg a day over the course of 2 weeks May be given in divided doses to decrease gastrointestinal side effects	Anafranil™ YES/$$$$	Take with food to limit GI side effects Gradually increase dose. May give twice a day when initiating to limit side effects.	Tricyclic antidepressant Inhibits norepinephrine and serotonin reuptake by neurons	Obsessive-compulsive disorder (OCD)	NOTE: P = % of patients on placebo who reported side effect Dry mouth - 84%, P - 17% Somnolence - 54%, P - 16% Tremor - 54%, P - 2% Dizziness - 54%, P - 14% Headache - 52%, P - 41% Constipation - 47%, P - 11% Ejaculation failure - 42%, P - 2% Nausea - 33%, P - 14% Increased sweating - 29%, P - 3% Insomnia - 25%, P - 15% Libido change - 21%, P - 3% Impotence - 20%, P - 3% Weight gain - 18%, P - 1% Abnormal vision - 18%, P - 4% Nervousness - 18%, P - 2% Urinary retention - 14%, P - 2% Diarrhea - 13%, P - 9% Myalgia - 13%, P - 9% Muscle twitching - 13%, P - 0% Increased appetite - 11%, P - 2% Orthostatic hypotension Elevated liver enzymes - 1-3% of patients	MAO inhibitors - DO NOT COMBINE Anticholinergic medications - may potentiate side effects Methylphenidate (Ritalin®, Concerta®) - may increase clomipramine levels Haloperidol (Haldol®) - may increase clomipramine levels Phenobarbital - may increase phenobarbital levels Carbamazepine - may increase clomipramine levels Anticoagulant/Antiplatelet meds - may increase bleeding risk Serotonergic drugs - may increase risk of serotonin syndrome CYP2D6 inhibitors - may increase clomipramine levels CYP1A2 inhibitors - may increase clomipramine levels CYP2C19 inhibitors and substrates - clomipramine is a CYP2C19 strong inhibitor and substrate CYP3A4 inhibitors - may increase clomipramine levels Valproic acid - valproic acid may increase clomipramine levels Clonidine - clomipramine may decrease the effectiveness of clonidine Drugs that prolong the QT interval	Seizure - may increase risk Serotonin syndrome Glaucoma - may cause pupil dilation that precipitates angle-closure glaucoma Urinary retention - may worsen Prolonged QT syndrome - may worsen QT prolongation Abnormal bleeding - through platelet inhibition Suicide - possible increase in risk when starting therapy in patients ≤ 24 years old Bipolar - may precipitate mania in bipolar patients Abrupt discontinuation - anxiety, confusion, paresthesias, etc. Liver disease - use caution Kidney disease - use caution

Drug

Dosage form

Dosage

Generic/Price

Other

Class/Mechanism of Action

Indications
(FDA-approved)

Side Effects

Drug Interactions

Precautions/
Contraindications

Clomipramine

(Anafranil™)

Clomipramine capsule

25 mg
50 mg
75 mg

Obsessive compulsive disorder

Starting: 25 mg a day
Maintenance: 100 mg a day
Max: 250 mg a day
When initiating, increase to 100 mg a day over the course of 2 weeks
May be given in divided doses to decrease gastrointestinal side effects

Anafranil™
YES/$$$$

Take with food to limit GI side effects
Gradually increase dose. May give twice a day when initiating to limit side effects.

Tricyclic antidepressant
Inhibits norepinephrine and serotonin reuptake by neurons

Obsessive-compulsive disorder (OCD)

NOTE: P = % of patients on placebo who reported side effect

Dry mouth - 84%, P - 17%
Somnolence - 54%, P - 16%
Tremor - 54%, P - 2%
Dizziness - 54%, P - 14%
Headache - 52%, P - 41%
Constipation - 47%, P - 11%
Ejaculation failure - 42%, P - 2%
Nausea - 33%, P - 14%
Increased sweating - 29%, P - 3%
Insomnia - 25%, P - 15%
Libido change - 21%, P - 3%
Impotence - 20%, P - 3%
Weight gain - 18%, P - 1%
Abnormal vision - 18%, P - 4%
Nervousness - 18%, P - 2%
Urinary retention - 14%, P - 2%
Diarrhea - 13%, P - 9%
Myalgia - 13%, P - 9%
Muscle twitching - 13%, P - 0%
Increased appetite - 11%, P - 2%
Orthostatic hypotension
Elevated liver enzymes - 1-3% of patients

MAO inhibitors - DO NOT COMBINE
Anticholinergic medications - may potentiate side effects
Methylphenidate (Ritalin®, Concerta®) - may increase clomipramine levels
Haloperidol (Haldol®) - may increase clomipramine levels
Phenobarbital - may increase phenobarbital levels
Carbamazepine - may increase clomipramine levels
Anticoagulant/Antiplatelet meds - may increase bleeding risk
Serotonergic drugs - may increase risk of serotonin syndrome
CYP2D6 inhibitors - may increase clomipramine levels
CYP1A2 inhibitors - may increase clomipramine levels
CYP2C19 inhibitors and substrates - clomipramine is a CYP2C19 strong inhibitor and substrate
CYP3A4 inhibitors - may increase clomipramine levels
Valproic acid - valproic acid may increase clomipramine levels
Clonidine - clomipramine may decrease the effectiveness of clonidine
Drugs that prolong the QT interval

Seizure - may increase risk
Serotonin syndrome
Glaucoma - may cause pupil dilation that precipitates angle-closure glaucoma
Urinary retention - may worsen
Prolonged QT syndrome - may worsen QT prolongation
Abnormal bleeding - through platelet inhibition
Suicide - possible increase in risk when starting therapy in patients ≤ 24 years old
Bipolar - may precipitate mania in bipolar patients
Abrupt discontinuation - anxiety, confusion, paresthesias, etc.
Liver disease - use caution
Kidney disease - use caution

Drug	Dosage form	Dosage	Generic/Price	Other	Class/Mechanism of Action	Indications (FDA-approved)	Side Effects	Drug Interactions	Precautions/ Contraindications
Desipramine (Norpramin®)	Desipramine tablet 10 mg 25 mg 50 mg 75 mg 100 mg 150 mg	Depression Starting: 50 mg/day Maintenance: 100 - 200 mg/day Max: 300 mg/day May be given once daily or in divided doses	Desipramine YES/$$-$$$	May take without regard to food	Tricyclic antidepressant Inhibits norepinephrine and serotonin reuptake by neurons	Depression	NOTE: Side effect profile not well-defined. Clomipramine is another TCA. It has the most extensive side effect information available. (see clomipramine for more) Dry mouth - > 50% of patients in some trials Drowsiness - common Blurred vision Constipation Urinary retention Postural hypotension	MAO inhibitors - DO NOT COMBINE Anticholinergic medications - may potentiate side effects Serotonergic drugs - may increase risk of serotonin syndrome Anticoagulant/Antiplatelet meds - may increase bleeding risk CYP2D6 inhibitors - may increase levels of desipramine OCT2 substrates - desipramine is an OCT2 inhibitor Clonidine - desipramine may decrease the effectiveness of clonidine Drugs that prolong the QT interval	Seizure - may increase risk Serotonin syndrome Glaucoma - may cause pupil dilation that precipitates angle-closure glaucoma Urinary retention - may worsen Prolonged QT syndrome - may worsen QT prolongation Abnormal bleeding - through platelet inhibition Suicide - possible increase in risk when starting therapy in patients ≤ 24 years old Bipolar - may precipitate mania in bipolar patients Abrupt discontinuation - anxiety, confusion, paresthesias, etc. Liver disease - use caution Kidney disease - use caution

Drug

Dosage form

Dosage

Generic/Price

Other

Class/Mechanism of Action

Indications
(FDA-approved)

Side Effects

Drug Interactions

Precautions/
Contraindications

Desipramine

(Norpramin®)

Desipramine tablet

10 mg
25 mg
50 mg
75 mg
100 mg
150 mg

Depression

Starting: 50 mg/day
Maintenance: 100 - 200 mg/day
Max: 300 mg/day
May be given once daily or in divided doses

Desipramine
YES/$$-$$$

May take without regard to food

Tricyclic antidepressant
Inhibits norepinephrine and serotonin reuptake by neurons

Depression

NOTE: Side effect profile not well-defined. Clomipramine is another TCA. It has the most extensive side effect information available. (see clomipramine for more)

Dry mouth - > 50% of patients in some trials
Drowsiness - common
Blurred vision
Constipation
Urinary retention
Postural hypotension

MAO inhibitors - DO NOT COMBINE
Anticholinergic medications - may potentiate side effects
Serotonergic drugs - may increase risk of serotonin syndrome
Anticoagulant/Antiplatelet meds - may increase bleeding risk
CYP2D6 inhibitors - may increase levels of desipramine
OCT2 substrates - desipramine is an OCT2 inhibitor
Clonidine - desipramine may decrease the effectiveness of clonidine
Drugs that prolong the QT interval

Seizure - may increase risk
Serotonin syndrome
Glaucoma - may cause pupil dilation that precipitates angle-closure glaucoma
Urinary retention - may worsen
Prolonged QT syndrome - may worsen QT prolongation
Abnormal bleeding - through platelet inhibition
Suicide - possible increase in risk when starting therapy in patients ≤ 24 years old
Bipolar - may precipitate mania in bipolar patients
Abrupt discontinuation - anxiety, confusion, paresthesias, etc.
Liver disease - use caution
Kidney disease - use caution

Drug	Dosage form	Dosage	Generic/Price	Other	Class/Mechanism of Action	Indications (FDA-approved)	Side Effects	Drug Interactions	Precautions/ Contraindications
Imipramine (Tofranil™) (Tofranil-PM™)	Tofranil™ tablet 10 mg 25 mg 50 mg Tofranil-PM™ capsule 75 mg 100 mg 125 mg 150 mg	Depression Tofranil™ Starting: 75 mg a day Maintenance: 50 - 150 mg a day Max: 200 mg a day May be given once daily or in divided doses Tofranil PM™ Starting: 75 mg a day Maintenance: 75 - 150 mg a day Max: 200 mg a day May be given once daily or in divided doses Childhood enuresis (≥ 6 years old) Tofranil™ Starting: 25 mg one hour before bedtime Maintenance: (6-11 years) 25 - 50 mg at night (≥ 12 years) 25 - 75 mg at night Max: 2.5 mg/kg/day or 75 mg a day, whichever is less For early bedwetters, a divided dose of 25 mg given midafternoon and repeated at bedtime may be more effective	Tofranil™ YES/$ Tofranil PM™ YES/$$$$	May take without regard to food	Tricyclic antidepressant Inhibits norepinephrine and serotonin reuptake by neurons	Tofranil™ Depression Childhood enuresis (bedwetting) Tofranil PM™ Depression	NOTE: Side effect profile not well-defined. Clomipramine is another TCA. It has the most extensive side effect information available. (see clomipramine for more) Dry mouth - > 50% of patients in some trials Drowsiness - common Blurred vision Constipation Urinary retention Postural hypotension	MAO inhibitors - DO NOT COMBINE Anticholinergic medications - may potentiate side effects Methylphenidate (Ritalin®, Concerta®) - may increase imipramine levels Serotonergic drugs - may increase risk of serotonin syndrome Anticoagulant/Antiplatelet meds - may increase bleeding risk CYP2D6 inhibitors - may increase levels of imipramine CYP2C19 substrates - imipramine is a strong CYP2C19 inhibitor CYP1A2 substrates - imipramine is a moderate CYP1A2 inhibitor OCT2 substrates - imipramine is an OCT2 inhibitor Clonidine - imipramine may decrease the effectiveness of clonidine Drugs that prolong the QT interval	Seizure - may increase risk Serotonin syndrome Glaucoma - may cause pupil dilation that precipitates angle-closure glaucoma Urinary retention - may worsen Prolonged QT syndrome - may worsen QT prolongation Abnormal bleeding - through platelet inhibition Suicide - possible increase in risk when starting therapy in patients ≤ 24 years old Bipolar - may precipitate mania in bipolar patients Abrupt discontinuation - anxiety, confusion, paresthesias, etc. Liver disease - use caution Kidney disease - use caution

Drug

Dosage form

Dosage

Generic/Price

Other

Class/Mechanism of Action

Indications
(FDA-approved)

Side Effects

Drug Interactions

Precautions/
Contraindications

Imipramine

(Tofranil™)
(Tofranil-PM™)

Tofranil™ tablet

10 mg
25 mg
50 mg

Tofranil-PM™ capsule

75 mg
100 mg
125 mg
150 mg

Depression

Tofranil™

Starting: 75 mg a day
Maintenance: 50 - 150 mg a day
Max: 200 mg a day
May be given once daily or in divided doses

Tofranil PM™

Starting: 75 mg a day
Maintenance: 75 - 150 mg a day
Max: 200 mg a day
May be given once daily or in divided doses

Childhood enuresis (≥ 6 years old)

Tofranil™

Starting: 25 mg one hour before bedtime
Maintenance:
(6-11 years) 25 - 50 mg at night
(≥ 12 years) 25 - 75 mg at night
Max: 2.5 mg/kg/day or 75 mg a day, whichever is less
For early bedwetters, a divided dose of 25 mg given midafternoon and repeated at bedtime may be more effective

Tofranil™
YES/$

Tofranil PM™
YES/$$$$

May take without regard to food

Tricyclic antidepressant
Inhibits norepinephrine and serotonin reuptake by neurons

Tofranil™

Depression
Childhood enuresis (bedwetting)

Tofranil PM™

Depression

NOTE: Side effect profile not well-defined. Clomipramine is another TCA. It has the most extensive side effect information available. (see clomipramine for more)

Dry mouth - > 50% of patients in some trials
Drowsiness - common
Blurred vision
Constipation
Urinary retention
Postural hypotension

MAO inhibitors - DO NOT COMBINE
Anticholinergic medications - may potentiate side effects
Methylphenidate (Ritalin®, Concerta®) - may increase imipramine levels
Serotonergic drugs - may increase risk of serotonin syndrome
Anticoagulant/Antiplatelet meds - may increase bleeding risk
CYP2D6 inhibitors - may increase levels of imipramine
CYP2C19 substrates - imipramine is a strong CYP2C19 inhibitor
CYP1A2 substrates - imipramine is a moderate CYP1A2 inhibitor
OCT2 substrates - imipramine is an OCT2 inhibitor
Clonidine - imipramine may decrease the effectiveness of clonidine
Drugs that prolong the QT interval

Seizure - may increase risk
Serotonin syndrome
Glaucoma - may cause pupil dilation that precipitates angle-closure glaucoma
Urinary retention - may worsen
Prolonged QT syndrome - may worsen QT prolongation
Abnormal bleeding - through platelet inhibition
Suicide - possible increase in risk when starting therapy in patients ≤ 24 years old
Bipolar - may precipitate mania in bipolar patients
Abrupt discontinuation - anxiety, confusion, paresthesias, etc.
Liver disease - use caution
Kidney disease - use caution

Drug	Dosage form	Dosage	Generic/Price	Other	Class/Mechanism of Action	Indications (FDA-approved)	Side Effects	Drug Interactions	Precautions/ Contraindications
Nortriptyline (Pamelor™)	Nortriptyline capsule 10 mg 25 mg 50 mg 75 mg	Depression Starting: 25 mg a day Maintenance: 25 - 100 mg a day given in 1 - 4 divided doses Max: 150 mg a day Herpes zoster neuralgia (off-label) Starting: 25 mg at bedtime Max: 150 mg a day Increase by 25 mg daily every 2–3 days as tolerated Dosing recommendation from the Infectious Disease Society of America	Pamelor™ YES/$	May take without regard to food When taking doses > 100 mg a day, plasma levels of nortriptyline should be monitored. Ideal plasma level is 50 - 150ng/ml.	Tricyclic antidepressant Inhibits norepinephrine and serotonin reuptake by neurons	Depression	NOTE: Side effect profile not well-defined. Clomipramine is another TCA. It has the most extensive side effect information available. (see clomipramine for more) Dry mouth - > 50% of patients in some trials Drowsiness - common Blurred vision Constipation Urinary retention Postural hypotension	MAO inhibitors - DO NOT COMBINE Anticholinergic medications - may potentiate side effects Anticoagulant/Antiplatelet meds - may increase bleeding risk Serotonergic drugs - may increase risk of serotonin syndrome CYP2D6 inhibitors - may increase levels of nortriptyline Clonidine - nortriptyline may decrease the effectiveness of clonidine Valproic acid - valproic acid may increase nortriptyline levels Drugs that prolong the QT interval	Seizure - may increase risk Serotonin syndrome Glaucoma - may cause pupil dilation that precipitates angle-closure glaucoma Urinary retention - may worsen Prolonged QT syndrome - may worsen QT prolongation Abnormal bleeding - through platelet inhibition Suicide - possible increase in risk when starting therapy in patients ≤ 24 years old Bipolar - may precipitate mania in bipolar patients Abrupt discontinuation - anxiety, confusion, paresthesias, etc. Liver disease - use caution Kidney disease - use caution

Drug

Dosage form

Dosage

Generic/Price

Other

Class/Mechanism of Action

Indications
(FDA-approved)

Side Effects

Drug Interactions

Precautions/
Contraindications

Nortriptyline

(Pamelor™)

Nortriptyline capsule

10 mg
25 mg
50 mg
75 mg

Depression

Starting: 25 mg a day
Maintenance: 25 - 100 mg a day given in 1 - 4 divided doses
Max: 150 mg a day

Herpes zoster neuralgia (off-label)

Starting: 25 mg at bedtime
Max: 150 mg a day
Increase by 25 mg daily every 2–3 days as tolerated
Dosing recommendation from the Infectious Disease Society of America

Pamelor™
YES/$

May take without regard to food
When taking doses > 100 mg a day, plasma levels of nortriptyline should be monitored. Ideal plasma level is 50 - 150ng/ml.

Tricyclic antidepressant
Inhibits norepinephrine and serotonin reuptake by neurons

Depression

NOTE: Side effect profile not well-defined. Clomipramine is another TCA. It has the most extensive side effect information available. (see clomipramine for more)

Dry mouth - > 50% of patients in some trials
Drowsiness - common
Blurred vision
Constipation
Urinary retention
Postural hypotension

MAO inhibitors - DO NOT COMBINE
Anticholinergic medications - may potentiate side effects
Anticoagulant/Antiplatelet meds - may increase bleeding risk
Serotonergic drugs - may increase risk of serotonin syndrome
CYP2D6 inhibitors - may increase levels of nortriptyline
Clonidine - nortriptyline may decrease the effectiveness of clonidine
Valproic acid - valproic acid may increase nortriptyline levels
Drugs that prolong the QT interval

Seizure - may increase risk
Serotonin syndrome
Glaucoma - may cause pupil dilation that precipitates angle-closure glaucoma
Urinary retention - may worsen
Prolonged QT syndrome - may worsen QT prolongation
Abnormal bleeding - through platelet inhibition
Suicide - possible increase in risk when starting therapy in patients ≤ 24 years old
Bipolar - may precipitate mania in bipolar patients
Abrupt discontinuation - anxiety, confusion, paresthesias, etc.
Liver disease - use caution
Kidney disease - use caution

Drug	Dosage form	Dosage	Generic/Price	Other	Class/Mechanism of Action	Indications (FDA-approved)	Side Effects	Drug Interactions	Precautions/ Contraindications
Trazodone (Desyrel®) (Oleptro™)	Trazodone tablet 50 mg 100 mg 150 mg 300 mg Oleptro® extended-release tablet 150 mg 300 mg	Depression Trazodone Starting: 150 mg a day given in divided doses Maintenance: 150 - 400 mg a day given in divided doses Max: 400 mg a day Increase dose by 50 mg/day every 3 - 4 days Oleptro™ Starting: 150 mg once daily Maintenance: 150 - 300 mg once daily Max: 375 mg once daily Increase dose by 75 mg/day every 3 days Insomnia (off-label) Trazodone Starting: 50 mg at bedtime Maintenance: 50 - 150 mg at bedtime	Trazodone YES/$ Oleptro™ NO/$$$	Trazodone When taken after a meal or light snack, absorption is increased Trazodone tablets are scored and can be broken in half Oleptro™ Oleptro™ tablets are scored and can be broken in half. Tablets should not be crushed or chewed. Oleptro™ should be taken on an empty stomach, preferably at bedtime	Serotonin modulator Blocks postsynaptic serotonin receptors and inhibits postsynaptic serotonin reuptake	Depression Sleep aid - not FDA-approved	NOTE: P = % of patients on placebo who reported side effect Drowsiness - 41%, P - 20% Dry mouth - 34%, P - 20% Dizzy/Lightheaded - 28%, P - 15% Headache - 20%, P - 16% Blurred vision - 15%, P - 4% Nausea - 13%, P - 10% Decreased libido - 1.3%, P - < 1% Orthostatic hypotension Priapism (erection lasting > 6 hours)	MAO inhibitors - DO NOT COMBINE Serotonergic drugs - may increase risk of serotonin syndrome Anticoagulant/Antiplatelet meds - may increase bleeding risk CYP3A4 inducers and inhibitors - may affect levels of trazodone Drugs that prolong the QT interval	Seizure - may increase risk Serotonin syndrome Prolonged QT syndrome - may worsen QT prolongation Abnormal bleeding - through platelet inhibition Low sodium (hyponatremia) - may cause SIADH Glaucoma - may cause pupil dilation that precipitates angle-closure glaucoma Suicide - possible increase in risk when starting therapy in patients ≤ 24 years old Bipolar - may precipitate mania in bipolar patients Abrupt discontinuation - anxiety, confusion, paresthesias, etc. Liver disease - use caution Kidney disease - use caution

Drug

Dosage form

Dosage

Generic/Price

Other

Class/Mechanism of Action

Indications
(FDA-approved)

Side Effects

Drug Interactions

Precautions/
Contraindications

Trazodone

(Desyrel®)
(Oleptro™)

Trazodone tablet

50 mg
100 mg
150 mg
300 mg

Oleptro®
extended-release tablet

150 mg
300 mg

Depression

Trazodone

Starting: 150 mg a day given in divided doses
Maintenance: 150 - 400 mg a day given in divided doses
Max: 400 mg a day
Increase dose by 50 mg/day every 3 - 4 days

Oleptro™

Starting: 150 mg once daily
Maintenance: 150 - 300 mg once daily
Max: 375 mg once daily
Increase dose by 75 mg/day every 3 days

Insomnia (off-label)

Trazodone

Starting: 50 mg at bedtime
Maintenance: 50 - 150 mg at bedtime

Trazodone
YES/$

Oleptro™
NO/$$$

Trazodone

When taken after a meal or light snack, absorption is increased
Trazodone tablets are scored and can be broken in half

Oleptro™

Oleptro™ tablets are scored and can be broken in half. Tablets should not be crushed or chewed.
Oleptro™ should be taken on an empty stomach, preferably at bedtime

Serotonin modulator
Blocks postsynaptic serotonin receptors and inhibits postsynaptic serotonin reuptake

Depression
Sleep aid - not FDA-approved

NOTE: P = % of patients on placebo who reported side effect

Drowsiness - 41%, P - 20%
Dry mouth - 34%, P - 20%
Dizzy/Lightheaded - 28%, P - 15%
Headache - 20%, P - 16%
Blurred vision - 15%, P - 4%
Nausea - 13%, P - 10%
Decreased libido - 1.3%, P - < 1%
Orthostatic hypotension
Priapism (erection lasting > 6 hours)

MAO inhibitors - DO NOT COMBINE
Serotonergic drugs - may increase risk of serotonin syndrome
Anticoagulant/Antiplatelet meds - may increase bleeding risk
CYP3A4 inducers and inhibitors - may affect levels of trazodone
Drugs that prolong the QT interval

Seizure - may increase risk
Serotonin syndrome
Prolonged QT syndrome - may worsen QT prolongation
Abnormal bleeding - through platelet inhibition
Low sodium (hyponatremia) - may cause SIADH
Glaucoma - may cause pupil dilation that precipitates angle-closure glaucoma
Suicide - possible increase in risk when starting therapy in patients ≤ 24 years old
Bipolar - may precipitate mania in bipolar patients
Abrupt discontinuation - anxiety, confusion, paresthesias, etc.
Liver disease - use caution
Kidney disease - use caution

Drug	Dosage form	Dosage	Generic/Price	Other	Class/Mechanism of Action	Indications (FDA-approved)	Side Effects	Drug Interactions	Precautions/ Contraindications
Vilazodone (Viibryd®)	Viibryd® tablet 10 mg 20 mg 40 mg Starter kit: 10 mg X 7 20 mg X 7 40 mg X 16	Depression Starting: 10 mg once daily for 7 days, then 20 mg once daily for 7 days, then 40 mg once daily Maintenance: 40 mg once daily Max: 40 mg once daily When taken with CYP3A4 strong inhibitors Dose should not exceed 20 mg a day When taken with CYP3A4 moderate inhibitors Dose should not exceed 20 mg a day in patients with significant side effects When taken with CYP3A4 strong inducers Consider doubling the dose Viibryd® dose should not exceed 80 mg/day	Viibryd® NO/$$$$	Take with food. Food increases absorption.	Serotonin modulator Blocks postsynaptic serotonin receptors and inhibits postsynaptic serotonin reuptake	Depression	NOTE: P = % of patients on placebo who reported side effect Diarrhea - 28%, P - 9% Nausea - 23%, P - 5% Dizziness - 9%, P - 5% Dry mouth - 8%, P - 5% Insomnia - 6%, P - 2% Decreased libido - 4%, P - < 1% Delayed ejaculation - 2%, P - 0%	MAO inhibitors - DO NOT COMBINE CYP3A4 inducers and inhibitors - may affect levels of vilazodone. See Dosage for dosing recommendations Serotonergic drugs - may increase risk of serotonin syndrome Anticoagulant/Antiplatelet meds - may increase bleeding risk	Seizure - may increase risk Glaucoma - may cause pupil dilation that precipitates angle-closure glaucoma Low sodium (hyponatremia) - may cause SIADH Serotonin syndrome Abnormal bleeding - through platelet inhibition Suicide - possible increase in risk when starting therapy in patients ≤ 24 years old Bipolar - may precipitate mania in bipolar patients Abrupt discontinuation - anxiety, confusion, paresthesias, etc. Liver disease Mild-moderate (Child-Pugh A/B): no dose adjustment necessary Severe (Child-Pugh C): has not been studied Kidney disease - no dose adjustment necessary

Drug

Dosage form

Dosage

Generic/Price

Other

Class/Mechanism of Action

Indications
(FDA-approved)

Side Effects

Drug Interactions

Precautions/
Contraindications

Vilazodone

(Viibryd®)

Viibryd® tablet

10 mg
20 mg
40 mg

Starter kit:
10 mg X 7
20 mg X 7
40 mg X 16

Depression

Starting: 10 mg once daily for 7 days, then 20 mg once daily for 7 days, then 40 mg once daily
Maintenance: 40 mg once daily
Max: 40 mg once daily

When taken with CYP3A4 strong inhibitors

Dose should not exceed 20 mg a day

When taken with CYP3A4 moderate inhibitors

Dose should not exceed 20 mg a day in patients with significant side effects

When taken with CYP3A4 strong inducers

Consider doubling the dose
Viibryd® dose should not exceed 80 mg/day

Viibryd®
NO/$$$$

Take with food. Food increases absorption.

Serotonin modulator
Blocks postsynaptic serotonin receptors and inhibits postsynaptic serotonin reuptake

Depression

NOTE: P = % of patients on placebo who reported side effect

Diarrhea - 28%, P - 9%
Nausea - 23%, P - 5%
Dizziness - 9%, P - 5%
Dry mouth - 8%, P - 5%
Insomnia - 6%, P - 2%
Decreased libido - 4%, P - < 1%
Delayed ejaculation - 2%, P - 0%

MAO inhibitors - DO NOT COMBINE
CYP3A4 inducers and inhibitors - may affect levels of vilazodone. See Dosage for dosing recommendations
Serotonergic drugs - may increase risk of serotonin syndrome
Anticoagulant/Antiplatelet meds - may increase bleeding risk

Seizure - may increase risk
Glaucoma - may cause pupil dilation that precipitates angle-closure glaucoma
Low sodium (hyponatremia) - may cause SIADH
Serotonin syndrome
Abnormal bleeding - through platelet inhibition
Suicide - possible increase in risk when starting therapy in patients ≤ 24 years old
Bipolar - may precipitate mania in bipolar patients
Abrupt discontinuation - anxiety, confusion, paresthesias, etc.
Liver disease

Mild-moderate (Child-Pugh A/B): no dose adjustment necessary
Severe (Child-Pugh C): has not been studied

Kidney disease - no dose adjustment necessary

Drug	Dosage form	Dosage	Generic/Price	Other	Class/Mechanism of Action	Indications (FDA-approved)	Side Effects	Drug Interactions	Precautions/ Contraindications
Mirtazapine (Remeron®) (Remeron Soltab®)	Remeron® tablet 7.5 mg 15 mg 30 mg 45 mg Remeron Soltab® orally disintegrating tablet 15 mg 30 mg 45 mg	Depression Starting: 15 mg once daily at bedtime Maintenance: 15 - 45 mg once daily at bedtime Max: 45 mg once daily Increase dose at intervals of no less than 1 - 2 weeks	Remeron® YES/$	May take without regard to food Soltabs® are placed on tongue where they dissolve and are swallowed. Water is not necessary. Do not break Soltabs® Use Soltabs® immediately after removing from blister pack. They cannot be stored.	Blocks alpha-2 adrenergic receptors which increases norepinephrine and serotonin activity Blocks serotonergic 5-HT2 and 5-HT3 receptors which increases serotonergic activity Blocks histamine receptors which causes sedation Blocks alpha-1 receptors which may cause orthostatic hypotension Blocks muscarinic receptors (anticholinergic effects)	Depression	NOTE: P = % of patients on placebo who reported side effect Somnolence - 54%, P - 18% Dry mouth - 25%, P - 15% Increased appetite - 17%, P - 2% Elevated cholesterol/triglycerides - 15%, P - 7% Constipation - 13%, P - 7% Weight gain - 12%, P - 2% Dizziness - 7%, P - 3% Elevated liver enzymes - 2%, P - 0.3% Sexual side effects are comparable to placebo in trials Orthostatic hypotension - may occur	MAO inhibitors - DO NOT COMBINE Mirtazapine is a CYP2D6, CYP1A2, and CYP3A substrate CYP2D6 inhibitors and inducers - may affect mirtazapine levels CYP1A2 inhibitors and inducers - may affect mirtazapine levels CYP3A4 inhibitors and inducers - may affect mirtazapine levels Serotonergic drugs - may increase risk of serotonin syndrome Phenytoin - may decrease mirtazapine levels by 45% Carbamazepine - may decrease mirtazapine levels by 60% Warfarin - mirtazapine may increase warfarin levels Cimetidine - may increase mirtazapine levels by more than 50% Ketoconazole - may increase mirtazapine levels by more than 50% Alpha blockers - mirtazapine may potentiate the effect of alpha blockers Anticholinergic medications - may potentiate side effects	Serotonin syndrome Seizure - possible increase risk Suicide - possible increase in risk when starting therapy in patients ≤ 24 years old Bipolar - may precipitate mania in bipolar patients Low white blood cells - agranulocytosis has occurred in rare cases in patients taking mirtazapine Low sodium (hyponatremia) - may cause SIADH Abrupt discontinuation - anxiety, confusion, paresthesias, etc. Liver disease - clearance is decreased. No specific recommendations given. Use caution. Kidney disease CrCl 11 - 39 ml/min: clearance is decreased 30% CrCl < 10 ml/min: clearance is decreased 50%; use caution

Drug

Dosage form

Dosage

Generic/Price

Other

Class/Mechanism of Action

Indications
(FDA-approved)

Side Effects

Drug Interactions

Precautions/
Contraindications

Mirtazapine

(Remeron®)
(Remeron Soltab®)

Remeron® tablet

7.5 mg
15 mg
30 mg
45 mg

Remeron Soltab®
orally disintegrating tablet

15 mg
30 mg
45 mg

Depression

Starting: 15 mg once daily at bedtime
Maintenance: 15 - 45 mg once daily at bedtime
Max: 45 mg once daily
Increase dose at intervals of no less than 1 - 2 weeks

Remeron®
YES/$

May take without regard to food

Soltabs® are placed on tongue where they dissolve and are swallowed. Water is not necessary.

Do not break Soltabs®

Use Soltabs® immediately after removing from blister pack. They cannot be stored.

Blocks alpha-2 adrenergic receptors which increases norepinephrine and serotonin activity
Blocks serotonergic 5-HT2 and 5-HT3 receptors which increases serotonergic activity
Blocks histamine receptors which causes sedation
Blocks alpha-1 receptors which may cause orthostatic hypotension
Blocks muscarinic receptors (anticholinergic effects)

Depression

NOTE: P = % of patients on placebo who reported side effect

Somnolence - 54%, P - 18%
Dry mouth - 25%, P - 15%
Increased appetite - 17%, P - 2%
Elevated cholesterol/triglycerides - 15%, P - 7%
Constipation - 13%, P - 7%
Weight gain - 12%, P - 2%
Dizziness - 7%, P - 3%
Elevated liver enzymes - 2%, P - 0.3%
Sexual side effects are comparable to placebo in trials
Orthostatic hypotension - may occur

MAO inhibitors - DO NOT COMBINE
Mirtazapine is a CYP2D6, CYP1A2, and CYP3A substrate
CYP2D6 inhibitors and inducers - may affect mirtazapine levels
CYP1A2 inhibitors and inducers - may affect mirtazapine levels
CYP3A4 inhibitors and inducers - may affect mirtazapine levels
Serotonergic drugs - may increase risk of serotonin syndrome
Phenytoin - may decrease mirtazapine levels by 45%
Carbamazepine - may decrease mirtazapine levels by 60%
Warfarin - mirtazapine may increase warfarin levels
Cimetidine - may increase mirtazapine levels by more than 50%
Ketoconazole - may increase mirtazapine levels by more than 50%
Alpha blockers - mirtazapine may potentiate the effect of alpha blockers
Anticholinergic medications - may potentiate side effects

Serotonin syndrome
Seizure - possible increase risk
Suicide - possible increase in risk when starting therapy in patients ≤ 24 years old
Bipolar - may precipitate mania in bipolar patients
Low white blood cells - agranulocytosis has occurred in rare cases in patients taking mirtazapine
Low sodium (hyponatremia) - may cause SIADH
Abrupt discontinuation - anxiety, confusion, paresthesias, etc.
Liver disease - clearance is decreased. No specific recommendations given. Use caution.
Kidney disease

CrCl 11 - 39 ml/min: clearance is decreased 30%
CrCl < 10 ml/min: clearance is decreased 50%; use caution

Drug	Dosage form	Dosage	Generic/Price	Other	Class/Mechanism of Action	Indications (FDA-approved)	Side Effects	Drug Interactions	Precautions/ Contraindications
Vortioxetine (Trintellix®)	Trintellix® tablet 5 mg 10 mg 15 mg 20 mg	Depression Starting: 10 mg once daily Maintenance: 20 mg once daily Max: 20 mg once daily When taken with CYP2D6 strong inhibitors Reduce dose by half CYP2D6 poor metabolizers Maximum dose is 10 mg once daily When taken with CYP3A4 strong inducers Consider increasing the dose Dose should not exceed three times the original dose	Trintellix® NO/$$$$	May take without regard to food Brand name was changed from Brintellix to Trintellix in 2016 to avoid confusion with Brilinta	Serotonin Reuptake Inhibitor 5-HT3 receptor antagonist 5-HT1A receptor agonist	Depression	NOTE: P = % of patients on placebo who reported side effect Nausea - 32%, P - 9% Dizziness - 9%, P - 6% Dry mouth -8%, P - 6% Constipation - 8%, P - 3% Sexual dysfunction - 5%, P - 2%	MAO inhibitors - DO NOT COMBINE Serotonergic drugs - may increase risk of serotonin syndrome Anticoagulant/Antiplatelet meds - may increase bleeding risk CYP2D6 strong inhibitors - reduce vortioxetine dose by half when coadministered CYP3A4 strong inducers - consider increasing vortioxetine dose when used together for > 14 days. Dose should not exceed three times the original dose.	CYP2D6 poor metabolizers - maximum dose is 10 mg once daily Serotonin syndrome Seizure - possible increase risk Glaucoma - may cause pupil dilation that precipitates angle-closure glaucoma Suicide - possible increase in risk when starting therapy in patients ≤ 24 years old Bipolar - may precipitate mania in bipolar patients Abnormal bleeding - through platelet inhibition Low sodium (hyponatremia) - may cause SIADH Abrupt discontinuation - anxiety, confusion, paresthesias, etc. Liver disease Mild-moderate (Child-Pugh A/B): no dose adjustment necessary Severe (Child-Pugh C): has not been studied Kidney disease - no dose adjustment necessary

Drug

Dosage form

Dosage

Generic/Price

Other

Class/Mechanism of Action

Indications
(FDA-approved)

Side Effects

Drug Interactions

Precautions/
Contraindications

Vortioxetine

(Trintellix®)

Trintellix® tablet

5 mg
10 mg
15 mg
20 mg

Depression

Starting: 10 mg once daily
Maintenance: 20 mg once daily
Max: 20 mg once daily

When taken with CYP2D6 strong inhibitors

Reduce dose by half

CYP2D6 poor metabolizers

Maximum dose is 10 mg once daily

When taken with CYP3A4 strong inducers

Consider increasing the dose
Dose should not exceed three times the original dose

Trintellix®
NO/$$$$

May take without regard to food

Brand name was changed from Brintellix to Trintellix in 2016 to avoid confusion with Brilinta

Serotonin Reuptake Inhibitor
5-HT3 receptor antagonist
5-HT1A receptor agonist

Depression

NOTE: P = % of patients on placebo who reported side effect

Nausea - 32%, P - 9%
Dizziness - 9%, P - 6%
Dry mouth -8%, P - 6%
Constipation - 8%, P - 3%
Sexual dysfunction - 5%, P - 2%

MAO inhibitors - DO NOT COMBINE
Serotonergic drugs - may increase risk of serotonin syndrome
Anticoagulant/Antiplatelet meds - may increase bleeding risk
CYP2D6 strong inhibitors - reduce vortioxetine dose by half when coadministered
CYP3A4 strong inducers - consider increasing vortioxetine dose when used together for > 14 days. Dose should not exceed three times the original dose.

CYP2D6 poor metabolizers - maximum dose is 10 mg once daily
Serotonin syndrome
Seizure - possible increase risk
Glaucoma - may cause pupil dilation that precipitates angle-closure glaucoma
Suicide - possible increase in risk when starting therapy in patients ≤ 24 years old
Bipolar - may precipitate mania in bipolar patients
Abnormal bleeding - through platelet inhibition
Low sodium (hyponatremia) - may cause SIADH
Abrupt discontinuation - anxiety, confusion, paresthesias, etc.
Liver disease

Mild-moderate (Child-Pugh A/B): no dose adjustment necessary
Severe (Child-Pugh C): has not been studied

Kidney disease - no dose adjustment necessary

ANTIDEPRESSANTS

Depression

Depression

Generalized anxiety disorder

Other

Studies

Fluoxetine (Prozac®)

Prozac weekly®

Sarafem®

Olanzapine + fluoxetine (Symbyax®)

Obsessive compulsive disorder

Depression

Obsessive compulsive disorder (OCD)

Panic disorder

Social anxiety disorder

Generalized anxiety disorder

Posttraumatic stress disorder

Premenstrual dysphoric disorder

Vasomotor symptoms associated with menopause

Depression

Obsessive compulsive disorder

Panic disorder,Posttraumatic stress disorder (PTSD), Social anxiety disorder

Premenstrual dysphoric disorder

Depression

Depression

Generalized anxiety disorder

Diabetic peripheral neuropathy

Fibromyalgia

Chronic musculoskeletal pain

Depression

Depression

Generalized anxiety disorder

Social anxiety disorder

Panic disorder

Migraine prevention (off-label)

Diabetic neuropathy (off-label)

Depression

Seasonal affective disorder

Smoking cessation

Weight loss

Other

Studies

Depression

Migraine prevention (off-label)

Diabetic neuropathy (off-label)

Obsessive compulsive disorder

Depression

Depression

Childhood enuresis (≥ 6 years old)

Depression

Herpes zoster neuralgia (off-label)

Depression

Insomnia (off-label)

Depression

Depression

Depression

Panic disorder,
Posttraumatic stress disorder (PTSD),
Social anxiety disorder