Search Straight Healthcare
HOME    ABOUT US     CONTACT US

  • ANTIDEPRESSANT MEDICATION REFERENCE
    • NOTE: This page is intended to be a quick reference for properties of commonly used antidepressants. It is NOT a comprehensive review of each medication. Other drug interactions, side effects, precautions, and contraindications may exist for each drug. All information pertains to adult patients only.

Selective Serotonin Reuptake Inhibitors (SSRIs) Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs) Tricyclic antidepressants (TCAs)
Norepinephrine-Dopamine Reuptake Inhibitors Serotonin modulators Other

RECENT ANTIDEPRESSANT STUDIES OTHER INFORMATION




Drug Dosage form Dosage Generic/Price Other Class/Mechanism of Action Indications
(FDA-approved)
Side Effects
P = % of patients on placebo who experienced side effect
Drug Interactions Precautions/
Contraindications
Citalopram

(Celexa®)
Citalopram tablet
  • 10mg
  • 20mg
  • 40mg
Depression
  • Starting - 20mg a day
  • Maintenance - 20 - 40mg a day
  • Max - 40mg a day
  • Max dose of 20mg a day recommended for patients > 60 years old, and patients with liver disease

Poor CYP2C19 metabolizers, and patients taking CYP2C19 inhibitors
  • 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
  • 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%
  • Prolonged QT syndrome - citalopram should be stopped in patients with persistent QTc longer than 500ms
  • 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 20mg a day
  • Liver disease - maximum dose is 20mg 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
P = % of patients on placebo who experienced side effect
Drug Interactions Precautions/
Contraindications
Escitalopram

(Lexapro®)
Escitalopram tablet
  • 5mg
  • 10mg
  • 20mg
Depression/Generalized anxiety disorder
  • Starting - 10mg once daily
  • Maintenance - 10 - 20mg once daily
  • Max - 20mg once daily
  • Liver disease - 10mg once daily
  • Elderly - 10mg once daily
  • Increase dose after a minimum of one week
Escitalopram
YES/$
  • May take without regard to food
  • SSRI
  • Inhibits serotonin reuptake by neurons
  • Depression
  • Generalized anxiety disorder
  • Nausea- 15%, P - 7%
  • Insomnia- 9%, P - 4%
  • Ejaculation disorder (delay) - 9%, P - <1%
  • Diarrhea - 8%, P - 5%
  • Somnolence- 6%, P - 2%
  • 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 10mg 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
P = % of patients on placebo who experienced side effect
Drug Interactions Precautions/
Contraindications
Fluoxetine

(Prozac®)
(Prozac weekly™)
(Sarafem®)
Fluoxetine + olanzapine

(Symbyax®)
Fluoxetine capsule
  • 10mg
  • 20mg
  • 40mg

Fluoxetine tablet
  • 10mg
  • 20mg
  • 60mg

Prozac Weekly®
  • 90mg capsule

Sarafem® tablet
  • 10mg
  • 15mg
  • 20mg

Symbyax® capsule
Fluoxetine(mg):Olanzapine(mg)
  • 25:3
  • 25:6
  • 25:12
  • 50:6
  • 50:12

NOTE: see also olanzapine
Fluoxetine (Prozac®)
 Depression
  • Starting - 20mg once daily
  • Maintenance - 20 - 40mg once daily
  • Max - 80mg once daily
Obsessive compulsive disorder
  • Starting - 20mg once daily
  • Maintenance - 20 - 60mg once daily
  • Max - 80mg once daily
Bulimia nervosa
  • Target dose - 60mg once daily
  • Max - 60mg once daily
  • In trials, only the 60mg dose was superior to placebo
Panic disorder
  • Starting - 10mg once daily
  • Maintenance - 10 - 60mg once daily
  • Max - 60mg once daily

Prozac weekly®
Depression
  • 90mg once a week

Sarafem®
Premenstrual dysphoric disorder
  • Continuous dosing: 20mg once daily
  • Intermittent dosing: 20mg once daily starting 14 days before menstruation through first full day of menses

Fluoxetine + olanzapine (Symbyax®)
Depression associated with Bipolar 1 and
Treatment resistant depression

  • Starting - 25/6mg once daily in the evening
  • Maintenance - 25/6mg - 50/18mg once daily
  • Max - 75/18mg once daily
  • NOTE: see also olanzapine

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: see also olanzapine
  • 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.
  • 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
P = % of patients on placebo who experienced side effect
Drug Interactions Precautions/
Contraindications
Fluvoxamine

(Luvox®)
(Luvox® CR)
Luvox® tablet
  • 25mg
  • 50mg
  • 100mg

Luvox CR® capsule
  • 100mg
  • 150mg
Depression
Luvox®
  • Starting - 50mg once daily at bedtime
  • Maintenance - 100 - 300mg a day
  • Max - 300mg a day
  • Doses > 100mg should be given in 2 divided doses
  • Increase in increments of 50mg/day every 4 - 7 days
Luvox® CR
  • Starting - 100mg once daily at bedtime
  • Maintenance - 100 - 300mg once daily
  • Max - 300mg once daily
  • Increase in increments of 50mg/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)
  • 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%
  • 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
P = % of patients on placebo who experienced side effect
Drug Interactions Precautions/
Contraindications
Paroxetine

(Paxil®)
(Paxil CR®)
(Brisdelle™)
(Pexeva®)
Paxil® (paroxetine HCL) tablet
  • 10mg
  • 20mg
  • 30mg
  • 40mg

Paxil CR® (paroxetine HCL) tablet
  • 12.5mg
  • 25mg
  • 37.5mg

Pexeva® (paroxetine mesylate) tablet
  • 10mg
  • 20mg
  • 30mg
  • 40mg

Brisdelle™ (paroxetine mesylate)
  • 7.5mg
Depression
Paxil®, Pexeva®
  • Starting - 20mg once daily
  • Maintenance - 20 - 50mg once daily
  • Max - 50mg once daily
  • Increase in increments of 10mg/day every 7 days
  • Liver and kidney disease - initial dose 10mg a day. Do not exceed 40mg a day.
Paxil CR®
  • Starting - 25mg once daily
  • Maintenance - 25 - 62.5mg once daily
  • Max - 62.5mg once daily
  • Increase in increments of 12.5mg/day every 7 days
  • Liver and kidney disease - initial dose 12.5mg a day. Do not exceed 50mg a day.

Obsessive compulsive disorder (OCD)
Paxil®, Pexeva®
  • Starting - 20mg once daily
  • Target - 40mg once daily
  • Max - 60mg once daily
  • Increase in increments of 10mg/day every 7 days

Panic disorder
Paxil®, Pexeva®
  • Starting - 10mg once daily
  • Target - 40mg once daily
  • Max - 60mg once daily
  • Increase in increments of 10mg/day every 7 days
Paxil CR®
  • Starting - 12.5mg once daily
  • Maintenance - 12.5 - 75mg once daily
  • Max - 75mg once daily
  • Increase in increments of 12.5mg/day every 7 days
Social anxiety disorder
Paxil®
  • Starting - 20mg once daily
  • Maintenance - 20 - 60mg once daily
  • Max - 60mg once daily
  • Increase in increments of 10mg/day every 7 days
Paxil CR®
  • Starting - 12.5mg once daily
  • Maintenance - 12.5 - 37.5mg once daily
  • Max - 37.5mg once daily
  • Increase in increments of 12.5mg/day every 7 days

Generalized anxiety disorder
Paxil®, Pexeva®
  • Starting - 20mg once daily
  • Target - 20 once daily
  • Max - 50mg once daily
  • Increase in increments of 10mg/day every 7 days

Posttraumatic stress disorder
Paxil®
  • Starting - 20mg once daily
  • Target - 20 once daily
  • Max - 50mg once daily
  • Increase in increments of 10mg/day every 7 days

Premenstrual dysphoric disorder
Paxil CR®
  • Continuous - 12.5 - 25mg once daily
  • Intermittent - 12.5 - 25mg 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™
  • 7.5mg 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
  • 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.
  • 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
P = % of patients on placebo who experienced side effect
Drug Interactions Precautions/
Contraindications
Sertraline

(Zoloft®)
Zoloft®
  • 25mg
  • 50mg
  • 100mg
Depression and
Obsessive compulsive disorder
  • Starting - 50mg once daily
  • Maintenance - 50 - 200mg once daily
  • Max - 200mg once daily
  • Increase dose at intervals of ≥ 1 week

Panic disorder,
Posttraumatic stress disorder (PTSD),
Social anxiety disorder
  • Starting - 25mg once daily
  • Maintenance - 50 - 200mg once daily
  • Max - 200mg a day
  • Increase dose at intervals of ≥ 1 week

Premenstrual dysphoric disorder
  • Continuous - 50 - 150mg once daily
  • Intermittent - 50 - 100mg 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 100mg/day intermittent dosing, use 50mg/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
  • 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%
  • 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
P = % of patients on placebo who experienced side effect
Drug Interactions Precautions/
Contraindications
Desvenlafaxine Succinate

(Pristiq®)

Desvenlafaxine

(Khedezla™)
Pristiq®
extended-release tablet

  • 25mg
  • 50mg
  • 100mg

Khedezla™
extended-release tablet

  • 50mg
  • 100mg
Depression
Pristiq®, Khedezla™
  • Starting - 50mg once daily
  • Maintenance - 50 - 400mg once daily
  • Max - 400mg once daily
Pristiq®
NO/$$$$


Khedezla™
NO/$$$
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 50mg a day
  • Serotonin-Norepinephrine Reuptake Inhibitor (SNRI)
  • Inhibits serotonin and norepinephrine reuptake by neurons
  • Depression
  • 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)
  • NOTE: Side effects incidence are for 100mg a day dosing
  • MAO inhibitors - DO NOT COMBINE
  • Serotonergic drugs - may increase risk of serotonin syndrome
  • Anticoagulant/Antiplatelet meds - may increase bleeding risk
  • CYP2D6 substrates - desvenlafaxine is a weak CYP2D6 inhibitor. When taking desvenlafaxine 400mg 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 - through platelet inhibition
  • 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 50mg a day; do not exceed 100mg a day
  • Kidney disease
    • CrCl 30 - 50 ml/min: max dose is 50mg a day
    • CrCl < 30 ml/min: max dose is 50mg every other day

Drug Dosage form Dosage Generic/Price Other Class/Mechanism of Action Indications
(FDA-approved)
Side Effects
P = % of patients on placebo who experienced side effect
Drug Interactions Precautions/
Contraindications
Duloxetine

(Cymbalta®)
Cymbalta® capsule
  • 20mg
  • 30mg
  • 60mg
Depression
  • Starting - 30 - 60mg a day
  • Maintenance - 40 - 60mg a day
  • Max - 120mg a day
  • May be given once daily or in two divided doses

Generalized anxiety disorder
  • Starting - 30 - 60mg once daily
  • Maintenance - 60 - 120mg once daily
  • Max - 120mg once daily

Diabetic peripheral neuropathy
  • Starting - 30 - 60mg once daily
  • Target - 60mg once daily
  • Max - 60mg once daily

Fibromyalgia
  • Starting - 30 - 60mg once daily
  • Target - 60mg once daily
  • Max - 60mg once daily

Chronic musculoskeletal pain
  • Starting - 30 - 60mg once daily
  • Target - 60mg once daily
  • Max - 60mg once daily
Cymbalta®
YES/$
  • May take without regard to food
  • Do not open, crush, or chew capsule
  • In most studies, doses > 60mg 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
  • 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
  • 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
P = % of patients on placebo who experienced side effect
Drug Interactions Precautions/
Contraindications
Levomilnacipran

(Fetzima™)
Fetzima™
extended-release capsule

  • 20mg
  • 40mg
  • 80mg
  • 120mg

Titration pack:
20mg capsule X 2
40mg capsule X 26
Depression
  • Starting - 20mg once daily for 2 days, then 40mg once daily
  • Maintenance - 40 - 120mg once daily
  • Max - 120mg once daily
  • Increase in increments of 40mg/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 80mg a day
  • CrCl 15 - 29 ml/min: do not exceed 40mg/day
  • CrCl < 15 ml/min: not recommended

Dosing with strong CYP3A4 inhibitors
  • Do not exceed 80mg a day
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
  • 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 80mg 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 - See Dosage

Drug Dosage form Dosage Generic/Price Other Class/Mechanism of Action Indications
(FDA-approved)
Side Effects
P = % of patients on placebo who experienced side effect
Drug Interactions Precautions/
Contraindications
Venlafaxine

(Effexor®)
(Effexor XR®)
Effexor® tablet
  • 25mg
  • 37.5mg
  • 50mg
  • 75mg
  • 100mg

Effexor XR®
extended-release capsule

  • 37.5mg
  • 75mg
  • 150mg

Effexor XR®
extended-release tablet

  • 37.5mg
  • 75mg
  • 150mg
  • 225mg
Depression
    Effexor®
    • Starting - 75mg a day
    • Maintenance - 75 - 225mg a day
    • Max - 375mg a day
    • Give in 2 to 3 divided doses
    • Increase dose in increments of up to 75mg/day at intervals of ≥ 4 days
    • Doses higher than 225mg a day have not been extensively studied
    Effexor XR®
    • Starting - 37.5 - 75mg once daily
    • Maintenance - 75 - 225mg once daily
    • Max - 225mg once daily
    • Increase dose in increments of up to 75mg/day at intervals of ≥ 4 days

Generalized anxiety disorder
    Effexor XR®
    • Starting - 37.5 - 75mg once daily
    • Maintenance - 75 - 225mg once daily
    • Max - 225mg once daily
    • Increase dose in increments of up to 75mg/day at intervals of ≥ 4 days

Social anxiety disorder
    Effexor XR®
    • Target - 75mg once daily
    • There is no evidence that higher doses are beneficial

Panic disorder
    Effexor XR®
    • Starting - 37.5 once daily
    • Maintenance - 75 - 225mg once daily
    • Max - 225mg once daily
    • Increase dose in increments of up to 75mg/day at intervals of ≥ 7 days

Migraine prevention (off-label)
    Effexor XR®
    • 75 - 150 mg/day

Diabetic neuropathy (off-label)
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
  • 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
P = % of patients on placebo who experienced side effect
Drug Interactions Precautions/
Contraindications
Bupropion

(Wellbutrin®)
(Wellbutrin SR®)
(Wellbutrin XL®)
(Zyban®)
(Aplenzin®)
(Forfivo XL™)
(Contrave®)
Wellbutrin® tablet
  • 75mg
  • 100mg

Wellbutrin SR® tablet
  • 100mg
  • 150mg
  • 200mg

Wellbutrin XL® tablet
  • 150mg
  • 300mg

Forfivo XL™ tablet
  • 450mg

Zyban® tablet
  • 150mg

Aplenzin®
(Bupropion hydrobromide)
tablet

  • 174mg
  • 348mg
  • 522mg

Contrave®
(naltrexone + bupropion)
see Contrave®
Depression
Wellbutrin®
  • Starting - 100mg twice a day for 3 days
  • Maintenance - 100mg three times a day
  • Max - 450mg a day
Wellbutrin SR®
  • Starting - 150mg once a day for 3 days
  • Maintenance - 150mg twice a day
  • Max - 200mg twice a day
Wellbutrin XL®
  • Starting - 150mg once daily
  • Maintenance - 300mg once daily
  • Max - 450mg once daily
  • Increase dose at intervals ≥ 4 days
Aplenzin®
  • Starting - 174mg once daily for 4 days
  • Maintenance - 348mg once daily
  • Max - 522mg once daily
  • Aplenzin-Wellbutrin XL equivalence:
    174mg = 150mg, 348mg = 300mg, 522 = 450mg
Forfivo XL™
  • Starting - use another form of bupropion to initiate therapy
  • Maintenance - 450mg once daily
  • Max - 450mg once daily

Seasonal affective disorder
 Wellbutrin XL®
  • Starting - 150mg once daily
  • Target - 300mg once daily
  • Max - 300mg 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 = 150mg, 348mg = 300mg, 522 = 450mg

Smoking cessation
Zyban®
  • Starting - 150mg once daily for 3 days
  • Maintenance - 150mg twice a day
  • Max - 150mg twice a day

Weight loss
Contrave® (naltrexone + bupropion)
Wellbutrin®
YES/$
Wellbutrin SR®
YES/$
Wellbutrin XL®
YES/$
Forfivo XL™
NO/$$$$
Aplenzin®
NO/$$$$
Zyban®
YES/$-$$
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
  • Norepinephrine-Dopamine Reuptake Inhibitor
  • Inhibits norepinephrine and dopamine reuptake by neurons
  • Depression
  • Seasonal affective disorder
  • Smoking cessation
  • 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.
  • 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 75mg a day
    • Wellbutrin SR
      • Mild (Child-Pugh A): consider dose/frequency reduction
      • Moderate-severe (Child-Pugh B/C): max dose is 100mg a day or 150mg every other day
    • Wellbutrin XL, Zyban
      • Mild (Child-Pugh A): consider dose/frequency reduction
      • Moderate-severe (Child-Pugh B/C): max dose is 150mg 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
P = % of patients on placebo who experienced side effect
Drug Interactions Precautions/
Contraindications
Amitriptyline

(Elavil®)
Amitriptyline tablet
  • 10mg
  • 25mg
  • 50mg
  • 75mg
  • 100mg
  • 150mg
Depression
  • Starting - 25- 50mg once daily
  • Maintenance - 50 - 100mg once daily
  • Max - 150mg once daily

Migraine prevention (off-label)
  • 25 - 150 mg/day

Diabetic neuropathy (off-label)
Amitriptyline
YES/$
  • May take without regard to food
  • Tricyclic antidepressant
  • Inhibits norepinephrine and serotonin reuptake by neurons
  • Depression
  • Dry mouth - > 50% of patients in some trials
  • Drowsiness- common
  • Blurred vision
  • Constipation
  • Urinary retention
  • Postural hypotension

  • NOTE: Clomipramine is another TCA. It has the most extensive side effect information available. (see clomipramine below)
  • 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
P = % of patients on placebo who experienced side effect
Drug Interactions Precautions/
Contraindications
Clomipramine

(Anafranil™)
Clomipramine capsule
  • 25mg
  • 50mg
  • 75mg
Obsessive compulsive disorder
  • Starting - 25mg a day
  • Maintenance - 100mg a day
  • Max - 250mg a day
  • When initiating, increase to 100mg 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)
  • 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
  • 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
P = % of patients on placebo who experienced side effect
Drug Interactions Precautions/
Contraindications
Desipramine

(Norpramin®)
Desipramine tablet
  • 10mg
  • 25mg
  • 50mg
  • 75mg
  • 100mg
  • 150mg
Depression
  • Starting - 50mg a day
  • Maintenance - 100 - 200mg a day
  • Max - 300mg a 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
  • Dry mouth - > 50% of patients in some trials
  • Drowsiness- common
  • Blurred vision
  • Constipation
  • Urinary retention
  • Postural hypotension

  • NOTE: Clomipramine is another TCA. It has the most extensive side effect information available. (see clomipramine above)
  • 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
P = % of patients on placebo who experienced side effect
Drug Interactions Precautions/
Contraindications
Imipramine

(Tofranil™)
(Tofranil-PM™)
Tofranil™ tablet
  • 10mg
  • 25mg
  • 50mg

Tofranil-PM™ capsule
  • 75mg
  • 100mg
  • 125mg
  • 150mg
Depression
Tofranil™
  • Starting - 75mg a day
  • Maintenance - 50 - 150mg a day
  • Max - 200mg a day
  • May be given once daily or in divided doses
Tofranil PM™
  • Starting - 75mg a day
  • Maintenance - 75 - 150mg a day
  • Max - 200mg a day
  • May be given once daily or in divided doses

Childhood enuresis (≥ 6 years old)
Tofranil™
  • Starting - 25mg one hour before bedtime
  • Maintenance:
    (6-11 years) 25 - 50mg at night
    (≥ 12 years) 25 - 75mg at night
  • Max - 2.5mg/kg/day or 75mg a day, whichever is less
  • For early bedwetters, a divided dose of 25mg 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
  • Dry mouth - > 50% of patients in some trials
  • Drowsiness- common
  • Blurred vision
  • Constipation
  • Urinary retention
  • Postural hypotension

  • NOTE: Clomipramine is another TCA. It has the most extensive side effect information available. (see clomipramine above)
  • 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
P = % of patients on placebo who experienced side effect
Drug Interactions Precautions/
Contraindications
Nortriptyline

(Pamelor™)
Nortriptyline capsule
  • 10mg
  • 25mg
  • 50mg
  • 75mg
Depression
  • Starting - 25mg a day
  • Maintenance - 25 - 100mg a day given in 1 - 4 divided doses
  • Max - 150mg a day

Herpes zoster neuralgia (IDSA rec)
  • Starting - 25mg at bedtime
  • Max - 150mg a day
  • Increase by 25 mg daily every 2–3 days as tolerated
  • IDSA - Infectious disease society of America
Pamelor™
YES/$
  • May take without regard to food
  • When taking doses > 100mg 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
  • Dry mouth - > 50% of patients in some trials
  • Drowsiness- common
  • Blurred vision
  • Constipation
  • Urinary retention
  • Postural hypotension

  • NOTE: Clomipramine is another TCA. It has the most extensive side effect information available. (see clomipramine above)
  • 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
P = % of patients on placebo who experienced side effect
Drug Interactions Precautions/
Contraindications
Trazodone

(Desyrel®)
(Oleptro™)
Trazodone tablet
  • 50mg
  • 100mg
  • 150mg
  • 300mg

Oleptro®
extended-release tablet

  • 150mg
  • 300mg
Depression
Trazodone
  • Starting - 150mg a day given in divided doses
  • Maintenance - 150 - 400mg a day given in divided doses
  • Max - 400mg a day
  • Increase dose by 50mg/day every 3 - 4 days
Oleptro™
  • Starting - 150mg once daily
  • Maintenance - 150 - 300mg once daily
  • Max - 375mg once daily
  • Increase dose by 75mg/day every 3 days

Sleep aid (off-label)
Trazodone
  • Starting - 50mg at bedtime
  • Maintenance - 50 - 150mg 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
  • 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)
  • 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
P = % of patients on placebo who experienced side effect
Drug Interactions Precautions/
Contraindications
Vilazodone

(Viibryd®)
Viibryd® tablet
  • 10mg
  • 20mg
  • 40mg

Starter kit:
10mg X 7
20mg X 7
40mg X 16
Depression
  • Starting - 10mg once daily for 7 days, then 20mg once daily for 7 days, then 40mg once daily
  • Maintenance - 40mg once daily
  • Max - 40mg once daily

When taken with CYP3A4 strong inhibitors
  • Dose should not exceed 20mg a day

When taken with CYP3A4 moderate inhibitors
  • Dose should not exceed 20mg a day in patients with significant side effects

When taken with CYP3A4 strong inducers
  • Consider doubling the dose
  • Viibryd® dose should not exceed 80mg/day
Viibryd®
NO/$$$$
  • Take with food. Food increases absorption.
  • Serotonin modulator
  • Blocks postsynaptic serotonin receptors and inhibits postsynaptic serotonin reuptake
  • Depression
  • 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%
  • 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
P = % of patients on placebo who experienced side effect
Drug Interactions Precautions/
Contraindications
Mirtazapine

(Remeron®)
(Remeron Soltab®)
Remeron® tablet
  • 7.5mg
  • 15mg
  • 30mg
  • 45mg

Remeron Soltab®
orally disintegrating tablet

  • 15mg
  • 30mg
  • 45mg
Depression
  • Starting - 15mg once daily at bedtime
  • Maintenance - 15 - 45mg once daily at bedtime
  • Max - 45mg 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
  • 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
  • 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
P = % of patients on placebo who experienced side effect
Drug Interactions Precautions/
Contraindications
Vortioxetine

(Trintellix®)
(formerly Brintellix®)
Trintellix® tablet
  • 5mg
  • 10mg
  • 15mg
  • 20mg
Depression
  • Starting - 10mg once daily
  • Maintenance - 20mg once daily
  • Max - 20mg once daily

When taken with CYP2D6 strong inhibitors
  • Reduce dose by half

CYP2D6 poor metabolizers
  • Maximum dose is 10mg 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 in 2016 to avoid confusion with Brilinta
  • Serotonin Reuptake Inhibitor
  • 5-HT3 receptor antagonist
  • 5-HT1A receptor agonist
  • Depression
  • Nausea- 32%, P - 9%
  • Dizziness- 9%, P - 6%
  • Dry mouth -8%, P - 6%
  • Constipation- 8%, P - 3%
  • Sexual dysfunction - 5%, P - 2%
  • 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



  • STUDIES

    • Use during pregnancy

      • 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.

    • Use with antipsychotics

      • 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.

    • Use with tamoxifen

      • 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.

    • 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
        • 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.


    • Depression and heart failure

      • 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
        • 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.



  • PRICING

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

    • Pricing based on one month of therapy at standard dosing in an adult
    • Pricing based on survey of GoodRX.com®, HEB®, and Costco®, [accessed 12/2014]
    • Pricing may vary by region and availability



  • REFERENCES

    • References:
    • 1 - Manufacturer's Package Insert for each drug listed