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Clinician’s Corner: Antidepressants Wrap-up

This column wraps up a very long journey through the antidepressants.  These last three drugs don’t seem to get used a lot primarily due to the costs.  With aripiprazole (Abilify) and buspirone (Buspar) being so cheap most insurance companies want patients to try and fail on a traditional antidepressant plus augmenting before they approve these expensive drugs.

Vortioxetine (Trintellix®) 5, 10, 15, 20mg IR tablets

Released October 2013, currently costs $450.00 per month. Was initially named “Brintellix” and was changed to Trintellix in June 2016 because of confusion with antiplatelet Brilinta (ticagrelor)

Indication: treatment of major depressive disorder.

Mechanism: increases serotonin levels and activates some serotonin receptors in the brain.

Use: May help improve cognitive function, especially with major depression. This drug also helps with anxiety.

Dosage: start with 10mg.

Side Effects: causes minimal sexual dysfunction, low weight gain. Common side effects include nausea, constipation, vomiting.

Vilazodone HCl (Viibryd®) 10,20,40mg tablets

Released 2011 and currently costs around $320.00 per month

Indication: treatment of major depressive disorder (MDD)

Mechanism: increases serotonin levels and activates some serotonin receptors in the brain.

Use: Seems to work faster for depression. Viibryd is marketed to both augment SSRI effects and to have SSRI effects itself. Similar to using Abilify (aripiprazole) or Buspar (buspirone) to augment SSRI effects. Marketed as having less sexual side effects

Take with food because administration without food can result in inadequate drug concentrations and may diminish effectiveness

Side effects: diarrhea (28%), nausea (23%), less sexual side effects.

Esketamine (Spravato) CIII    

Ketamine first became available in 1970; Spravato was approved 2019. Cost estimated at $900/dose.  Ketamine is frequently used in anesthesia for surgery.

Mechanism: used in conjunction with an oral antidepressant, for the treatment of treatment-resistant depression (TRD) in adults. Given as a nasal spray only in authorized clinics. So far, the nearest clinic is in State College.

  • Most adverse effects occur in the first two hours after administration.
  • Patients self-administer in a clinic-based setting to have their blood pressure (for hypertension) monitored and mental-status monitoring (dissociation reactions~41%)
  • Be sure to stay on their oral antidepressants.

St. John’s Wort: See Clinician Corner 5/17/18 for a discussion of this herbal product.

Serotonin Syndrome

Serotonin is responsible for:

  • Central effects: regulates attention, behavior and body temperature.
  • Peripheral effects:  regulating digestive process, blood flow and breathing.

Culprits: All SSRI, SNRI, and MAOIs have the potential to cause serotonin syndrome, especially at higher doses. Most likely to occur with addition or increase of known serotonergic agent to an established medication regimen

Drug-Drug Interactions

  • SSRIs, TCAs, SNRIs, mirtazapine, MAOIs
  • Carbamazepine, cyclobenzaprine
  • Sibutramine (appetite suppressant)
  • Linezolid
  • Dextromethorphan, meperidine, methadone, tramadol

Symptoms of Serotonin Syndrome include:

  • Hyperthermia (high fever) and heavy sweating
  • Muscle rigidity, myoclonus (clonic muscle twitching), loss of coordination.
  • Changes in mental status and vital signs
  • Agitation, restlessness or confusion
  • Rapid heart rate, arrhythmias and high blood pressure
  • Dilated pupils
  • Diarrhea
  • Headache
  • Shivering and piloerection (goose bumps)
  • Unconsciousness, possibly leading to death

I added a discussion of Serotonin Syndrome (SS), since we frequently see warning flags when we are filling prescriptions.  Although it is rare, as we see higher and higher doses of antidepressants, we need to have a great deal of respect for this condition.  I have only seen one case of serotonin syndrome.  She was a 40-year-old Multiple Sclerosis (MS) patient that took 40mg of fluoxetine (Prozac).  She came to the pharmacy escorted by her husband hand had jerked motions as well profusely sweating.  They were just to the emergency department and she got SS after taking a couple doses of dextromethorphan! I have great deal of respect for dextromethorphan and its drug interactions with antidepressants.

And that is why you need to consult your Thompson Pharmacist before taking any over the counter medications, especially if you take prescription medications for your mental health.

Go Ahead and ASK… at Thompson Pharmacy it’s All for YOU!!