Selective serotonin reuptake inhibitors withdrawal

Markowitz JS, DeVane CL. Rifampin-induced selective serotonin reuptake inhibitor withdrawal syndrome in a patient treated with sertraline. J Clin Psychopharmacol 2000 20 109-110. 

Serotonin syndrome was reported in a 56-year-old white woman who received intravenous linezolid shortly after withdrawal of a selective serotonin reuptake inhibitor, paroxetine (115). 

Sanz EJ, De Las-Cuevas C, Bate A, Edwards R. Selective serotonin reuptake inhibitors in pregnant women and neonatal withdrawal syndrome a database analysis. Lancet 2005 365 482-87. 

Bipolar depression affects 1% of the general population, and treatment resistance is a significant problem. The addition of pindolol can lead to significant improvement in depressed patients who are resistant to antidepressant drugs, such as selective serotonin reuptake inhibitors or phenelzine. Of 17 patients with refractory bipolar depression, in whom pindolol was added to augment the effect of antidepressant drugs, eight responded favorably (95). However, two developed transient hypo-mania, and one of these became psychotic after the resolution of hypomanic symptoms. In both cases transient hypomanic symptoms resolved without any other intervention, while psychosis required pindolol withdrawal. 

Antidepressants selective serotonin reuptake inhibitors, tricyclic antidepressants Antihypertensives felodipine Antibiotics quinolones, isoniazid Bronchodilators albuterol, theophylline Corticosteroids prednisone Dopa agonists levodopa Herbals ma huang, ginseng, ephedra Nonsteroidal anti-inflammatory drugs ibuprofen Stimulants amphetamines, methylphenidate, caffeine, cocaine Sympathomimetics pseudoephedrine Thyroid hormones levothyroxine Toxicity anticholinergics, antihistamines, digoxin Withdrawal alcohol, sedatives... 

Other clinical uses Tricyclic drugs are also used in the treatment of bipolar affective disorders, acute panic attacks, phobic disorders (compare with alprazolam Chapter 22), enuresis, and chronic pain states. Clomipramine and the selective serotonin reuptake inhibitors, including fiuvoxamine, are effective in obsessive-compulsive disorders. SSRls are also effective in patients who suffer from panic attacks, social phobias, bulimia, and premenstrual syndrome (PMS) and may also be useful in the treatment of alcohol dependence. Bupropion is used for management of patients attempting to withdraw from nicotine dependence. 

Tricyclics modify peripheral sympathetic effects in two ways through blockade of norepinephrine reuptake at neuroeffector junctions and through alpha adrenoceptor blockade. Sedation and atropine-like side effects are common with tricyclics, especially amitriptyline. In contrast to sedative-hypnotics, tricyclics lower the threshold to seizures. The answer is (B). Selective serotonin reuptake inhibitors cause sexual dysfunction in some patients, with changes in libido, erectile dysfunction, and anorgasmia. Tricyclic antidepressants may also decrease libido or prevent ejaculation. Of the heterocyclic antidepressants bupropion is the least likely to affect sexual performance. The drug is also used in withdrawal from nicotine dependence. The answer is (B). 

ECG after withdrawal of the selective serotonin reuptake inhibitor paroxetine. Heart 2010 96(14) 1165-6. 

Seizures have been reported in patients receiving tramadol. The risk of seizure is increased with doses of tramadol above the recommended range. Concomitant use of tramadol increases the seizure risk in patients taking tricyclic antidepressants, selective serotonin reuptake inhibitors, or other opioids. Tramadol may enhance the seizure risk in patients taking MAO inhibitors, neuroleptics, or other drugs that reduce the seizure threshold. Risk of convulsions may also increase in patients with epilepsy, those with a history of seizures, or in patients with a recognized risk for seizure (such as head trauma, metabolic disorders, alcohol and drug withdrawal, CNS infections). 

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