Selective serotonin reuptake management

Selective serotonin reuptake inhibitor antidepressant selection and anxiolytic and sedative hypnotic prescribing a multivariate analysis./ Clin Outcomes Manage 4, 16—22. 

A number of non-hormonal therapies have been studied for symptomatic management of vasomotor symptoms, including antidepressants [e.g., selective serotonin reuptake inhibitors (SSRIs) and venlafaxine], herbal products (e.g., soy, black cohosh, and dong quai), and a group of miscellaneous agents (e.g., gabapentin, clonidine, and megestrol). The choice of therapy depends on the patient s concomitant disease states, such as depression and hypertension, and the risk for potential adverse effects. 

Dexamethasone has been used successfully in the management of chemotherapy-induced nausea and vomiting (CINV) and postoperative nausea and vomiting (PONV), either as a single agent or in combination with selective serotonin reuptake inhibitors (SSRIs). For CINV, dexamethasone is effective in the prevention of both cisplatin-induced acute emesis and when used alone or in combination for the prevention of delayed nausea and vomiting associated with CINV. 

Example 3 Managing Partial Response to a Selective Serotonin Reuptake Inhibitor in Obssessive-Compulsive Disorder... 

In more recent years the tricyclic anhdepressants have lost their position as the mainstay of therapy for depression and have been gradually supplanted by the selective serotonin reuptake inhibitors (SSRIs), such as fluoxetine. The tricyclics, however, do continue to be valuable in the management of chronic pain states such as headache or neuropathy. 

Selective serotonin reuptake inhibitors (SSRIs) are the most popular treatment option due to safety in overdose situations, low side effect burden, and ease of administration (i.e., once-daily dosing with minimal titration required). SSRIs are also effective treatment for the management of anxiety disorders, a common psychiatric comorbidity among the depressed. 

Pentel PR, Keyler DE, Haddad LM. Tricyclic antidepressants and selective serotonin reuptake inhibitors. In Haddad LM, Shannon MW, Winchester JF, eds. Clinical management of poisoning and drug overdose, 3 ed. Philadelphia WB Saunders Co, 1998 437-51. 

Chronic pain patients tend to have concurrent depression however, the antidepressants chosen may not have any pain-relieving properties. Antidepressants that affect one neurotransmitter in the brain, such as selective serotonin reuptake inhibitors have not appeared to be effective in the management of pain in clinical trials. Antidepressants that affect multiple neurotransmitters— namely, serotonin and norepinephrine—have been shown to be effective pain relievers.Two published metaanalyses have shown that tricyclic antidepressants amitriptyline, desipramine, imipramine, and nortriptyline are the most effective treatment for the management of neuropathic pain. ° These publications review the published clinical trial data for all agents available for the management of neuropathic pain. 

Consider use of selective serotonin reuptake inhibitors (e.g., paroxetine) or tricyclic antidepressants in difficult-to-manage patients... 

FIGURE 70-2. Algorithm for management of obsessive-compulsive disorder in adults. A. Overall approach to treatment. B. Pharmacotherapeutic approach to treatment. CBT, cognitive behavioral therapy SSRI, selective serotonin reuptake inhibitor. (Derived from Expert Consensus Panel for Obsessive-Compulsive Disorder and American Pharmaceutical Association. )... 

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. 

Individuals on psychotropic medications (such as selective serotonin reuptake inhibitors or SSRIs, monoamine oxidase inhibitors, and methylating agents) being managed for depression and anxiety should be carefully counseled before starting the LNAA diet. LNAA products contain significant amounts of tyrosine and tryptophan, precursors to dopamine and serotonin, respectively. Taking too much LNAA may exacerbate the brain serotonin systems. 

Compounds such as fluoxetine and other serotonin-selective reuptake inhibitors, which modulate serotonergic transmission by blocking reuptake of the transmitter, are among the most widely prescribed drugs for the management of depression and other behavioral disorders. These drugs are discussed in Chapter 30 Antidepressant Agents. 

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