Type of Medication

Selective serotonin reuptake inhibitors

***Please note: In March 2004, the Food and Drug Administration (FDA) issued a Public Health Advisory that cautions physicians, patients, families and caregivers of patients with depression to closely monitor adults, teens, and children receiving certain antidepressant medications. The FDA is concerned about the possibility of worsening depression and/or the emergence of suicidal thoughts at the beginning of treatment or when there’s an increase or decrease in the dose. The medications of concern—mostly SSRIs (Selective Serotonin Re-uptake Inhibitors)—are: Prozac (fluoxetine), Zoloft (sertraline), Paxil (paroxetine), Luvox (fluvoxamine), Celexa (citalopram); Lexapro (escitalopram), Wellbutrin (bupropion), Effexor (venlafaxine), Serzone (nefazodone), and Remeron (mirtazapine). Of these, only Prozac (fluoxetine) is approved for use in children and adolescents for the treatment of major depressive disorder. Prozac (fluoxetine), Zoloft (sertraline), and Luvox (fluvoxamine) are approved for use in children and adolescents for the treatment of obsessive compulsive disorder. Evidence available through 2006 suggests an excess risk of suicidal thoughts or actions among children and adolescents, but does not yet clearly confirm that risk for adults. For more information, please visit http://www.fda.gov/cder/drug/antidepressants .

Medications and Their Commonly Used Brand Names

What They Are Prescribed For

• Depression (all five SSRIs)
• Obsessive-compulsive disorder (OCD) (fluoxetine, fluvoxamine, paroxetine, sertraline)
• Bulimia nervosa (fluoxetine)
• Panic attacks and panic disorder (paroxetine, sertraline)

How SSRIs Work:

These medications increase the activity of serotonin, a brain chemical that is associated with a sense of well-being.

It may take several weeks for you to notice the effects of an SSRI.

Precautions While Using These Medicines

See Your Doctor Regularly

It is important that your doctor check your progress at regular visits, to allow for dosage adjustments and to help reduce any side effects. Also, tell your doctor if you are pregnant or breastfeeding, or thinking of becoming pregnant; this may affect the choice and/or dosage of medication.

Alert your doctor if you are taking any of the following medications; some should not be taken with SSRIs, while others may require a different dosage level.

• Alprazolam (Xanax)
• Anticoagulants (Miradon, Dicumarol, Coumadin, Warfarin sodium, Normiflo, Fragmin, Lovenox, Heparin, Orgaran)
• Astemizole (Hismanal)
• Bromazepam (Lectopam)
• Bromocriptine (Parlodel)
• Buspirone (BuSpar)
• Cisapride (Propulsid)
• Clozapine (Clozaril)
• Dextromethorphan (cough remedies: Benylin, Cough-X, Creo-Terpin, Delsym, Diabe-TUS DM, Hold DM, Pertussin, Robitussin, Sucrets 4 Hour, Trocal, Vicks 44)
• Diazepam (Valium)
• Digitalis medicines (Lanoxin, Digitoxin, Digitalis)
• Dihydroergotamine (Cafergot, Cafertine, Cafetrate, DHE 45, Ercaf, Ergo-Caff, Ergomar, Ergostat, Gotamine, Migergot, Wigraine)
• Fenfluramine (Pondimin)
• Levodopa (Sinemet)
• Lithium (Cibalith, Eskalith, Lithane, Lithobid, Lithonate, Lithotabs)
• Meperidine (Demerol)
• Metoprolol (Lopressor)
• Midazolam (Versed)
• Moclobemide (Manerex)
• Monoamine oxidase (MAO) inhibitors :
  • Furazolidone (Furoxone)
  • Isocarboxazid (Marplan)
  • Phenelzine (Nardil)
  • Procarbazine (Matulane)
  • Selegiline (Eldepryl)
  • Tranylcypromine (Parnate)
• Nefazodone (Serzone)
• Other SSRIs
• Pentazocine (Talwin)
• Phenytoin (Dilantin)
• Propanolol (Inderal)
• Street drugs (LSD, MDMA [e.g., ecstasy], marijuana)
• Sumatriptan (Imitrex)
• Terfenadine (Seldane)
• Theophylline (Theo-Dur)
• Tramadol (Ultram)
• Trazodone (Desyrel, Trazon, Trialodine)
• Triazolam (Halcion)
• Tricyclic antidepressants :
  • Amitriptyline (Elavil)
  • Amoxapine (Asendin)
  • Clomipramine (Anafranil)
  • Desipramine (Pertofrane)
  • Doxepin (Sinequan)
  • Imipramine (Tofranil)
  • Nortriptyline (Aventyl)
  • Protriptyline (Vivactil)
  • Trimipramine (Surmontil)
• Tryptophan
• Venlafaxine (Effexor)

Tell your doctor about all the medications you take; some should not be taken with SSRIs, while others may require a different dosage level.

Be especially careful with monoamine oxidase (MAO) inhibitors (furazolidone, phenelzine, procarbazine, selegiline, or tranylcypromine). Do not take an SSRI within two weeks of taking an MAO inhibitor, and do not take an MAO inhibitor for at least five weeks after taking an SSRI. If you do, you may develop dangerously high blood pressure, convulsions, or other severe effects.

Avoid Alcohol

Avoid drinking alcohol while taking an SSRI.

Be Cautious With Certain Medical Conditions

The presence of other medical problems may affect the use of SSRIs. Tell your doctor if you have any other medical problems, especially:

• History of seizures--the chance of having a seizure may increase while taking an SSRI
• Diabetes --the amount of insulin or oral medicine that you need may change
• Kidney or liver disease--higher blood levels of the SSRI may occur, increasing the chance of side effects
• Parkinson's disease --this condition may be worsened with an SSRI
• Weight loss--fluoxetine and sertraline may cause weight loss, which is usually small, but if a large weight loss occurs, it may be harmful to some people
• Thoughts of suicide--people being treated for depression may also be at risk for suicide. This risk does not subside immediately with the initiation of SSRI therapy. People who have suicidal thoughts should be closely monitored during initial therapy and until clinical remission is apparent
• Mania or a history of mania--this may be aggravated with some SSRIs
• Brain disease or mental retardation

Watch Your Skin

Alert your doctor as soon as possible if you develop a skin rash, hives, or itching while you are taking an SSRI.

Beware of Drowsiness

SSRIs may cause some people to become drowsy or less able to think clearly, or to have poor muscle control. Make sure you know how you react to these drugs before you drive, use machines, or do anything else that could be dangerous if you are not alert and able to control your movements.

Don't Stop Suddenly

Do not stop taking your SSRI without first checking with your doctor. You should be weaned off this medication to avoid unpleasant symptoms.

Missed Dose

Citalopram, Sertraline: Check with your doctor on how to deal with a missed dose, since citalopram and sertraline may be given to different patients at different times of day.

Fluoxetine: If you miss a single dose it is not necessary to make up the missed dose. Skip the missed dose and continue with your next scheduled dose. Do not double doses. If you miss multiple doses you should talk with your doctor about how to take medication more effectively.

Fluvoxamine: What to do when you miss a dose of fluvoxamine depends on your dosing schedule:

One time a day--take the missed dose as soon as possible if you remember the same day and go back to your regular dosing schedule. Do not double doses.

Two times a day--skip the missed dose and go back to your regular dosing schedule. Do not double doses.

Paroxetine: If you miss a dose, take it as soon as possible. However, if it is almost time for your next dose, skip the missed dose and go back to your regular dosing schedule. Do not double doses.

Possible Side Effects

The side effects listed here have been reported for at least one of the SSRIs, not necessarily all of them. However, since many of the effects of SSRIs are similar, it is possible that these side affects may occur with any one of these medicines, although they may be more common with some than with others.

Check with your doctor if any of the following side effects occur frequently and/or become bothersome:

These side effects are considered more common:

• Decreased sexual drive or ability
• Restlessness
• Skin rash, hives, or itching

These side effects are considered less common:

• Agitation, anxiety, or nervousness
• Blurred vision
• Changes in, or pain in urinating
• Chills or fever
• Confusion
• Constipation
• Decreased appetite or weight loss
• Diarrhea
• Dizziness
• Dryness of mouth
• Fast or irregular heartbeat
• Headache
• Increased sweating
• Joint or muscle pain
• Lack of emotion
• Loss of memory
• Menstrual changes
• Muscle pain or weakness
• Nausea or vomiting
• Stomach or abdominal cramps, gas, or pain
• Trouble breathing
• Trouble sleeping
• Twitching, trembling, or shaking
• Unusual tiredness or weakness

After you stop taking an SSRI, your body may need time to adjust. During this time, check with your doctor if you notice any of the following side effects:

• Agitation
• Anxiety
• Confusion
• Dizziness or lightheadedness
• Feeling of constant movement of self or surroundings
• Headache
• Increased sweating
• Nausea or vomiting
• Trembling or shaking
• Trouble sleeping
• Unusual tiredness or weakness

Other Uses For SSRIs

Once a medicine has been approved for marketing for a certain use, experience may show that it is also useful for other medical problems. Although these uses are not included in product labeling, SSRIs may be used in certain people with these conditions:

• Bipolar disorder (fluoxetine)
• Obesity (fluoxetine)
• Panic attacks and disorder (fluoxetine)
• Myoclonus (fluoxetine)
• Premenstrual dysphoric disorder (fluoxetine, paroxetine, sertraline)
• Premature ejaculation (paroxetine)

RESOURCES:

Medline Plus: Drug Information National Institutes of Health.
http://www.nlm.nih.gov

National Institute of Mental Health
http://www.nimh.nih.gov

References:

Gunnell D, Saperia J, Ashby D. Selective serotonin reuptake inhibitors (SSRIs) and suicide in adults: meta-analysis of drug company data from placebo controlled, randomised controlled trials submitted to the MHRA's safety review. BMJ . 2005 Feb 19;330(7488):385.

Martinez C, Rietbrock S, Wise L, Ashby D, Chick J, Moseley J, et al. Antidepressant treatment and the risk of fatal and nonfatal self-harm in first episode depression: nested case-control study. BMJ . 2005 Feb 19;330(7488):389.

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