Antidepressant medications

TCAs	Dose range	Labs / monitor	Side effects
Amitriptyline	25-150 mg/day	Do not take if have you have problems with liver, kidney, heart, seizures, pregnant glaucoma or diabetes. Do not take with opioids or St John’s wort.	Irregular heart beat, yellow skin, eye pain or swelling, confused (low sodium), dry mouth dizziness difficulty peeing
Nortriptyline/Pamelor, Noritren	Start 10 mg at bedtime; increase to 50-70 mg	EKG in patients over 40 Contraindicated in patients with narrow angle glaucoma, urinary retention, benign prostatic hypertension, impaired liver function, cardiovascular disease (ischemic cardiac disease, MI)	Xerostomia, blurred vision, constipation, urinary retention, postural hypotension, compensatory reflex tachycardia, memory dysfxn, cardiac depression, cardiac electrical conduction problems, arrhythmias
Bupropion (Wellbutrin) XL	150 mg/day in morning Max dosage 450mg/day Good as monotherapy for depression, Smoking cessation, effective for weight loss (combo of Bup + Topiramate) Lease likely of AD to flip patient into mania NO sexual side effects		Avoid in anorexia/bulimia May precipitate seizures, do not use with pts with substance abuse. STRONG 2D6 inhibition Abusable, crushing and snorting will get people high. Substituted cathinone = rx bath salt Use with care in anxious patients
Trazadone (Desynel)	75-150mg before bed. Increase every three days up to MAX 300mg/day Elderly Max dose 100mg For sleep 50-100mg/day	Kidney and Liver function test initially and periodically during therapy. Check potassium and magnesium because this can increase risk of QT prolongation. It may also be increased if pt is on diuretics, or has vomiting or diarrhea. hyponaturema	Headache, fatigue, Dizzy/somnolence, blurred vision, QT prolongation
SSRIs	Dose range	Labs / monitor	Side effects
Fluoxetin (Prozac)	5-20mg ; incremental increase every 2-4 weeks. Max dose 60 “safest in pregnancy”		Avoid in geriatric patient due to drug-drug interactions and long t ½ Activating effect may limit use for those with significant anxiety or panic disorder
Sertraline (Zoloft)	12.5-50mg ; incremental increase every 2-4 weeks Max dose 200 Suppoeted for use in post-MI , post-CVA “safest in breast feeding’ Few DDI		Second worse sexual side effects of SSRI
Paroxetine (Paxil)	10-20mg (immediate release) Max dose 60mg		“friends don’t let friends prescribe Paxil” Limited usefulness and significant side effect. Many DDI Don’t use in geriatric patients Worst sexual side effects
Citalopram (Celexa)	10-20mg; incremental increase every 2-4 weeks Max dose 40mg few DDI		BLACK BOX warning for QTc prolongation at doses >40mg(20mg in elderly)
escitalopram (Lexapro)	5-10mg-; incremental increase every 2-4 weeks Max dose 20mg Few DDI, cheap, effective “most bang for buck”		Can be sedating in some people
SNRI	Dose range	Labs / monitor	Side effects
Venlafaxine (Effexor) XR extended release	Initally 37.5-75mg/day; mean dose 225mg/day; Max 375mg/day XR take one daily Takes weeks to be effective Good for migraine and neuropathic pain Good option if failed SSRI Few DDI Can combine with Mirtazapine for “California Rocket Fuel”	Hyponatremia (in older adult patients Higher dosage will increase BP- must monitor	May increase risk of Serotonin Syndrome when used with TCAs, SSRIs, TCAs, tramadol, bupropion and buspirone. Caution with HTN, or seizures Nausea, headache, nervousness, tremor, dry mouth constipation and sexual dysfunction Significant discontinuation syndrome one of the worst besides Paroxetine. Taper slowly may need to use fluoxetine to bridge discontinuation.
Duloxetine (Cymbalta)	Start 20 mg at bedtime; increase to max of 60 mg/day One study says dose in AM another says PM Good for neuropathic pain, migraines, complex pain syndromes >/= gabapentin for neuropathic pain.	Higher dose will increase BP-must monitor	Less effective as an antidepressant Contraindicated with any level of liver impairment; can increase liver enzymes Brain fog common at higher doses GI and nervous systems, not to be used with MAOIs or CYP450 1A2 inhibitors
ANXIOLYTIC
Buspirone (Buspar). 5-HT1A partial agonist for the treatment of generalized anxiety disorder (non-benzo).	5mg tid. Max is 30mg/day. Can be used for severe bruxism.