Therapeutic Starting P450 Enzyme Dose Range SSRI’s Notes Side Effects Dose (mg) Inhibition (Max dose) Fluoxetine 20 20-40 daily Strong 2D6 long half-life, slightly Common: initial (Prozac) (max 60) activating activation, nausea, Mod 1A2 diarrhea and Lowest risk of headaches. (if discontinuation anxious, start with syndrome among ½ starting dose x SSRI’s weeks) Paroxetine 20 bedtime 20-40 Strong 2D6 Weight gain, Can also cause bedtime sedating, greatest (Paxil) decreased libido, (max 60) risk of erectile dysfunction, discontinuation insomnia, akathisia, syndrome increased risk of SSRI’s falls. Increase GI bleed risk with NSAIDs Citalopram 20 daily 20-40 daily -- No drug interactions (max 40) (Celexa) Escitalopram 10 daily 10-20 Mild 2D6 S-enantiomer of (max 20) citalopram (Lexapro) Sertraline 50 daily 50-200 daily Mild 2D6 Take with food (max 200) (Zoloft) Therapeutic Starting P450 Enzyme Dose Range SNRI’s Notes Side Effects Dose (mg) Inhibition (Max dose) Venlafaxine ER 37.5 daily 75-150 daily -- Same as SSRI + dry (max 375) activation, (Effexor XR) Discontinuation constipation, syndrome risk tachycardia and similar to paroxetine elevated blood pressure, especially at doses > 150 daily Duloxetine 30 daily 60 daily Mod 2D6 Also approved for Same as SSRI + dry (max 120) fibromyalgia, mouth, activation, (Cymbalta) diabetic peripheral constipation, neuropathy tachycardia and elevated blood pressure, especially at doses > 60 daily
SSRI’s Starting Dose (mg) Therapeutic Dose Range (Max dose) P450 Enzyme Inhibition Notes Side Effects Fluoxetine (Prozac) 20 20-40 daily (max 60) Strong 2D6 Mod 1A2 long half-life, slightly activating Lowest risk of discontinuation syndrome among SSRI’s Common: initial activation, nausea, diarrhea and headaches. (if anxious, start with ½ starting dose x weeks) Can also cause decreased libido, erectile dysfunction, insomnia, akathisia, increased risk of falls. Increase GI bleed risk with NSAIDs Paroxetine (Paxil) 20 bedtime 20-40 bedtime (max 60) Strong 2D6 Weight gain, sedating, greatest risk of discontinuation syndrome SSRI’s Citalopram (Celexa) 20 daily 20-40 daily (max 40) -- No drug interactions Escitalopram (Lexapro) 10 daily 10-20 (max 20) Mild 2D6 S-enantiomer of citalopram Sertraline (Zoloft) 50 daily 50-200 daily (max 200) Mild 2D6 Take with food SNRI’s Starting Dose (mg) Therapeutic Dose Range (Max dose) P450 Enzyme Inhibition Notes Side Effects Venlafaxine ER (Effexor XR) 37.5 daily 75-150 daily (max 375) -- Discontinuation syndrome risk similar to paroxetine Same as SSRI + dry activation, constipation, tachycardia and elevated blood pressure, especially at doses > 150 daily Duloxetine (Cymbalta) 30 daily 60 daily (max 120) Mod 2D6 Also approved for fibromyalgia, diabetic peripheral neuropathy Same as SSRI + dry mouth, activation, constipation, tachycardia and elevated blood pressure, especially at doses > 60 daily
BHICCI-Major-Depression-Final.docx