Understanding Antidepressant Medications (cont.)

Atypical Antidepressants

Atypical antidepressants may be prescribed when SSRIs or TCAs have not worked. Atypical antidepressants include:

• bupropion (Wellbutrin, Wellbutrin SR, Wellbutrin XL),
  
  
• duloxetine (Cymbalta),
  
  
• maprotiline (Ludiomil),
  
  
• mirtazapine (Remeron),
  
  
• nefazodone (Serzone),
  
  
• trazodone (Desyrel), and
  
  
• venlafaxine (Effexor).

How do atypical antidepressants work?

Each of these drugs inhibit uptake of the various neurotransmitters in the brain.

Who should not use these medications?

• Individuals with a prior allergic reaction to any atypical antidepressant



• Individuals with seizure disorders (Do not use bupropion and maprotiline.)



• Individuals taking MAOIs (Do not use duloxetine, maprotiline, and venlafaxine.)



• Other contraindications include the following:
  
  
  • Bupropion (Wellbutrin, Wellbutrin SR, Wellbutrin XL): Individuals with bulimia or anorexia nervosa, or those in the process of withdrawal from alcohol or sedatives should not take bupropion.
  
  
  
  • Duloxetine (Cymbalta): Individuals with uncontrolled narrow-angle glaucoma should not take duloxetine.
  
  
  
  • Maprotiline (Ludiomil), mirtazapine (Remeron), nefazodone (Serzone), and trazodone (Desyrel): Individuals who have experienced a recent heart attack should not take these medications.
  
  
  
  • Nefazodone (Serzone): Individuals should not take nefazodone if they have liver impairment or are currently using cisapride (Propulsid), pimozide (Orap), carbamazepine (Tegretol), or triazolam (Halcion).

Use

• Atypical antidepressants are administered orally.



• Mirtazapine (Remeron SolTab) is a tablet that dissolves when placed in the mouth instead of swallowing with water.



• Some atypical antidepressants are available as sustained-release tablets or capsules and should only be swallowed whole (do not crush, divide, or chew).



• Abrupt discontinuation of some atypical antidepressants, such as duloxetine, may cause withdrawal-like symptoms such as agitation, anxiety, confusion, dizziness, headache, and insomnia. Ask a doctor or pharmacist if the medication dose should be gradually tapered down to avoid these symptoms. 

Children: Safety and efficacy of duloxetine, bupropion, maprotiline, mirtazapine, nefazodone, and trazodone have not been established in children younger than 18 years.

Drug or food interactions: Tell the doctor what medications are currently being taken because many drugs interact with atypical antidepressants. Do not take any nonprescription or herbal medications without first consulting the doctor or pharmacist. The following are examples of interactions, but they do not represent a complete list.

Bupropion (Wellbutrin, Wellbutrin SR, Wellbutrin XL)

• Bupropion (Wellbutrin, Wellbutrin SR, Wellbutrin XL) may increase the blood levels and/or risk of toxicity of the following drugs:
  
  
  • Alcohol or other drugs that depress the central nervous system such as drugs taken for insomnia
  
  
  
  • SSRIs
  
  
  
  • TCAs
  
  
  
  • Beta blockers such as propranolol (Inderal)
  
  
  
  • Antiarrhythmic drugs such as flecainide (Tambocor) or propafenone (Rythmol)
  
  
  
  • warfarin (Coumadin)
     
• The following drugs may increase bupropion blood levels or toxicity:
  
  
  • Other drugs that increase seizure risk
  
  
  
  • amantadine (Symmetrel)
  
  
  
  • levodopa (Sinemet)
  
  
  
  • carbamazepine (Tegretol)
  
  
  
  • MAOIs
  
  
  
  • ritonavir (Norvir)

Duloxetine (Cymbalta)

• Duloxetine (Cymbalta) may increase the blood levels and/or risk of toxicity of the following drugs:
  
  
  • Alcohol or other drugs that depress the central nervous system such as drugs taken for insomnia
  
  
  
  • Antiarrhythmic drugs such as flecainide (Tambocor) or propafenone (Rythmol)
  
  
  
  • Phenothiazines such as thioridazine (Mellaril)
  
  
  
  • TCAs
  
  
  
  • MAOIs
  
  
  
  • warfarin (Coumadin)
     
• The following drugs may increase duloxetine blood levels or toxicity:
  
  
  • fluvoxamine (Luvox)
  
  
  
  • fluoxetine (Prozac)
  
  
  
  • paroxetine (Paxil)
  
  
  
  • quinidine (Cardioquin, Quinaglute)
  
  
  
  • quinolone antibiotics such as ciprofloxacin (Cipro) and levofloxacin (Levaquin)
     

Maprotiline (Ludiomil), mirtazapine (Remeron)

• Maprotiline (Ludiomil) may increase the blood levels and/or risk of toxicity of the following drugs:
  
  
  • Alcohol or other drugs that depress the central nervous system such as drugs taken for insomnia
  
  
  
  • Drugs with similar side effects such as TCAs or antihistamines (Benadryl)
    
    
• The following drugs may increase maprotiline blood levels or toxicity:
  
  
  • Thyroid medication may add to the risk of increased heart rate and abnormal rhythm.
  
  
  
  • Phenothiazines and benzodiazepines [such as diazepam (Valium)] increase risk for seizures. 

Nefazodone (Serzone)

• Nefazodone (Serzone) may increase the blood levels and/or risk of toxicity of the following drugs:
  
  
  • Alcohol or other drugs that depress the central nervous system such as drugs taken for insomnia
  
  
  
  • buspirone (Buspar)
  
  
  
  • carbamazepine (Tegretol)
  
  
  
  • cisapride (Propulsid)
  
  
  
  • cyclosporine (Neoral, Sandimmune)
  
  
  
  • digoxin (Lanoxin)
  
  
  
  • pimozide (Orap)
  
  
  
  • thioridazine (Mellaril)
  
  
  
  • triazolam (Halcion)
  
  
  
  • St. John's wort
  
  
  
  • SSRIs
  
  
  
  • TCAs
  
  
  
  • Drugs that may cause abnormal heart rhythms (check with the doctor or pharmacist)
  
  
  
  • Drugs indicated to treat high cholesterol such as simvastatin (Zocor) or atorvastatin (Lipitor)
    
    
• The following drugs may increase nefazodone blood levels or toxicity:
  
  
  • buspirone (Buspar)
  
  
  
  • sibutramine (Meridia)
  
  
  
  • sumatriptan (Imitrex) or other similar drugs for migraine headache
     

Trazodone (Desyrel)

• Trazodone (Desyrel) may alter the blood levels and/or risk of toxicity of the following drugs:
  
  
  • Alcohol or other drugs that depress the central nervous system such as drugs taken for insomnia
  
  
  
  • clonidine (Catapres) (enhances blood pressure lowering effect)
  
  
  
  • digoxin (Lanoxin)
  
  
  
  • MAOIs
  
  
  
  • phenytoin or fosphenytoin (Dilantin, Cerebyx)
  
  
  
  • warfarin (Coumadin)   
     
• The following drugs may increase trazodone blood levels or toxicity:
  
  
  • Antifungal agents such as itraconazole (Sporanox) or ketoconazole (Nizoral)
  
  
  
  • carbamazepine (Tegretol)
  
  
  
  • Phenothiazines such as thioridazine (Mellaril)
  
  
  
  • ritonavir (Norvir)
  
  
  
  • SSRIs, sibutramine (Meridia), sumatriptan (Imitrex), trazodone (Desyrel), venlafaxine (Effexor), and St. John's wort (These medications may increase the risk for serotonin syndrome—symptoms include hypertension, fever, muscle tremor, or confusion.)
  
  
  
  • Drugs that may cause abnormal heart rhythms (check with the doctor or pharmacist)
     

Venlafaxine (Effexor)

• Venlafaxine (Effexor) may alter the blood levels and/or risk of toxicity of the following drugs:
  
  
  • clozapine
  (Clozaril)
  
  
  • desipramine (Norpramin)
    
    
  • haloperidol (Haldol)
  
  
  
  • indinavir
  (Crixivan)
  
  
  • SSRIs, sibutramine (Meridia), sumatriptan (Imitrex), trazodone (Desyrel), and St. John's wort (These medications may increase the risk for serotonin syndrome—symptoms include hypertension, fever, muscle tremor, or confusion.)
  
  
  
  • warfarin (Coumadin)
    
    
• The following drugs may increase venlafaxine blood levels or toxicity:
  
  
  • cimetidine (Tagamet)
    
    
  • MAOIs
  
  
  
  SSRIs, nefazodone (Serzone), St. John's wort, and venlafaxine (These medications may increase the risk for serotonin syndrome—symptoms include hypertension, fever, muscle tremor, or confusion.)

Side Effects: This is NOT a complete list of side effects reported with atypical antidepressants. The doctor, health care provider, or pharmacist can discuss a more complete list of side effects.

• Manic episodes in persons with bipolar disorder (If not combined with a mood-stabilizing drug, atypical antidepressants may induce manic episodes in individuals with bipolar disorder.)
  
  
• Seizures (Atypical antidepressants may lower the threshold for seizures; that is, seizures may occur more easily. Caution is advised for individuals prone to seizures or those who have a history of seizures.)
  
  
• Drowsiness (Caution is advised when operating machinery, driving, or performing other tasks that require alertness.)
  
  
• bupropion (Wellbutrin, Wellbutrin SR, Wellbutrin XL, Zyban)
  
  
  • Contains the same active ingredient found in Zyban, which is used as an aid in smoking cessation treatment (Do not use bupropion with Zyban or other medications containing bupropion.)
  
  
  
  • More likely to cause seizures than other antidepressants, especially with doses above 450 mg/day (Seizures are also more likely in patients who have bulimia or anorexia nervosa and are treated with bupropion.)
  
  
  
  • Caution in narrow-angle glaucoma
  
  
  
  • Caution in slow gastric emptying (often present in diabetes)
     
• maprotiline (Ludiomil), mirtazapine (Remeron)
  
  
  • May increase appetite and cause weight gain
  
  
  
  • May decrease white blood cell count (The doctor will monitor this throughout the therapy.)
  
  
  
  • May cause urinary retention, blurred vision, heart rhythm abnormalities, dizziness, or constipation
  
  
  
  • Caution in heart disease and abnormal heart rhythms
     
• nefazodone (Serzone)
  
  
  • May cause liver impairment (Contact the doctor immediately if dark urine, anorexia, stomach or abdominal pain, or yellowing of the skin or eyes occurs.)
  
  
  
  • Caution in heart disease and abnormal heart rhythms
  
  
  
  • Lightheadedness or fainting when standing up from a sitting or lying position (Stand up gradually from lying down or sitting positions.)
     
• trazodone (Desyrel)
  
  
  • Caution in heart disease and abnormal heart rhythms 
     
• venlafaxine (Effexor)
  
  
  • May cause sustained increases in blood pressure
  
  
  
  • May cause weight loss
  
  
  
  • May cause anxiety and insomnia
  
  
  
  • Decreased dose required for individuals with kidney or severe liver impairment

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