NURS 660 EVALUATION EXAM TIPS QUESTIONS AND
SOLUTIONS RATED A+
✔✔Paroxetine lab tests - ✔✔None for healthy individuals
Renal Impairment:
Lower dose [initial 10 mg/day (12.5 mg CR), maximum 40 mg/day (50 mg/day CR)]
Hepatic Impairment:
Lower dose [initial 10 mg/day (12.5 mg CR), maximum 40 mg/day (50 mg/day CR)]
Cardiac Impairment
Preliminary research suggests that paroxetine is safe in cardiovascular patients
Treating depression with SSRIs in patients with acute angina or following myocardial
infarction may reduce cardiac events and improve survival as well as mood
✔✔Paroxetine pregnancy risks - ✔✔Not generally recommended for use during
pregnancy, especially during first trimester
Epidemiological data have shown an increased risk of cardiovascular malformations
(primarily ventricular and atrial septal defects) in infants born to women who took
paroxetine during the first trimester (absolute risk is small)
Unless the benefits of paroxetine to the mother justify continuing treatment, consider
discontinuing paroxetine or switching to another antidepressant
Paroxetine use late in pregnancy may be associated with higher risk of neonatal
complications, including respiratory distress
At delivery there may be more bleeding in the mother and transient irritability or
sedation in the newborn
Must weigh the risk of treatment (first trimester fetal development, third trimester
newborn delivery) to the child against the risk of no treatment (recurrence of depression,
maternal health, infant bonding) to the mother and child
For many patients this may mean continuing treatment during pregnancy
SSRI use beyond the 20th week of pregnancy may be associated with increased risk of
pulmonary hypertension in newborns, although this is not proven
Exposure to SSRIs late in pregnancy may be associated with increased risk of
gestational hypertension and preeclampsia
Neonates exposed to SSRIs or SNRIs late in the third trimester have developed
complications requiring prolonged hospitalization, respiratory support, and tube feeding;
reported symptoms are consistent with either a direct toxic effect of SSRIs and SNRIs
or, possibly, a drug discontinuation syndrome, and include respiratory distress,
cyanosis, apnea, seizures, temperature instability, feeding difficulty, vomiting,
hypoglycemia, hypotonia, hypertonia, hyperreflexia, tremor, jitteriness, irritability, and
constant crying
✔✔Paroxetine neurotransmitters and moa - ✔✔-Boosts neurotransmitter serotonin
-Blocks serotonin reuptake pump (serotonin transporter)
-Desensitizes serotonin receptors, especially serotonin 1A autoreceptors
-Presumably increases serotonergic neurotransmission
-Paroxetine also has mild anticholinergic actions
,-Paroxetine may have mild norepinephrine reuptake blocking actions
✔✔Fluvoxamine (Luvox) SSRI Major Side Effects
Commonly Prescribed for
Obsessive-compulsive disorder (OCD) (fluvoxamine and fluvoxamine CR)
Social anxiety disorder (fluvoxamine CR) - ✔✔*Fluvoxamine's sigma 1 agonist
properties may contribute to sedation and fatigue in some patients
Notable Side Effects
Sexual dysfunction (men: delayed ejaculation, erectile dysfunction; men and women:
decreased sexual desire, anorgasmia)
Gastrointestinal (decreased appetite, nausea, diarrhea, constipation, dry mouth)
Mostly CNS (insomnia but also sedation, agitation, tremors, headache, dizziness)
Note: patients with diagnosed or undiagnosed bipolar or psychotic disorders may be
more vulnerable to CNS-activating actions of SSRIs
Autonomic (sweating)
Bruising and rare bleeding
Rare hyponatremia
✔✔Fluvoxamine Major Adverse Reactions - ✔✔Rare seizures
Rare induction of mania
Rare activation of suicidal ideation and behavior (suicidality) (short-term studies did not
show an increase in the risk of suicidality with antidepressants compared to placebo
beyond age 24)
✔✔Fluvoxamine Major Drug Interactions - ✔✔-Tramadol increases the risk of seizures
in patients taking an antidepressant
-Can increase tricyclic antidepressant levels; use with caution with TCAs
-Can cause a fatal "serotonin syndrome" when combined with MAO inhibitors (MAOIs),
so do not use with MAOIs or for at least 14 days after MAOIs are stopped
-Do not start an MAOI for at least 5 half-lives (5 to 7 days for most drugs) after
discontinuing fluvoxamine
-May displace highly protein-bound drugs (e.g., warfarin)
-Can rarely cause weakness, hyperreflexia, and incoordination when combined with
sumatriptan or possibly with other triptans, requiring careful monitoring of patient
-Possible increased risk of bleeding, especially when combined with anticoagulants
(e.g., warfarin, NSAIDs)
NSAIDs may impair effectiveness of SSRIs
Via CYP450 1A2 inhibition, fluvoxamine may reduce clearance of theophylline and
clozapine, thus raising their levels and requiring their dosing to be lowered
Fluvoxamine administered with either caffeine or theophylline can thus cause jitteriness,
excessive stimulation, or rarely seizures, so concomitant use should proceed cautiously
Metabolism of fluvoxamine may be enhanced in smokers and thus its levels lowered,
requiring higher dosing
Via CYP450 3A4 inhibition, fluvoxamine may reduce clearance of carbamazepine and
benzodiazepines such as alprazolam and triazolam, and thus require dosage reduction
, Via CYP450 3A4 inhibition, fluvoxamine could theoretically increase concentrations of
certain cholesterol lowering HMG CoA reductase inhibitors, especially simvastatin,
atorvastatin, and lovastatin, but not pravastatin or fluvastatin, which would increase the
risk of rhabdomyolysis; thus, coadministration of fluvoxamine with certain HMG CoA
reductase inhibitors should proceed with caution
Via CYP450 3A4 inhibition, fluvoxamine could theoretically in
✔✔Fluvoxamine lab tests - ✔✔None for healthy individuals
Renal Impairment
Consider lower initial dose
Hepatic Impairment
Lower dose or give less frequently, perhaps by half; use slower titration
Cardiac Impairment
Preliminary research suggests that fluvoxamine is safe in these patients
Treating depression with SSRIs in patients with acute angina or following myocardial
infarction may reduce cardiac events and improve survival as well as mood
✔✔Fluvoxamine neurotransmitters and moa - ✔✔Boosts neurotransmitter serotonin
Blocks serotonin reuptake pump (serotonin transporter)
Desensitizes serotonin receptors, especially serotonin 1A receptors
Presumably increases serotonergic neurotransmission
Fluvoxamine also binds at sigma 1 receptors
✔✔Fluvoxamine pregnancy risks - ✔✔Controlled studies have not been conducted in
pregnant women
Not generally recommended for use during pregnancy, especially during first trimester
Nonetheless, continuous treatment during pregnancy may be necessary and has not
been proven to be harmful to the fetus
At delivery there may be more bleeding in the mother and transient irritability or
sedation in the newborn
Must weigh the risk of treatment (first trimester fetal development, third trimester
newborn delivery) to the child against the risk of no treatment (recurrence of depression,
maternal health, infant bonding) to the mother and child
For many patients this may mean continuing treatment during pregnancy
Exposure to SSRIs early in pregnancy may be associated with increased risk of septal
heart defects (absolute risk is small)
SSRI use beyond the 20th week of pregnancy may be associated with increased risk of
pulmonary hypertension in newborns, although this is not proven
Exposure to SSRIs late in pregnancy may be associated with increased risk of
gestational hypertension and preeclampsia
Neonates exposed to SSRIs or SNRIs late in the third trimester have developed
complications requiring prolonged hospitalization, respiratory support, and tube feeding;
reported symptoms are consistent with either a direct toxic effect of SSRIs and SNRIs
or, possibly, a drug discontinuation syndrome, and include respiratory distress,
cyanosis, apnea, seizures, temperature instability, feeding difficulty, vomiting,
SOLUTIONS RATED A+
✔✔Paroxetine lab tests - ✔✔None for healthy individuals
Renal Impairment:
Lower dose [initial 10 mg/day (12.5 mg CR), maximum 40 mg/day (50 mg/day CR)]
Hepatic Impairment:
Lower dose [initial 10 mg/day (12.5 mg CR), maximum 40 mg/day (50 mg/day CR)]
Cardiac Impairment
Preliminary research suggests that paroxetine is safe in cardiovascular patients
Treating depression with SSRIs in patients with acute angina or following myocardial
infarction may reduce cardiac events and improve survival as well as mood
✔✔Paroxetine pregnancy risks - ✔✔Not generally recommended for use during
pregnancy, especially during first trimester
Epidemiological data have shown an increased risk of cardiovascular malformations
(primarily ventricular and atrial septal defects) in infants born to women who took
paroxetine during the first trimester (absolute risk is small)
Unless the benefits of paroxetine to the mother justify continuing treatment, consider
discontinuing paroxetine or switching to another antidepressant
Paroxetine use late in pregnancy may be associated with higher risk of neonatal
complications, including respiratory distress
At delivery there may be more bleeding in the mother and transient irritability or
sedation in the newborn
Must weigh the risk of treatment (first trimester fetal development, third trimester
newborn delivery) to the child against the risk of no treatment (recurrence of depression,
maternal health, infant bonding) to the mother and child
For many patients this may mean continuing treatment during pregnancy
SSRI use beyond the 20th week of pregnancy may be associated with increased risk of
pulmonary hypertension in newborns, although this is not proven
Exposure to SSRIs late in pregnancy may be associated with increased risk of
gestational hypertension and preeclampsia
Neonates exposed to SSRIs or SNRIs late in the third trimester have developed
complications requiring prolonged hospitalization, respiratory support, and tube feeding;
reported symptoms are consistent with either a direct toxic effect of SSRIs and SNRIs
or, possibly, a drug discontinuation syndrome, and include respiratory distress,
cyanosis, apnea, seizures, temperature instability, feeding difficulty, vomiting,
hypoglycemia, hypotonia, hypertonia, hyperreflexia, tremor, jitteriness, irritability, and
constant crying
✔✔Paroxetine neurotransmitters and moa - ✔✔-Boosts neurotransmitter serotonin
-Blocks serotonin reuptake pump (serotonin transporter)
-Desensitizes serotonin receptors, especially serotonin 1A autoreceptors
-Presumably increases serotonergic neurotransmission
-Paroxetine also has mild anticholinergic actions
,-Paroxetine may have mild norepinephrine reuptake blocking actions
✔✔Fluvoxamine (Luvox) SSRI Major Side Effects
Commonly Prescribed for
Obsessive-compulsive disorder (OCD) (fluvoxamine and fluvoxamine CR)
Social anxiety disorder (fluvoxamine CR) - ✔✔*Fluvoxamine's sigma 1 agonist
properties may contribute to sedation and fatigue in some patients
Notable Side Effects
Sexual dysfunction (men: delayed ejaculation, erectile dysfunction; men and women:
decreased sexual desire, anorgasmia)
Gastrointestinal (decreased appetite, nausea, diarrhea, constipation, dry mouth)
Mostly CNS (insomnia but also sedation, agitation, tremors, headache, dizziness)
Note: patients with diagnosed or undiagnosed bipolar or psychotic disorders may be
more vulnerable to CNS-activating actions of SSRIs
Autonomic (sweating)
Bruising and rare bleeding
Rare hyponatremia
✔✔Fluvoxamine Major Adverse Reactions - ✔✔Rare seizures
Rare induction of mania
Rare activation of suicidal ideation and behavior (suicidality) (short-term studies did not
show an increase in the risk of suicidality with antidepressants compared to placebo
beyond age 24)
✔✔Fluvoxamine Major Drug Interactions - ✔✔-Tramadol increases the risk of seizures
in patients taking an antidepressant
-Can increase tricyclic antidepressant levels; use with caution with TCAs
-Can cause a fatal "serotonin syndrome" when combined with MAO inhibitors (MAOIs),
so do not use with MAOIs or for at least 14 days after MAOIs are stopped
-Do not start an MAOI for at least 5 half-lives (5 to 7 days for most drugs) after
discontinuing fluvoxamine
-May displace highly protein-bound drugs (e.g., warfarin)
-Can rarely cause weakness, hyperreflexia, and incoordination when combined with
sumatriptan or possibly with other triptans, requiring careful monitoring of patient
-Possible increased risk of bleeding, especially when combined with anticoagulants
(e.g., warfarin, NSAIDs)
NSAIDs may impair effectiveness of SSRIs
Via CYP450 1A2 inhibition, fluvoxamine may reduce clearance of theophylline and
clozapine, thus raising their levels and requiring their dosing to be lowered
Fluvoxamine administered with either caffeine or theophylline can thus cause jitteriness,
excessive stimulation, or rarely seizures, so concomitant use should proceed cautiously
Metabolism of fluvoxamine may be enhanced in smokers and thus its levels lowered,
requiring higher dosing
Via CYP450 3A4 inhibition, fluvoxamine may reduce clearance of carbamazepine and
benzodiazepines such as alprazolam and triazolam, and thus require dosage reduction
, Via CYP450 3A4 inhibition, fluvoxamine could theoretically increase concentrations of
certain cholesterol lowering HMG CoA reductase inhibitors, especially simvastatin,
atorvastatin, and lovastatin, but not pravastatin or fluvastatin, which would increase the
risk of rhabdomyolysis; thus, coadministration of fluvoxamine with certain HMG CoA
reductase inhibitors should proceed with caution
Via CYP450 3A4 inhibition, fluvoxamine could theoretically in
✔✔Fluvoxamine lab tests - ✔✔None for healthy individuals
Renal Impairment
Consider lower initial dose
Hepatic Impairment
Lower dose or give less frequently, perhaps by half; use slower titration
Cardiac Impairment
Preliminary research suggests that fluvoxamine is safe in these patients
Treating depression with SSRIs in patients with acute angina or following myocardial
infarction may reduce cardiac events and improve survival as well as mood
✔✔Fluvoxamine neurotransmitters and moa - ✔✔Boosts neurotransmitter serotonin
Blocks serotonin reuptake pump (serotonin transporter)
Desensitizes serotonin receptors, especially serotonin 1A receptors
Presumably increases serotonergic neurotransmission
Fluvoxamine also binds at sigma 1 receptors
✔✔Fluvoxamine pregnancy risks - ✔✔Controlled studies have not been conducted in
pregnant women
Not generally recommended for use during pregnancy, especially during first trimester
Nonetheless, continuous treatment during pregnancy may be necessary and has not
been proven to be harmful to the fetus
At delivery there may be more bleeding in the mother and transient irritability or
sedation in the newborn
Must weigh the risk of treatment (first trimester fetal development, third trimester
newborn delivery) to the child against the risk of no treatment (recurrence of depression,
maternal health, infant bonding) to the mother and child
For many patients this may mean continuing treatment during pregnancy
Exposure to SSRIs early in pregnancy may be associated with increased risk of septal
heart defects (absolute risk is small)
SSRI use beyond the 20th week of pregnancy may be associated with increased risk of
pulmonary hypertension in newborns, although this is not proven
Exposure to SSRIs late in pregnancy may be associated with increased risk of
gestational hypertension and preeclampsia
Neonates exposed to SSRIs or SNRIs late in the third trimester have developed
complications requiring prolonged hospitalization, respiratory support, and tube feeding;
reported symptoms are consistent with either a direct toxic effect of SSRIs and SNRIs
or, possibly, a drug discontinuation syndrome, and include respiratory distress,
cyanosis, apnea, seizures, temperature instability, feeding difficulty, vomiting,
