NURS 660: KEY POINTS ON MAOIS, SSRIS,
SNRIS, AND ADVERSE EFFECTS
PSYCHOPHARM & ADVANCED MENTAL
HEALTH (MARYVILLE UNIVERSITY)
,Note: Exam 2 will cover content from Weeks 6, 7, and 8.
1. Know how to switch patients to and from an MAOI to another antidepressant.
Switching from a serotonergic drug to an MAOI = 5 half-lives
o 5-7 days for most drugs
o 5 weeks for fluoxetine (Prozac) d/t its long half-life
Having your patient on no medication for 5 weeks is scary; if they were that unstable that you were going to make a med
switch. Big reason we don’t use MAOIs
o “5 to keep them alive”
Switching from and MAOI to a serotonergic Drug = 14 days (2 weeks)
o It takes the liver 2 weeks to produce new MAO enzymes
2. Know the major side effects, adverse reactions, drug interactions, food-drug interactions, applicable lab tests to
order when the medication is prescribed and during treatment, the neurotransmitters they work on, pregnancy
risk, and the mechanism of action for the following medications:
SSRIs – Selective Serotonin Reuptake Inhibitors
• Fluoxetine (Prozac) - SSRI
o MOA: Blocks serotonin reuptake pump
Also has 5HT2C antagonist properties, which could increase NE and DA
o Uses: MDD (ages ≥ 8), OCD (ages ≥ 7), PMDD, Bulimia, Panic disorder, Bipolar depression [in combination with olanzapine],
treatment-resistant depression (in combination with olanzapine), social anxiety disorder, PTSD
May be activating/energizing (*might not be good for an anxious/overacted patient)
Improve concentration/motivation (*good choice for sluggish/unmotivated patient b/c 5HT2C antagonism -> increase NE and
DA)
o Adverse effects:
▪ Seizures, induction of mania, activation of suicidal ideation and behavior
o Overdose: rarely lethal in monotherapy OD; respiratory depression, esp. with alcohol, ataxia, sedation, seizure
o Side effects:
▪ GI: diarrhea, decreased appetite, nausea, constipation, dry mouth
▪ CNS: insomnia, sedation, emotional flattening, cognitive slowing, apathy, agitation, anxiety, tremors, HA, dizziness
▪ Sexual dysfunction
▪ Sweating, bruising, bleeding, SIADH
o Pharmacokinetics:
Very long half-life (2 weeks)
Good for noncompliant patients (less likely to have withdrawal symptoms)
Bad in that it takes a long time to clear completely
o Drug Interactions: CYP2D6 and 3A4
▪ Tramadol increases the risk of seizures
▪ Can increase TCA levels
▪ Can cause fetal serotonin syndrome when combined with MAOIs (see question # 1)
▪ May displace highly protein bound drugs (warfarin)
▪ Possible risk of bleeding when combined with anticoagulants (warfarin, NSAIDs)
▪ NSAIDs may impair effectiveness of SSRIs
▪ 2D6 inhibition could increase the plasma levels of some beta blockers and atomoxetine; and thioridazine and cause dangerous
cardiac arrhythmias
▪ May reduce clearance of diazepam or trazodone
▪ 3A4 inhibition may increase levels of alprazolam, buspirone, triazolam, cholesterol lowering HMG CoA reductase inhibitors
(increased risk of rhabdomyolysis), and pimozide (QTc prolongation)
o Lab Tests: none for healthy individuals
o Pregnancy: not generally recommended for use during pregnancy, esp. 1st trimester
▪ Has not been proven to be harmful to the fetus
• Sertraline (Zoloft) - SSRI
o MOA: blocks serotonin reuptake pump
, ▪ Also has some ability to block dopamine reuptake pump (DAT), which could increase DA
• May improve energy, motivation, and concentration
▪ Also binds at sigma 1 receptors
• May help with anxiolytic effects and addressing psychotic/delusional depression
o Uses: MDD, PMDD, panic disorder, PTSD, social phobia, OCD, GAD
▪ May be useful for atypical depressive symptoms (hypersomnia, anergia, mood reactivity)
o Adverse effects:
▪ Seizures, induction of mania, activation of suicidal ideation and behavior
o Overdose: rarely lethal in monotherapy overdose; vomiting, sedation, heart rhythm disturbances, dilated pupils, agitation; fatalities
have been reported in sertraline OD combined with other drugs or alcohol
o Side effects:
▪ CNS: insomnia, sedation, tremors, HA, dizziness
• Emotional flattening, cognitive slowing, apathy (theoretically be diminished by DAT blockade)
▪ GI: decreased appetite, nausea, diarrhea, constipation, dry mouth
▪ Agitation, anxiety, undesirable activation (DAT blockade)
▪ Sweating, bruising, bleeding, hyponatremia, hypotension, SIADH
o Drug Interactions: moderate inhibitor of CYP2D6 (only at doses > 150mg, so potential for DDI but less so than other SSRIs)
▪ Tramadol increases the risk of seizures
▪ Can increase TCA levels
▪ Can cause fetal serotonin syndrome when combined with MAOIs (see question # 1)
▪ May displace highly protein bound drugs (warfarin)
▪ Possible risk of bleeding when combined with anticoagulants (warfarin, NSAIDs)
▪ NSAIDs may impair effectiveness of SSRIs
▪ 2D6 inhibition could increase the plasma levels of some beta blockers and atomoxetine; and thioridazine and cause dangerous
cardiac arrhythmias
▪ May reduce clearance of diazepam or trazodone
▪ 3A4 inhibition may increase levels of alprazolam, buspirone, triazolam, cholesterol lowering HMG CoA reductase inhibitors
(increased risk of rhabdomyolysis), and pimozide (QTc prolongation)
o Lab Tests: none for healthy individuals
o Pregnancy: Tends to be the agent of choice for pregnant/breastfeeding women
• Paroxetine (Paxil) – SSRI
o MOA: blocks serotonin reuptake pump
▪ Has mild anticholinergic actions
▪ Mild NET reuptake actions (further antidepressant actions)
▪ Inhibits nitric oxidase synthesis (sexual dysfunction)
o Uses: MDD, OCD, panic disorder, social anxiety disorder, PTSD, GAD, PMDD, vasomotor symptoms
▪ Tends to be calming and sedating (*good for anxious/agitated/depressed patient)
o Adverse effects:
▪ Seizures
▪ Induction of mania
▪ Activation of suicidal ideation and behaviors
o Side effects:
▪ Sexual dysfunction and weight gain are common
▪ GI: decreased appetite, nausea, diarrhea, constipation, dry mouth
▪ CNS: insomnia, sedation, agitation, dose-dependent tremors, HA, dizziness
▪ Sweating, bruising, bleeding, SIADH
▪ NOTORIOUS for withdrawal reactions if stopped suddenly (may be d/t anticholinergic rebound?)
• Akathisia, restlessness, GI symptoms, dizziness, tingling, dysesthesias, nausea
o Drug Interactions: very potent CYP2D6 inhibitor
▪ Same as other SSRIs
o Lab Tests: none for healthy individuals
o Pregnancy: not generally recommended for use during pregnancy, esp. during 1st trimester
▪ Increased risk of cardiovascular malformations
• Fluvoxamine (Luvox) – SSRIs
o MOA: blocks serotonin reuptake pump
SNRIS, AND ADVERSE EFFECTS
PSYCHOPHARM & ADVANCED MENTAL
HEALTH (MARYVILLE UNIVERSITY)
,Note: Exam 2 will cover content from Weeks 6, 7, and 8.
1. Know how to switch patients to and from an MAOI to another antidepressant.
Switching from a serotonergic drug to an MAOI = 5 half-lives
o 5-7 days for most drugs
o 5 weeks for fluoxetine (Prozac) d/t its long half-life
Having your patient on no medication for 5 weeks is scary; if they were that unstable that you were going to make a med
switch. Big reason we don’t use MAOIs
o “5 to keep them alive”
Switching from and MAOI to a serotonergic Drug = 14 days (2 weeks)
o It takes the liver 2 weeks to produce new MAO enzymes
2. Know the major side effects, adverse reactions, drug interactions, food-drug interactions, applicable lab tests to
order when the medication is prescribed and during treatment, the neurotransmitters they work on, pregnancy
risk, and the mechanism of action for the following medications:
SSRIs – Selective Serotonin Reuptake Inhibitors
• Fluoxetine (Prozac) - SSRI
o MOA: Blocks serotonin reuptake pump
Also has 5HT2C antagonist properties, which could increase NE and DA
o Uses: MDD (ages ≥ 8), OCD (ages ≥ 7), PMDD, Bulimia, Panic disorder, Bipolar depression [in combination with olanzapine],
treatment-resistant depression (in combination with olanzapine), social anxiety disorder, PTSD
May be activating/energizing (*might not be good for an anxious/overacted patient)
Improve concentration/motivation (*good choice for sluggish/unmotivated patient b/c 5HT2C antagonism -> increase NE and
DA)
o Adverse effects:
▪ Seizures, induction of mania, activation of suicidal ideation and behavior
o Overdose: rarely lethal in monotherapy OD; respiratory depression, esp. with alcohol, ataxia, sedation, seizure
o Side effects:
▪ GI: diarrhea, decreased appetite, nausea, constipation, dry mouth
▪ CNS: insomnia, sedation, emotional flattening, cognitive slowing, apathy, agitation, anxiety, tremors, HA, dizziness
▪ Sexual dysfunction
▪ Sweating, bruising, bleeding, SIADH
o Pharmacokinetics:
Very long half-life (2 weeks)
Good for noncompliant patients (less likely to have withdrawal symptoms)
Bad in that it takes a long time to clear completely
o Drug Interactions: CYP2D6 and 3A4
▪ Tramadol increases the risk of seizures
▪ Can increase TCA levels
▪ Can cause fetal serotonin syndrome when combined with MAOIs (see question # 1)
▪ May displace highly protein bound drugs (warfarin)
▪ Possible risk of bleeding when combined with anticoagulants (warfarin, NSAIDs)
▪ NSAIDs may impair effectiveness of SSRIs
▪ 2D6 inhibition could increase the plasma levels of some beta blockers and atomoxetine; and thioridazine and cause dangerous
cardiac arrhythmias
▪ May reduce clearance of diazepam or trazodone
▪ 3A4 inhibition may increase levels of alprazolam, buspirone, triazolam, cholesterol lowering HMG CoA reductase inhibitors
(increased risk of rhabdomyolysis), and pimozide (QTc prolongation)
o Lab Tests: none for healthy individuals
o Pregnancy: not generally recommended for use during pregnancy, esp. 1st trimester
▪ Has not been proven to be harmful to the fetus
• Sertraline (Zoloft) - SSRI
o MOA: blocks serotonin reuptake pump
, ▪ Also has some ability to block dopamine reuptake pump (DAT), which could increase DA
• May improve energy, motivation, and concentration
▪ Also binds at sigma 1 receptors
• May help with anxiolytic effects and addressing psychotic/delusional depression
o Uses: MDD, PMDD, panic disorder, PTSD, social phobia, OCD, GAD
▪ May be useful for atypical depressive symptoms (hypersomnia, anergia, mood reactivity)
o Adverse effects:
▪ Seizures, induction of mania, activation of suicidal ideation and behavior
o Overdose: rarely lethal in monotherapy overdose; vomiting, sedation, heart rhythm disturbances, dilated pupils, agitation; fatalities
have been reported in sertraline OD combined with other drugs or alcohol
o Side effects:
▪ CNS: insomnia, sedation, tremors, HA, dizziness
• Emotional flattening, cognitive slowing, apathy (theoretically be diminished by DAT blockade)
▪ GI: decreased appetite, nausea, diarrhea, constipation, dry mouth
▪ Agitation, anxiety, undesirable activation (DAT blockade)
▪ Sweating, bruising, bleeding, hyponatremia, hypotension, SIADH
o Drug Interactions: moderate inhibitor of CYP2D6 (only at doses > 150mg, so potential for DDI but less so than other SSRIs)
▪ Tramadol increases the risk of seizures
▪ Can increase TCA levels
▪ Can cause fetal serotonin syndrome when combined with MAOIs (see question # 1)
▪ May displace highly protein bound drugs (warfarin)
▪ Possible risk of bleeding when combined with anticoagulants (warfarin, NSAIDs)
▪ NSAIDs may impair effectiveness of SSRIs
▪ 2D6 inhibition could increase the plasma levels of some beta blockers and atomoxetine; and thioridazine and cause dangerous
cardiac arrhythmias
▪ May reduce clearance of diazepam or trazodone
▪ 3A4 inhibition may increase levels of alprazolam, buspirone, triazolam, cholesterol lowering HMG CoA reductase inhibitors
(increased risk of rhabdomyolysis), and pimozide (QTc prolongation)
o Lab Tests: none for healthy individuals
o Pregnancy: Tends to be the agent of choice for pregnant/breastfeeding women
• Paroxetine (Paxil) – SSRI
o MOA: blocks serotonin reuptake pump
▪ Has mild anticholinergic actions
▪ Mild NET reuptake actions (further antidepressant actions)
▪ Inhibits nitric oxidase synthesis (sexual dysfunction)
o Uses: MDD, OCD, panic disorder, social anxiety disorder, PTSD, GAD, PMDD, vasomotor symptoms
▪ Tends to be calming and sedating (*good for anxious/agitated/depressed patient)
o Adverse effects:
▪ Seizures
▪ Induction of mania
▪ Activation of suicidal ideation and behaviors
o Side effects:
▪ Sexual dysfunction and weight gain are common
▪ GI: decreased appetite, nausea, diarrhea, constipation, dry mouth
▪ CNS: insomnia, sedation, agitation, dose-dependent tremors, HA, dizziness
▪ Sweating, bruising, bleeding, SIADH
▪ NOTORIOUS for withdrawal reactions if stopped suddenly (may be d/t anticholinergic rebound?)
• Akathisia, restlessness, GI symptoms, dizziness, tingling, dysesthesias, nausea
o Drug Interactions: very potent CYP2D6 inhibitor
▪ Same as other SSRIs
o Lab Tests: none for healthy individuals
o Pregnancy: not generally recommended for use during pregnancy, esp. during 1st trimester
▪ Increased risk of cardiovascular malformations
• Fluvoxamine (Luvox) – SSRIs
o MOA: blocks serotonin reuptake pump
