Pick a card, any card

This post is inspired by a clinic conversation yesterday. Our clinical question was about which antidepressant to choose.  It can kind of feel like a game at times: you make a random pick,and see what happens. Is there a more evidence based way to go about it?  

The evidence behind SSRIs is a whole different post, but suffice it to say that they have similar efficacy and tolerablity. Citalopram (Celexa), Paroxetine (Paxil), Fluvoxamine (Fluvox), Fluoxetine (Prozac), Sertraline (Zoloft), and Escitalopram (Lexapro) are all available widely.

So how to decide what to prescribe when a patient is sitting in front of you. You could pick based on your favorite commercial, or which drug rep bought the best dinner, but maybe there is a less biased method.

Generally we use patient preference, side effects, and cost as the driving factor in picking among similar medicines.  So I thought I’d review the last two for you here.

Cost is easier.  All of these come in generic forms now.  Citalopram and paroxetine are on the $4 drug list at WalMart. A quick search on GoodRx shows prices around $5 for fluoxetine, $8-10 for sertraline, and $15 for fluvoxamine and escitalopram.

Artwork by Robin D Snyder. Text at the bottom of the screen says: “Certain Side Effects May Occur”.

Now for side effects. All of them can cause weight gain, decreased libido, and diarrhea, which are often pretty important to patients. Scarier side effects are QTc prolongation, and hypotension and anticholinergic effects, which may make you think twice about prescribing to an older patient. You can sort out which side effect is most important to your patient, and then steer clear of the worst offenders.

  • Weight gain: Paroxetine seems to be the worst, anecdotally I have had complaints about citalopram as well.
  • Sexual Dysfunction: A big problem with all of them.  Again, paroxetine is the worst, but none are really great.  Your best bet if this is a big factor for your patient: use bupropion instead of an SSRI.
  • GI side effects: Diarrhea is the most common complaint from a GI standpoint.  Sertraline is the worst offender here.
  • QTc prolongation: Citalopram, Escitalopram, and Fluoxetine are the ones known to cause some QT troubles. The others are probably OK.
  • Hypotension and anticholinergic effects: Again, paroxetine is the troublemaker here, although any can contribute.

Often listed as a side effect is agitation or “activation”. Sometimes I try to use this as a benefit.  If patients are particularly apathetic, or have the psychomotor retardation often seen in major depression, you can use this to your advantage.  I think of fluoxetine and sertraline as being more “activating“, while citalopram and paroxetine are more sedating.  The latter two can be helpful for the anxious patient.

At the end of the day, I don’t know that there is a ton of difference between these. I rely on patient experience and preference to guide my choice more than anything else.

 

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