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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Unicorn Sighting

Happy guideline season!

I’ve been hearing about JNC 8 for so long, that I thought it didn’t really exist.  Thanks to some persistent hypertension experts, it is here at long last.  Here’s a quick review of the major points. I’m sure that we will see some commentary in the days and weeks to come, I’ll try to keep you updated on that as well.   I’d love to hear what you think- start the conversation in the comments below.

Higher BP targets

We are used to aiming for 140/90 for most people, and 130/80 for those with CKD, diabetes, CAD, and other comorbidities.  But new evidence  has emerged that these may not be so great, particularly for elderly patients.  So JNC 8 says- Adults 18-60 (even with DM or CKD) should aim for BP <140/90.  We can be a little more relaxed with patients over 60, and aim at 150/90 for them, so long as they don’t have CKD or DM.  Most of this change comes because there really was no outcome data for our prior target, and it seems that getting people to the 140s systolic provides just as much benefit as the 130s range.

Relaxed first line medicine choices

We’ve known that this was coming for a while.  JNC 7 recommended thiazides as first line for all, but there was never any real data to back that up.  So JNC 8 says that we can use thiazides, ACE-I/ARBs, or calcium channel blockers as a first choice for most patients.  They do acknowledge the racial difference in response to ACE inhibition, and recommend that we DON’T use ACE/ARB as first line for our black patients. EXCEPT (there’s always an exception) that for patients with chronic kidney disease (but not necessarily diabetes without ckd), use ACE-I first, no matter the race.

Second, and third, and fourth line medicines

Really not much different here, except there are not really recommendations about when to start two medicines at first visit.  JNC 8 says we can pick a variety of treatment strategies– maximize one medicine at a time, add a second agent before maximizing the first, or start two medicines at once.  When you add agents; pick from that first line list (thiazides, ACE/ARB, CCB) until you’ve used them all, then use aldosterone antagonists, beta blockers, central agents, or other vasodilators.  They do recommend avoiding ACE-I and ARB combos for most patients.

What’s Missing

JNC 7 discussed prehypertension, secondary hypertension, resistant hypertension, adherence, how to measure blood pressure, and lots of other related issues. The JNC 8 group just picked 3 questions that they felt were most important: does starting treatment at a particular threshold improve outcomes, does a particular treatment goal improve outcomes, do various drugs have important differences in risk/benefit calculation and outcomes.  Very evidence based and outcome oriented, which is kind of refreshing.

What about my patients now?

For all of us who have been trying to follow JNC 7 (and the subsequent performance measures created from that guideline), should we go adjusting therapy on our patients to meet new targets?  No, say these experts.  If your patient has a blood pressure of <150/90 on their current therapy, and is doing well, no need to change. Stay tuned to see if any of our performance targets change.

A great big picture algorithm from the JNC 8 group is here, and the link to the guidelines themselves is here (on the JAMA website subscription may be needed).

Here’s a great, plain language summary from the NYT Well blog.

Link Roundup: Less is more edition

I Hate Rashes is practicing restraint during this week of excess.  Cleanse your palate with these links from around the web.

I’m beginning to think that the future of medicine is to use less of it.  Here’s a great post from one of my favorite bloggers: Gaia and Snake Oil

And here’s something from the New Yorker on Prescription Opiates.  We could definitely use less of these. Who is Responsible for the Pain Pill Epidemic

Similarly, two links on insomnia that DON’T mention medicines. Just don’t read these after your turkey sandwich.  Sleep Therapy as Depression Treatment and Sleep Help Guide. The second link was mentioned in the last blog post; it’s a great patient self-help website.

Once you finish eating, check out this short commentary from the UK. Green snot does not equal a Z-pack. 

After a long weekend with your nieces and nephews, you might appreciate this.  The less is more, Babies edition. Contraception Practice Essentials. A quick, comprehensive guide for diagnosis and treatment. (requires Medscape Subscription)
Check this HILARIOUS patient education website for contraception in the real world. bedsider.org.

Finally, after the third helping of sweet potato pie, some more perspective on lipid guidelines.  The Statinization of America.  Dr. Centor’s (and here)and Dr. Shaneyfelt’s take on the risk calculator in the new ACC/AHA guidelines.

Happy Thanksgivukkah Everyone!