22 Psychiatric Medications for Monitoring in Primary Care Medication Warnings, Precautions, and Adverse Events Comments Class: SSRI Fluvoxamine Boxed Warnings: Suicidality Used much less than SSRIs in the group of eight Indications: Warnings and Precautions: Similar to other SSRIs medications for prescribing, probably because it has no Adult: OCD Adverse Events: Similar to other SSRIs FDA indication for MDD or any anxiety disorder. Still Child/Adolescent: OCD (10-17 years) somewhat popular as a medication for OCD. Uses: Anxiety, OCD Monitoring: Same as other SSRIs Citalopram Boxed Warning: Suicidality. Escitalopram, one of the SSRIs in the group of Indications: Warnings and Precautions: Similar to other SSRIs medications for prescribing, is an active metabolite of Adult: MDD Adverse Events: Similar to other SSRIs citalopram. Escitalopram reportedly has fewer AEs and Child/Adolescent: None less interaction with hepatic metabolic enzymes than Uses: Anxiety, MDD, OCD citalopram but is otherwise essentially identical. Citalopram offers no advantage other than price, as Monitoring: Same as other SSRIs escitalopram is branded until 2012. Paroxetine Boxed Warnings: Suicidality. Paroxetine used much less than the SSRIs for Indications: Warnings and Precautions: Similar to other SSRIs prescribing, probably because of its nonlinear kinetics. Adult: MDD, OCD, Panic Disorder, Generalized Anxiety Adverse Events: Similar to other SSRIs A study of children and adolescents showed doubling Disorder, Social Anxiety Disorder, Posttraumatic Stress Disorder the dose of paroxetine from 10 mg/day to 20 mg/day Child/Adolescent: None resulted in a 7-fold increase in blood levels (Findling et Uses: Anxiety, MDD, OCD al, 1999). Thus, once metabolic enzymes are saturated, paroxetine levels can increase dramatically with dose Monitoring: Same as other SSRIs increases and decrease dramatically with dose decreases, sometimes leading to adverse events. Compiled by Mark A. Riddle, MD, and Susan dosReis, PhD, Center for Mental Health Services in Pediatric Primary Care, Johns Hopkins School of Public Health. Updated July 2011. Medication Warnings, Precautions, and Adverse Events Comments Class: SNRI Venlafaxine Boxed Warnings: Suicidality Venlafaxine was compared to a second SSRI in children Indications: Warnings and Precautions: Serotonin syndrome, and adolescents with depression who had not responded Adult: MDD sustained hypertension, mydriasis, discontinuation to initial treatment with an SSRI (TORDIA study; Brent Child/Adolescent: None symptoms — especially anxiety and insomnia, et al, 2008). The second SSRI and venlafaxine showed decreased appetite and weight, height deceleration, comparable efficacy, however, venlafaxine was Uses: Anxiety, MDD activation of mania/hypomania, hyponatremia, associated with more adverse events and Monitoring: BP, HR, Ht, Wt, suicidality seizures, increased risk of bleeding events, serum discontinuations. cholestoral elevation, interstitial lung disease and eosinophilic pneumonia Adverse Events: Asthenia, sweating, nausea, constipation, anorexia, vomiting, somnolence, dry mouth, dizziness, nervousness, anxiety, tremor, blurred vision, abnormal ejaculation/orgasm and impotence in men Compiled by Mark A. Riddle, MD, and Susan dosReis, PhD, Center for Mental Health Services in Pediatric Primary Care, Johns Hopkins School of Public Health. Updated July 2011. Medication Warnings, Precautions, and Adverse Events Comments Class: TRICYCLIC ANTIDEPRESSANTS Nortriptyline Boxed Warnings: Suicidality Venlafaxine was compared to a second SSRI in children Indications: Warnings and Precautions: Serotonin syndrome, and adolescents with depression who had not responded Adult: MDD sustained hypertension, mydriasis, discontinuation to initial treatment with an SSRI (TORDIA study; Brent Child/Adolescent: None symptoms — especially anxiety and insomnia, et al, 2008). The second SSRI and venlafaxine showed decreased appetite and weight, height deceleration comparable efficacy, however, venlafaxine was Uses: Anxiety, MDD activation of mania/hypomania, hyponatremia, associated with more adverse events and Monitoring: BP, HR, Ht, Wt, suicidality seizures, increased risk of bleeding events, serum discontinuations. cholestoral elevation, interstitial lung disease and eosinophilic pneumonia Adverse Events: Asthenia, sweating, nausea, constipation, anorexia, vomiting, somnolence, dry mouth, dizziness, nervousness, anxiety, tremor, blurred vision, abnormal ejaculation/orgasm and impotence in men Clomipramine Boxed Warnings: Suicidality The most selectively serotonergic of the TCAs, Indications: Warnings and Precautions: Seizures, orthostatic clomipramine is used for refractory OCD. Adult: OCD decreases in BP and increases in HR, psychosis, Child/Adolescent: OCD (8-17 years) confusion, mania or hypomania, hepatic enzyme increases, hematologic changes, hyperthermia, sexual Uses: Refractory OCD dysfunction, weight gain, withdrawal symptoms with Monitoring: Orthostatic BP, HR, blood levels, EKGs to rule out abrupt discontinuation prolonged QTc, suicidality Adverse Events: Gastrointestinal, including dry mouth, constipation, nausea, dyspepsia, and anorexia; nervous system complaints, including somnolence, tremor, dizziness, nervousness, and myoclonus; genitourinary complaints, including changed libido, ejaculatory failure, impotence, and micturition disorder; and other miscellaneous complaints, including fatigue, sweating, increased appetite, weight gain, and visual changes Compiled by Mark A. Riddle, MD, and Susan dosReis, PhD, Center for Mental Health Services in Pediatric Primary Care, Johns Hopkins School of Public Health. Updated July 2011. Medication Warnings, Precautions, and Adverse Events Comments Class: OTHER ANTIDEPRESSANTS Buproprion Boxed Warnings: Suicidality Because of its structural similarity to stimulants, Indications: Warnings and Precautions: Seizures, hepatotoxicity, bupropion is sometimes used to treat both depression Adult: MDD agitation and insomnia, psychosis and confusion, and symptoms of ADHD. Child/Adolescent: None weight gain or loss, allergic reactions, hypertension Uses: Depression, ADHD Adverse Events: Agitation, dry mouth, insomnia, headache/migraine, nausea/vomiting, constipation, Monitoring: BP, HR, HT, WT, suicidality and tremor Mirtazapine Adverse Events: Somnolence, increased appetite, Mirtazapine is a tetra-cyclic atypical antidepressant. It is Indications: weight gain, dizziness associated with more somnolence, appetite increase and Adult: MDD weight gain than other antidepressants. Child/Adolescent: None Uses: Depression Monitoring: Ht, Wt, suicidality Compiled by Mark A. Riddle, MD, and Susan dosReis, PhD, Center for Mental Health Services in Pediatric Primary Care, Johns Hopkins School of Public Health. Updated July 2011. Medication Warnings, Precautions, and Adverse Events Comments Class: ANXIOLYTICS Buspirone (azaspirone anxiolytic) Boxed Warnings: None Buspirone is one of the safest and easiest to monitor of Indications: Warnings: Co-administration with an MAOI can psychiatric medications used to treat children and Adult: Anxiety cause elevated blood pressure adolescents. However, two large, multisite 6-week Child/Adolescent: None Precautions: Interference with cognitive and motor RCTs found no significant differences between performance, potential for withdrawal reactions in buspirone and placebo with regard to the symptoms of Uses. Anxiety sedative/hypnotic/anxiolytic drug-dependent patients, generalized anxiety disorder (GAD) following doses Monitoring: None beyond general health possible concerns (e.g., a syndrome of restlessness) recommended for the treatment of GAD in adults. shortly after initiation of treatment Lorazepam (benzodiazepine) Boxed Warnings: None Primarily because of the possibility of physical and Indications: Warnings: Worsening or emergence of depression, psychological dependence with prolonged use of Adult: Acute anxiety suicidality, respiratory depression, interference with benzodiazepines, lorazepam is generally recommended Child/Adolescent: None cognitive and motor performance, physical and only for short-term use (days to a few weeks) for Uses: Acute anxiety psychological dependence, risk of use in pregnancy, treatment of acute and severe anxiety following a withdrawal symptoms trauma or preceding a medical procedure. Monitoring: Pregnancy testing Precautions: Paradoxical reactions (i.e., behavioral disinhibition), should not be used with alcohol. Adverse Events: In a sample of about 3500 adult patients treated for anxiety, the most frequent adverse reaction was sedation (15.9%), followed by dizziness (6.9%), weakness (4.2%), and unsteadiness (3.4%) Clonazepam (benzodiazepine) Boxed Warnings: None Clonazepam is similar to lorazepam, except for its Indications: Warnings: Interference with cognitive and motor shorter half-life and once daily dosing. Adult: Panic disorder performance, suicidality, physical and psychological Child/Adolescent: None dependence, risk of use in pregnancy, withdrawal symptoms. Uses: Acute anxiety Precautions: Worsening of seizures, hypersalivation, should not be used with alcohol Monitoring: Pregnancy testing Adverse Events: Somnolence, coordination abnormal, ataxia, depression Compiled by Mark A. Riddle, MD, and Susan dosReis, PhD, Center for Mental Health Services in Pediatric Primary Care, Johns Hopkins School of Public Health. Updated July 2011. Medication Warnings, Precautions, and Adverse Events Comments Class: SECOND GENERATION ANTIPSYCHOTICS Risperidone