Selective serotonin reuptake inhibitors in older patients. A tolerability perspective

Hyponatremia associated with paroxetine induced by sodium-restricted diet and hypotonic saline

CASE DESCRIPTION

An 89-year-old woman taking paroxetine was admitted to our hospital for femoral neck fracture; her diet became sodium restricted due to hypertension. After admission, the femoral head replacement was performed and hypotonic saline was administered over 2 days. On the fifth day after the operation, severe hyponatremia was observed and treated with oral fluid restriction, furosemide, sodium chloride and paroxetine discontinuance. In a few days, serum sodium concentration returned to baseline level.

CONCLUSIONS

Besides risk factors for SIADH, a sodium-restricted diet and infusions of hypotonic saline in the perioperative period should be considered risk factors for SIADH associated with paroxetine.

Prevalence of Potentially Severe Drug-Drug Interactions in Ambulatory Patients with Dyslipidaemia Receiving HMG-CoA Reductase Inhibitor Therapy

BACKGROUND

Drug-drug interactions (DDIs) are a well known risk factor for adverse drug reactions. HMG-CoA reductase inhibitors ('statins') are a cornerstone in the treatment of dyslipidaemia and patients with dyslipidaemia are concomitantly treated with a variety of additional drugs. Since DDIs are associated with adverse reactions, we performed a cross-sectional study to assess the prevalence of potentially critical drug-drug and drug-statin interactions in an outpatient adult population with dyslipidaemia.

METHODS

Data from patients with dyslipidaemia treated with a statin were collected from 242 practitioners from different parts of Switzerland. The medication list was screened for potentially harmful DDIs with statins or other drugs using an interactive electronic drug interaction program.

RESULTS

We included 2742 ambulatory statin-treated patients (mean age +/- SD 65.1 +/- 11.1 years; 61.6% males) with (mean +/- SD) 3.2 +/- 1.6 diagnoses and 4.9 +/- 2.4 drugs prescribed. Of those, 190 patients (6.9%) had a total of 198 potentially harmful drug-statin interactions. Interacting drugs were fibrates or nicotinic acid (9.5% of patients with drug-statin interactions), cytochrome P450 (CYP) 3A4 inhibitors (70.5%), digoxin (22.6%) or ciclosporin (cyclosporine) [1.6%]. The proportion of patients with a potential drug-statin interaction was 12.1% for simvastatin, 10.0% for atorvastatin, 3.8% for fluvastatin and 0.3% for pravastatin. Additionally, the program identified 393 potentially critical non-statin DDIs in 288 patients.

CONCLUSIONS

CYP3A4 inhibitors are the most frequent cause of potential drug interactions with statins. As the risk for developing rhabdomyolysis is increased in patients with drug-statin interactions, clinicians should be aware of the most frequently observed drug-statin interactions and how these interactions can be avoided.

Sertraline: a review of its use in the management of major depressive disorder in elderly patients

Sertraline is a selective serotonin reuptake inhibitor (SSRI) with well established antidepressant and anxiolytic activity. Results from several well designed trials show that sertraline (50 to 200 mg/day) is effective in the treatment of major depressive disorder in elderly patients (> or =60 years of age). Primary endpoints in most studies included the Hamilton Depression Rating Scale (HDRS), Clinical Global Impression (CGI) score and the Montgomery-Asberg Depression Rating Scale (MADRS). Sertraline was significantly more effective than placebo, and was as effective as fluoxetine, nortriptyline and imipramine in elderly patients. During one trial, amitriptyline was significantly more effective than sertraline [mean reduction from baseline on one of six primary outcomes (HDRS)], although no quantitative data were provided. Subgroup analysis of data from a randomised, double-blind trial in elderly patients with major depressive disorder suggests that vascular morbidity, diabetes mellitus or arthritis does not affect the antidepressant effect of sertraline. Secondary endpoints from these clinical trials suggest that sertraline has significant benefits over nortriptyline in terms of quality of life. In addition, significant differences favouring sertraline in comparison with nortriptyline and fluoxetine have been recorded for a number of cognitive functioning parameters. Sertraline is generally well tolerated in elderly patients with major depressive disorder, and lacks the marked anticholinergic effects that characterise the adverse event profiles of tricyclic antidepressants (TCAs). The most frequently reported adverse events in patients aged > or =60 years with major depressive disorder receiving sertraline 50 to 150 mg/day were dry mouth, headache, diarrhoea, nausea, insomnia, somnolence, constipation, dizziness, sweating and taste abnormalities. The tolerability profile of sertraline is generally similar in younger and elderly patients. Sertraline has a low potential for drug interactions at the level of the cytochrome P450 enzyme system. In addition, no dosage adjustments are warranted for elderly patients solely based on age.

CONCLUSION

Sertraline is an effective and well tolerated antidepressant for the treatment of major depressive disorder in patients aged > or =60 years. Since elderly patients are particularly prone to the anticholinergic effects of TCAs as a class, SSRIs such as sertraline are likely to be a better choice for the treatment of major depressive disorder in this age group. In addition, sertraline may have advantages over the SSRIs paroxetine, fluoxetine and fluvoxamine in elderly patients because of the drug's comparatively low potential for drug interactions, which is of importance in patient groups such as the elderly who are likely to receive more than one drug regimen.

Drug and ECT treatment of depression in the elderly, 1996-2001: a literature review

A computer-based literature search of all antidepressant and electroconvulsive therapy (ECT) treatment studies published between 1995 and September 2001 was conducted. In addition, a review of published chapters, review articles, and metaanalyses was also conducted. Articles were categorized into those reporting comparative studies, those in which the therapeutic agent was not compared with another, articles about ECT, and review articles. These recent publications support the conclusions from prior reviews that antidepressants and ECT are effective and safe treatments for depressed elderly patients. Differences in efficacy and side effects appear to be slight among the various types of antidepressants. Research studies of depressed elderly increased markedly since 1995 compared with all previous years although more studies are still necessary.

Delayed recurrent SIADH associated with SSRIs

BACKGROUND

Depression is a common problem in elderly patients and is frequently treated with selective serotonin-reuptake inhibitors (SSRIs).

OBJECTIVE

To report a case of delayed recurrent hyponatremia after switching from one SSRI to another.

CASE SUMMARY

An 87-year-old depressed woman began treatment with fluvoxamine. One week later, she was diagnosed with hyponatremia, most likely syndrome of inadequate antidiuretic hormone. Following discontinuation of fluvoxamine, the serum sodium concentration normalized. Later, she began treatment with paroxetine. Sixteen months after initiating paroxetine, she developed symptomatic recurrent hyponatremia. After paroxetine was discontinued, the sodium concentration normalized.

DISCUSSION

In this case, unlike those previously reported, hyponatremia recurred 16 months after a different SSRI was initiated. The Naranjo probability scale indicates a probable relationship between recurrent hyponatremia and paroxetine. The mechanism of SSRI-induced hyponatremia is multifactorial.

CONCLUSIONS

This case illustrates that replacement of one SSRI with another can cause delayed, recurrent hyponatremia in elderly patients. Plasma sodium concentrations must be monitored, not only in the first weeks of treatment, but throughout the full course.

Depression after stroke: a review of the evidence base to inform the development of an integrated care pathway. Part 2: Treatment alternatives

BACKGROUND

Depression is a common complication of stroke, leading to increased morbidity and mortality. It can impede the process of rehabilitation, and has been associated with poorer outcomes and increased length of stay in hospital. This systematic review was undertaken as a preliminary step to the development of an evidence-based integrated care pathway (ICP) for the management of post-stroke depression (PSD) in a rehabilitation setting, and is divided into two parts. In part 1 we reviewed the frequency of depression in stroke, its impact on functional recovery and the different methods for assessment.

AIMS AND OBJECTIVES

In part 2, we discuss the rationale for treatment of PSD, appraise the evidence for effectiveness of the different antidepressant drugs, and consider whether we can identify a recommended first-line treatment for use in our ICP.

METHODS

Data sources comprised a computer-aided search of published studies on depression in stroke and references to literature used in reviews.

MAIN FINDINGS

From the few controlled trials of anti-depressant therapy in PSD, both tricyclics and selective serotonin re-uptake inhibitors (SSRIs) appear to be effective, but the latter may be preferable in stroke because of their prompt action and better side-effect profiles. Within the group of SSRIs there is currently no direct evidence to guide the choice of agent. In the absence of firm guidance, sertraline was chosen on theoretical grounds as one of the most potent with minimal sedative effects and no reported interaction with warfarin. Citalopram may offer an appropriate second choice.

CONCLUSIONS

A suggested regimen for the use of sertraline in PSD was put forward. Development of an ICP may help to establish a more consistent approach to assessment and treatment of PSD, and form a basis for future comparison of different treatments as they become available.

Prevalence and recognition of depressive symptoms among homebound older adults with urinary incontinence

Within a group of homebound elders with urinary incontinence, the objectives of this study were to (1) examine the prevalence of depressive symptoms, (2) examine the extent to which depression had previously been recognized by health care providers, (3) describe the type and intensity of antidepressant treatment prescribed for subjects, and (4) identify the demographic and functional characteristics associated with depressive symptomatology. A descriptive correlational design was used. The 15-item Geriatric Depression Scale (GDS-15) was administered to 345 homebound adults age 60 years and over referred to a study examining the effectiveness of behavioral therapy for urinary incontinence. Individuals were referred to the study by home care nurses from two large Medicare-approved home health agencies in a large metropolitan county in Pennsylvania. Data were collected during in-home assessments and by chart review. Measures included the GDS-15, structured medical history, in-home review of medications, Older Americans Research and Service Center Physical and Instrumental Activities of Daily Living scales, Mini-Mental State Examination (MMSE), Clock Drawing Test, Performance-Based Toileting Assessment, and bladder diaries. One half of the participants (n = 173; 50.1%) had significant depressive symptomatology, with 35.7% having scores suggesting mild depression and 14.5% severe depression. Only 26.4% and 34.7% of those with mild and severe depressive symptoms, respectively, had a previous diagnosis of depression and only 21.7% and 34.0%, respectively, had been prescribed an antidepressant. The most commonly prescribed class of antidepressants was tricyclic antidepressants, being taken by 9.0% (n = 31) of the total sample, 14 (11.4%) of those with mild symptoms and 4 (8.0%) of those with severe depressive symptomatology. A little over half (60.0%) of subjects being treated with antidepressants continued to exhibit significant depressive symptomatology. Greater dependence in physical activities of daily living, the need for assistance during ambulation, higher MMSE scores, and higher levels of comorbidity were associated (P < .05) with a GDS-15 score of 5 or higher. Depression symptoms are common in homebound older adults with urinary incontinence, but clinical recognition and treatment are limited.

The lowest effective dose of fluoxetine in the forced swim test significantly affects the firing rate of lateral septal nucleus neurones in the rat

The administration of a relatively high dose of antidepressant drugs produces an increased neuronal firing rate of the lateral septal nucleus (LSN) in the rat and a decreased immobility in rats forced to swim. However, it is unknown whether a minimally effective low-dose 21-day treatment with the selective serotonin reuptake inhibitor, fluoxetine, while reducing immobility in the forced swim test, also increases the neuronal firing rate of the LSN in Wistar rats. The total time of immobility decreased with a daily injection of 0.5, 1.0 or 2.0 mg/kg of fluoxetine (p < 0.001), and the lowest dose increasing the latency to the first immobility period (p < 0.0001) was 1.0 mg/kg. Therefore, the action of the 21-day fluoxetine treatment (1.0 mg/kg) on the firing rate of LSN neurones was tested in another group of rats. A total amount of 78 single-unit extracellular recordings was taken from the LSN of eight control rats (n = 40) and eight fluoxetine treated rats (n = 38). The LSN firing rate in the fluoxetine group was double (18.3 +/- 2.5 spikes per 10 s, p < 0.05) that in the control group (7.0 +/- 0.9 spikes per 10 s), and the first order interval of firing proved to be significantly lower in the fluoxetine group compared to the control group (384.3 +/- 22.3 and 639.7 +/- 27.5 ms, respectively; p < 0.05). In conclusion, the increased neuronal tiring rate of the LSN in the animals treated with a low dose of fluoxetine may be associated with an increased motivation to escape from the stressful situation that the forced swim represents.

SSRI Antidepressant Medications: Adverse Effects and Tolerability

Side effects of antidepressants can be predicted by receptor selectivity and site of action. Although the selective serotonin reuptake inhibitors (SSRIs) have better overall safety and tolerability than older antidepressants, broad-based experience with SSRIs has shown the frequency and type of side effects to be increased relative to clinical trial data. The author explores the reasons for the different profiles and discusses adverse effects, especially sexual dysfunction, weight gain, and sleep disturbance, the most troubling adverse events seen during long-term SSRI therapy. The informed management of these side effects by primary care practitioners supports successful treatment of depression.

Pharmacotherapy of behavioral and psychological symptoms of dementia: time for a different paradigm?

Behavioral and psychological symptoms of dementia can occur in 60-80% of patients with Alzheimer's disease or other dementing illnesses, and are important in that they are a source of significant caregiver stress and often precipitate nursing home placement. These symptoms, namely, aggression, delusions, hallucinations, apathy, anxiety, and depression, are clinically managed with a variety of psychotropic drugs such as antipsychotics, antidepressants, antiepileptic drugs, and benzodiazepines. Various advances in the neuropathophysiology and pharmacotherapy must be considered in the optimal design of regimens for patients with these symptoms.

Psychopharmacological and electroconvulsive treatment of anxiety and depression in the elderly

The pharmacotherapeutics of antianxiety and antidepressant medication in the elderly is reviewed, and the benefits and risks of electroconvulsive therapy (ECT) are discussed. Physiological changes in normal ageing are described, and the pharmacodynamic and pharmacokinetic implications are addressed. Finally, the role of the advanced practice nurse (mental health/psychiatry) is discussed in terms of accountability, collaboration, and the development of empirical knowledge to enhance quality patient care.