Mood Disorders
Vincenzo Berghella in Maternal-Fetal Evidence Based Guidelines, 2022
When the use of antidepressant medication is indicated in a nursing woman, the drugs that should be preferred as first-line choice in a treatment-naive patient are paroxetine and sertraline, because of their good safety profiles as reported in exposed infants. However, if a woman has been stable on an antidepressant throughout her pregnancy, preference is usually to remain on that same medication postpartum, as evidence suggests that most infant SSRI levels are compatible with breastfeeding. The postpartum period, a period of significant vulnerability for women with mood disorders, is generally an inappropriate time to stop an effective medication and try another that has not been previously used or demonstrated to be helpful in a particular patient. These findings are in line with the recommendations of most authoritative guidelines [46, 200, 201, 203]. For the tricyclic antidepressants, nortriptyline is the preferred choice [201, 206]. Although most antidepressant drugs do not pose a risk to the nursing infant; consideration to the individual risk/benefit is necessary in each individual patient. Medications with longer half-lives are less preferred options as first-line treatment as they may accumulate in the infants, especially those that are premature or those with underlying medical conditions [199, 207]. Overall, positive benefits of breastfeeding outweigh possible adverse side effects of antidepressant drugs [206]. Long-term effects of infant exposure to SSRIs through nursing have been less well studied [206].
Hospice, Cancer Pain Management, and Symptom Control
Mark V. Boswell, B. Eliot Cole in Weiner's Pain Management, 2005
Because 2 weeks of dexamethasone was not helping and because of concerns over the long-term use of steroids, this medication was tapered off over the next week and he was started on magnesium choline trisalicylate 750 mg three times daily for his bone involvement. Nortriptyline was continued for its antidepressant effect. Within 2 days of starting methadone his pain had subsided to the 4 to 5 range and it was in the 1 to 2 range by the fifth day. At this point his gabapentin was stopped with no increase in his pain level. Review of his methadone dosing over 9 days showed the following total daily doses: 80, 80, 40, 60, 50, 60, 55, 40, and 45 mg. His pain continued to be well controlled, and he was subsequently given a scheduled methadone dose of 20 mg every 12 hours with 5 mg every 4 hours as needed.
Antidepressants: Predicting Response/Maximizing Efficacy
Mark S. Gold, R. Bruce Lydiard, John S. Carman in Advances in Psychopharmacology: Predicting and Improving Treatment Response, 2018
As seen in the two studies utilizing specific groups of depressed patients, nortriptyline with nortriptyline levels monitoring of antidepressant levels can improve efficacy. For carefully selected major depressives, response rates to antidepressants have been reported as low as 50 to 60% without monitoring of plasma levels and as high as 70 to 90% of adolescents and adults with monitoring of levels.1–3,43 Many clinicians, including ourselves, find the monitoring of plasma levels at approximately weekly intervals quite useful, especially in the early weeks of dosage adjustment. It is especially useful in patients at the extremes of normal — those who require extremely low or extremely high dosage to achieve therapeutic effects.
An update on the pharmacological management of pain in patients with multiple sclerosis
Published in Expert Opinion on Pharmacotherapy, 2020
Clara G. Chisari, Eleonora Sgarlata, Sebastiano Arena, Emanuele D’Amico, Simona Toscano, Francesco Patti
Tricyclic antidepressants such as amitriptyline, nortriptyline, and clomipramine have historically been considered first-line drugs for the treatment of central pain [81]. The mechanism of action consists of increasing the serotoninergic and noradrenergic transmission at the synaptic level, as well as of inhibiting sodium and L-type calcium channels. The analgesic effects are thought to be associated with the indirect modulation of the opioid system via serotonergic and noradrenergic modulation [87]. For these reasons, nortriptyline and other tricyclic antidepressants were also used for neuropathic pain due to several causes. Only one randomized controlled trial studied MS patients with pain, comparing nortriptyline to transcutaneous electrical nerve stimulation (TENS), and showed a significant improvement in pain symptoms in both study groups at 8 weeks, with no evidence of superiority of one treatment over the other [88]. Drowsiness, dry mouth, constipation, urinary retention, and hypotension are the most frequently reported adverse events and limit their use in MS patients [89]. Moreover, recommendations as to optimal dose scheduling are to date unavailable [87].
Depression, anxiety and acute pain: links and management challenges
Published in Postgraduate Medicine, 2019
Athena Michaelides, Panagiotis Zis
Monoamine transmitters such as serotonin and norepinephrine have a role in downregulating pain perception and their depletion results in comorbid pain and anxiety or depression. Studies have shown that pain signals are blocked when giving serotonin and norepinephrine intrathecally [20]. Similarly, antidepressants that work by increasing the amount of serotonin and norepinephrine in the brain also have a role in pain modulation. Although limited data exists on the use of anti-depressants for the treatment of concomitant depression and acute pain, the most commonly used antidepressants for neuropathic pain are the selective serotonin reuptake inhibitors (SSRIs) and serotonin and norepinephrine reuptake inhibitors (SNRIs) [53]. In addition to the monoamine modulators, tricyclic antidepressant such as amitriptyline, imipramine and nortriptyline inhibit the reuptake of norepinephrine and serotonin and also enhance endogenous pain inhibition in the CNS [53]. Multiple studies have demonstrated its use in easing neuropathic pain such as postherpetic neuralgia [53].
Developments in treating the nonmotor symptoms of stroke
Published in Expert Review of Neurotherapeutics, 2020
Argye E. Hillis
A number of medications have been shown to be effective in ameliorating depression, including selective serotonin reuptake inhibitors (SSRIs) [10–12], serotonin-norepinephrine reuptake inhibitor (SNRIs), tricylclic antidepressants, and those with mixed effects [6,12–14]. For example, an early randomized clinical trial (RCT) of nortriptyline showed significantly lower scores on the Hamilton Depression Scale (p = 0.006) at 5 or 6 weeks after the start of treatment [13]. Daily dosages were: 20 mg, for 1 week, 50 mg for 2 weeks, 70 mg for 1 week, and 100 mg for 2 weeks. Although effective, nortriptyline has many common adverse side effects, including dizziness, drowsiness, dry mouth, increased hunger and weight gain, as well as rare but serious side effects such as cardiac arrhythmia. SSRIs are generally better tolerated, but have common side effects of reduce libido, dizziness, anxiety, and diarrhea, or constipation. One meta-analysis of 12 SSRI trials (with various doses and medications over 1–16 weeks) reported a weighted mean difference in the Hamilton Depression Scale of −5.5 (−8.3 to -2.7) after treatment versus 0.5 (0.0–1.0) before treatment, with a rate difference of 0.23 (0.03–0.43) and a significant benefit after just 3–4 weeks of treatment [15]. Another meta-analysis of seven SSRI trials and three tricyclic antidepressant trials reported that the standardized mean difference on the Hamilton Depression Scale between placebo and antidepressant at 6–26 weeks was −0.53 (−0.97 to −0.09) for SSRIs and −1.41 (−2.51 to −0.31) for tricyclic antidepressants [16].
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