Difference between revisions of "Antidepressants and other psychiatric medications in cancer care"
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| − | ''' | + | =Guidelines= |
| + | '''Given the rapid change in evidence in many areas of hematology/oncology, readers are encouraged to consider any guideline published 5+ years ago to be for historical purposes, only.''' | ||
| + | ==ASCO== | ||
| + | *'''2023:''' Andersen et al. [https://doi.org/10.1200/jco.23.00293 Management of Anxiety and Depression in Adult Survivors of Cancer: ASCO Guideline Update] [https://pubmed.ncbi.nlm.nih.gov/37075262/ PubMed] | ||
| + | **'''2014:''' Andersen et al. [https://www.ncbi.nlm.nih.gov/pmc/articles/pmc4090422/ Screening, assessment, and care of anxiety and depressive symptoms in adults with cancer: an American Society of Clinical Oncology guideline adaptation] [https://pubmed.ncbi.nlm.nih.gov/24733793/ PubMed] | ||
| + | |||
| + | ==SIO/ASCO== | ||
| + | *'''2023:''' Carlson et al. [https://doi.org/10.1200/jco.23.00857 Integrative Oncology Care of Symptoms of Anxiety and Depression in Adults With Cancer: Society for Integrative Oncology-ASCO Guideline] [https://pubmed.ncbi.nlm.nih.gov/37582238/ PubMed] | ||
| + | |||
| + | =Medications= | ||
<br> | <br> | ||
<br> | <br> | ||
| Line 8: | Line 17: | ||
!Starting dose | !Starting dose | ||
!Target dose | !Target dose | ||
| + | !Half-life | ||
!Interactions | !Interactions | ||
!Side effects | !Side effects | ||
|- | |- | ||
| − | |Citalopram (Celexa) | + | |[[Citalopram (Celexa)]] |
|SSRI | |SSRI | ||
|Anxiety | |Anxiety | ||
| Line 17: | Line 27: | ||
|10 mg | |10 mg | ||
|20-40 mg | |20-40 mg | ||
| + | |35 hours | ||
|Mild 2D6 inhibition | |Mild 2D6 inhibition | ||
Platelet dysfunction | Platelet dysfunction | ||
| + | |||
| + | QTc prolongation | ||
|Nausea | |Nausea | ||
fatigue | fatigue | ||
|- | |- | ||
| − | |Escitalopram (Lexapro) | + | |[[Escitalopram (Lexapro)]] |
|SSRI | |SSRI | ||
|Anxiety | |Anxiety | ||
| Line 28: | Line 41: | ||
|5 mg | |5 mg | ||
|10-20 mg | |10-20 mg | ||
| + | |27-32 hours; 50% greater in elderly patients | ||
|Mild 2D6 inhibition | |Mild 2D6 inhibition | ||
Platelet dysfunction | Platelet dysfunction | ||
| Line 33: | Line 47: | ||
fatigue | fatigue | ||
|- | |- | ||
| − | |Fluoxetine (Prozac) | + | |[[Fluoxetine (Prozac)]] |
|SSRI | |SSRI | ||
| − | |Depression | + | |Anxiety |
| − | + | Depression | |
|10 mg | |10 mg | ||
|20-60 mg | |20-60 mg | ||
| + | |4-6 days (fluoxetine); 9.3 days (norfluoxetine) | ||
|CYP450 2D6 inhibition | |CYP450 2D6 inhibition | ||
Very long half-life and multiple drug interactions | Very long half-life and multiple drug interactions | ||
| Line 44: | Line 59: | ||
Sedation | Sedation | ||
|- | |- | ||
| − | |Sertraline (Zoloft) | + | |[[Sertraline (Zoloft)]] |
|SSRI | |SSRI | ||
| − | |Depression | + | |Anxiety |
| − | + | Depression | |
|50 mg | |50 mg | ||
|150-200 mg | |150-200 mg | ||
| + | |26 hours | ||
|Weak 2D6 inhibition | |Weak 2D6 inhibition | ||
Inhibits platelet function | Inhibits platelet function | ||
|Nausea | |Nausea | ||
|- | |- | ||
| − | |Venlafaxine (Effexor XR) | + | |[[Venlafaxine (Effexor XR)]] |
|SNRI | |SNRI | ||
| − | |Depression | + | |Anxiety |
| − | + | Depression | |
|37.5 mg | |37.5 mg | ||
|150 mg | |150 mg | ||
| + | |5 hours (parent drug); 11 hours (active metabolite) | ||
|2D6 inhibition | |2D6 inhibition | ||
Reduces platelet function | Reduces platelet function | ||
| Line 66: | Line 83: | ||
Flu-like withdrawal | Flu-like withdrawal | ||
|- | |- | ||
| − | |Bupropion (Wellbutrin | + | |[[Bupropion (Wellbutrin)]] |
|Other antidepressant | |Other antidepressant | ||
| − | |Depression | + | |Activating |
| − | + | Depression | |
| − | |SR: 50-75 mg | + | |SR: 50-75 mg |
XR: 150 mg | XR: 150 mg | ||
|150-300 mg | |150-300 mg | ||
| + | |21 hours | ||
|Strong 2D6 inhibition | |Strong 2D6 inhibition | ||
|Seizure risk (Black box) | |Seizure risk (Black box) | ||
Anxiety | Anxiety | ||
|- | |- | ||
| − | |Mirtazapine (Remeron) | + | |[[Mirtazapine (Remeron)]] |
|Other antidepressant | |Other antidepressant | ||
|Anxiety | |Anxiety | ||
| Line 84: | Line 102: | ||
|7.5 mg | |7.5 mg | ||
|30-40 mg | |30-40 mg | ||
| + | |20-40 hours | ||
|Neutropenia reported | |Neutropenia reported | ||
2D6 substrate | 2D6 substrate | ||
| Line 89: | Line 108: | ||
Sedation | Sedation | ||
|- | |- | ||
| − | |Trazodone (Desyrel) | + | |[[Trazodone (Desyrel)]] |
|Other antidepressant | |Other antidepressant | ||
|Anxiety | |Anxiety | ||
| Line 95: | Line 114: | ||
|25-50 mg | |25-50 mg | ||
|50-100 mg | |50-100 mg | ||
| + | |3-6 hours (first phase); 5-9 hours (second phase) | ||
|3A4 substrate | |3A4 substrate | ||
|Sedation | |Sedation | ||
Nausea | Nausea | ||
|- | |- | ||
| − | |Desipramine (Norpramin) | + | |[[Desipramine (Norpramin)]] |
|Tricyclic | |Tricyclic | ||
| − | |Depression | + | |Anxiety |
| − | + | Depression | |
Insomnia | Insomnia | ||
Boost pain control | Boost pain control | ||
|10-25 mg | |10-25 mg | ||
|Check blood levels and EKG | |Check blood levels and EKG | ||
| + | |12-27 hours | ||
|Strong 2D6 inhibition | |Strong 2D6 inhibition | ||
Rare agranulocytosis | Rare agranulocytosis | ||
|Anticholinergic symptoms | |Anticholinergic symptoms | ||
|- | |- | ||
| − | |Imipramine (Tofranil) | + | |[[Imipramine (Tofranil)]] |
|Tricyclic | |Tricyclic | ||
| − | |Depression | + | |Anxiety |
| − | + | Depression | |
Insomnia | Insomnia | ||
Boost pain control | Boost pain control | ||
|10-25 mg | |10-25 mg | ||
|Check blood levels and EKG | |Check blood levels and EKG | ||
| + | |11-25 hours | ||
|Strong 2D6 inhibition | |Strong 2D6 inhibition | ||
Rare agranulocytosis | Rare agranulocytosis | ||
|Anticholinergic symptoms | |Anticholinergic symptoms | ||
|- | |- | ||
| − | |Nortriptyline (Pamelor) | + | |[[Nortriptyline (Pamelor)]] |
|Tricyclic | |Tricyclic | ||
| − | |Depression | + | |Anxiety |
| − | + | Depression | |
Insomnia | Insomnia | ||
Boost pain control | Boost pain control | ||
|10-25 mg | |10-25 mg | ||
|Check blood levels and EKG | |Check blood levels and EKG | ||
| + | |18-44 hours | ||
|Strong 2D6 inhibition | |Strong 2D6 inhibition | ||
Rare agranulocytosis | Rare agranulocytosis | ||
|Anticholinergic symptoms | |Anticholinergic symptoms | ||
|- | |- | ||
| − | |Gabepentin (Neurontin) | + | |[[Gabepentin (Neurontin)]] |
|Anti-seizure | |Anti-seizure | ||
| − | | | + | |Anxiety |
| − | Anxiety | ||
Insomnia | Insomnia | ||
| + | Pain control | ||
|100 mg | |100 mg | ||
|Large range from 300-3600 mg | |Large range from 300-3600 mg | ||
| + | |5-7 hours | ||
|Renal excreted (i.e. not metabolized) | |Renal excreted (i.e. not metabolized) | ||
|Sedation | |Sedation | ||
|- | |- | ||
| − | |Lamotrigine (Lamictal) | + | |[[Lamotrigine (Lamictal)]] |
|Anti-seizure | |Anti-seizure | ||
|Elevates mood | |Elevates mood | ||
|25 mg | |25 mg | ||
|200 mg (for psych) | |200 mg (for psych) | ||
| + | |14 hours with enzyme-inducing anticonvulsants (EIA); 59 hours with valproic acid (VPA); 28 hours with EIA & VPA | ||
|No weight gain | |No weight gain | ||
Other anti-seizure medications can double blood levels of lamotrigine | Other anti-seizure medications can double blood levels of lamotrigine | ||
|Stevens-Johnson with any change in dose (Black box) | |Stevens-Johnson with any change in dose (Black box) | ||
|- | |- | ||
| − | |Aripiprazole (Abilify) | + | |[[Aripiprazole (Abilify)]] |
|Antipsychotic | |Antipsychotic | ||
|Agitation | |Agitation | ||
| Line 160: | Line 185: | ||
|5 mg | |5 mg | ||
|15-20 mg | |15-20 mg | ||
| + | |75 hours (CYP2D6 extensive metabolizers); 146 hours CYP2D6 poor metabolizers) | ||
|QTc prolongation may be less than other atypicals | |QTc prolongation may be less than other atypicals | ||
No CYP450 inhibition | No CYP450 inhibition | ||
| + | |||
Rare agranulocytosis | Rare agranulocytosis | ||
|Less weight gain | |Less weight gain | ||
Extrapyramidal symptoms including akathisia and risk of tardive dyskinesia when mixed with prochlorperazine (Compazine) or metoclopramide (Reglan) | Extrapyramidal symptoms including akathisia and risk of tardive dyskinesia when mixed with prochlorperazine (Compazine) or metoclopramide (Reglan) | ||
|- | |- | ||
| − | |Olanzapine (Zyprexa) | + | |[[Olanzapine (Zyprexa)]] |
|Antipsychotic | |Antipsychotic | ||
|Agitation | |Agitation | ||
| + | Anxiety | ||
Insomnia | Insomnia | ||
| − | |||
|2.5-5 mg | |2.5-5 mg | ||
|10 mg | |10 mg | ||
| + | |21-54 hours | ||
|QTc prolongation | |QTc prolongation | ||
|Sedation | |Sedation | ||
Weight gain | Weight gain | ||
|- | |- | ||
| − | |Quetiapine (Seroquel) | + | |[[Quetiapine (Seroquel)]] |
|Antipsychotic | |Antipsychotic | ||
| − | | | + | |Agitation |
Anxiety | Anxiety | ||
Insomnia | Insomnia | ||
| − | + | Nausea | |
|25-50 mg | |25-50 mg | ||
|100-300 mg | |100-300 mg | ||
| + | |6-7 hours | ||
|3A4 substrate, limited drug/drug interactions | |3A4 substrate, limited drug/drug interactions | ||
QTc prolongation | QTc prolongation | ||
| Line 190: | Line 219: | ||
Weight gain | Weight gain | ||
|- | |- | ||
| − | |Zolpidem (Ambien) | + | |[[Zolpidem (Ambien)]] |
|Insomnia | |Insomnia | ||
|Insomnia | |Insomnia | ||
|5 mg | |5 mg | ||
|5-10 mg | |5-10 mg | ||
| + | |2.5-3.1 hours | ||
|Alcohol interaction | |Alcohol interaction | ||
Hepatic metabolism | Hepatic metabolism | ||
| Line 202: | Line 232: | ||
|- | |- | ||
|} | |} | ||
| − | |||
Information adapted from a table created by Christine Wittmann, MD and Laurie Rosenblatt, MD. Used with permission. | Information adapted from a table created by Christine Wittmann, MD and Laurie Rosenblatt, MD. Used with permission. | ||
| + | [[Category:General reference pages]] | ||
| + | [[Category:Supportive oncology]] | ||
Latest revision as of 12:10, 23 June 2024
Guidelines
Given the rapid change in evidence in many areas of hematology/oncology, readers are encouraged to consider any guideline published 5+ years ago to be for historical purposes, only.
ASCO
- 2023: Andersen et al. Management of Anxiety and Depression in Adult Survivors of Cancer: ASCO Guideline Update PubMed
SIO/ASCO
- 2023: Carlson et al. Integrative Oncology Care of Symptoms of Anxiety and Depression in Adults With Cancer: Society for Integrative Oncology-ASCO Guideline PubMed
Medications
| Medication | Class | Indication | Starting dose | Target dose | Half-life | Interactions | Side effects |
|---|---|---|---|---|---|---|---|
| Citalopram (Celexa) | SSRI | Anxiety
Depression |
10 mg | 20-40 mg | 35 hours | Mild 2D6 inhibition
Platelet dysfunction QTc prolongation |
Nausea
fatigue |
| Escitalopram (Lexapro) | SSRI | Anxiety
Depression |
5 mg | 10-20 mg | 27-32 hours; 50% greater in elderly patients | Mild 2D6 inhibition
Platelet dysfunction |
Nausea
fatigue |
| Fluoxetine (Prozac) | SSRI | Anxiety
Depression |
10 mg | 20-60 mg | 4-6 days (fluoxetine); 9.3 days (norfluoxetine) | CYP450 2D6 inhibition
Very long half-life and multiple drug interactions |
Nausea
Sedation |
| Sertraline (Zoloft) | SSRI | Anxiety
Depression |
50 mg | 150-200 mg | 26 hours | Weak 2D6 inhibition
Inhibits platelet function |
Nausea |
| Venlafaxine (Effexor XR) | SNRI | Anxiety
Depression |
37.5 mg | 150 mg | 5 hours (parent drug); 11 hours (active metabolite) | 2D6 inhibition
Reduces platelet function |
Hypertension
Nausea Flu-like withdrawal |
| Bupropion (Wellbutrin) | Other antidepressant | Activating
Depression |
SR: 50-75 mg
XR: 150 mg |
150-300 mg | 21 hours | Strong 2D6 inhibition | Seizure risk (Black box)
Anxiety |
| Mirtazapine (Remeron) | Other antidepressant | Anxiety
Depression Insomnia |
7.5 mg | 30-40 mg | 20-40 hours | Neutropenia reported
2D6 substrate |
Weight gain
Sedation |
| Trazodone (Desyrel) | Other antidepressant | Anxiety
Insomnia |
25-50 mg | 50-100 mg | 3-6 hours (first phase); 5-9 hours (second phase) | 3A4 substrate | Sedation
Nausea |
| Desipramine (Norpramin) | Tricyclic | Anxiety
Depression Insomnia Boost pain control |
10-25 mg | Check blood levels and EKG | 12-27 hours | Strong 2D6 inhibition
Rare agranulocytosis |
Anticholinergic symptoms |
| Imipramine (Tofranil) | Tricyclic | Anxiety
Depression Insomnia Boost pain control |
10-25 mg | Check blood levels and EKG | 11-25 hours | Strong 2D6 inhibition
Rare agranulocytosis |
Anticholinergic symptoms |
| Nortriptyline (Pamelor) | Tricyclic | Anxiety
Depression Insomnia Boost pain control |
10-25 mg | Check blood levels and EKG | 18-44 hours | Strong 2D6 inhibition
Rare agranulocytosis |
Anticholinergic symptoms |
| Gabepentin (Neurontin) | Anti-seizure | Anxiety
Insomnia Pain control |
100 mg | Large range from 300-3600 mg | 5-7 hours | Renal excreted (i.e. not metabolized) | Sedation |
| Lamotrigine (Lamictal) | Anti-seizure | Elevates mood | 25 mg | 200 mg (for psych) | 14 hours with enzyme-inducing anticonvulsants (EIA); 59 hours with valproic acid (VPA); 28 hours with EIA & VPA | No weight gain
Other anti-seizure medications can double blood levels of lamotrigine |
Stevens-Johnson with any change in dose (Black box) |
| Aripiprazole (Abilify) | Antipsychotic | Agitation
Anxiety |
5 mg | 15-20 mg | 75 hours (CYP2D6 extensive metabolizers); 146 hours CYP2D6 poor metabolizers) | QTc prolongation may be less than other atypicals
No CYP450 inhibition Rare agranulocytosis |
Less weight gain
Extrapyramidal symptoms including akathisia and risk of tardive dyskinesia when mixed with prochlorperazine (Compazine) or metoclopramide (Reglan) |
| Olanzapine (Zyprexa) | Antipsychotic | Agitation
Anxiety Insomnia |
2.5-5 mg | 10 mg | 21-54 hours | QTc prolongation | Sedation
Weight gain |
| Quetiapine (Seroquel) | Antipsychotic | Agitation
Anxiety Insomnia Nausea |
25-50 mg | 100-300 mg | 6-7 hours | 3A4 substrate, limited drug/drug interactions
QTc prolongation |
Sedation
Weight gain |
| Zolpidem (Ambien) | Insomnia | Insomnia | 5 mg | 5-10 mg | 2.5-3.1 hours | Alcohol interaction
Hepatic metabolism |
Sedation
Dizziness Parasomnias |
Information adapted from a table created by Christine Wittmann, MD and Laurie Rosenblatt, MD. Used with permission.