Antidepressants and other psychiatric medications in cancer care



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/Zyban) 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.