6/23/2011 A Z From nemia to aps: ESCALATING OUR KNOWLEDGE OF THE SSRIS TO A HIGHER LEVEL 1 Lisa C. Hutchison, PharmD, MPH, BCPS, FCCP Associate Professor, UAMS College of Pharmacy OBJECTIVES  Summarize labeled and off-label uses of SSRIs in the elderly.  Apply current guidelines and evidence for SSRI use in the elderly.  Identify adverse effects from SSRIs common in older adults.  Assess a geriatric patient for therapeutic and adverse effects from SSRIs.  Design a therapeutic plan to minimize risk of serotonin syndrome and serotonin discontinuation syndrome. 2 1 6/23/2011 OUTLINE Introduction  Therapeutic uses  Adverse effects  Patient assessment  Regulations  Practice Cases  Conclusion  3 HISTORY OF SSRI‟S IN THE U.S. 1950‟s 1970‟s- L bei MAOI‟s 1990‟s mre & TCA‟s SSRI‟s na J ,III C nil P ys hc 2 , 0 1990‟s- 0 1960‟s 3 2003 Clinical SNRI‟s use of & others TCA‟s 4 2 6/23/2011 RISING NUMBER OF SSRI PRESCRIPTIONS Frequency in Medicaid Population 5 SSRI USE GROWING IN PRIMARY CARE P arri g ail J , nilc P ys hc 2 , 0 0 3 6 3 6/23/2011 ISSUES WITH SSRI USE IN THE ELDERLY  Symptoms vs. Diagnosis of depression  Other FDA labeled indications  Non-FDA labeled indications for use  F329 Unnecessary Drugs  Adverse effects  Common  More Common in Older Adults  Drug Interactions  Preventable 7 LABELED USES OF SSRI‟S  Major depression  Obsessive-compulsive disorder  Panic disorder Post-traumatic stress disorder   Premenstrual dysphoric disorder  Generalized anxiety disorder  Social anxiety disorder  Also SNRI‟s  Diabetic neuropathy, fibromyalgia 8 4 6/23/2011 UNLABELED USES OF SSRI‟S  Impulse control disorders  Eating disorders  Vasomotor symptoms of menopause  Smoking cessation/alcohol abuse  Dementia-associated agitation, behavior  Stress incontinence  Chronic fatigue syndrome  Also Mirtazapine  Anorexia, Weight loss 9  Sleep disorders EVIDENCE-BASED USE IN DEPRESSION  STAR-D study: 50% respond and 30% achieve remission after 12 weeks; 20% more will achieve remission with augmentation or switching agents KG  Studies in late-life depression: 35-89% response, nietsnroC ,senya  1oCf9O p-7-aM2t%iEe nDrte ssm truiasdnsyigo:e n dC ao6nm7d-b7 9i5n- 3ye2de%a 2r sfdo orrul drge sc uvrsr. esninceg;l e A ge 1102 ,PJA , J cinilC dnalevel agent for first line Rx-remission rates (ranged M de 37.7-38.8%) and response rates (51-6-52.4%) not 02 , 0 8 significantly different; ADE rates were ; significantly higher (4.2% single drug vs. 10-15% dual drug) 10 5 6/23/2011 SYMPTOMS OF DEPRESSION OR NORMAL HUMAN EMOTIONS?  Sadness, anxiety, crying  Personal loss, serious illness, difficult situations “I don‟t want to live”  11 GUIDELINES FOR USE-DX OF DEPRESSION: AT LEAST 5 OF 9 SYMPTOMS  Depressed Mood  Anhedonia A  Weight Loss or Gain P m ys Insomnia or Hypersomnia hc  A  Psychomotor Agitation or Retardation 2 ,coss 0 0  Fatigue 4  Feelings of Worthlessness or Guilt  Diminished Concentration  Recurrent Thoughts of Death or Suicide 12 6 6/23/2011 IN ADDITION, FOR DIAGNOSIS  Symptoms Lasting for at Least 2 weeks  Clinical Significant Distress or Impaired A Functioning m P ys  Not Due to a Medication or Medical Condition hc A  Not Due to Bereavement (2 months) 2 ,coss 0 0 4 13 ACUTE PHASE TREATMENT OPTIONS: 4-8 WEEKS •Specific Psychotherapy 1 •Medication 2 •Medication and Specific 3 Psychotherapy •Electroconvulsive Therapy 4 14 7 6/23/2011 ASSESSING TREATMENT RESPONSE Expect a Moderate Response at 4-8 Weeks  Less than Moderate Response?   Re-appraise diagnosis  Assess for side effects  Review adherence Switch to Another Antidepressant  Augment with Psychotherapy  Augment with Antidepressant from  Another Class 15 AFTER SUCCESSFUL ACUTE PHASE TREATMENT : •4-9 months Continuation •To reduce risk for Phase relapse •If 3+ episodes Maintenance •Use full therapeutic Phase dose 16 8 6/23/2011 DISCONTINUATION OF ANTIDEPRESSANT  Taper Over Several Weeks  Educate Patient about Potential for Relapse  Monitor for Several Months 17 ANXIETY GUIDELINES FOR USE  Late-life anxiety-10-15% of older adults; 3 times more often combined with depression  Includes generalized anxiety disorder (GAD), panic disorder (PD), and others with various dx criteria  GAD excessive worry > 6 months plus 3/6 sx:  Restlessness, Fatigue, Trouble concentrating, Irritability, Muscle tension, Sleep disturbance  PD panic attacks X 10-30 minutes with 4/13 sx  Palpitations, sweating, trembling, chills/hot flashes, SOB, choking, chest pain, GI distress, paresthesias, dizziness, depersonlization, losing control, fear of dying 18 9 6/23/2011 USE OF SSRIS/SNRIS IN GAD & PANIC DISORDER  Always assess for co-existant depression  Consider CBT or buspirone  SSRIs are first line, but slow onset of action  GAD therapy continued X 12 months  PD therapy continued X 12-18 months  Re-occurrence continue treatment long-term 19 ADVERSE EVENTS  Common  Serious  Drug Interactions  Preventable 20 10