Selective Serotonin Reuptake Inhibitors

These agents are primarily effective for the treatment of depression associated with chronic pain syndromes. Although there are sporadic reports of the effectiveness of certain SSRIs in pain treatment, they are for the most part adjuncts to the other nonopioid analgesics. Care must be used in combination with other serotonergic medications as serotonin toxicity (serotonin syndrome) can occur. The combination of SSRIs and monoamine oxidase inhibitors (MAOIs) pose a particularly severe risk of a life-threatening serotonin syndrome. Clinical features of serotonin toxicity are included in Table 34.7.

Table 34.7 Clinical signs and symptoms of serotonin toxicity.

Autonomic effects

Somatic effects

Cognitive effects

• Hyper/hypotension

• Tremors

• Confusion

• Tachycardia

• Myoclonus

• Agitation

• Hyperthermia

• Hyperreflexia

• Hallucinations

• Diarrhea

• Central nervous system

• Nausea/vomiting

hyperactivity

Fluoxetine (Prozac®®) 10-80 mg/day (10, 20,40 mg capsules) Sertraline (Zoloft®®) 50-200 mg/day (25, 50, 100 mg tablets)

Paroxetine (Paxil®®) 10-50 mg/day (10, 20, 30, 40 mg tablets) Best for anxiety-related disorders.

Aripiprazole (Abilify®®) maximum dose 30 mg/day (2, 5, 10, 15, 20, 30 mg tablets, 1 mg/ml oral solution). Best for add-on adjunct to other antidepressants, or for bipolar disease or schizophrenia.

Olanzapine (Zyprexa®®) usual dose range 10-15 mg/day, safety of doses greater than 20 mg/day have not been established (2.5, 5, 7.5, 10, 15, 20 mg tablets, and disintegrating tablets of 5, 10, 15, 20 mg). Bipolar disorder and schizophrenia.

Citalopram (Celexa®®) 20-40 mg/day (10, 20,40 mg tablets and 2 mg/ml solution). Escitalopram (Lexapro®®) 10-20 mg/day (5, 10, 20 mg tablets; oral solution 1 mg/ml). S-stereoisomer of citalopram. More rapid onset of antidepressant effects with less side effects.

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