1. Strategies to Switch Antidepressants Brittany Parmentier, PharmD PGY2 Behavioral Care Resident Butler University/Community Health Network This speaker has no actual or potential conflicts of interest to disclose in relation to this presentation.

2. AD – antidepressant SSRI – selective serotonin reuptake inhibitor SNRI – serotonin norepinephrine reuptake inhibitor TCA – tricyclic antidepressant MAOI – monoamine oxidase inhibitor Abbreviations

3. 27.5% of STAR*D patients achieved remission with 1 st treatment 50% of depression patients respond to 1 st treatment 35-50% of responders still have residual symptoms Intolerance to side effects Need for Switch Trivedi MH e al. Am J Psychiatry. 2006;163:28-40. Fava M et al. Psychiatr Clin N Am. 2003;26:457-494.

4. Optimize dose Adequate duration Key Points before Switching American Psychiatric Association. Practice guideline for the treatment of patients with major depressive disorder (3 rd ed). Oct 2010. Available at: http://psychiatryonline.org/pb/assets/raw/sitewide/practice_guidelines/guidelines/mdd.pdf. Accessed July 30, 2015.

5. Individualized therapy for each patient Variations in acute and ambulatory practice Limited data comparing one strategy to another General Considerations Jefferson JW. J Clin Psychiatry. 2008;69(Suppl E1):14-18.

6. Switching Effects Serotonin Syndrome Sweating Insomnia Tremor Akathisia Antidepressant Discontinuation Zerumsky K et al. P&T. 2005;30(12):740-747. Flu-like symptoms Insomnia Nausea Imbalance Sensory disturbances Hyperarousal (anxiety/agitation)

7. Between SSRIs SSRI (except fluoxetine)  SSRI Direct switch to equivalent dose Direct switch to lower new dose of new SSRI Fluoxetine  Other SSRI Stop fluoxetine, 4-7 day washout with no antidepressant, start new SSRI at low dose Marangell. J Clin Psychiatry. 2001;62(Suppl 18):12-7. Zerumsky K et al. P&T. 2005;30(12):740-747.

8. SSRIDose Fluoxetine20 mg Paroxetine20 mg Citalopram20 mg Escitalopram10 mg Sertraline50 mg Fluvoxamine50 mg SSRI Dose Equivalency Hayasaka Y et al. J Affect Disord. 2015;180:179-184.

9. SSRI  duloxetine Direct switch to duloxetine 60mg daily Start duloxetine 60mg and taper SSRI down SSRI  venlafaxine Direct switch to low dose venlafaxine (37.5 mg – 75mg) Cross-taper SSRI to SNRI Marangell. J Clin Psychiatry. 2001;62(Suppl 18):12-7. Jefferson JW. J Clin Psychiatry. 2008;69(Suppl E1):14-18.

10. Venlafaxine  SSRI Direct switch to therapeutic SSRI dose Cross-taper Duloxetine  SSRI Direct switch to therapeutic SSRI dose Cross-taper SNRI to SSRI Marangell. J Clin Psychiatry. 2001;62(Suppl 18):12-7. Jefferson JW. J Clin Psychiatry. 2008;69(Suppl E1):14-18.

11. To/from another agent Cross-taper Bupropion, Mirtazapine, and TCAs Marangell. J Clin Psychiatry. 2001;62(Suppl 18):12-7. Jefferson JW. J Clin Psychiatry. 2008;69(Suppl E1):14-18.

12. MAOI  MAOI MAOI  Other antidepressant Other antidepressant (except fluoxetine)  MAOI Stop medication, 2 week washout with no AD, start new AD Fluoxetine  MAOI Stop fluoxetine, 5 week washout with no AD, start MAOI MAOIs – High Risk for Toxicity Marangell. J Clin Psychiatry. 2001;62(Suppl 18):12-7. Jefferson JW. J Clin Psychiatry. 2008;69(Suppl E1):14-18.

13. When would it be most appropriate to do a direct switch from a therapeutic dose of old AD to a therapeutic dose of new AD? A. Imipramine  tranylcypromine B. Escitalopram  nortriptyline C. Citalopram  sertraline D. Venlafaxine  phenelzine Assessment Question

14. When would it be most appropriate to do a direct switch from a therapeutic dose of old AD to a therapeutic dose of new AD? A. Imipramine  tranylcypromine B. Escitalopram  nortriptyline C. Citalopram  sertraline D. Venlafaxine  phenelzine Assessment Question

15. Strategies to Switch Antidepressants Brittany Parmentier, PharmD PGY2 Behavioral Care Resident Butler University/Community Health Network bparmentier@ecommunity.com