II. Adverse Effects: Least Tolerated Agents (early discontinuation)

IV. Adverse Effects: Weight gain (Histamine H1 receptor blockade)

  1. Weight gain may be >5%
    1. Highest risk in first 2 years (but may continue to increase over the longterm)
  2. Most Weight Gain
    1. Tricyclic Antidepressants (e.g. Amitriptyline)
    2. Mirtazapine (Remeron)
    3. Paroxetine (Paxil)
  3. Least Weight Gain
    1. Bupropion
    2. Fluoxetine (Prozac)

V. Adverse Effects: Orthostatic Hypotension (alpha 1 receptor blockade)

VI. Adverse Effects: Cardiac Arrhythmia (Type 1A Antiarrhythmic effect)

  1. Most Risk for Cardiac Arrhythmia
    1. Tricyclic Antidepressants (Tertiary amines, e.g. Amitriptyline)
      1. See Tricyclic Antidepressant Overdose
  2. Least Risk for Cardiac Arrhythmia
    1. Bupropion
  3. Other cardiac considerations
    1. Although QTc Prolongation has been reported with Citalopram and Escitalopram, ventricular Arrhythmia risk is very low
      1. FDA recommends Citalopram maximum dose limited to 40 mg (20 mg if age >60 years old)
      2. Prasitlumkum (2021) Med Sci 9(2): 26 [PubMed]
    2. Ischemic Heart Disease
      1. Consider Sertraline (antiplatelet activity, low side effect profile)
      2. Teply (2016) Prog Cardiovasc Dis 58(5): 514-28 [PubMed]

VII. Adverse Effects: Bleeding Risk (Drug Interaction)

  1. SSRI and SNRI agents increase risk of bleeding events when combined with Anticoagulants and antiplatelet agents
    1. Drug Interactions occur primarily with Warfarin
    2. SSRI use may as much as double the risk of Abnormal Bleeding (esp. Gastrointestinal Bleeding)
      1. Avoid combining with NSAIDs and other risk factors for Gastrointestinal Bleeding
      2. Overall Odds Ratio 1.55
        1. Jiang (2015) Clin Gastroenterol Hepatol 13(1): 42-50.e3 [PubMed]
    3. One additional patient on Warfarin for Atrial Fibrillation with SNRI or SSRI will have have a major bleeding event
      1. However, also affect other Anticoagulants such as Pradaxa and antiplatelet agents
  2. Most Bleeding Risk
    1. Fluoxetine (Prozac)
    2. Flovoxamine (especially with Warfarin)
    3. Paroxetine (Paxil)
    4. Sertraline (Zoloft)
  3. Least Bleeding Risk
    1. Mirtazapine (Remeron)
    2. Bupropion
  4. References
    1. (2014) Presc Lett 21(11): 65
    2. Sansone (2009) Psychiatry 6(7): 24–29 [PubMed]

VIII. Adverse Effects: Gastrointestinal Effects (Serotonin reuptake blockade)

  1. Nausea and Vomiting are the most common Antidepressant Adverse Effects (esp. SNRI)
  2. Most adverse effects
    1. Nausea or Vomiting: Venlafaxine (Effexor)
    2. Constipation: Paroxetine (Paxil)
    3. Diarrhea: Sertraline (Zoloft)
  3. Minimal Gastrointestinal adverse Effects
    1. Fluoxetine (Prozac)
    2. MAO Inhibitors
    3. Trazodone
  4. No Significant Gastrointestinal Effects
    1. Tricyclic Antidepressants (e.g. Amitriptyline)
    2. Bupropion

IX. Adverse Effects: Sedation (Histamine H1 receptor blockade)

X. Adverse Effects: Agitation, Activation or Insomnia

XIII. Adverse Effects: Hyponatremia (Serum Sodium <130 meq/L)

  1. Typically occurs in the first month of therapy
  2. Overall Odds Ratio (OR) up to 2.6, but SSRIs may have OR as high as 3.3
  3. Highest risk
    1. Selective Serotonin Reuptake Inhibitors or SSRI
    2. Serotonin Norepinephrine Reuptake Inhibitor (SNRI, e.g. Venlafaxine)
    3. Mirtazapine (Remeron)
    4. Tricyclic Antidepressants (e.g. Amitriptyline)
  4. References
    1. De Picker (2014) Psychosomatics 55(6): 536-47 [PubMed]

Images: Related links to external sites (from Bing)

Related Studies