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Table 25 7 Principal dietary restrictions in MAOI use
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1 Cheese, except cream cheese and cottage cheese and fresh yogurt 2 Fermented or aged meats such as bologna, salami 3 Broad bean pods such as Chinese bean pods 4 Liver of all types 5 Meat and yeast extracts 6 Red wine, sherry, vermouth, cognac, beer, ale 7 Soy sauce, shrimp paste, sauerkraut MAOI, monoamine oxidase inhibitor
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Table 25 8 Commonly used antidepressants
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Usual Daily Oral Dose (mg) 5 40 100 300 300 600 20 30 50 150 20 10 150 250 150 200 100 100 250 150 200 150 200 100 200 100 150 15 40 45 60 20 30 6 (skin patch) 150 225 40 15 45 3003 300 100 300 75 200 Usual Daily Maximum Dose (mg) 80 300 600 50 200 40 20 300 400 250 300 300 300 300 150 60 90 50 12 Sedative Effects1 <1 1 2 1 <1 <1 <1 4 2 3 1 4 3 4 2 1 Anticholinergic Effects1 <1 <1 <1 1 <1 1 1 4 2 3 1 3 3 2 2 3 Cost for 30 Days Treatment Based on Maximum Dosage2 $32040 $23760 $14400 $16380 $16320 $7950 $8430 $6960 $20040 $15720 $13500 $9000 $21960 $11160 $13140 $53100 $10800 $14250 $49267
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Drug SSRIs Fluoxetine (Prozac, Sarafem) Fluvoxamine (Luvox) Nefazodone (Serzone) Paroxetine (Paxil) Sertraline (Zoloft) Citalopram (Celexa) Escitalopram (Lexapro) Amitriptyline (Elavil) Amoxapine (Asendin) Clomipramine (Anafranil) Desipramine (Norpramin) Doxepin (Sinequan) Imipramine (Tofranil) Maprotiline (Ludiomil) Nortriptyline (Aventyl, Pamelor) Protriptyline (Vivactil) Monoamine oxidase inhibitors Phenelzine (Nardil) Tranylcypromine (Parnate) Selegiline transdermal (Emsam) Other compounds Venlafaxine XR (Effexor) Duloxetine (Cymbalta) Mirtazapine (Remeron) Bupropion XL (Wellbutrin XL) Bupropion SR (Wellbutrin SR) Trazodone (Desyrel) Trimipramine (Surmontil)
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Cost per Unit $267/20 mg $264/100 mg $160/200 mg $273/20 mg $272/100 mg $265/40 mg $281/20 mg $116/150 mg $167/100 mg $147/75 mg $150/100 mg $100/100 mg $122/50 mg $093/75 mg $146/50 mg $295/10 mg $060/15 mg $095/10 mg $1642/6 mg patch
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225 60 45 4503 4004 400 200
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<1 3 2 <1 <1
$368/75 mg $404/60 mg $280/30 mg $547/300 mg $359/200 mg $073/100 mg $440/100 mg
$33120 $12120 $16546 $28831 $21540 $8760 $26400
<1 4
4, strong effect; 1, weak effect Average wholesale price (AWP, for AB-rated generic when available) for quantity listed Source: Red Book Update, Vol 26, No 3, March 2007 AWP may not accurately represent the actual pharmacy cost because wide contractual variations exist among institutions 3 Wellbutrin XL is a once-daily form of bupropion Bupropion is still available as immediate release, and, if used, no single dose should exceed 150 mg 4 200 mg twice daily SSRIs, serotonin selective reuptake inhibitors
2 3 weeks after cessation of therapy Termination of therapy with MAO inhibitors may be associated with anxiety, agitation, cognitive slowing, and headache Very gradual withdrawal and short-term benzodiazepine therapy will ameliorate symptoms 4 Switching and combination therapy If the therapeutic response has been poor after an adequate trial with the chosen drug, the diagnosis should be reassessed Assuming
that the trial has been adequate and the diagnosis is correct, a trial with a second drug is appropriate In switching from one group to another, an adequate washout time must be allowed This is critical in certain situations eg, in switching from an MAO inhibitor to a TCA, allow 2 3 weeks between stopping one drug and starting another; in switching from an SSRI to an MAO inhibitor, allow 4 5 weeks In switching within groups eg, from one TCA to another (amitriptyline
Psychiatric Disorders
to desipramine, etc) no washout time is needed, and one can rapidly decrease the dosage of one drug while increasing the other Combining two antidepressants requires caution and is usually reserved for clinicians who feel comfortable managing this or after psychiatric consultation 5 Maintenance and tapering When clinical relief of symptoms is obtained, medication is continued for 12 months in the effective maintenance dosage, which is the dosage required in the acute stage The full dosage should be continued indefinitely when the individual has a first episode before age 20 or after age 50, is over age 40 with two episodes, or has had three episodes at any age Major depression should often be considered as a chronic disease If the medication is being tapered, it should be done gradually over several months, monitoring closely for relapse 6 Drug interactions Interactions with other drugs are listed in Table 25 9 7 Electroconvulsive therapy ECT causes a generalized central nervous system seizure (peripheral convulsion is not necessary) by means of electric current The key objective is to exceed the seizure threshold, which can be accomplished by a variety of means The mechanism of action is not known, but it is thought to involve major neurotransmitter responses at the cell membrane Electrical current insufficient to cause a seizure produces no therapeutic benefit ECT is the most effective (about 70 85%) treatment of severe depression particularly the delusions and agitation commonly seen with depression in the elderly It is indicated when medical conditions preclude the use of antidepressants, nonresponsiveness to these medications, and extreme suicidality Comparative controlled studies of ECT in severe depression show that it is more effective than chemotherapy It is also effective in the manic disorders and psychoses during pregnancy (when drugs may be contraindicated) It has not been shown to be helpful in chronic schizophrenic disorders, and it is generally not used in acute schizophrenic episodes unless drugs are not effective and it is urgent that the psychosis be controlled (eg, a catatonic stupor complicating an acute medical condition) The most common side effects are memory disturbance and headache Memory loss or confusion is usually related to the number and frequency of ECT treatments and proper oxygenation during treatment Unilateral ECT is associated with less memory loss than bilateral ECT Some memory loss is occasionally permanent, but most memory faculties return to full capacity within several weeks There have been reports that lithium administration concurrent with ECT resulted in greater memory loss Increased intracranial pressure is a serious contraindication Other problems such as cardiac disorders, aortic aneurysms, bronchopulmonary disease, and venous thrombosis are relative contraindications and must be evaluated in light of the severity of the medical problem versus the need for ECT Serious complications arising from ECT occur in less than 1 in 1000 cases Most of these problems are cardiovascular or respiratory in nature (eg, aspiration of gastric contents) Poor patient understanding and lack of acceptance of the technique by the public are the biggest obstacles to the use of ECT
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