2nd Line Stratagies
What are possible responses to a patient not responding to a first line antidepressant?
(ROSA-CI)
What is:
Reassess, Optimize, Switch, Augment, Combine, Interventional (TMS/Spravato/ECT).
his is an appropriate short-term role for a benzodiazepine while an SSRI or SNRI is being initiated
What is bridge treatment for panic disorder?
This SSRI strongly inhibits CYP2D6 and can raise metoprolol exposure.
What is fluoxetine? or duloxetine? or paroxetine? or bupropion?
Combining citalopram or escitalopram with amiodarone, sotalol, macrolides, or fluoroquinolones increases risk for this ECG abnormality.
What is QT prolongation?
These two antidepressant classes are first-line daily pharmacotherapies for most anxiety disorders.
What are SSRIs and SNRIs?
his atypical antipsychotic has the strongest and most robust evidence signal for antidepressant augmentation; monitor for akathisia and weight gain.
What is aripiprazole?
This benzodiazepine’s long half-life makes it useful as a rescue option for infrequent discrete panic attacks.
What is clonazepam?
This SSRI should be avoided with diazepam because it inhibits metabolism and can lead to accumulation.
What is fluvoxamine?
This antidepressant combined with tramadol increases seizure risk and may decrease tramadol analgesic efficacy through CYP2D6 inhibition.
What is bupropion?
This sedating antihistamine can be used as-needed for anxiety but warrants caution because of anticholinergic effects and QT prolongation risk.
What is hydroxyzine?
This FDA-cleared treatment can be considered after one to two failed adequate antidepressant trials and commonly causes scalp discomfort or headache.
What is rTMS?
In hepatic impairment, these two benzodiazepines are preferred because they undergo glucuronidation rather than CYP oxidation.
What is lorazepam or oxazepam?
Estrogen-containing oral contraceptives increase clearance of this mood stabilizer, potentially reducing its clinical efficacy; stopping estrogen can raise its level.
What is lamotrigine?
This antibiotic should generally be avoided in a patient receiving lithium because it can reduce lithium clearance and cause tremor, ataxia, diarrhea, dysarthria, and confusion.
What is TMP-SMX?
This atypical antipsychotic may be reserved for refractory anxiety but has important sedation, weight gain, hyperglycemia, and hyperlipidemia risks.
What is quetiapine?
This treatment-resistant depression intervention requires in-office administration and at least 2 hours of monitoring because of sedation, dissociation, and misuse risk.
What is Spravato (esketamine)?
Effect of starting a macrolide or azole antifungal on clonazepam/alprazolam/diazepam
What is increased blood level via 3A4 inhibition?
This strong enzyme inducer can lower concentrations of alprazolam, buspirone, trazodone, zolpidem, lamotrigine, quetiapine, and aripiprazole, reducing clinical efficacy.
What is rifampin?
Fluoxetine, paroxetine, and bupropion may reduce the analgesic benefit of these two opioids by inhibiting the CYP2D6-mediated conversion to active metabolites.
What is codeine and hydrocodone?
This standardized lavender-oil preparation is a non-sedating, nondependence option with evidence in subthreshold anxiety and generalized anxiety disorder.
What is Silexan?
This intervention has the highest response/remission rates and is especially important when a rapid response is needed for psychotic depression, catatonia, food refusal, or high suicide risk.
What is ECT?
When to stop long term benzodiazepines abruptly
What is never?
Fluoxetine and omeprazole inhibit the metabolism of this antiplatelet agent preventing it from having its full effect?
What is clopidogrel (Plavix)?
Combining an MAOI with dextromethorphan, tramadol, meperidine, SSRIs, SNRIs, TCAs, linezolid, or sympathomimetics risks these two life-threatening syndromes.
What is serotonin syndrome and hypertensive crisis?
For treatment-resistant generalized anxiety disorder, this class may be used as a maintenance strategy only after first-line options fail, with careful assessment for substance-use and overdose risk.
What are benzodiazepines?