For CYP2D6 poor and intermediate metabolizers, the Royal Dutch Pharmacists Association – Pharmacogenetics Working Group (DPWG) guidelines recommend an alternative to venlafaxine or to adjust the dose to and to monitor the patient’s plasma metabolite level. Venlafaxine is also metabolized by CYP2D6. Excessive drug dose is one of the most common reasons why some people cannot tolerate SSRIs. In one study, poor CYP2D6 metabolizers of duloxetine experienced a six-fold increase of the the drug in their blood versus those who metabolize it normally. People who do not metabolize duloxetine normally based on their pharmacogenetic profile may experience serious side effects because fluvoxamine interferes with CYP1A2 enzymes and is also metabolized by CYP2D6. Fluvoxamine is used to treat obsessive-compulsive disorder which often occurs with GAD. Sometimes, duloxetine and the drug fluvoxamine are prescribed together.
Duloxetine is cleared in the liver by two important enzymes in drug metabolism called CYP2D6 and CYP1A2. Duloxetine is ususally preferred because it may have less sexual side effects than venlafaxine does. Duloxetine may also be useful for patients suffering from neuropathic pain and fibromyalgia. Duloxetine and Venlafaxineĭuloxetine (Cymbalta) and venlafaxine (Effexor) come from another family of medications called SNRIs that are FDA-approved for the treatment of GAD. There are multiple reasons for SSRI intolerance – you can find more details here.īelow we provide an overview of some alternative medications that can be used for treatment of anxiety and the role of pharmacogenetic variations that have an impact on tolerability and response. Some patients with GAD frequently experience SSRI-induced sexual side effects, worsening of anxiety or sleep disruption. A prescribing algorithm, or process to be followed for GAD treatment is available at: psychopharm.mobi. These include serotonin-norepinephrine reuptake inhibitors (SNRIs), buspirone, hydroxyzine, pregabalin, and bupropion. It can help determine which of the other possible treatment options for GAD are right for an individual. Pharmacogenetic testing will indicate if an individual is a normal, intermediate, ultrarapid, or poor metabolizer for commonly prescribed medications. Pharmacogenetic testing, which determines how you respond to medications based on your unique DNA, can help individuals and their healthcare providers to understand why some cannot tolerate SSRIs and help predict how other anxiety medications will work for them. Trials show that only 50% to 60% of people respond to these medications, remission rates between 25% and 35% are achieved, and a large proportion of patients experience significant SSRI side effects. Normally, people are first prescribed the SSRIs citalopram, escitalopram or sertraline. doi:10.1016/j.addbeh.2018.08.Generalized anxiety disorder (GAD) is often treated with Selective Serotonin Reuptake Inhibitors (SSRIs). A systematic review into the incidence, severity and duration of antidepressant withdrawal effects: Are guidelines evidence-based? Addict Behav. Predicting relapse after antidepressant withdrawal - a systematic review. A case of interdose discontinuation symptoms with venlafaxine extended release. Physical exercise in major depression: Reducing the mortality gap while improving clinical outcomes. doi:10.3233/JRS-140632īelvederi Murri M, Ekkekakis P, Magagnoli M, et al. Interaction between antidepressants and alcohol: signal amplification by multiple case reports. A review of novel antidepressants: A guide for clinicians. doi:10.18773/austprescr.2016.039įaquih AE, Memon RI, Hafeez H, Zeshan M, Naveed S. Discontinuing antidepressants: Pearls and pitfalls. Protracted withdrawal syndrome after stopping antidepressants: a descriptive quantitative analysis of consumer narratives from a large internet forum. Hengartner MP, Schulthess L, Sorensen A, Framer A. When discontinuing SSRI antidepressants is a challenge: Management tips.
How long does antidepressant withdrawal typically last? Am J Psychiatry. A review of the management of antidepressant discontinuation symptoms. Antidepressant withdrawal and rebound phenomena. Antidepressant discontinuation syndrome: A common but underappreciated clinical problem.
Estimating risk of antidepressant withdrawal from a review of published data. Horowitz MA, Framer A, Hengartner MP, Sørensen A, Taylor D. Description of antidepressant withdrawal symptoms in clinical practice guidelines on depression: A systematic review.
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