Generic Name: fluoxetine hydrochloride

Brand Name: Apo-Fluoxetine (CAN), Co-Fluoxetine (CAN), Novo-Fluoxetine (CAN), PMS-Fluoxetine (CAN), Prozac, Prozac Pulvules, Prozac Weekly, ratio-Fluoxetine (CAN), Sarafem

Other Info: Pregnancy Category C

Drug class: Antidepressant, SSRI

Indications

• Treatment of depression; most effective in patients with major depressive disorder
• Treatment of OCD
• Treatment of bulimia
• Treatment of PMDD (Sarafem)
• Treatment of panic disorder with or without agoraphobia
• Unlabeled use: Treatment of obesity, alcoholism, numerous psychiatric disorders, chronic pain, various neuropathies

Contraindications and cautions

• Contraindicated with hypersensitivity to fluoxetine, pregnancy.
• Use cautiously with impaired hepatic or renal function, diabetes mellitus, lactation, seizures; history of suicide attempts.

Available forms

Tablets—10, 20 mg; capsules—10, 20, 40 mg; liquid—20 mg/5 mL; DR capsules—90 mg

Dosages

Individualize dosage; same for oral or IV routes because of rapid and almost complete absorption.

ADULTS

• Antidepressant: The full antidepressant effect may not be seen for up to 4–6 wk. Initially, 20 mg/day PO in the morning. If no clinical improvement is seen, increase dose after several weeks. Administer doses > 20 mg/day on a bid schedule. Do not exceed 80 mg/day. Once stabilized, may switch to 90-mg DR capsules once a week.
• OCD: Initially, 20 mg/day PO. If no clinical improvement is seen, increase dose after several weeks. Usual dosage range, 20–60 mg/day PO; may require up to 5 wk for effectiveness. Do not exceed 80 mg/day.
• Bulimia: 60 mg/day PO in the morning.
• PMDD (Sarafem): 20 mg/day PO or 20 mg/day PO starting 14 days before the anticipated beginning of menses and continuing through the first full day of menses, then no drug until 14 days before next menses; do not exceed 80 mg/day.
• Panic disorder (Prozac): 10 mg/day PO for the first week; increase to 20 mg/day if needed. Maximum dose, 60 mg/day.

PEDIATRIC PATIENTS 8–18 YR

• Major depressive disorder: 10 mg/day PO; may be increased to 20 mg/day after several weeks.

PEDIATRIC PATIENTS 7–17 YR

• OCD: Initially, 10 mg/day PO. After 2 wk increase to 20 mg/day. Suggested range, 20–60 mg/day PO.

PEDIATRIC PATIENTS < 7 YR

• Safety and efficacy not established.

GERIATRIC PATIENTS OR PATIENTS WITH HEPATIC OR RENAL IMPAIRMENT

Give a lower or less frequent dose. Monitor response to guide dosage.

Pharmacokinetics

Metabolism: Hepatic; T_1/2: 9 days

Distribution: Crosses placenta; enters breast milk

Excretion: Feces, urine

Adverse effects

• CNS: Headache, nervousness, insomnia, drowsiness, anxiety, tremor, dizziness, light-headedness, agitation, sedation, abnormal gait, seizures
• CV: Hot flashes, palpitations
• Dermatologic: Sweating, rash, pruritus, acne, alopecia, contact dermatitis
• GI: Nausea, vomiting, diarrhea, dry mouth, anorexia, dyspepsia, constipation, taste changes, flatulence, gastroenteritis, dysphagia, gingivitis
• GU: Painful menstruation, sexual dysfunction, frequency, cystitis, impotence, urgency, vaginitis
• Respiratory: URIs, pharyngitis, cough, dyspnea, bronchitis, rhinitis
• Other: weight changes, asthenia, fever

Interactions

Drug-drug

• WARNING: Possible fatal reactions with MAOIs; do not administer together; 2-wk washout period needed.
• Increased therapeutic and toxic effects of TCAs
• Do not use with thioridazine (increased levels of thioridazine)
• Decreased effectiveness if taken while smoking
• Increased toxicity of lithium; avoid this combination
• Additive CNS effects if combined with benzodiazepines, alcohol; avoid these combinations
• Avoid administration with other serotonergic drugs; may lead to serotonin syndrome

Drug-alternative therapy

• Increased risk of severe reaction if combined with St. John’s wort therapy

Nursing considerations

CLINICAL ALERT! Name confusion has occurred between Sarafem (fluoxetine) and Serophene (clomiphene); use caution.

Assessment

• History: Hypersensitivity to fluoxetine, impaired hepatic or renal function, diabetes mellitus, lactation, pregnancy, seizures
• Physical: Weight, T; skin rash, lesions; reflexes, affect; bowel sounds, liver evaluation; P, peripheral perfusion; urinary output, LFTs, renal function tests

Interventions

• Arrange for lower or less frequent doses in elderly patients and patients with hepatic or renal impairment.
• BLACK BOX WARNING: Establish suicide precautions for severely depressed patients. Limit quantity of capsules dispensed; high risk in children and adolescents.
• Administer drug in the morning.
• Monitor patient for response to therapy for up to 4 wk before increasing dose.
• Switch to once a week therapy by starting weekly dose 7 days after last 20 mg/day dose. If response is not satisfactory, reconsider daily dosing.

Teaching points

• It may take up to 4 weeks before the full effect occurs. Take in the morning. If you feel sleepy or tired, you may take it at night. If you are taking the once-weekly capsule, mark calendar with reminders of drug day.
• Do not take this drug during pregnancy. If you think that you are pregnant or wish to become pregnant, consult your health care provider.
• Keep this drug, and all medications, out of the reach of children.
• You may experience these side effects: Dizziness, drowsiness, nervousness, insomnia (avoid driving or performing hazardous tasks); nausea, vomiting, weight loss (eat small frequent meals; monitor your weight loss); sexual dysfunction; flulike symptoms.
• Report rash, mania, seizures, severe weight loss.

Fluoxentine HCl (Prozac) Original source at: Nurseslabs

Brand Name: Lexapro

Other Info: Pregnancy Category C

Drug classes: Antidepressant, SSRI

Therapeutic actions

Potentiates serotonergic activitity in the CNS by inhibiting reuptake of serotonin resulting in antidepressant effect with little effect on norepinephrine or dopamine; an isomer of citalopram.

Indications

• Treatment of major depressive disorder
• Maintenance treatment for patients with major depressive disorder
• Treatment of generalized anxiety disorder
• Unlabeled use: Panic disorder

Contraindications and cautions

• Contraindicated with MAOI use; with allergy to drug or to citalopram or any component of the drug.
• Use cautiously in the elderly, and with renal or hepatic impairment, illnesses of metabolism or hemodynamic response, pregnancy, lactation, suicidal patients, patients with mania or seizure disorders.

Available forms

Tablets—5, 10, 20 mg; oral solution—5 mg/5 mL

Dosages

ADULTS

• Major depressive disorder: Initially, 10 mg/day PO as a single daily dose; if needed, may be increased to 20 mg/day after a minimum of 1-wk trial period. For maintenance, 10–20 mg/day PO; reassess periodically.
• Generalized anxiety disorder: 10 mg/day PO; may be increased to 20 mg/day after 1 wk if needed. Treatment beyond 8 wk not tested.

PEDIATRIC PATIENTS

Safety and efficacy not established.

GERIATRIC PATIENTS OR ADULTS WITH HEPATIC IMPAIRMENT

10 mg/day PO as a single dose, do not increase dose.

Pharmacokinetics

Metabolism: Hepatic metabolism; T_1/2: 27–32 hour

Distribution: Crosses placenta; enters breast milk

Excretion: Urine

Adverse effects

• CNS: Somnolence, dizziness, insomnia, fatigue
• Dermatologic: Sweating
• GI: Nausea, dry mouth, constipation, diarrhea, indigestion, abdominal pain, decreased appetite
• GU: Ejaculatory disorders, impotence, anorgasmia in females, decreased libido
• Respiratory: Rhinitis, sinusitis, flulike symptoms

Interactions

Drug-drug

• Risk of serious toxic effects if combined with citalopram; do not use these drugs concomitantly
• Increased escitalopram levels and toxicity if taken with MAOIs; ensure that patient has been off the MAOI for at least 14 days before administeringescitalpram
• Risk of serotonin syndrome—a syndrome characterized by increased BP, T, severe anxiety, agitation, rigidity, and can occur when multiple serotonin elevating drugs are used. Monitor patient carefully
• Possible severe adverse effects if combined with other centrally acting CNS drugs including alcohol; use caution
• Possible decreased effects of escitalopram if combined with carbamazepine, lithium; monitor patient closely

Drug-alternative therapy

• Increased risk of severe reaction if combined with St. John’s wort; avoid this combination

Nursing considerations

CLINICAL ALERT!

There is potential for name confusion between escitalopram and citalopram and Lexapro (escitalopram) and Loxitane (loxapine); use caution.

Assessment

• History: MAOI use; allergy to drug, citalopram, or any component of the drug; renal or hepatic impairment; the elderly; pregnancy; lactation; suicidal tendencies; metabolic illnesses or problems with hemodynamic response; alcoholism
• Physical: Orientation, reflexes; P, BP, perfusion; R, bowel sounds, normal output; urinary output; liver evaluation; LFTs, renal function tests

Interventions

• BLACK BOX WARNING: Monitor patient for risk of suicidality, especially when starting or altering dosage; children and adolescents at increased risk.
• Administer once a day, in the morning or the evening; may be taken with food if desired.
• Encourage patient to continue use for 4–6 weeks, as directed, to ensure adequate levels to affect depression.
• WARNING: Limit amount of drug given in prescription to potentially suicidal patients.
• Advise any depressed patients to avoid the use of alcohol while being treated with antidepressive drugs.
• Establish appropriate safety precautions if patient experiences adverse CNS effects.
• Institute appropriate therapy for patient suffering from depression.

Teaching points

• Take this drug exactly as directed, and as long as directed; it may take several weeks to realize the benefits of the drug. The drug may be taken with food if desired.
• Avoid the use of alcohol while you are taking this drug.
• This drug should not be taken during pregnancy or when nursing a baby; using barrier contraceptive is suggested.
• You may experience these side effects: Drowsiness, dizziness, tremor (use caution and avoid driving a car or performing other tasks that require alertness if you experience daytime drowsiness); GI upset (frequent small meals, frequent mouth care may help); alterations in sexual function (this is a drug effect and will pass when drug therapy is ended).
• Report severe nausea, vomiting; blurred vision; excessive sweating, suicidal ideation, sexual dysfunction, insomnia.

Escitalopram Original source at: Nurseslabs