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Antidepressant Therapy

Adjustments in Chronic Kidney Disease and Hepatic Dysfunction


Antidepressant Adjustments in Chronic Kidney Disease and Hepatic Dysfunction


Background


The purpose of this program is to provide dosing recommendations for a particular antidepressant for a patient with renal or hepatic insufficiency.  Most of these drugs are hepatically metabolized and may require dosage adjustments in some cases.  Dosage changes based on renal function, regardless of the severity, are relatively uncommon.

Using the program:
Select an antidepressant from the list and press 'Display Info' in order to generate a report for that particular drug.  Information generated includes:

  • Dosage in renal impairment
  • Hepatic Dosing
  • Half-life
  • Initial dosage and range
  • Link to prescribing information
  • Individual receptor actions (5-HT, NE, M1, etc.)
  • Dosing comments


Make a Selection




 
 
 




depression



Treatment failures or inadequate response top of page

Clinical result -  Action taken

  • Most patients are started on an SSRI --> if inadequate response consider maximizing the dose after confirming compliance with therapy.  If the patient had an adverse effect specific to that drug, consider changing to an alternative SSRI or move to one of the other classes such as a dual reuptake inhibitor.
  • If the patient has an inadequate response after maximizing the dose, consider the addition of a second agent or switching to a non-SSRI antidepressant.
  • If the patient responds to therapy, maintain current regimen and reevaluate the patient at each visit.
  • [Refractory patients] If the patient fails to respond to single or dual therapy at maximal doses while attempting changes within some of the classes, consider adding an atypical antipsychotic (2nd generation) drug such as aripiprasole, brexipiprazole, olanzepine or quetiapine for refractory patients.



References top of page

 

  1. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed. Arlington, VA: American Psychiatric Association;2013.

  2. Bousman CA, Dunlop BW. Genotype, phenotype, and medication recommendation agreement among commercial pharmacogenetic-baseddecision support tools. Pharmacogenomics J. 2018;18(5):613-
    622. [
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  3. Cleare A, Pariante CM, Young AH et al. Evidence-based guidelines for treating depressive disorders with antidepressants: A revision of the 2008 British Association for Psychopharmacology guidelines. J Psychopharmacol. 2015;29(5):459-525. [PubMed: 25969470]

  4. Cipriani A, Forukawa TA, Salanti G, et al. Comparative efficacy and acceptability of 21 antidepressant drugs for the acute treatment of adults with major depressive disorder: A systematic review and network meta-analysis. Lancet. 2018;391:1357-1366. [PubMed: 29477251]

  5. Gaynes BN, Rush AJ, Trivedi MH, et al. The STAR*D study: Treating depression in the real world. Cleve Clin J Med. 2008;75(1):57-66. [PubMed:18236731]

  6. Hasin DS, Sarvet AL, Meyers JL et al. Epidemiology of adult DSM-5 major depressive disorder and its specifiers in the united states. JAMA
    Psychiatry. 2018;75(4):336-346. [
    PubMed: 29450462]

  7. Kok RM, Reynolds CF. Management of depression in older adults: A review. JAMA. 2017;317(20):2114-2122. [PubMed: 28535241]

  8. La Torre A, Giupponi G, Duffy D, Conca A. Sexual dysfunction related to psychotropic drugs: A critical review—part I: Antidepressants.
    Pharmacopsychiatry. 2013;46(5):191-199. [
    PubMed: 23737245]

  9. Lesch KP, Gutknecht L. Pharmacogenetics of the serotonin transporter. Prog Neuropsychopharmacol Biol Psychiatry . 2005;29(6):1062-1073. [PubMed: 15951088]

  10. Maletic V, Robinson M, Oakes T, et al. Neurobiology of depression: an integrated view of key findings. Int J Clin Pract . 2007;61(12):2030-2040. [PubMed: 17944926]

  11. Mann JJ. The medical management of depression. N Engl J Med. 2005;353(17):1819-1834. [PubMed: 16251538]

  12. McIntyre RS. The role of new antidepressants in clinical practice in Canada: A brief review of vortioxetine, levomilnacipran ER, and vilazodone. Neuropsychiatr Dis Treat. 2017;13:2913-2919. [PubMed: 29238196]

  13. Mohamed S, Johnson GR, Chen P et al. Effect of antidepressant switching vs augmentation on remission among patients with major depressive disorder unresponsive to antidepressant treatment. The VAST-D randomized clinical trial. JAMA. 2018;318:132-145.

  14. Rosenblat JD, Lee Y, McIntyre RS. Does pharmacogenomics testing improve clinical outcomes for major depressive disorder. A systematic review of clinical trials and cost-effectiveness studies. J Clin Psychiatry. 2017;78(6):720-729. [PubMed: 28068459]

  15. Sullivan PF, Neale MC, Kendler KS. Genetic epidemiology of major depression: Review and meta-analysis. Am J Psychiatry. 2000;157(10):1552-1562.  https://pubmed.ncbi.nlm.nih.gov/11007705/.

  16. Stone EA, Lin Y, Quartermain D. A final common pathway for depression? Progress toward a general conceptual framework. Neurosci Biobehav Rev. 2008;32(3):508-524. [PubMed: 18023876]

  17. Taylor C, Fricker AD, Devi L, et al. Mechanisms of action of antidepressants: From neurotransmitter systems to signaling pathways. Cell Signal. 2005;17(5):549-557. PubMed: 15683730]].

 

Antidepressants in Renal insufficiency or Hepatic Disease