pharmacology

  // Adult/Geriatric Depression

Adult/Geriatric Depression Hispanic Male With MDD

 

Decision Point One Begin zoloft 25 mg orally daily

RESULTS OF DECISION POINT ONE

• Client returns to clinic in four weeks
• Reports a 25% decrease in symptoms
• Client is concerned over the new onset of erectile dysfunction

Decision Point Two

Select what you should do next:

Decrease dose to 12.5 mg orally daily

RESULTS OF DECISION POINT TWO

• Client returns to clinic in four weeks
• Erectile dysfunction has subsided
• Depressive symptoms have worsened

Decision Point Three

Select what you should do next:

Increase dose back to 25 mg orally daily

Guidance to Student Increasing dose back to 25 mg orally daily may be appropriate as there is no guarantee that the side effect will return. If it does return at 25 mg orally daily, then you should consider changing to another drug. Changing to Paxil 20 mg may also be appropriate at this point, as not all SSRIs have the same side effect profile. Changing to an SNRI would not be appropriate at this point as the issue is not that the client has not responded to SSRI therapy, rather, he has had a negative side effect to one drug in the class. Start Over

Change to Paxil 20 mg orally daily

Guidance to Student Increasing dose back to 25 mg orally daily may be appropriate as there is no guarantee that the side effect will return. If it does return at 25 mg orally daily, then you should consider changing to another drug. Changing to Paxil 20 mg may also be appropriate at this point, as not all SSRIs have the same side effect profile. Changing to an SNRI would not be appropriate at this point as the issue is not that the client has not responded to SSRI therapy, rather, he has had a negative side effect to one drug in the class. Start Over

Change to Cymbalta 40 mg orally daily

Guidance to Student Increasing dose back to 25 mg orally daily may be appropriate as there is no guarantee that the side effect will return. If it does return at 25 mg orally daily, then you should consider changing to another drug. Changing to Paxil 20 mg may also be appropriate at this point, as not all SSRIs have the same side effect profile. Changing to an SNRI would not be appropriate at this point as the issue is not that the client has not responded to SSRI therapy, rather, he has had a negative side effect to one drug in the class. Start Over

Continue same dose and counsel client

RESULTS OF DECISION POINT TWO

• Client returns to clinic in four weeks
• Client informed you that he stopped taking the drug because his inability to perform sexually was worsening his self-esteem

Decision Point Three

Select what you should do next:

Encourage client to re-start drug at previous dose

Guidance to Student Encouraging client to restart at previous dose would not be appropriate. Obviously, the side effect did not abate- so there is no reason to assume that it would abate at the previous dose. Re-starting the drug at 50% of starting dose may be appropriate to determine whether or not side effect is dose dependent. If the side effect of erectile dysfunction returns once the drug is returned to full dose, you would need to change the drug. Changing to Wellbutrin XL may be appropriate at this point, but may worsen his insomnia. Additionally, guidelines tell us that another SSRI should be attempted for an adequate trial before switching drug classes. Start Over

Re-start drug at 50% initial dose

Guidance to Student Encouraging client to restart at previous dose would not be appropriate. Obviously, the side effect did not abate- so there is no reason to assume that it would abate at the previous dose. Re-starting the drug at 50% of starting dose may be appropriate to determine whether or not side effect is dose dependent. If the side effect of erectile dysfunction returns once the drug is returned to full dose, you would need to change the drug. Changing to Wellbutrin XL may be appropriate at this point, but may worsen his insomnia. Additionally, guidelines tell us that another SSRI should be attempted for an adequate trial before switching drug classes. Start Over

Change to Wellbutrin XL

Guidance to Student Encouraging client to restart at previous dose would not be appropriate. Obviously, the side effect did not abate- so there is no reason to assume that it would abate at the previous dose. Re-starting the drug at 50% of starting dose may be appropriate to determine whether or not side effect is dose dependent. If the side effect of erectile dysfunction returns once the drug is returned to full dose, you would need to change the drug. Changing to Wellbutrin XL may be appropriate at this point, but may worsen his insomnia. Additionally, guidelines tell us that another SSRI should be attempted for an adequate trial before switching drug classes. Start Over

Add augmenting agent such as Wellbutrin IR 150 mg in morning

RESULTS OF DECISION POINT TWO

• Client returns to clinic in four weeks
• Client stated that depressive symptoms have decreased even more and his erectile dysfunction has abated
• Client reports that he has been feeling “jittery” and sometimes “nervous”

Decision Point Three

Select what you should do next:

Discontinue Zoloft altogether and continue with Wellbutrin

Guidance to Student You should be aware that Zoloft or Wellbutrin could be responsible for the client complaints of Jitteriness. This feeling is usually temporary with SSRIs, however. The cause of the client’s complaint of “jitteriness” is most likely related to the Wellbutrin immediate release. As a result, the most appropriate answer would be to change the Wellbutrin to an extended release formulation. It would not be appropriate to add Ativan as you should never add an additional medication to treat the side effect of another medication without first attempting to modify/change the medication causing the side effect. Start Over

Change Wellbutrin to XL 150 mg orally daily in AM

Guidance to Student You should be aware that Zoloft or Wellbutrin could be responsible for the client complaints of Jitteriness. This feeling is usually temporary with SSRIs, however. The cause of the client’s complaint of “jitteriness” is most likely related to the Wellbutrin immediate release. As a result, the most appropriate answer would be to change the Wellbutrin to an extended release formulation. It would not be appropriate to add Ativan as you should never add an additional medication to treat the side effect of another medication without first attempting to modify/change the medication causing the side effect. Start Over

Add Ativan 0.5 mg orally TID/PRN for anxiety

Guidance to Student You should be aware that Zoloft or Wellbutrin could be responsible for the client complaints of Jitteriness. This feeling is usually temporary with SSRIs, however. The cause of the client’s complaint of “jitteriness” is most likely related to the Wellbutrin immediate release. As a result, the most appropriate answer would be to change the Wellbutrin to an extended release formulation. It would not be appropriate to add Ativan as you should never add an additional medication to treat the side effect of another medication without first attempting to modify/change the medication causing the side effect. Start Over