Clinical Manual for Management of the HIV-Infected ... - myCME.com

of symptoms. The risk of recurrence is higher if the
first depressive episode is inadequately treated or if the
patient has had multiple depressive episodes.
Table 1. SSRI and SNRI Antidepressant Medications and Possible Positive and Negative Effects
Section 8—Neuropsychiatric Disorders | 8–7
Table 1 lists the available antidepressant medications
(SSRIs and serotonin/norepinephrine reuptake
inhibitors [SNRIs]), including therapeutic dosages and
possible positive and negative effects.
Medication: Usual Dosage Possible Positive Effects Possible Negative Effects
Fluoxetine (Prozac): 10-40 mg once
daily
Paroxetine* (Paxil): 10-40 mg once
daily
Sertraline (Zoloft): 50-100 mg once
daily
Venlafaxine XR** (Effexor XR): 75-
375 mg once daily
Citalopram (Celexa): 10-60 mg once
daily or escitalopram (Lexapro):
10-20 mg once daily
Rarely sedating, often energizing, no cardiovascular
adverse effects, no anticholinergic effects, nonfatal
in overdose
May be sedating (for patients experiencing sedation
with paroxetine, dose at bedtime; can be useful with
depression-associated insomnia)
May have lower incidence of significant drugdrug
interactions compared with fluoxetine and
paroxetine; nevertheless, start with lower dosages
when this medication is used with protease
inhibitors
May have lower risk of significant drug-drug
interactions compared with SSRIs
May have lower risk of significant drug-drug
interactions than other SSRIs
Insomnia, agitation, nausea, headache, sexual
dysfunction in men and women, long half-life
Insomnia, agitation (for patients experiencing these
effects, administer dose in mornings), nausea,
headache, sexual dysfunction in men and women
Insomnia, agitation, nausea, headache, sexual
dysfunction in men and women, long half-life
Nausea, headache, nervousness, sexual dysfunction
Mild nausea, possible sedation
* When discontinuing paroxetine therapy, carefully titrate the dosage reduction to avoid serious adverse effects associated with abrupt discontinuation. Such effects include confusion, agitation, irritability, sensory
disturbances, and insomnia.
** Note: Monitor blood pressure at higher dosages of venlafaxine.
Other Agents
Newer antidepressants such as mirtazapine may be
particularly useful in patients who have significant
insomnia and in those who have experienced sexual
dysfunction with other antidepressant agents such as
SSRIs.
♦
♦
Mirtazapine (Remeron) should be administered at
bedtime because of its sedating effects. Sedation
is commonly noted with the starting dosage of 15
mg once daily, but may be lessened by increasing
the dosage to 30 mg at bedtime. Individuals may
also experience an increase in appetite, weight gain,
and dry mouth. Mirtazapine has minimal drugdrug
interactions. The therapeutic dosage range is
15-45 mg once daily. Consider starting with 15 mg
at bedtime for 7 days, then increasing to 30 mg if
sedation is problematic.
Bupropion (Wellbutrin) sustained-release (SR) or
extended-release (XL) formulation may be used in
individuals with depression who experience sexual
dysfunction with other antidepressant agents.
♦
Bupropion SR or XL dosing should not exceed
400 mg per day (the SR formulation should be
administered twice daily in divided doses) because
of an increased risk of seizures at higher bupropion
dosages, particularly in individuals who have other
risk factors for seizures. For patients taking protease
inhibitors, caution should be used as the dosage
approaches 300-400 mg per day because of possible
increases in levels of bupropion. Bupropion may
have an activating effect, which some patients may
experience as agitation, insomnia, or both, and also
may have an appetite suppressant effect.
Nefazodone (Serzone) may cause liver toxicity and
generally is not recommended as an antidepressant
for patients with HIV/AIDS because of the high
rates of preexisting liver abnormalities in HIVinfected
patients. This medication has recently
received a black box warning regarding severe
liver toxicity from the U.S. Food and Drug
Administration. If the patient has ever had liver
toxicity from the drug, restarting is contraindicated.