Therapeutic AreaFormulary ChoicesCost for 28
(unless otherwise stated)
Rationale for decision / comments
4.3 AntidepressantsRelated guidance:NICE CG90 Depression in adults: recognition and management
NHS Rightcare patient decision aid depression
Do not routinely prescribe antidepressants for initial treatment of mild depression or persistent sub-threshold depressive symptoms. DO NOT INITIATE DOSULEPIN

Anticholinergic load
. Antidepressants, particularly tricyclics have an anticholinergic activity which accumulates with other anticholinergic drugs such as medicines for PD, psychosis, overactive bladder, COPD and N&V.In the elderly this can cause serious physical instability, delirium and cognitive decline.
Selective serotonin re uptake inhibitors (SSRI)NB. SSRIs are known to increase risk of GI bleeds especially if co prescribed with NSAIDs and in the very elderly.
Prescribers are reminded of the risk of serotonin syndrome with SSRI when combined with other antidepressants, triptans, and opioids including tramadol.
Citalopram and escitalopram prolong the QT interval in a dose-dependent fashion. To a lesser extent, the concern has also been raised for fluoxetine. Sertraline is associated with QT interval prolongation but the evidence is less well established. There is little compelling evidence that recommended doses of other SSRIs prolong the QT interval.
More here
Fluoxetine, citalopram and sertraline are all included as first-line options for SSRI. The long half-life of fluoxetine is a benefit on withdrawal, but a drawback when switching drugs, e.g. to a TCA.

In elderly or with reduced hepatic function maximum dose of citalopam is 20mg and maximum dose of escitalopram is 10mg.

See flowchart below for options

In generalised anxiety disorder, if the patient cannot tolerate SSRIs or SNRIs, consider offering pregabalin (as Rewiska® or Alzain® brand)

http://www.nice.org.uk/guidance/CG113/chapter/1-Guidance
Fluoxetine
as Oxactin®

as Olena®
20mg capsules: £0.94 (30)
20mg capsules: £0.83 (30)

20mg dispersible tablets
£3.44 (28)
If 10mg strength indicated, break 20mg tablets in half to avoid expensive liquid special preparations


Less expensive than fluoxetine liquid for patients unable to swallow capsules
Or
Sertraline
50mg tablets: £1.23
100mg tablets: £1.38
Joint First-line SSRI for the pharmacological treatment of social anxiety disorder in accordance with NICE CG159.
Or
Citalopram
10mg tablets: £0.79
20mg tablets: £0.86
40mg tablets: £0.90
Escitalopram5mg tablets: £1.45
10mg tablets: £1.47
20mg tablets: £1.66
Joint First-line SSRI for the pharmacological treatment of social anxiety disorder in accordance with NICE CG159.
See Somerset Partnership Guidance below

NB: Maximum dose restrictions – see MHRA DSU (Dec-11) for details.
Tricyclic and related antidepressantsTCAs should be avoided for the treatment of depression in the elderly, due to increased risk of adverse effects, e.g. cardiac especially in high doses.
First line:Lofepramine70mg tablets: £13.12 (56)Lofepramine is the drug of choice in this group as it is safer and produces fewer adverse effects than traditional tricyclics.
NB: Lofepramine is now more expensive than Fluoxetine.
Second line:Amitriptyline10mg tablets: £1.20
25mg tablets: £0.79
50mg tablets: £1.15
Depression initial dose: Usually 75 mg daily in divided doses (or a single dose at night). This may be increased gradually if necessary to a total of 150 mg a day, with the additional doses being given in the late afternoon and/or at bedtime.
The sedative effect is usually rapidly apparent, while antidepressant activity may be seen within three or four days or may take up to 30 days to develop adequately.
Maintenance dose:The usual maintenance dosage is 50-100 mg daily. The total dosage may be given in a single dose preferably in the evening or at bedtime. When satisfactory improvement has been reached, dosage should be reduced to the lowest amount that will maintain relief of symptoms. Elderly should be restricted to 50mg daily maximum
Enuresis: Children from 6-10 years may receive 10-20 mg a day, while those aged 11-16 years may need 25 mg a day
Other antidepressantsMirtazapine


Oro-dispersible tablets:
15mg tablets: £1.22
30mg tablets: £1.24
45mg tablets: £1.50
15mg tablets: £1.45 (30)
30mg tablets: £1.46 (30)
45mg tablets: £2.00 (30)
Mirtazapine is a second-line option; sedating properties may be useful where insomnia is a problem.
Venlafaxine
First-line:
Immediate release
37.5mg tablets: £1.82 (56)
75mg tablets: £1.87 (56)
See MHRA guidance
Second-line:
Modified-release
as
Vensir XL®
or
Venlalic XL® or generic
or
Venlablue®
or
Vencarm XL®

Prescribe 225mg as
Vencarm XL®



75mg capsules: £2.60
150mg capsules: £3.90

75mg tablets: £2.60
150mg tablets: £3.90

37.5mg capsules: £5.25

37.5mg: £3.30
75mg: £2.59
150mg: £3.89
225mg prolonged-release capsules

225mg capsules: £9.90
There is no rationale for prescribing M/R products as a BD dose
Vortioxetine5mg tablets: £27.72 (28)
10mg tablets: £27.72 (28)
20mg tablets: £27.72 (28)
NICE TA367 (Nov 15): Vortioxetine (Brintellix) is recommended as a possible treatment for adults having a first or recurrent major depressive episode, if the current episode has not responded to 2 antidepressants. Approved by PAMM Jan 16

Citalopram max dose

Escitalopram max dose