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About LinkBacksBecause google is not EBP.Originally Posted by Jeff
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Because google is not EBP.
A google search for "depression guidelines UK" brings up NICE as it's first hit - isn't that evidence based enough for you?
What makes Maudsley better than NICE?
Active Member
Never said Maudsley was better than NICE, I just asked you if you had a copy. You never mentioned NICE in your google search, I just commented on the fact that you said you used google scholar.
Newly registered in 1981
Nice only mentioned augmentation with another antidepressant.
Didn't see anything specific about TCA use with SSRI, unless I missed it!
Where am I?; In the Pharmacy.
Who are you?; The new Number 2.
Who is number 1?; You are number 6.
What do you want?;..................
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http://www.nice.org.uk/nicemedia/pdf...ideamended.pdf
Treatments such as dosulepin, phenelzine, combined antidepressants, and lithium augmentation
of antidepressants should be routinely initiated only by specialist mental healthcare professionals
(including General Practitioners with a Special Interest in Mental Health).
patient past history?
is the doctor or GP with a special interest in MH?
Depression Treatment: Antidepressant Combination Therapy Canadian Mental Health
COMBINATION
The ability to proceed quickly, with no "down" time during treatment of the depressed patient provides a strong rationale for combination therapy. Indeed, combination strategies have superseded substitution in some specialty practices today. The underlying principle of combination therapy involves using the pharmacokinetics of each agent in such a way as to arrive at a different and potentially more effective therapy than might be possible with either drug alone. While several combination strategies involve standard doses of both antidepressants, often lower doses of both drugs must be given.
Potentially, any number of antidepressant medications might be considered for combination therapy; however, some are clearly more attractive and potentially more effective than others. Two TCAs, given in full dose combination, for example, is not a prudent approach, largely because of the side effect burden such a combination would entail, without evidence of improved efficacy.
Similarly, while theoretically possible to combine a TCA with a MAOI, studies now show that the combination is no more effective than substitution, and it is more logical to stop the TCA altogether, and initiate the MAOI than to use both of them together. (That said, a small percentage of resistant patients may benefit from this combination).
In contrast, evidence suggests that the combination of a TCA and a SSRI, both initiated together or added following a complete trial of one agent, appears to bring about a more rapid onset of action and a more profound response than TCAs alone. There's also some evidence - largely for the combination of desipramine and fluoxetine - to suggest that a certain percentage of patients who fail both a TCA and a SSRI may respond to the combined use of both agents.
Because the SSRIs are generally better tolerated than the TCAs, combination therapy in which a SSRI is used initially, followed by an additional TCA if response to the single agent should prove inadequate, is a particularly attractive approach.
The same SSRI-TCA combination also allows clinicians to go immediately to full-dose TCA therapy, used as a single agent, should the patient fail to respond to the SSRI/TCA combination. (Of note: when using the SSRI/TCA combination approach, it is important to manipulate the dose of the TCA and not the SSRI, if the dosage of one agent needs to be reduced. It should also be noted that doses of the TCA used are lower than normal - in the range of l mg/kg/day - when used in combination with most SSRIs; normal dosage being in the range of 2.5 mg/kg/day).
Preliminary work also suggests a role for combined SSRI / RIMA (moclobmide) therapy, consisting of the usual recommended dose of the SSRI combined with up to 600 mg of moclobemide. Although side effects can be pronounced during the first 24 hours following introduction of this particular combination, early results suggest up to 60 percent of previously refractory patients respond to this combination. (This has to be confirmed in double-blind, controlled trials.) High dose combination SSRI therapy has also been used by a few investigators with some success.
Recent reports on the combined use of bupropion and an SSRI suggests that bupropion, given in relatively low doses, may be able to reverse some of the sexual side effects associated with certain SSRIs. However, data on the antidepressant efficacy and side effect profile of this particular combination is unavailable.
For SSRI-induced insomnia, trazodone has been recommended as an appropriate treatment. Nevertheless, there is little empirical data to support the recommendation, and this particular combination should not be confused with true "combination" therapy, whose purpose is to improve the overall antidepressant effect.
It is important to stress that caution is needed in certain circumstances when using combination therapy. Moreover, before recommendations can be made for wholesale adoption of this particular strategy, results from appropriate, double-blind, placebo-controlled trials are clearly needed. Until clinicians gain more experience with managing patients on combination therapy, it is currently recommended that patients who may potentially benefit from combination therapy be referred to a psychiatrist with an interest in this area. It is also important not to combine any of the conventional, older MAOIs without consulting a specialist.
Finally, although many combinations are possible, the SSRIs, in general, are safe in combination with a wide variety of other antidepressants and they may be a more appropriate choice in the absence of specialist consultation.
Conclusion
For patients who fail to respond to an initial course of antidepressant medication, a number of options exist which serve to enhance therapeutic outcome. The first and most important is optimization.
Failing optimization, where adequate doses of the selected medication have been given for an adequate period of time to reach a therapeutic effect, augmentation, where one of several, non-antidepressant agents may be added to the existing antidepressant medication, is a second option. Substitution is another alternative for patients who fail to achieve an adequate response to initial therapy.
However, with the development of newer and better tolerated antidepressant medications, many now feel that the combined use of two active antidepressant agents is a more rapid and potentially more effective response than substituting one active antidepressant drug for another. Independent of the strategy chosen, the goal of the practitioner is to successfully treat depression, with the least amount of discomfort for the patient.
For patients who may be severely depressed, more aggressive combination therapy may be justified in order to prevent prolonged disability and self-harm.
This paper was developed and written by Dr. Russell Joffe, Dr. Anthony Levitt, Dr. Stephen Sokolov, and Dr. L. Trevor Young while they were on staff at the Mood Disorders Program, Department of Psychiatry and Behavioural Neurosciences, McMaster University.The paper was supported by an educational grant from Eli Lilly Canada Inc.
Want to know how to switch?
http://www.cks.nhs.uk/mobiledevices/...rapy#-220507:1
Clarification / Additional information
When cross-tapering is recommended, the dose of the drug to be discontinued is slowly reduced while the new drug is slowly introduced.
The speed of cross-tapering is best judged by monitoring how well it is tolerated. No clear guidelines are available, so caution is required.
An example of a cross-tapering regimen is shown in Table 1.
[Taylor et al, 2007]
Table 2. Switching from a tricyclic antidepressant to a selective serotonin reuptake inhibitor — an example of a cross-tapering regimen.
Pre-switch dosage Week 1 Week 2 Week 3 Week 4
Withdrawing dosulepin 150 mg daily 100 mg daily 50 mg daily 25 mg daily nil
Introducing citalopram nil 10 mg daily 10 mg daily 20 mg daily 20 mg daily
Last edited by howe928; 4th, October 2009 at 02:54 PM.
Loyal Member
lol google is the best
Do remember that it is a search engine and i am sure pharmacists are capable of selecting relevant information from reputable sources.
Newly registered in 1981
And do remember, the original search for information concerning this posting was done using Google Scholar.
Google Scholar
Where am I?; In the Pharmacy.
Who are you?; The new Number 2.
Who is number 1?; You are number 6.
What do you want?;..................
Loyal Member
If the amitriptyline was at the normal antidepressant dose (75mg to 150mg) then i would be concerned. However 10mg wouldn't harm a fly.
I do know that ssri's can cause sleep disturbances when initiating so was most likely prescribed for it's sedative properties as the other guys on here have said.
Those pharmacists that do not have a Stockley's Drug Interactions Pocket Companion then my sincere advice is to get one. It is excellent and i refer to that more than the BNF.
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