Combined use of antidepressants

[Pharmanaut]

Anyone got any experience of combined use of antidepressants from different chemo-therapeutic classes.
Example from practice....
Bereaved male in mid-50's presents script for Citalopram 10mg Tablets 1od, Amitriptyline 10mg 1 on.
This is treatment initiation for both - confirmed with patient.
No previous antidepressant (any class) on PMR.
Prescriber is locum GP.
Day is saturday.
After a chat with patient, no special instructions etc.
Dispensed citalopram 10mg and queried Amitriptyline with GP on monday.
Confirmed proceed dispense.
Now I'm wondering about serotonin syndrome and all that and would you really want to initiate together. Would have thought to start one, review and possibly start the other and review.

Anyone want to comment....
(but don't make me look a fool!)
Lets all log some CPD here!

PS My little dispensing radar suspected the Amitriptyline 10mg Tablets 1 ON might be Atorvastatin 10mg Tablets, but on this occasion the little voice in my head was wrong.

[bobbin]

Bereaved male in mid-50's presents script for Citalopram 10mg Tablets 1od, Amitriptyline 10mg 1 on.

At a 10mg dose, the main effect of the amitriptyline will be night sedation, which is probably why it was prescribed. Citalopram is one the safer SSRIs to combine with tricyclics because of the low potential for pharmacokinetic drug interactions.

The risk of serotonin syndrome with this combination is extremely low. Serotonin syndrome is variable in severity. Severe cases occur when serotonin reuptake inhibitors are combined with MAOIs such as phenelzine. Mild cases can occur as a result of taking multiple SSRIs or an SSRI + clomipramine.

To be honest, 10mg ami + 10mg citalopram will probably elevate serotonin levels to a lesser extent than 20mg citalopram on its own. I would not be concerned.

[Pharmanaut]

At a 10mg dose, the main effect of the amitriptyline will be night sedation, which is probably why it was prescribed. Citalopram is one the safer SSRIs to combine with tricyclics because of the low potential for pharmacokinetic drug interactions.

The risk of serotonin syndrome with this combination is extremely low. Serotonin syndrome is variable in severity. Severe cases occur when serotonin reuptake inhibitors are combined with MAOIs such as phenelzine. Mild cases can occur as a result of taking multiple SSRIs or an SSRI + clomipramine.

To be honest, 10mg ami + 10mg citalopram will probably elevate serotonin levels to a lesser extent than 20mg citalopram on its own. I would not be concerned.

Sounds reasonable, but initiating both at once seemed odd to me.

[bobbin]

Sounds reasonable, but initiating both at once seemed odd to me.

Increased anxiety and insomnia can occur when starting SSRIs in some patients. The doc could have prescribed a bit of temazepam as an alternative to the amitriptyline but perhaps he felt that benzodiazepines were not appropriate for this patient.

[sharifhs]

Now I'm wondering about serotonin syndrome and all that and would you really want to initiate together. Would have thought to start one, review and possibly start the other and review.

Hello Pharmanaut

It also seems to me odd prescribing citalopram and amitriptyline initiating together.

However, the combined treatment give better response in patients with depression, migraine and tension-type headache without producing major side effects such as those commonly related to the 'serotonergic' syndrome.

Have you seen this page?..........if not, pls see this page:

Evaluation of the Prophylactic Efficacy of Amitriptyline and Citalopram, Alone or in Combination, in Patients with Comorbidity of Depression, Migraine, and Tension-Type Headache

Hey, could you inform me how to give a reference link page? Is it correct form of mentioning a link that I've mentioned above?

Thank you

[sharifhs]

Hey, could you inform me how to give a reference link page? Is it correct form of mentioning a link that I've mentioned above?

wao.........I think i'm correct. I didn't mention that link just like that but simply as a web address. After posting this message it turned into this form automatically!!! Don't make me fool, I'm somewhat new in internet................

Thank you

[Nikolai]

Quoted from the abstract:

"The results indicate that a combined therapy with amitriptyline and citalopram may be particularly beneficial for patients with TTH, migraine and comorbid depression that do not respond to monotherapy."

I believe Pharmanaut mentioned that the patient had taken neither of these before

[Pharmanaut]

Quoted from the abstract:

"The results indicate that a combined therapy with amitriptyline and citalopram may be particularly beneficial for patients with TTH, migraine and comorbid depression that do not respond to monotherapy."

I believe Pharmanaut mentioned that the patient had taken neither of these before

That's right.
To quickly recap...
It was Saturday - contact with surgery not possible.
After a chat with the patient, both preparations new.
No PMR history of using any antidepressants.
Not patients regular GP - Locum doctor.
Hence decision (someone has to make one!) to dispense citalopram and ask Locum GP about amitriptyline.

[Rafael]

pharm, we had a GP on this forum stating that prescribing citalopram and amitiprtyline together is possible and increasing. do a detailed search for more info, could not find the link
xx

[sharifhs]

hmm........Citalopram has a critical issue that withdrawal of this drug might cause premature ejaculation