September 3, 2023 • 18 mins
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Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
Dr. Handratta (00:00):
Because it happen and whenever you are actually
(00:02):
eating with friends and bro havea lot of opiates that is
released in your body, does haveantidepressant property,
Thanh (00:13):
Welcome to the Y in Psychiatry!
Dr. Amayo (00:14):
Hi, this is Dr.
Amayo C/L fellow.
Thanh (00:18):
Where we delve into the intricate nuances of psychiatric
topics.
Dr. Handratta (00:21):
My name is Dr.
Handratta attendingpsychiatrist.
I did my residency fromUniversity of Connecticut and
then I did my fellowship fromGeorgetown University in
consultation and liaison.
Thanh (00:31):
Each episode features interview style discussions that
explore the intersection of themind medicine and the human
experience.
Together we'll uncover thehidden why and the
groundbreaking discovery shapingthe psychiatric landscape.
So grab a seat, warm beverage,tune in, and let's embark on
this journey to unlock themysteries of the human psyche.
(00:54):
Only on The Y in Psychiatry.
Dr. Amayo (00:58):
Welcome back to The Y in psychiatry.
This is your host, Dr.
Amayo C/L fellow.
I go by Miracle and here with meis Dr.
Handratta.
Say hi, bro.
Dr. Handratta (01:08):
Hi bro.
Hello guys.
How are you doing?
Dr. Amayo (01:11):
Today we're gonna be continuing on that algorithm of
depression.
Two episodes ago we talked aboutwhy to treat depression, how you
diagnose depression, and thefirst step.
Last episode we talked aboutother factors you need to
optimize besides medication,including psychotherapy, sleep,
making sure there's no otherconfounding diagnosis and
(01:32):
comorbidities.
And today we are gonna talkabout what I know you guys came
for the medication part, right?
What medication to use why touse those medication, what steps
to pick.
So if I'm gonna pick an SSRI,which one should I pick?
Dr. Handratta (01:45):
So let's jump into SSRIs, right?
So how do we select our SSRIs?
So the SSRIs, they basicallywork the same way, except there
is small differences betweenthem, right?
So I don't want people toconsider all SSRIs are the same,
Let's go stepwise.
So few things that I look forwhen I'm using an SSRI.
(02:07):
Like I've ruled out bipolardisorder in a patient, I've
ruled out underlying medicalconditions that is causing
depression.
I've ruled a substance use uh,and all the other factors, which
might precipitate depression, Sothis particular patient has a
family history of depression andjust had an acute episode of
depression, which is causingfunctional impairment, first I
look at the side effect profileas Miracle mentioned.
(02:28):
what is the side effect of themedication?
Some side effects.
You can actually use it for yourbenefits for the patient's
benefit and some side effectsyou know, that the patient will
not be able to tolerate and youneed to avoid it.
Second thing is I need to knowthe steady state.
How long does it take for themedication to reach a steady
state?
Because that will tell that isabout approximately five
(02:48):
half-lives.
that basically will tell youwhen do you increase the dose of
the medication.
So I like medications, which hasa steady state of one week
because then I can increase thedose every week, Rather than a
medication which has a steadystate of one month, which you
have to wait for four weeksbefore you increase the dosage.
Because if a medication has asteady state of four weeks and
you increase it every one week,then what is gonna happen is
(03:09):
that the fourth week when itreaches steady state, you see
the side effects because it hasaccumulated, right?
So it's very important to knowthe steady state.
And then what's it cardiaceffect?
How safe it is on the heart?
Because now we are one of themedication that the F D A
basically said, Hey, you need towatch for Q TC prolongation And
then when do you dose them?
Morning or evening?
(03:29):
Because a lot of time, amedication that is dosed in the
evening, you dose in themorning, it'll cause a lot of
fatigue and sedation.
And the patient basically comesand tells you, doc, I am tired
the entire day.
So you're not helping thepatient at all, You're causing
more functional impairment.
So it's very important to knowwhen you're going to dose it.
And then the drug interaction,right?
(03:49):
Young patient 20, 25 years oldis not on too many medications,
so you don't have to worry.
But patients over the age of 40,You start accumulating different
medical conditions, you startaccumulating medications itself.
So you're on a long list ofmedications.
So you need to know the drugdrug interaction.
so these are some of the factorsI take into consideration when
I'm picking my antidepressant.
Dr. Amayo (04:10):
So it sounds like you're keeping track of side
effects and it sounds likesometimes side effects might be
wanted depending on the patient.
I would guess like Sleeping oreating more.
You also want to keep track Ofhalf life of the medication,
other comorbidities and theneffects like cardiovascular
effects Let's get deep into, sowhat symptoms would make you
(04:31):
pick something.
So what's, what symptoms wouldmake you pick Sertraline over
Fluoxetine?
Dr. Handratta (04:36):
So let's delve into it.
So let's talk about citalopram.
I'm not going to use any brandname because we are not funded
by anybody, right?
Sadly.
Yeah.
We are poor little bros.
Three bro, four bros.
Here, actually barely survivingand episodes just for the
education purpose and we lovedoing this, right?
So citalopram has anantihistamine property, So it's
(04:59):
pretty good choice in patientswho have insomnia,Patients who
are not eating well, becauseantihistamine medications can
increase your appetite too, Sojust make sure citalopram is
dosed in the, at bedtime and notin the morning.
Antidepressants always tell thepatients to eat when they take
antidepressants, right?
Because the five HT3 receptors,which are present in your gut
when you stimulated, can causenausea and vomiting.
(05:22):
So when you eat with food, itcan decrease the nausea and
vomiting.
A patient taught me, he saiddoc, I took my medication, I ate
a little bit, took mymedication, and then finished
the meal.
That was the best advice apatient ever gave me.
And I have been telling this toevery patient.
And the nausea is helped
Dr. Amayo (05:39):
So you take it in between your meal?
Dr. Handratta (05:40):
Yes.
Like a sandwich.
Eat a little bit of yourbreakfast, take the medication
completely, eat a little bit ofyour dinner, take the medication
and finish your dinner so I takethat patient experience and let
the other patients know, but Igive the credit to that
particular patient.
Okay.
This is not something that Icame up with.
We learn every day.
And then so citalopram bedtimewith dinner, Steady state of
citalopram is just a week Soit's great you can increase the
(06:01):
dose every week, but just becareful.
Don't go above 40 milligrambecause of the risk of QTC.
But if you want to use a higherdose, suppose a patient has
obsessive compulsive disorder,get an E K G, increase the dose
and do a follow-up E K G, justto make sure that the QTC is not
prolonged.
This is not going happen inevery patient, So you should not
deprive a patient or the benefitof the medication just because
(06:22):
you're worried that the, there'sa Q T C risk, Take the
precaution that you need totake, monitor the patient and
use it.
So the problem, is that when F DA came up with this patients who
are on 60 milligrams citalopramor 80 milligrams citalopram,
physicians are scared and theydecrease the dose.
And these patients decompensatedthough they didn't have any Q T
C problem, So you have to becareful.
You should take it actually, allthese advice with a grain of
(06:43):
salt, Every patient isdifferent, right?
For example, a cardiologist willtell you, don't treat the EKG.
Treat the patient.
Same thing here, Look at theclinical symptoms.
Be cautious.
Don't just blindly prescribe it.
Dr. Amayo (06:55):
Sounds like citalopram is a good medication.
Just have to, watch for that Q TC prolongation when you go above
40.
Dose at night because of theantihistaminergic properties
that can make people sleepy.
Is there any reason why I shouldpick citalopram?
If I have someone that mightmiss a medication, I'll pick
Fluoxetine because that has avery long half-life.
is there, one niche area thatcitalopram is like amazing for?
(07:18):
Like a patient that citalopramwould be wonderful for
Dr. Handratta (07:21):
So citalopram can actually be used in patients
with liver disease who havedepression.
That's one condition that youcan use it, you can use
citalopram in patients who havesevere insomnia.
It's also a pretty goodmedication to pick.
So especially in these twoconditions, You can pick
citalopram.
And one more addition is that ingeriatric patients dosage, more
than 20 milligram, just get a EK G before you actually go up on
(07:43):
the dosage.
So if the patient has liverdisease, go with citalopram.
Now, suppose that you are prettybusy in your practice, you don't
have time to open up your iPhoneand look for drug interaction,
citalopram is a great medicationbecause it doesn't have much of
cytochrome P450 interaction.
It's a very mild 2D6 inhibitor.
So that also makes it a greatmedication actually, because you
(08:03):
don't have to look for druginteractions.
Dr. Amayo (08:06):
So great for liver disease Great for if there's
multiple drugs the patient ison, is great because there is
less drug interaction.
Okay.
I've never thought of citalopramlike that.
Good to know So that's it forcitalopram.
How about escitalopram?
What's so special aboutescitalopram?
Dr. Handratta (08:21):
So, escitalopram Is very similar to citalopram,
but there is a changes inS-enantiomer.
So it's, there's a structurechange.
The advantage of escitalopram isthat it's antihistamine property
is six times less than that ofcitalopram, right?
But it's still slightlysedating.
It does have an antihistaminicproperty.
So again, dose it in theevening.
(08:41):
I always tell the patient, takeit in the evening.
If it causes insomnia, switch itto the morning.
Again, take it with food.
Steady state one week you canincrease the dose on a weekly
basis.
Cardiovascular effect, plus andminus.
There is mixed data on it.
But you want to be a littlecautious, get an EKG done.
Once you reach a dosage of likearound 20 milligrams and then
(09:02):
follow the E K G, the patient's,the next E K G is normal.
You don't have to worry.
Plus the patient doesn't haveany cardiovascular risk factor.
It should be good.
There's no hypomagnesemia,there's no hypokalemia, there is
no bradycardia.
So escitalopram again, no druginteraction because it's a very
mild cytochrome 2D6 inhibitorplus like citalopram.
You can use it in liver disease.
(09:23):
so citalopram and escitalopram,both can be used in liver
disease.
No drug interaction.
Steady state one week, easy totitrate the dosage.
Dr. Amayo (09:31):
So the problem I have with escitalopram, it has a very
limited range, so it's five to20 for escitalopram.
why is that?
Is it just more potent or why isit such a low range
Dr. Handratta (09:41):
So we don't know whether it's actually more
potent, but if you look at theenantiomer, the s enantiomer is
more potent than the Rs.
But we don't know that for sure.
And most likely in the clinicaltrial, the doses that they used
actually, the 5, 10, 15, 20 wasthe most effective.
But there are people who use upto 30 milligrams So it totally
depends upon what are youtreating Be very careful
(10:03):
actually, because it totallydepends upon your
pharmacogenomics.
if you're a poor 2C19metabolizer or you're an
extensive or ultra rapid 2C19metabolizer.
So if you're extensive or ultrarapid, then you'll have to use a
higher dose of escitalopram tosee the benefit.
If you're a poor metabolizer,then you have to actually use a
lower dosage, right?
(10:25):
For example, if you look at asmall subset, African American
and Asian population, they arepoor 2C19 metabolizers.
So in that population you haveto be a little careful, start
low and go slow.
Okay?
Dr. Amayo (10:37):
And so citalopram and escitalopram are metabolized by
CYP 2C19?
Dr. Handratta (10:42):
Yeah, both citalopram and citalopram.
Dr. Amayo (10:44):
All right, so let's talk about sertraline.
Dr. Handratta (10:46):
So sertraline, again, a medication metabolized
by 2C19.
I just actually threw it thereso that you can actually, the
three medications by 2C19.
Sertraline is a greatmedication, This is one of the
medication.
I like the reason being is thatit's safe in patients with
cardiovascular problem, QTCinterval.
Plus the studies that they didpost MI was with sertraline,
It's safe in patients with therenal disease we can give to
(11:08):
patients with dialysis.
And we spoke about it in one ofour podcasts which I don't think
so, we have published yet.
That it's also prevents the postdialysis hypotension.
Don't ask me why I do not know,bro.
And plus it can also be actuallyused in patients who are
pregnant.
It's very safe in pregnancy aswell as breastfeeding.
So a lot of advantage, but don'tuse it in liver disease because
(11:31):
it undergoes first pastmetabolism.
Right?
So sertraline is a pretty goodchoice, right?
Plus you don't have to worryabout the drug interaction
unless you go above 150, then itbecomes a moderate 2D6
inhibitor, plus the little bitof disadvantage of sertraline is
It cause more nausea, vomiting,and headache as compared to
other medication because it doeshave affinity for 5HT3
(11:53):
receptors.
It has a steady state of onemonth, so you have to actually
do a very slow dose titration,And it is also the, one of the
only SSRI that is preferred inpatients with A D H D because
serotonergic medication candecrease the dopamine and
therefore can affect theprocessing speed.
But sertraline also has adopaminergic effect to it.
(12:13):
So it's considered to be one ofthe SSRI that can prescribe to
patients with A D H D withoutaffecting the processing speed.
And you can dose it in theevening, but you can also dose
it in the morning if you want.
Dr. Amayo (12:25):
If I didn't know better I would think sertraline
was sponsoring you.
So for sertraline steady stateof one month metabolized by 2C19
at higher doses up to 150.
It's a 2D6 inhibitor.
Safe in cardiovascular, safe inrenal patients and preferred in
patients with A D H D because italso has some dopaminergic
(12:47):
properties to it.
Side effects.
It's more likely to have thenausea, vomiting side effect
cause it has a affinity for the5HT3 and besides the inhibition
of 2D6, that's pretty muchsertraline and I'm guessing less
sedating, right?
Because of the dopaminergic dosein the morning
Dr. Handratta (13:05):
You can dose, but some patients do feel a little
tired on it.
So majority of the time, like inmy experience, I usually dose it
in the evening and the patientbasically says I cannot sleep.
Then I say, Hey, take it in themorning.
Dr. Amayo (13:15):
Okay.
is that your normal go-to allthe SSRIs in the evening.
Dr. Handratta (13:19):
No.
So the SSRIs like citalopram,escitalopram, sertraline,
fluvoxamine and paroxetine.
So all the SSRIs are dosed inthe evening except fluoxetine.
Dr. Amayo (13:29):
And we'll get to Fluoxetine in a while and then I
think I forgot to talk aboutthis sertraline is also good for
the pregnant population, goodfor breastfeeding.
Let's see what we have next: paroxetine! (13:37):
undefined
Dr. Handratta (13:40):
Paroxetine is a good SSRI r, right?
But you have to be a littlecareful when you're using
paroxetine, First of all,because it has an
anticholinergic side effect.
So you ought to be careful inpatients with benign prostatic,
hypoplasia with myastheniagravis.
Patients who are delirious orare cognitive impairment peptic
ulcer disease, so all thosethings, you have to be a little
(14:01):
bit careful, but you canprescribe it, It has a steady
state of about a month.
So you have to wait four weeksbecause you increase before you
increase the dose, because ifyou do a quick increase, then
you'll see the side effects whenit reaches a steady state.
Dr. Amayo (14:12):
Even though it has a short half-life it still has a
long, steady state?
Dr. Handratta (14:16):
That's a great question.
So don't quote me on this, butparoxetine inhibits its own
metabolism, right?
It's metabolized by 3D6 and it'salso an inhibitor of 2D6 so it
can cause an auto inhibitionincreasing its own plasma level.
That could be the reason why thestudy state is a month, right?
So I basically, I'm littlecareful, especially with any
(14:37):
medication that auto inhibitsitself, like paroxetine is one
and fluoxetine is another one.
So you ought to be very carefulincreasing the dose wait watch,
Because otherwise, like you willbasically just build up the dose
of medication and you'll havesevere anticholinergic side
effects, Plus it has a very safeQ T C profile.
in patients with Q TCprolongation, the two SSRIs that
(14:58):
you can safely use is paroxetineas well as sertraline, always
dose in the evening you giveparoxetine in the morning, the
patient with it is sleepy.
And this is very common.
Patient will go to primary careproviders for depression.
Majority of our patient goes toa, go to a P C P to manage
depression.
And this prescribed paroxetine,they say once a day, whenever
you say once a day, patient willtake it in the morning and
(15:19):
they're tired the entire day, Sothat's the easiest consult
you're going to get, Miracle: patient tired and sleepy during (15:23):
undefined
the daytime on paroxetine"Doc,what should I do?" Switch it to
the bedtime (15:29):
done! So that is actually about paroxetine, but
you also keep an eye on theweight according to research
data.
With paroxetine, when you gainweight, you keep on gaining
weight in susceptible patients.
So you have to be carefulactually with the weight gain,
And then withdrawal, if you skipa dose short half, like you
actually see severe withdrawal,right?
(15:51):
And plus it inhibits 2D6, so youhave to be careful regarding the
drug-drug interaction.
Dr. Amayo (15:57):
Wow.
And then also it's one of theleast favorite SSRI for
pregnancy, especially in thefirst trimester because of its
risk of causing cardiacmalformation.
But apparently It's very goodfor breastfeeding because
there's little percentage of itfound in the breast milk, but
not great during the firsttrimester.
So in summary paroxetine hasanticholinergic properties.
(16:18):
Is sedating, can cause weightgain.
Give it At night.
It is a 2D6 inhibitor, sothere's a possibility it auto
induces itself.
So starts low, go slow.
And then there is thewithdrawal.
Down titrates easily, but it'sgreat for patients with cardiac
issues It has less Q T Cprolongation.
Dr. Handratta (16:39):
One correction actually, that it inhibits 2D6
so it calls auto inhibition of2D6.
Dr. Amayo (16:45):
Real quick, big highlight.
Citalopran escitalopram used forliver disease, less c y p drug
interactions.
Citalopram has antihistaminicstomach properties so maybe more
sedating dose at night.
Paroxetine, anticholinergic donot use in the first trimester
for pregnancy.
safe for Q T C prolongation,however.
(17:05):
And sertraline, our babyfavorites out of the four
Negative issues might be morenausea generating but safe with
cardiac as well.
Is a moderate inhibitor of 2D6,especially at higher doses.
Preferred in ADHD'cause it hassome dopaminergic properties and
paroxetine and citalopram andthey have a one month lag to get
(17:27):
to steady state.
So in both of them don't go uptoo fast.
So we've talked aboutcitalopram, escitalopram,
sertraline, and paroxetine, andthose are four out of the six
SSRIs.
We're gonna talk about the twoother SSRIs with the SNRIs and
that is it for today in the Y ispsychiatry.
(17:47):
Peace out guys.
Katrina (17:48):
Thank you for joining us on today's episode.
our tireless team is alreadyhard at work, cobbling together
another potpourri of fascinatingdiscussion for next week, so be
sure to tune in, visit ourwebsite and our podcast feed and
let us know your thoughts on theepisode.
Subscribe so you don't miss ourreleases every Wednesday.
Until next time, keep smiling,keep shining, and stay curious.
Because it happen and whenever you are actually
(00:02):
eating with friends and bro havea lot of opiates that is
released in your body, does haveantidepressant property,
Thanh (00:13):
Welcome to the Y in Psychiatry!
Dr. Amayo (00:14):
Hi, this is Dr.
Amayo C/L fellow.
Thanh (00:18):
Where we delve into the intricate nuances of psychiatric
topics.
Dr. Handratta (00:21):
My name is Dr.
Handratta attendingpsychiatrist.
I did my residency fromUniversity of Connecticut and
then I did my fellowship fromGeorgetown University in
consultation and liaison.
Thanh (00:31):
Each episode features interview style discussions that
explore the intersection of themind medicine and the human
experience.
Together we'll uncover thehidden why and the
groundbreaking discovery shapingthe psychiatric landscape.
So grab a seat, warm beverage,tune in, and let's embark on
this journey to unlock themysteries of the human psyche.
(00:54):
Only on The Y in Psychiatry.
Dr. Amayo (00:58):
Welcome back to The Y in psychiatry.
This is your host, Dr.
Amayo C/L fellow.
I go by Miracle and here with meis Dr.
Handratta.
Say hi, bro.
Dr. Handratta (01:08):
Hi bro.
Hello guys.
How are you doing?
Dr. Amayo (01:11):
Today we're gonna be continuing on that algorithm of
depression.
Two episodes ago we talked aboutwhy to treat depression, how you
diagnose depression, and thefirst step.
Last episode we talked aboutother factors you need to
optimize besides medication,including psychotherapy, sleep,
making sure there's no otherconfounding diagnosis and
(01:32):
comorbidities.
And today we are gonna talkabout what I know you guys came
for the medication part, right?
What medication to use why touse those medication, what steps
to pick.
So if I'm gonna pick an SSRI,which one should I pick?
Dr. Handratta (01:45):
So let's jump into SSRIs, right?
So how do we select our SSRIs?
So the SSRIs, they basicallywork the same way, except there
is small differences betweenthem, right?
So I don't want people toconsider all SSRIs are the same,
Let's go stepwise.
So few things that I look forwhen I'm using an SSRI.
(02:07):
Like I've ruled out bipolardisorder in a patient, I've
ruled out underlying medicalconditions that is causing
depression.
I've ruled a substance use uh,and all the other factors, which
might precipitate depression, Sothis particular patient has a
family history of depression andjust had an acute episode of
depression, which is causingfunctional impairment, first I
look at the side effect profileas Miracle mentioned.
(02:28):
what is the side effect of themedication?
Some side effects.
You can actually use it for yourbenefits for the patient's
benefit and some side effectsyou know, that the patient will
not be able to tolerate and youneed to avoid it.
Second thing is I need to knowthe steady state.
How long does it take for themedication to reach a steady
state?
Because that will tell that isabout approximately five
(02:48):
half-lives.
that basically will tell youwhen do you increase the dose of
the medication.
So I like medications, which hasa steady state of one week
because then I can increase thedose every week, Rather than a
medication which has a steadystate of one month, which you
have to wait for four weeksbefore you increase the dosage.
Because if a medication has asteady state of four weeks and
you increase it every one week,then what is gonna happen is
(03:09):
that the fourth week when itreaches steady state, you see
the side effects because it hasaccumulated, right?
So it's very important to knowthe steady state.
And then what's it cardiaceffect?
How safe it is on the heart?
Because now we are one of themedication that the F D A
basically said, Hey, you need towatch for Q TC prolongation And
then when do you dose them?
Morning or evening?
(03:29):
Because a lot of time, amedication that is dosed in the
evening, you dose in themorning, it'll cause a lot of
fatigue and sedation.
And the patient basically comesand tells you, doc, I am tired
the entire day.
So you're not helping thepatient at all, You're causing
more functional impairment.
So it's very important to knowwhen you're going to dose it.
And then the drug interaction,right?
(03:49):
Young patient 20, 25 years oldis not on too many medications,
so you don't have to worry.
But patients over the age of 40,You start accumulating different
medical conditions, you startaccumulating medications itself.
So you're on a long list ofmedications.
So you need to know the drugdrug interaction.
so these are some of the factorsI take into consideration when
I'm picking my antidepressant.
Dr. Amayo (04:10):
So it sounds like you're keeping track of side
effects and it sounds likesometimes side effects might be
wanted depending on the patient.
I would guess like Sleeping oreating more.
You also want to keep track Ofhalf life of the medication,
other comorbidities and theneffects like cardiovascular
effects Let's get deep into, sowhat symptoms would make you
(04:31):
pick something.
So what's, what symptoms wouldmake you pick Sertraline over
Fluoxetine?
Dr. Handratta (04:36):
So let's delve into it.
So let's talk about citalopram.
I'm not going to use any brandname because we are not funded
by anybody, right?
Sadly.
Yeah.
We are poor little bros.
Three bro, four bros.
Here, actually barely survivingand episodes just for the
education purpose and we lovedoing this, right?
So citalopram has anantihistamine property, So it's
(04:59):
pretty good choice in patientswho have insomnia,Patients who
are not eating well, becauseantihistamine medications can
increase your appetite too, Sojust make sure citalopram is
dosed in the, at bedtime and notin the morning.
Antidepressants always tell thepatients to eat when they take
antidepressants, right?
Because the five HT3 receptors,which are present in your gut
when you stimulated, can causenausea and vomiting.
(05:22):
So when you eat with food, itcan decrease the nausea and
vomiting.
A patient taught me, he saiddoc, I took my medication, I ate
a little bit, took mymedication, and then finished
the meal.
That was the best advice apatient ever gave me.
And I have been telling this toevery patient.
And the nausea is helped
Dr. Amayo (05:39):
So you take it in between your meal?
Dr. Handratta (05:40):
Yes.
Like a sandwich.
Eat a little bit of yourbreakfast, take the medication
completely, eat a little bit ofyour dinner, take the medication
and finish your dinner so I takethat patient experience and let
the other patients know, but Igive the credit to that
particular patient.
Okay.
This is not something that Icame up with.
We learn every day.
And then so citalopram bedtimewith dinner, Steady state of
citalopram is just a week Soit's great you can increase the
(06:01):
dose every week, but just becareful.
Don't go above 40 milligrambecause of the risk of QTC.
But if you want to use a higherdose, suppose a patient has
obsessive compulsive disorder,get an E K G, increase the dose
and do a follow-up E K G, justto make sure that the QTC is not
prolonged.
This is not going happen inevery patient, So you should not
deprive a patient or the benefitof the medication just because
(06:22):
you're worried that the, there'sa Q T C risk, Take the
precaution that you need totake, monitor the patient and
use it.
So the problem, is that when F DA came up with this patients who
are on 60 milligrams citalopramor 80 milligrams citalopram,
physicians are scared and theydecrease the dose.
And these patients decompensatedthough they didn't have any Q T
C problem, So you have to becareful.
You should take it actually, allthese advice with a grain of
(06:43):
salt, Every patient isdifferent, right?
For example, a cardiologist willtell you, don't treat the EKG.
Treat the patient.
Same thing here, Look at theclinical symptoms.
Be cautious.
Don't just blindly prescribe it.
Dr. Amayo (06:55):
Sounds like citalopram is a good medication.
Just have to, watch for that Q TC prolongation when you go above
40.
Dose at night because of theantihistaminergic properties
that can make people sleepy.
Is there any reason why I shouldpick citalopram?
If I have someone that mightmiss a medication, I'll pick
Fluoxetine because that has avery long half-life.
is there, one niche area thatcitalopram is like amazing for?
(07:18):
Like a patient that citalopramwould be wonderful for
Dr. Handratta (07:21):
So citalopram can actually be used in patients
with liver disease who havedepression.
That's one condition that youcan use it, you can use
citalopram in patients who havesevere insomnia.
It's also a pretty goodmedication to pick.
So especially in these twoconditions, You can pick
citalopram.
And one more addition is that ingeriatric patients dosage, more
than 20 milligram, just get a EK G before you actually go up on
(07:43):
the dosage.
So if the patient has liverdisease, go with citalopram.
Now, suppose that you are prettybusy in your practice, you don't
have time to open up your iPhoneand look for drug interaction,
citalopram is a great medicationbecause it doesn't have much of
cytochrome P450 interaction.
It's a very mild 2D6 inhibitor.
So that also makes it a greatmedication actually, because you
(08:03):
don't have to look for druginteractions.
Dr. Amayo (08:06):
So great for liver disease Great for if there's
multiple drugs the patient ison, is great because there is
less drug interaction.
Okay.
I've never thought of citalopramlike that.
Good to know So that's it forcitalopram.
How about escitalopram?
What's so special aboutescitalopram?
Dr. Handratta (08:21):
So, escitalopram Is very similar to citalopram,
but there is a changes inS-enantiomer.
So it's, there's a structurechange.
The advantage of escitalopram isthat it's antihistamine property
is six times less than that ofcitalopram, right?
But it's still slightlysedating.
It does have an antihistaminicproperty.
So again, dose it in theevening.
(08:41):
I always tell the patient, takeit in the evening.
If it causes insomnia, switch itto the morning.
Again, take it with food.
Steady state one week you canincrease the dose on a weekly
basis.
Cardiovascular effect, plus andminus.
There is mixed data on it.
But you want to be a littlecautious, get an EKG done.
Once you reach a dosage of likearound 20 milligrams and then
(09:02):
follow the E K G, the patient's,the next E K G is normal.
You don't have to worry.
Plus the patient doesn't haveany cardiovascular risk factor.
It should be good.
There's no hypomagnesemia,there's no hypokalemia, there is
no bradycardia.
So escitalopram again, no druginteraction because it's a very
mild cytochrome 2D6 inhibitorplus like citalopram.
You can use it in liver disease.
(09:23):
so citalopram and escitalopram,both can be used in liver
disease.
No drug interaction.
Steady state one week, easy totitrate the dosage.
Dr. Amayo (09:31):
So the problem I have with escitalopram, it has a very
limited range, so it's five to20 for escitalopram.
why is that?
Is it just more potent or why isit such a low range
Dr. Handratta (09:41):
So we don't know whether it's actually more
potent, but if you look at theenantiomer, the s enantiomer is
more potent than the Rs.
But we don't know that for sure.
And most likely in the clinicaltrial, the doses that they used
actually, the 5, 10, 15, 20 wasthe most effective.
But there are people who use upto 30 milligrams So it totally
depends upon what are youtreating Be very careful
(10:03):
actually, because it totallydepends upon your
pharmacogenomics.
if you're a poor 2C19metabolizer or you're an
extensive or ultra rapid 2C19metabolizer.
So if you're extensive or ultrarapid, then you'll have to use a
higher dose of escitalopram tosee the benefit.
If you're a poor metabolizer,then you have to actually use a
lower dosage, right?
(10:25):
For example, if you look at asmall subset, African American
and Asian population, they arepoor 2C19 metabolizers.
So in that population you haveto be a little careful, start
low and go slow.
Okay?
Dr. Amayo (10:37):
And so citalopram and escitalopram are metabolized by
CYP 2C19?
Dr. Handratta (10:42):
Yeah, both citalopram and citalopram.
Dr. Amayo (10:44):
All right, so let's talk about sertraline.
Dr. Handratta (10:46):
So sertraline, again, a medication metabolized
by 2C19.
I just actually threw it thereso that you can actually, the
three medications by 2C19.
Sertraline is a greatmedication, This is one of the
medication.
I like the reason being is thatit's safe in patients with
cardiovascular problem, QTCinterval.
Plus the studies that they didpost MI was with sertraline,
It's safe in patients with therenal disease we can give to
(11:08):
patients with dialysis.
And we spoke about it in one ofour podcasts which I don't think
so, we have published yet.
That it's also prevents the postdialysis hypotension.
Don't ask me why I do not know,bro.
And plus it can also be actuallyused in patients who are
pregnant.
It's very safe in pregnancy aswell as breastfeeding.
So a lot of advantage, but don'tuse it in liver disease because
(11:31):
it undergoes first pastmetabolism.
Right?
So sertraline is a pretty goodchoice, right?
Plus you don't have to worryabout the drug interaction
unless you go above 150, then itbecomes a moderate 2D6
inhibitor, plus the little bitof disadvantage of sertraline is
It cause more nausea, vomiting,and headache as compared to
other medication because it doeshave affinity for 5HT3
(11:53):
receptors.
It has a steady state of onemonth, so you have to actually
do a very slow dose titration,And it is also the, one of the
only SSRI that is preferred inpatients with A D H D because
serotonergic medication candecrease the dopamine and
therefore can affect theprocessing speed.
But sertraline also has adopaminergic effect to it.
(12:13):
So it's considered to be one ofthe SSRI that can prescribe to
patients with A D H D withoutaffecting the processing speed.
And you can dose it in theevening, but you can also dose
it in the morning if you want.
Dr. Amayo (12:25):
If I didn't know better I would think sertraline
was sponsoring you.
So for sertraline steady stateof one month metabolized by 2C19
at higher doses up to 150.
It's a 2D6 inhibitor.
Safe in cardiovascular, safe inrenal patients and preferred in
patients with A D H D because italso has some dopaminergic
(12:47):
properties to it.
Side effects.
It's more likely to have thenausea, vomiting side effect
cause it has a affinity for the5HT3 and besides the inhibition
of 2D6, that's pretty muchsertraline and I'm guessing less
sedating, right?
Because of the dopaminergic dosein the morning
Dr. Handratta (13:05):
You can dose, but some patients do feel a little
tired on it.
So majority of the time, like inmy experience, I usually dose it
in the evening and the patientbasically says I cannot sleep.
Then I say, Hey, take it in themorning.
Dr. Amayo (13:15):
Okay.
is that your normal go-to allthe SSRIs in the evening.
Dr. Handratta (13:19):
No.
So the SSRIs like citalopram,escitalopram, sertraline,
fluvoxamine and paroxetine.
So all the SSRIs are dosed inthe evening except fluoxetine.
Dr. Amayo (13:29):
And we'll get to Fluoxetine in a while and then I
think I forgot to talk aboutthis sertraline is also good for
the pregnant population, goodfor breastfeeding.
Let's see what we have next: paroxetine! (13:37):
undefined
Dr. Handratta (13:40):
Paroxetine is a good SSRI r, right?
But you have to be a littlecareful when you're using
paroxetine, First of all,because it has an
anticholinergic side effect.
So you ought to be careful inpatients with benign prostatic,
hypoplasia with myastheniagravis.
Patients who are delirious orare cognitive impairment peptic
ulcer disease, so all thosethings, you have to be a little
(14:01):
bit careful, but you canprescribe it, It has a steady
state of about a month.
So you have to wait four weeksbecause you increase before you
increase the dose, because ifyou do a quick increase, then
you'll see the side effects whenit reaches a steady state.
Dr. Amayo (14:12):
Even though it has a short half-life it still has a
long, steady state?
Dr. Handratta (14:16):
That's a great question.
So don't quote me on this, butparoxetine inhibits its own
metabolism, right?
It's metabolized by 3D6 and it'salso an inhibitor of 2D6 so it
can cause an auto inhibitionincreasing its own plasma level.
That could be the reason why thestudy state is a month, right?
So I basically, I'm littlecareful, especially with any
(14:37):
medication that auto inhibitsitself, like paroxetine is one
and fluoxetine is another one.
So you ought to be very carefulincreasing the dose wait watch,
Because otherwise, like you willbasically just build up the dose
of medication and you'll havesevere anticholinergic side
effects, Plus it has a very safeQ T C profile.
in patients with Q TCprolongation, the two SSRIs that
(14:58):
you can safely use is paroxetineas well as sertraline, always
dose in the evening you giveparoxetine in the morning, the
patient with it is sleepy.
And this is very common.
Patient will go to primary careproviders for depression.
Majority of our patient goes toa, go to a P C P to manage
depression.
And this prescribed paroxetine,they say once a day, whenever
you say once a day, patient willtake it in the morning and
(15:19):
they're tired the entire day, Sothat's the easiest consult
you're going to get, Miracle: patient tired and sleepy during (15:23):
undefined
the daytime on paroxetine"Doc,what should I do?" Switch it to
the bedtime (15:29):
done! So that is actually about paroxetine, but
you also keep an eye on theweight according to research
data.
With paroxetine, when you gainweight, you keep on gaining
weight in susceptible patients.
So you have to be carefulactually with the weight gain,
And then withdrawal, if you skipa dose short half, like you
actually see severe withdrawal,right?
(15:51):
And plus it inhibits 2D6, so youhave to be careful regarding the
drug-drug interaction.
Dr. Amayo (15:57):
Wow.
And then also it's one of theleast favorite SSRI for
pregnancy, especially in thefirst trimester because of its
risk of causing cardiacmalformation.
But apparently It's very goodfor breastfeeding because
there's little percentage of itfound in the breast milk, but
not great during the firsttrimester.
So in summary paroxetine hasanticholinergic properties.
(16:18):
Is sedating, can cause weightgain.
Give it At night.
It is a 2D6 inhibitor, sothere's a possibility it auto
induces itself.
So starts low, go slow.
And then there is thewithdrawal.
Down titrates easily, but it'sgreat for patients with cardiac
issues It has less Q T Cprolongation.
Dr. Handratta (16:39):
One correction actually, that it inhibits 2D6
so it calls auto inhibition of2D6.
Dr. Amayo (16:45):
Real quick, big highlight.
Citalopran escitalopram used forliver disease, less c y p drug
interactions.
Citalopram has antihistaminicstomach properties so maybe more
sedating dose at night.
Paroxetine, anticholinergic donot use in the first trimester
for pregnancy.
safe for Q T C prolongation,however.
(17:05):
And sertraline, our babyfavorites out of the four
Negative issues might be morenausea generating but safe with
cardiac as well.
Is a moderate inhibitor of 2D6,especially at higher doses.
Preferred in ADHD'cause it hassome dopaminergic properties and
paroxetine and citalopram andthey have a one month lag to get
(17:27):
to steady state.
So in both of them don't go uptoo fast.
So we've talked aboutcitalopram, escitalopram,
sertraline, and paroxetine, andthose are four out of the six
SSRIs.
We're gonna talk about the twoother SSRIs with the SNRIs and
that is it for today in the Y ispsychiatry.
(17:47):
Peace out guys.
Katrina (17:48):
Thank you for joining us on today's episode.
our tireless team is alreadyhard at work, cobbling together
another potpourri of fascinatingdiscussion for next week, so be
sure to tune in, visit ourwebsite and our podcast feed and
let us know your thoughts on theepisode.
Subscribe so you don't miss ourreleases every Wednesday.
Until next time, keep smiling,keep shining, and stay curious.
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