Management of Cyclic Antidepressant Side Effects

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Most side effects caused by non-TCA agents are managed symptomatically; for example, antacids for nausea and analgesics for headache are often effective. Sexual side effects of SSRIs, which have been reported in up to 50% of adults, may respond to treatment with cyproheptadine, amantadine, yohim-bine, bupropion, or central nervous system stimulants such as methylpheni-date, but controlled studies are lacking (Ashton and Rosen 1998; Woodrum and Brown 1998). No effective treatment, other than dosage reduction or switching to another class of antidepressant, has been reported for SSRI-induced weight gain.

Side effects of TCAs include anticholinergic effects (dry mouth, constipation, blurry vision, urinary hesitancy, and delirium) and orthostatic hypotension. Most of the anticholinergic effects can be managed with dosage adjustment and adjunctive agents. Dry mouth is relieved by sucking on hard, preferably sugarless candies or by chewing gum. A 1% solution of pilocarpine used as a mouthwash every 3 or 4 hours also has been reported to be helpful (Bernstein 1983). Constipation can be managed with stool softeners, bulk laxatives, and adequate fluid intake. Blurry vision may respond to 1% pilocarpine eyedrops, one drop every 4-6 hours as needed. In milder cases, artificial tears usually suffice. Urinary hesitancy is often responsive to oral bethanechol, 1030 mg three times a day. Patients, particularly men, are instructed to be aware of the possibility of complete urinary obstruction and to have appropriate plans should complete obstruction occur (e.g., to report to the nearest emergency department). Delirium can be life threatening and is usually responsive to discontinuation of the offending agent and supportive treatment. In the extreme case, 1-2 mg of physostigmine administered by slow intravenous push is effective. Orthostatic hypotension is a more difficult problem. This symptom tends to occur early in treatment and appears to be a "threshold" phenomenon that occurs at a certain dosage but does not necessarily worsen if the dosage is increased. Because it is worsened by dehydration and by pooling of blood in the lower extremities, orthostatic hypotension may be ameliorated by increasing salt in the patient's diet or by administering small doses of salt-retaining steroids (e.g., 0.025-0.05 mg of fluorohydrocortisone). Support hose can be helpful, as can careful, repeated patient instruction in arising slowly and holding on to something stable for support.

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Constipation Prescription

Constipation Prescription

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