Prescriber's Guide: Stahl's Essential Psychopharmacology (Stahl's Essential Psychopharmacology(PPR)) by Stephen M. Stahl

Author:Stephen M. Stahl
Language: eng
Format: mobi
Publisher: Cambridge University Press
Published: 2014-05-14T21:00:00+00:00

• Many experience and/or can be significant in amount

• Can increase appetite and carbohydrate craving

Sedation

• Many experience and/or can be significant in amount

• Tolerance to sedative effect may develop with long-term use

What to Do About Side Effects

• Wait

• Wait

• Wait

• Lower the dose

• Switch to an SSRI or newer antidepressant

Best Augmenting Agents for Side Effects

• Many side effects cannot be improved with an augmenting agent

MAPROTILINE: DOSING AND USE

Usual Dosage Range

• 75–150 mg/day (for depression)

• 50–150 mg/day (for chronic pain)

Dosage Forms

• Tablet 25 mg, 50 mg, 75 mg

How to Dose

• Initial 25 mg/day at bedtime; increase by 25 mg every 3–7 days

• 75 mg/day; after 2 weeks increase dose gradually by 25 mg/day; maximum dose generally 225 mg/day

Dosing Tips

• If given in a single dose, should generally be administered at bedtime because of its sedative properties

• If given in split doses, largest dose should generally be given at bedtime because of its sedative properties

• If patients experience nightmares, split dose and do not give large dose at bedtime

• Patients treated for chronic pain may only require lower doses

✽ Risk of seizures increases with dose, especially with maprotiline above 200 mg/day

• If intolerable anxiety, insomnia, agitation, akathisia, or activation occur either upon dosing initiation or discontinuation, consider the possibility of activated bipolar disorder, and switch to a mood stabilizer or an atypical antipsychotic

Overdose

• Death may occur; convulsions, cardiac dysrhythmias, severe hypotension, CNS depression, coma, changes in EKG

Long-Term Use

• Safe

Habit Forming

• No

How to Stop

• Taper to avoid withdrawal effects

• Even with gradual dose reduction some withdrawal symptoms may appear within the first 2 weeks

• Many patients tolerate 50% dose reduction for 3 days, then another 50% reduction for 3 days, then discontinuation

• If withdrawal symptoms emerge during discontinuation, raise dose to stop symptoms and then restart withdrawal much more slowly

Pharmacokinetics

• Substrate for CYP450 2D6

• Mean half-life approximately 51 hours

• Peak plasma concentration 8–24 hours

Drug Interactions

• Tramadol increases the risk of seizures in patients taking TCAs

• Use of TCAs/tetracyclics with anticholinergic drugs may result in paralytic ileus or hyperthermia

• Fluoxetine, paroxetine, bupropion, duloxetine, and other CYP450 2D6 inhibitors may increase TCA/tetracyclic concentrations

• Cimetidine may increase plasma concentrations of TCAs/tetracyclics and cause anticholinergic symptoms

• Phenothiazines or haloperidol may raise TCA/tetracyclic blood concentrations

• May alter effects of antihypertensive drugs; may inhibit hypotensive effects of clonidine

• Use with sympathomimetic agents may increase sympathetic activity

• Methylphenidate may inhibit metabolism of TCAs/tetracyclics

• Activation and agitation, especially following switching or adding antidepressants, may represent the induction of a bipolar state, especially a mixed dysphoric bipolar II condition sometimes associated with suicidal ideation, and require the addition of lithium, a mood stabilizer or an atypical antipsychotic, and/or discontinuation of maprotiline

Other Warnings/Precautions

• Add or initiate other antidepressants with caution for up to 2 weeks after discontinuing maprotiline

• Generally, do not use with MAO inhibitors, including 14 days after MAOIs are stopped; do not start an MAOI for at least 5 half-lives (5 to 7 days for most drugs) after discontinuing maprotiline, but see Pearls

• Use with caution in patients with history of

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