Selective Serotonin Reuptake Inhibitors (SSRI)*

Drug	Dosage	Remarks
Citalopram	Children and adolescents 6-17 years old: 10 mg PO 24 hourly Max dose: 20 mg/day Adults: Initial dose: 20 mg PO 24 hourly Max dose: 40 mg/day	Adverse Reactions CNS and mental effects (insomnia, somnolence, headache, tremor, dizziness, agitation, nervousness, apathy, extrapyramidal disorders, suicidal attempt, confusion); GI effects (dry mouth, nausea/vomiting, constipation, diarrhea, dyspepsia, abdominal pain, flatulence, increased saliva, anorexia); CV effects (palpitation, postural hypotension, tachycardia); Dermatologic effects (rash, pruritus); Ophthalmologic effects (abnormal vision, abnormal accommodation); Other effects (increased sweating, sexual dysfunction) Special Instructions A US FDA warning was issued stating that doses >40 mg/day should not be used due to dosage-related prolongation of the QT interval and increased risk of cardiac arrhythmia, including torsades de pointes. Patients with heart failure, bradyarrhythmia, or those receiving concomitant medications known to prolong QT intervals should be monitored closely with ECG. Patients at risk for hypokalemia or hypomagnesemia are also at risk of torsades de pointes Contraindicated in patients with congenital long QT syndrome, with hypersensitivity, in patients concomitantly taking MAO inhibitors or within 2 weeks of discontinuing MAO inhibitors Use with caution in patients with hepatic or renal dysfunction and in patients with seizure disorders Use with caution in patients taking medications that will affect clotting of blood Start with low dose to minimize side effects and titrate upward to the desired dose or clinical response If discontinued after long-term use, taper dose over several weeks Gradual discontinuation if patient enters into manic phase Monitor serum magnesium and potassium levels, and ECG
Escitalopram	Initial dose: 10 mg PO 24 hourly May be increased after 1 week to 20 mg PO 24 hourly Max dose: 20 mg/day	Adverse Reactions Adverse effects are usually transient GI effects (nausea, diarrhea, constipation, taste disturbance, decreased appetite, weight loss); CNS effects (insomnia, somnolence, dizziness); CV effect (postural hypotension); Other effects (sexual dysfunction, sweating, pyrexia, yawning) Special Instructions Use with caution in patients whose work requires mental alertness See under Citalopram
Fluoxetine	Children and adolescents 7-17 years old: Initial dose: 10 mg PO 24 hourly May increase dose gradually to 20-60 mg PO 24 hourly after several weeks Max dose: 60 mg/day Adults: Initial dose: 20 mg PO 24 hourly or in 2 divided doses (morning and noon) May increase dose gradually to 60 mg/day PO after several weeks Max dose: 80 mg/day	Adverse Reactions Dose-related: Nervousness and anxiety, insomnia CNS and mental effects (headache, drowsiness, fatigue, dizziness, tremor, mixed manic states, abnormal dreams); GI effects (dry mouth, nausea/vomiting, diarrhea, anorexia); Other effects (blurred vision, hyponatremia, elevated LFT) Special Instructions See under Citalopram
Fluvoxamine	Children >8 years old: Initial dose: 25 mg PO at bedtime Dose may be increased in 25-mg increments every 4-7 days Max dose: 200 mg/day Adults: Initial dose: 50 mg PO 24 hourly preferably in the evening May increase dose by increments of 50 mg/day at 4-7 day intervals until effective dose is reached Maintenance dose: 100-300 mg/day PO Doses >150 mg/day PO should be given in 2-3 divided doses Max dose: 300 mg/day PO	Adverse Reactions CNS and mental effects (headache, tremor, anxiety, dizziness, nervousness, insomnia, somnolence, agitation); GI effects (dry mouth, nausea/vomiting, diarrhea, constipation); CV effect (palpitations); Respiratory effect (dyspnea); Other effects (urinary frequency, urinary retention, sexual dysfunction, yawning, muscle weakness) Special Instructions See under Citalopram
Paroxetine	Initial dose: 20 mg PO 24 hourly May increase dose by 10-mg increments at weekly intervals Maintenance dose: 40 mg PO 24 hourly Max dose: 50-60 mg/day PO	Adverse Reactions Dose-related: Somnolence, asthenia, dizziness, tremor, nausea CNS and mental effects (headache, anxiety, nervousness, insomnia, agitation, weakness, emotional lability); GI effects (dry mouth, vomiting, diarrhea, flatulence, constipation, abdominal pain); CV effects (palpitations, chest pain, hypertension); Respiratory effects (dyspnea, pharyngitis, sinusitis); GU effects (UTI, urinary frequency, urinary retention); Other effects (sexual dysfunction, myopathy, back pain, myalgia) Special Instructions See under Citalopram
Sertraline	Initial dose for children: 25 mg PO 24 hourly Initial dose for adults: 50 mg PO 24 hourly May increase dose in 50-mg increment at weekly intervals Max dose: 200 mg/day	Adverse Reactions GI effects (nausea/vomiting, anorexia, dyspepsia, constipation, diarrhea, dry mouth, flatulence); CNS and mental effects (somnolence, agitation, insomnia, headache, dizziness, anxiety, nervousness, tremor, paresthesia, blurred vision); Other effects (sexual dysfunction, blurred vision, hot flushes) Special Instructions Use with caution in patients with cardiac disease, recent MI, diabetes, and angle-closure glaucoma See under Citalopram
*Antidepressant therapy in children, adolescents and young adults is associated with clinical worsening, suicidality or unusual changes in behavior. Close observation of the patient and communication with the prescribing physician is warranted.

Tricyclic Antidepressant (TCA)*

Drug

Dosage

Remarks

Clomipramine

Children and adolescents >10 years old:
Initial dose: 10 mg PO 24 hourly over the first 2 weeks
May increase dose gradually to 200 mg PO 24 hourly after several weeks
Adults:
Initial dose: 25 mg PO 24 hourly
May increase dose gradually up to
100-150 mg/day
Maintenance dose:
50-100 mg PO 24 hourly
Max dose: 250 mg/day

Adverse Reactions

Side effects are mostly due to antimuscarinic actions and may be decreased if started at low dose and increased gradually
CNS and mental effects (hyperthermia, drowsiness, nervousness, insomnia, headache, peripheral neuropathy, ataxia, tremor, confusion/delirium can occur esp in older patients, extrapyramidal symptoms, tinnitus, dizziness); GI effects (dry mouth, constipation which may lead to paralytic ileus, nausea/vomiting, gastric irritation, weight gain); CV effects (hypotension, tachycardia); Ophthalmologic effects (blurred vision, increased intraocular pressure); Other effects (urinary retention, sweating, sexual dysfunction)

Special Instructions

Contraindicated in patients with hypersensitivity, mania, porphyria, severe hepatic impairment, heart block, arrhythmia; in patients in recovery phase following MI, in patients concomitantly using MAOIs
Use with caution in patients with urinary retention, prostatic hyperplasia, chronic constipation, narrow-angle glaucoma, CV disease, history of epilepsy, DM, impaired hepatic and renal function, hyperthyroidism or concomitant treatment with thyroid preparations, patients on electroconvulsive therapy
Start with low dose to minimize side effects and titrate upward to the desired response
Do not stop medication abruptly; taper dose over several weeks

*Antidepressant therapy in children, adolescents and young adults is associated with clinical worsening, suicidality or unusual changes in behavior. Close observation of the patient and communication with the prescribing physician is warranted.

Disclaimer

All dosage recommendations are for non-pregnant and non-breastfeeding women, and non-elderly adults with normal renal and hepatic function unless otherwise stated.
Not all products are available or approved for above use in all countries.
Products listed in the Drug Summary are based on indications stated in the locally approved product monographs.
Please refer to local product monographs in Related MIMS Drugs for country-specific prescribing information.

Obsessive-Compulsive Disorder Drug Summary

Selective Serotonin Reuptake Inhibitors (SSRI)*

Tricyclic Antidepressant (TCA)*

Disclaimer

Related MIMS Drugs