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The patient can be exposed to selective serotonin reuptake inhibitors (SSRIs), which are the most used antidepressants in the United States to tackle symptoms of major depression during pregnancy (Grzeskowiak et al., 2011). The most widely used SSRIs in pregnant women include fluoxetine, paroxetine, and escitalopram. Based on the personal and medical history of the patient, the first line of treatment would be to introduce fluoxetine at a starting dose of 10mg po each am and may increase to 20 mg po q am after the first four weeks of treatment. The dose may be increased to a maximum of 80 mg po q am by 10-20 mg q 4 weeks as tolerated or needed. Available literature demonstrate that fluoxetine has a good safety record with pregnant and lactating mothers, and it is well tolerated by most people since it has less histaminergic, dopaminergic and a-adrenergic side effects (Edmunds & Mayhew, 2004).
In the event that the patient is unable to tolerate flouxetine, escitalopram should be administered at 10 to 20 mg per day for 4 weeks, but extra caution should be taken in administering the drug if the patient is in her last 3 months of pregnancy as it may cause harm to the fetus (Dodd et al., 2011). Another alternative for the patient is paroxetine, with the recommended starting dose of 20mg per day because the patient is in a safe age and suffers from no renal or liver impairments (Dolder et al., 2010). Paroxetine is usually administered for 4 weeks before its benefits show (Pridmore & Turnier-Shea, 2004).
Available literature demonstrates that “…SSRIs exert their pharmacological effects by selectively inhibiting the reuptake of serotonin (5-HT) at the presynaptic junction, resulting in an increased concentration of serotonin in the synaptic cleft and thus enhanced serotonergic neurotransmission” (Grzeskowiak et al., 2011, p. 1028). Elsewhere, it is reported that the pharmacology of most SSRI agents is centered on reversing possible dysfunction of the monoamine neurotransmitters serotonin and nerepinephrine, which is often achieved by inhibiting the reuptake of these neurotransmitters into presynaptic neurons by obstructing the function of their respective reuptake transporters (Dolder et al., 2010).
The patient should be monitored very closely upon administration of the SSRIs for symptoms of drug intolerance and also due to the fact that she is pregnant. The discussed SSRIs are perceived by many health professionals as having a more favorable safety profile and reduced toxicity in overdose, especially in pregnant women. However, caution should be exercised in administering the SSRIs as they are associated with increased risk of omphalocele, craniosynostosis, anencephaly, and low birthweight (Dolder et al., 2010). Paroxetine is individually associated with increased risk of congenital malformations, suicidal ideation, and cardiovascular malformations following exposure to the drug at an average daily dose of >25 mg (Grzeskowiak et al., 2011). It is reported in the literature that the most commonly reported cardiovascular malformations in fetuses upon exposure to SSRIs are the ventricular septal defects (Tyrka et al., 2006).
Available literature demonstrates that “…specific adverse effects associated with antidepressant treatments may be reduced or identified earlier by baseline screening and agent-specific monitoring after commencing treatment” (Dodd et al., 2011, p. 712). Drugs with serious adverse events on patients should be withdrawn and another line of treatment started using antidepressants that are well tolerated by the patient. Drug augmentation is also a valid possibility in the treatment of major depression.
List of Prices of 3 Drugs
- Escitalopram – 20 mg tablets: cost of 100 tablets $85.00, available from CanDrugStore.com (2012)
- Fluoxetine – 20 mg generic version: cost of 30 tablets is $11.99, available from NorthWestPharmacy.com (PharmacyChecker.com, 2012)
- Paroxetine – 10 mg original version: cost of 30 tablets is $124.16 (BuckADayPharmacy.com, 2012).
Population Specific Implications
The drug escitalopram should be administered cautiously in geriatric patients and patients presenting with hepatic impairment as its half-life is enhanced in these patients, hence the need to reduce dosage (Dodd et al., 2011). Although the drug should also be given cautiously to patients with a history of hypersensitivity, suicidal ideation, seizures, and severe renal impairment, the patient in this case can use the drug as she does not have any history of hepatic, renal impairment, or suicidal ideation. Escitalopram enters breast milk during distribution and therefore may cause adverse effects in infants. The patient is not lactating at the present, so the drug can be prescribed. It should however be noted the patient is pregnant, and thus the drug should be used with a lot of caution as the fetus may develop drug discontinuation syndrome (e.g., respiratory distress, feeding problems, and petulance) upon exposure (Tyrka et al., 2006).
Apart from the usual adverse effects exhibited in decreased sexual desire, dizziness, dry mouth, loss of appetite, and trouble sleeping (Dodd et al., 2011), fluoxetine should be administered cautiously as the patient is pregnant. Unconfirmed findings have associated the drug with premature birth, low birth weight, high blood pleasure in mother and child, not mentioning that the child could experience symptoms such as irritability, feeding challenges and difficulty sleeping (Dolder et al., 2010). Paroxetine should also be administered with caution as it is associated with increased suicidal ideation, withdrawal effects, and increased risk of congenital malformations if it is taken within the first trimester of pregnancy (Grzeskowiak et al., 2011).
Sample Prescription Form
Mary Washington, FNP # 9876
Name: __Samuel Doe________ DOB: 07-26-1978
Address: 456 Southern Drive, LA; Date: 06-09-2012
Rx: Escitalopram 10 mg per day for at least 4 weeks. Dose can be increased to 20 mg per day depending on tolerance and side effects
__________________________ Refill [yes] _____
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BuckADayPharmacy.com. (2012). Buy paroxetine online. Web.
CanDrugStore.com. (2012). Escitalopram. Web.
Dodd, S., Malhi, G.S., Tiller, J., Schweitzer, I., Hickie, I., Khoo, J.P…Berk, M. (2011). A consensus statement for safety monitoring guidelines of treatments for major depressive disorder. Australian & New Zealand Journal of Psychiatry, 45(9), 712-725.
Dolder, C., Nelson, M., & Stump. A. (2010). Pharmacological and clinical profile for newer antidepressants: Implications for the treatment of elderly patients. Drugs & Aging, 27(8), 625-640.
Edmunds, M.W., & Mayhew, M.S. (2009). Pharmacology for the primary care provider (3rd ed.). St. Louis: Mosby-Elsevier.
Grzeskowiak, L.E., Gilbert, A.L., & Morrison, J.L. (2011). Investigating outcomes following the use of selective serotonin reuptake inhibitors for treating depression in pregnancy. Drug Safety, 34(11), 1027-1048.
PharmacyChecker.com. (2012). Flouxetine pricing & ordering comparisons. Web.
Pridmore, S., & Turnier-Shea, Y. (2004). Medication options in the treatment of treatment-resistant depression. Australian & New Zealand Journal of Psychiatry, 38(4), 219-225.
Tyrka, A.R., Price, L.H., Mello, M.F., & Carpenter, L.L. (2006). Psychotic major depression: A benefit-risk assessment of treatment options. Drugs Safety, 29(6), 491-508.