Table 1.
Antidepressants and Dosing Recommendations Included in HIV Adaptation of Measurement-Based Care
| |
|
|
|
|
|
Dosing recommendations (mg) |
||
|---|---|---|---|---|---|---|---|---|
| Medication | Generic available? | PAP available? | How to take | Principal side effects | Additional considerations | Starting dose | Progression | Maximum |
| Citalopram | Yes | Yes | Anytime, usually in am | Nausea Decreased libido | Nausea tends to resolve, decreased libido does not. | 10–20 mg qd | (10→) 20→40→60a→80a | 80a qd |
| Escitalopram | No | Yes | Anytime, usually in am | Nausea Decreased libido | Nausea tends to resolve, decreased libido does not. | 5–10 mg qd | (5→) 10→20→30→40 | 40 qd |
| Sertraline | Yes | Yes | Anytime, usually in am | Nausea Decreased libido | Nausea tends to resolve, decreased libido does not. | 25–50 mg qd | (25→) 50→100→150→200 | 200 qd |
| Mirtazapine | Yes | Yes | Take at night | Drowsiness Weight gain (∼5 kg) | No sexual side effects. Often increases appetite. Can help with insomnia at lower doses (<30 mg). May help with decreased libido if added to an SSRI. | 7.5–15 mg qd | (7.5→) 15→30→45→60 | 60 qd |
| Bupropion SR | Yes | Yes | Take in am and early pm | Insomnia Activation/restlessness | No sexual or weight side effects. Can help if focus and concentration are a concern. | 150 mg qd | 150 qd→150 bid→200 bid | 200 bid |
| Bupropion XL | No | Yes | Take in am | Insomnia Activation/restlessness | May exacerbate agitated depression or comorbid anxiety. Can help with smoking cessation, and may help decrease craving in patients with substance abuse history. For patients with seizure history, may increase risk of seizure at higher doses. | 150 mg qd | 150 qd→300 qd→450 qd | 450 qd |
| Venlafaxine XR | Yes | Yes | Take in am | Insomnia Activation/restlessness | Side effects similar to SSRIs, especially at lower doses (initial nausea; decreased libido). Blood pressure should be monitored, especially at higher doses. | 37.5–75 mg qd | (37.5→) 75→150→225→300→375 | 375 qdb |
a
Recent FDA evidence suggests greater risk of QT prolongation at doses>40 mg. EKG monitoring recommended above this dose range.
b
Limited evidence for increased efficacy at doses>225 mg, but clinical trials and measurement-based care algorithms have safely and successfully dosed up to 375 mg.
PAP, Patient Assistance Program; RTV, ritonavir; PI, protease inhibitor; NNRTI, non-nucleoside reverse transcriptase inhibitor; qd, once daily; bid, twice daily.