Prescribing

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Postural hypotension as antidepressant side-effect in adults aged ≥60

A study examined the risk of postural hypotension (PH) associated with antidepressants in adults aged ≥60 in UK primary care.
Data from >41,000 adults aged ≥60 in the IQVIA Medical Research Database (from 1 Jan 2000 to 31 Dec 2018) was used to determine the risk of PH before and after antidepressant prescriptions.
From 41,005 people with incident PH in the study period, 8,313 were prescribed a selective-serotonin reuptake inhibitor (SSRI); 8,899 were prescribed a tricyclic antidepressant (TCA); and 4,656 were prescribed an “Other antidepressant”.
There was a consistent increased risk of PH in day 1-28 in all antidepressants, that reduced thereafter.
Risk of PH was highest with SSRIs (IRR 4.22, 95% CI: 3.76-4.74), followed by “Other antidepressants” (IRR 2.17 (95% CI: 1.76- 2.68), TCAs (IRR 2.12, 95% CI: 1.79-2.50).

When initiating an antidepressant in an adult aged ≥60, warn about the risk of PH, particularly during the first month when using SSRIs.
To inform the safety of prescribing antidepressants, particularly SSRIs in older adults, check for a postural drop in blood pressure at baseline and on follow-up at 4-6 weeks. If someone is high risk for PH, consider potential complications, including falls and strokes, to help determine the benefits versus the risks of prescribing.

Read more about the research informing this GEM:

The median antidepressant treatment duration for depression is more than 2 years in the UK (more than 5 years in the US).
Due to potential adverse effects, treatment beyond 6 months after remission has only been suggested for people at high risk of relapse (up to 2 years initially).
Surveys of long-term antidepressant users have found that 30% to 50% have no evidence-based indication to continue treatment.
A cluster randomised clinical trial involving 330 adults investigated whether adding internet and telephone support to a GP review, to consider discontinuing long-term antidepressants, was more effective than GP review alone. Antidepressant discontinuation was achieved in 45.5% given additional support vs 41.9% without.
GP review for possible antidepressant discontinuation was found to be safe and effective, with remote support offering small additional benefits.

When adding an antidepressant to repeat, discuss suggested treatment duration and recommend a review after an appropriate time interval to discuss potential discontinuation.
Share this evidence with members of your MDT performing medication reviews to support conversations about discontinuing treatment when potentially not indicated.

In patients on long-term antidepressant treatment who are largely symptom-free, it can be useful to know relapse rates to inform discussions about stopping treatment. In a recent study of people on long-term antidepressants (70% taking antidepressants >3yrs), 56% who stopped their medication had a relapse within 12 months, compared to 39% who continued them. After 12 months, 61% who stopped their antidepressants remained off them.

Discuss stopping antidepressants with people who are largely symptom-free, using reported relapse rates to inform decisions made.
Share evidence with practice pharmacists performing medication reviews.

Read more about the research informing these recommendations here: https://www.nejm.org/doi/full/10.1056/NEJMoa2106356

56% experience withdrawal symptoms when stopping SSRIs. Withdrawal can be confused with relapse and make people feel reluctant to stop their medication. In stable patients, stopping antidepressants can prevent side-effects, avoid drug interactions and reduce burden and costs.

Withdrawal usually begins within days of stopping antidepressants (though it can begin weeks after stopping fluoxetine), whilst relapse takes weeks or months to start. Reintroducing antidepressants rapidly reduces the intensity of withdrawal symptoms whereas in relapse, symptoms usually take weeks to improve.

Withdrawal from SSRIs can cause psychological and physical symptoms, with some people reporting sensory disturbances described as ‘electric shocks’ or ‘brain zaps’. Nausea, muscle pain or these sensory disturbances, suggest withdrawal rather than relapse of anxiety and depression.

To reduce the risk of withdrawal, we should reduce the SSRI dose by 25 or 50% approximately every 4 weeks. If withdrawal symptoms occur, the SSRI dose should be increased to the previous effective dose and tapering performed slower, in 10-20% increments. Liquid doses may be required if some doses are not available in tablet form.

Have a look at some examples of tapering regimes published by the Royal College of Psychiatrists and discuss with colleagues at a clinical meeting how they taper antidepressant doses - could you all take a new approach?

Read more about the evidence informing this GEM here: https://bjgp.org/content/73/728/138#F1