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, emsam stimulants, trazodone, ✽ MAOIs should not be neglected as therapeutic agents for the treatmentresistant Table 1 . John’s wort, cyclobenzaprine, methadone, • If patient has pheochromocytoma • If patient is undergoing elective surgery and requires general anesthesia • If there is a proven allergy to selegiline SPECIAL POPULATIONS Renal Impairment • No dose adjustment necessary for transdermal administration in patients with mild to moderate renal impairment • Use oral administration with caution – drug may accumulate in plasma in patients with renal impairment • Oral administration may require lower than usual adult dose Hepatic Impairment • No dose adjustment necessary for transdermal administration in patients with mild to moderate hepatic impairment • Oral administration may require lower than usual adult dose Cardiac Impairment • May require lower than usual adult dose • Observe closely for orthostatic hypotension • Recommended dose for patients over 65 years old is 20 mg oral and 6 mg/day • Dose increases in the elderly should be made with caution and patients should be observed for postural changes in blood pressure throughout treatment • Reduction in the risk of suicidality with antidepressants compared to placebo in adults age 65 and older THE ART OF PSYCHOPHARMACOLOGY Children and Adolescents • Not recommended for use in children • Use with caution, observing for activation of known or unknown bipolar disorder and/ or suicidal ideation, and inform parents or guardians of this risk so they can help observe child or adolescent patients • Carefully weigh the risks and benefits of pharmacological treatment against the risks and benefits of nontreatment with antidepressants and make sure to document this in the patient’s chart • Monitor patients face-to-face regularly, particularly during the first several weeks • Effective June 30, 2015, the US FDA requires changes to the content and format of pregnancy zyvox drug class cost of zyvox zyvox contraindications zyvox iv zyvox package insert oral zyvox and lactation information in prescription drug labels, including the elimination of the pregnancy letter categories; the Pregnancy and Lactation Labeling Rule (PLLR or final rule) applies only to prescription drugs and will be phased in gradually for drugs approved on or after June 30, 2001 • Controlled studies have not been conducted in pregnant women • Not generally recommended for use during pregnancy, especially during first trimester • Should evaluate patient for treatment with an antidepressant with a better risk/benefit • Some drug is found in mother’s breast milk • Immediate postpartum period is a high-risk time for depression, especially in women who have had prior depressive episodes, so drug may need to be reinstituted late in the third trimester or shortly after childbirth to prevent a recurrence during the postpartum period • Should evaluate patient for treatment with an antidepressant with a better risk/benefit Potential Advantages • Treatment-resistant depression • Patients with atypical depression (hypersomnia, hyperphagia) • Patients who wish to avoid weight gain and sexual dysfunction • Parkinson’s patients inadequately responsive to levodopa Potential Disadvantages • Noncompliant patients • Patients with motor complications and fluctuations on levodopa treatment • Patients with cardiac problems or Primary Target Symptoms • Depressed mood (depression) • Somatic symptoms (depression) • Sleep and eating disturbances (depression) • Psychomotor disturbances (depression) • Motor symptoms (Parkinson’s disease) • Transdermal administration may allow freedom from dietary restrictions • Transdermal selegiline theoretically appealing as a triple action agent (serotonin, norepinephrine, and dopamine) for treatment-refractory and difficult cases • Transdermal selegiline may have low risk of weight gain and sexual dysfunction, and may be useful for cognitive dysfunction in attention deficit disorder and other cognitive disorders, as it increases dopamine and is metabolized to l-amphetamine and l-methamphetamine • Low-dose oral administration generally used as an adjunctive treatment for Parkinson’s disease after other drugs have • At oral doses used for Parkinson’s disease, virtually no risk of interactions with food • Neuroprotective effects are possible but ✽ Enhancement of levodopa action can occur for Parkinson’s patients at low oral doses, but antidepressant actions probably require high oral doses that do not have the potential tissue selectivity and lack SELEGILINE (continued) of dietary restrictions of the low-dose transdermal formulation ✽ High doses may lose safety features • MAOIs are generally reserved for second-line use after SSRIs, SNRIs, and combinations of newer antidepressants • Patient should be advised not to take any prescription or over-the-counter drugs without consulting their doctor because of possible drug interactions • Headache is often the first symptom of hypertensive crisis • Myths about the danger of dietary tyramine can be exaggerated, but prohibitions against concomitant drugs often not followed closely enough ✽ Combining multiple psychotropic agents with MAOIs should be for the expert, especially if combining with agents of potential risk (e .
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