What medication would you first prescribe to this patient?

What medication would you first prescribe to this patient?
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Peer 1

What medication would you first prescribe to this patient?
SSRI’s are commonly the initial drug of choice for patients with depression and many of the anxiety disorders (Woo et al., 2020). These drugs demonstrate equal efficacy to the nonspecific SNRI’s with a safe and lower side effect profile (Woo et al., 2020). Sertraline (Zoloft) would be the treatment of choice. Angela would be started on Zoloft 50mg PO daily. The medication must be started in low doses and the doses must be titrated, depending on the response and the side effects experienced (Grover et al., 2017).

She comes back in 2 weeks and states she has not noticed and change in her mood since starting on the medication. What would be your response?
Educating Angela on Zoloft and how long it may take to see results is key and should be initiated prior to starting any Antidepressant and re-educated throughout visits. During acute treatment phase of depression, it is important to monitor the patient’s response to ensure the treatment has been given for a sufficient duration, frequency and dose (Woo et al., 2020). A patient needs about 4 to 8 weeks of optimal dosing of medication to appropriately evaluate whether there is a partial response or no response at all (Woo et al., 2020). If there is some improvement in mood and symptoms, increasing the dose is may be effective.

What are the possible problems with the medication you prescribed?
Zoloft is the most effective and safe of all SSRI’s. Of course, patient’s must be educated on the FDA Black Box warning for any antidepressant: possibility for increase thoughts of suicide. Zoloft can cause birth defects; women of childbearing age should be advised to use birth control to prevent pregnancy. Angela is 54 but should still be educated on this if she has yet to go through menopause.

How long should you continue the treatment regimen?
Patients taking SSRI’s like Zoloft start to see improvement in mood/symptoms after 4 to 8 weeks of treatment (Woo et al., 2020). At times longer if the dose has to be titrated up. Patients show not stop treatment quickly after symptoms improve due to having depression return. It is recommended for patients to stay on their antidepressants after symptoms improve for 6 months to a year. Discussing tapering off any antidepressant is extremely important. Discontinuation syndrome may occur when a patient takes an NNSRI or an SSRI for more than 5 weeks and the dose is sharply reduced or stopped suddenly (Woo et al., 2020). Symptoms include agitation, anxiety, balance problems, nightmares, dizziness, diarrhea, nausea, vomiting, electric shock-like sensations, and flu-like symptoms (Woo et al., 2020).

Reference:

Grover, S., Gautam, S., Jain, A., Gautam, M., & Vahia, V. N. (2017). Clinical practice guidelines for the management of Depression. Indian Journal of Psychiatry, 59(5), 34. https://doi.org/10.4103/0019-5545.196973

Woo, T. M., Wynne, A. L., & Robinson, M. V. (2020). Pharmacotherapeutics for Advanced Practice Nurse prescribers. F.A. Davis Company.

Peer 2

Medication Prescribed for the Patient

The patient would be prescribed serotonin reuptake inhibitors (SSRIs) to manage her depression. SSRIs are effective antidepressants that work by improving the mood of the patient appetite (Godlewska et al., 2016). Their mechanism of action involves prevention or serotonin reuptake, thus increasing its levels in the brain. Serotonin also called a feel good hormone, which helps improve the mood of the patient. Fluoxetine would be the prescribed SSRI. The patient would be started on a low dose of 20mg, taken orally once daily (Micheli et al., 2018). The helps improve mood, increase appetite, and improve her sleep cycle. The dose can be increased after a few weeks if the patient does not show any improvement of her depression symptoms.

Response to Delayed Medication Effects

It would be important to inform the patient that the medication can take between 4-6 weeks before its therapeutic effects are achieved. The patient would be advised to continue taking the medication for a few more weeks. A follow up would be scheduled in 2-4 weeks to assess the response and effectiveness of the medication Micheli et al., 2018). Absence of improvements at that point would necessitate dose increment or change of medication.

Possible Problems with The Medication Prescribed

One possible thing that could be the problem of the medication is its side effects. Possible side effects of Fluoxetine include insomnia, headache, dizziness, anxiety, feeling tired, nausea, loss of appetite, and hot flashes. These effects may worsen her depression symptoms including sleeping disorders, fatigue, and loss of appetite (Godlewska et al., 2016). Additionally, Fluoxetine may interact with the current NSAIDs being taken by the patient, which can increase the risk of gut bleeding. Caution should be taken especially when taking the drugs. There should be a reasonable time interval to avoid drug interactions (Woo & Robinson, 2016).

Duration of Treatment Regimen

The patient would take the current Fluoxetine dose of 20mg for 4-6 weeks. A maintenance dose of 20-60mg would be prescribed depending on the patient’s response Micheli et al., 2018). The maintenance would last 6 months to one year for effective depression management, and to ensure the patient would not go back to depression.

References

Godlewska, B. R., Browning, M., Norbury, R., Cowen, P. J., & Harmer, C. J. (2016). Early changes in emotional processing as a marker of clinical response to SSRI treatment in depression. Translational psychiatry, 6(11), e957-e957.

Micheli, L., Ceccarelli, M., D’Andrea, G., & Tirone, F. (2018). Depression and adult neurogenesis: positive effects of the antidepressant fluoxetine and of physical exercise. Brain research bulletin, 143, 181-193.

Woo, T. M., & Robinson, M. V. (2016). Pharmacotherapeutics for advanced practice nurse prescribers with davisplus resources (4th ed.).

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