70. Anxiety that has failed 2 SSRIs: How to switch and which med to choose next with Dr. Strawn

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SSRI Switching in Pediatrics: When to Try a Third SSRI, When to Use Luvox, and Key Metabolism Pearls


Dr. Elise Fallucco continues her discussion with child psychiatrist Dr. Jeffrey Strawn (University of Cincinnati; co-author of Stahl’s DePrescribing) on practical tips regarding how to stop/decrease an SSRI and switch to another SSRI (or SNRI) for pediatric anxiety. 


Highlights from the Episode:

• After trying 2 different SSRIs for pediatric anxiety, in most cases, it makes sense to try a third SSRI as opposed to an SNRI
• Rationale: SSRIs tend to be more effective and have fewer side effects than SNRIs
• "We Don't Talk about LUVOX": Luvox can be a great option for youth with OCD OR anxiety (generalized, social, separation)
• Dosing strategy: start at 25mg with the plan to titrate up to a target dose of 150-200mg
• Consider grouping 3 of the SSRIs by their similar metabolic pathways (2C19): Sertraline, Citalopram, and Escitalopram
• If your patient develops significant side effects on a low dose of one of these 3 meds, they MIGHT be a 2C19 poor metabolizer, which means that you may want to avoid trials of the other 2C19 meds in the group
• Fluoxetine has a LOOOOONg half-life: and it's related 2D6 inhibition will persist 4–5 weeks after stopping Fluoxetine - and affect the metabolism of other 2D6-metabolized meds during that time
• The 2D6 group includes meds like Fluoxetine, Paroxetine and 2 of the SNRIs: Duloxetine and Venlafaxine

-- And Check Out  Dr. Jeffrey Strawn's new book which I highly recommend - Stahl's Deprescriber's Guide (https://www.amazon.com/Stahls-Depresc...)  available on Amazon!


00:00 Introduction of Dr. Jeffrey Strawn


00:38 Preview of Episode: Switching SSRIs, when to use FluVOXamine or SNRIs, plus 2D6 and 2C19 metabolism of antidepressant medication


01:59 Try 2 different SSRIs or Duloxetine?


03:45 CYP 2D6 Inhibition with Fluoxetine


04:28 Clinical Pearl: Fluoxetine 2D6 inhibition continues 4-5 weeks after stopping


05:05 2D6 Metabolized Antidepressants: Venlafaxine, Duloxetine, Paroxetine


05:31 Choosing a Third SSRI


05:48 SSRIs generally more effective, fewer side effects than SRNIs in youth


06:49 Only 1 SNRI for child anxiety


07:27 People forget about Fluvoxamine


08:30 Sertraline and Es/Citalopram 2C19 metabolism


09:32 Fluoxetine to FluVOXamine cross-titration


11:16 Gratitude for Dr. Strawn


11:31 Check out Stahl's DEPrescribing Guide


12:23 Recap of Advanced SSRI and SNRI case discussion


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