selective serotonin and noradrenaline reuptake inhibitors (SSRIs & SNRIs) (1)
SSRIs as an alternative to HRT - general principles
in general baseline effectiveness 20-50%
class effect of SSRIs are of antidepressant benefit and improved quality of life
class effect of SSRIs include initial side effects such as nausea, dizziness, shortterm aggravation of base-line anxiety and mood, so encourage your patient to persevere and if necessary take on alternative days, even ½ tablet
class effect of all SSRIs is sexual dysfunction- no one SSRI is better than any other in this respect and there is great individual variation in response
some SSRIs (paroxetine, fluoxetine, paroxetine, sertraline) interact with cytochrome P450, so avoid in patients on Tamoxifen
SSRI’s such as paroxetine (12.5-25mg daily) has shown to reduce flushes in 50%, while fluoxetine (20mg daily) has also been reported to reduce in 60% (2) (1)
paroxetine
dosage 10-20mg - baseline improvement 50-60%. Paroxetine has best evidence for vaso-motor control and has maximal benefit achieved at 10mg
class effect of SSRIs are of antidepressant benefit and improved quality of life
interacts with enzyme cytochrome P450 (CYN10) thereby rendering Tamoxifen less effective
fluoxetine (1)
dosage 20mg - baseline effectiveness 10-20mg
class effect of SSRIs are of antidepressant benefit and improved quality of life
like Paroxetine should be avoided in patients taking Tamoxifen
citalopram (Escitalopram) (1)
dosage 20mg - baseline benefit 40-50%
class effect of SSRIs are of antidepressant benefit and improved quality of life
much less effect on enzyme cytochrome P450 so can be used in patients on Tamoxifen
sertraline (1)
dosage 25-50mg - baseline benefit - little information
sertraline is the best anti-anxiety SSRI
least well tolerated with an increase in anxiety at the outset. Interacts with cytochrome P450, so avoid in patients on Tamoxifen
often poorly tolerated at outset with dizziness and other associated SSRI side effects including sexual dysfunction, slow titration may be the answer
no interaction with cytochrome P450 so may be safest choice for patients on Tamoxifen
Notes (3):
Finding Lasting Answers for Symptoms and Health (i.e., MsFLASH) studies revealed a significant reduction in hot flashes of 54% for escitalopram, 48% for estradiol, and 49% for venlafaxine
sexual desire was minimally better with estradiol than SSRI treatment, while venlafaxine was better than estradiol for therapy of anorgasmia, pain, and vaginal dryness
improvement in sleep quality and duration was minimally and equally improved with both forms of therapy
in a separate study, paroxetine 7.5 mg daily was shown to improve hot flashes without weight gain or sexual dysfunction
(3) Cobin RH, Goodman NF, on behalf of the AACE Reproductive Endocrinology Scientific Committee. American Association of Clinical Endocrinologists and American College of Endocrinology Position Statement on Menopause - 2017.
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