September 2025
September 2025
| General medical disorder | Antidepressants to avoid or use with caution | Comment |
| Hypertension | Venlafaxine | Venlafaxine can increase blood pressure, especially at higher doses (eg, greater than 300 mg/day). Thus, blood pressure should be monitored regularly. |
| Seizure disorder or increased risk of seizure | Bupropion | Bupropion is contraindicated in patients with seizure disorders or at increased risk of seizures. As an example, the drug is avoided in patients with cancers involving the central nervous system and patients receiving chemotherapy regimens that increase the risk of seizures. Refer to UpToDate content regarding other risk factors for seizure. |
| Cardiovascular disease | Tricyclics Trazodone | All TCAs are potentially cardiotoxic and should be avoided in susceptible individuals with heart disease. |
| Orthostatic hypotension | Tricyclics Trazodone | TCAs and trazodone at higher doses (eg, greater than 100 mg/day) can cause or worsen orthostatic hypotension; orthostatic blood pressure should be monitored. |
| Congenital long QT syndrome and other conditions that cause QT prolongation* | Citalopram | Citalopram can cause dose-dependent QTc prolongation. We avoid citalopram in patients with congenital long QT syndrome, persistent corrected QT measurements >500 milliseconds, bradycardia, uncorrected hypokalemia or hypomagnesemia, recent myocardial infarction, or uncompensated heart failure, as well as patients taking other drugs that prolong the QT interval.* |
| Escitalopram | Escitalopram is one of the two stereoisomers that constitute citalopram. We avoid its use in patients with congenital long QT syndrome and suggest avoiding doses of 30 mg/day or higher in patients with other medical conditions and/or on medications that can cause QT prolongation.* | |
| Kidney function or hepatic impairment | Duloxetine Bupropion Citalopram Escitalopram Mirtazapine Sertraline | Duloxetine is generally avoided in patients with severe kidney impairment (creatinine clearance <30 mL/minute), ESKD, or hepatic impairment (Child-Pugh class B or C), and should be used cautiously in patients with mild chronic liver disease or alcohol use disorder. Bupropion, citalopram, escitalopram, and mirtazapine should be used cautiously (ie, reduced doses with closer monitoring) or avoided in ESKD, dialysis, or Child-Pugh class C cirrhosis. Sertraline should be avoided in Child-Pugh class C cirrhosis. |
| Bleeding risk | SSRIs and SNRIs | In patients with either marked thrombocytopenia (ie, ≤50 × 109/L), or with less severe thrombocytopenia (ie, >50 to ≤150 × 109/L) and clinical evidence of bleeding, we suggest avoiding SSRIs and SNRIs, due to their effects upon platelet aggregation, particularly if used in conjunction with antiplatelet and/or anticoagulant medications. |
| Hyponatremia | SSRIs and SNRIs | SSRIs and SNRIs may be associated with hyponatremia, but the absolute risk of hyponatremia appears low. For patients at risk of hyponatremia (eg, age >65 years or concurrent use of drugs associated with hyponatremia [eg, thiazide diuretics]), we monitor sodium levels during treatment with these drugs. |
| Overweight or obese | Mirtazapine | Mirtazapine can cause significant weight gain (≥7% body weight) in up to 10% of patients. |
ESKD: end-stage kidney disease; QTc: corrected QT interval; SNRI: serotonin-norepinephrine reuptake inhibitor; SSRI: selective serotonin reuptake inhibitor; TCA: tricyclic antidepressants.
* Duloxetine or venlafaxine may be preferred in patients with risk factors for QT prolongation. Refer to UpToDate content for a list of drugs and other causes of long QT syndrome.
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