Am Fam Physician. 2001 Feb 1;63(3):443-444.
to the editor: Drs. Gurvich and Cunningham state in their article1 on psychotropic drugs in nursing homes that fluoxetine (Prozac) is not recommended in the geriatric population because of its longer half-life of active metabolite relative to other selective serotonin reuptake inhibitors (SSRIs), resulting in the potential for a longer duration of side effects.
While it is true that fluoxetine's active metabolite has a half-life of up to 16 days, because of its low incidence of side effects compared with other SSRIs, it has a very low discontinuation rate compared with paroxetine (Paxil), fluvoxamine (Luvox) and sertraline (Zoloft).2 Furthermore, because fluoxe-tine has a longer half-life, a missed dose is not as significant as it is with other SSRIs, and fluoxetine is not associated with the discontinuation syndrome that is found with other SSRIs.3 Fluoxetine should not be avoided in the geriatric population and may even be the drug of choice for selected patients.
1. Gurvich T, Cunningham JA. Appropriate use of psychotropic drugs in nursing homes. Am Fam Physician. 2000;61:1437–46.
2. Price JS, Waller PC, Wood SM, MacKay AV. A comparison of the post-marketing safety of four selective serotonin re-uptake inhibitors including the investigation of symptoms occurring on withdrawal. Br J Clin Pharmacol. 1996;42:757–63.
3. Coupland NJ, Bell CJ, Potokar JP. Serotonin reuptake inhibitor withdrawal. J Clin Psychopharmacol. 1996;16:356–62.
in reply: We agree that selected geriatric patients respond well to fluoxetine. In fact, the U.S. Food and Drug Administration (FDA) recently approved labeling for fluoxetine to be used to treat patients with depression in the geriatric population.
A placebo-controlled study1 that contributed to this recent FDA approval evaluated 671 geriatric patients with major depression. The study concluded that 20 mg per day of flu-oxetine is more effective than placebo and is as equally well tolerated as placebo. However, the patients participating in the study were out-patients, an average age of 67 years and were considerably younger and healthier than patients in a typical skilled nursing facility.
Our article2 focused on the more frail elderly patient who often responds differently to medications. Dosing titration of fluoxetine must be done carefully in this population: “The long half-lives of fluoxetine and norfluoxetine promote insidious drug accumulation, which takes considerable time to correct.”3 One way to use the long half-life to advantage, however, would be to dose fluoxetine every other day, thus reducing the risk of side effects and accumulation without compromising drug effectiveness.
Another issue to consider is drug interactions. Patients in skilled nursing facilities are often given multiple medications, and causing new drug interactions is a constant concern. Fluoxetine and its metabolite are more potent P450 inhibitors than sertraline, and citalopram (Celexa) appears to inhibit the P450 minimally, if at all.3,4 Clearly, drug selection is dependent on the practitioner's clinical experience and individual patient's tolerance of a given medication.
1. Tollefson GD, Holman SL. Analysis of the Hamilton Depression Rating Scale factors from a double-blind, placebo-controlled trial of fluoxetine in geriatric major depression. Int Clin Psychopharmacol. 1993;8:253–9.
2. Gurvich T, Cunningham JA. Appropriate use of psychotropic drugs in nursing homes. Am Fam Physician. 2000;61:1437–46.
3. Hay DP, Rodriguez MM, Franson KL. Treatment of depression in late life. Clin Geriatr Med. 1998;14:33–46.
4. Drug facts and comparisons. St. Louis, Mo.: Facts and Comparisons, 1999:918–26.
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