Katheryn Soto PA 644 – TR 2 10/18/2017

Overview
 Begin Paroxetine (Paxil) 10mg PO QAM
 Continue other medications as previously prescribed
F.W. is a 74y/o male NKDA with c/o increased stress, mood changes, loss of interest in activities
he previously enjoyed, insomnia and significant weight loss and was diagnosed with MDD. PMHx
significant for HTN, hyperlipidemia and BPH and are well controlled. Medications include
Lisinopril/HCTZ 20/12.5mg QD, Simvastatin 40mg QD, Terazosin 5mg QHS, ASA 81mg QD, and a
Men’s multivitamin. To treat his moderate (PHQ-9 score of 15-19) MDD symptoms, complete
psychiatric assessment with evaluation of suicide risk, substance use and the impact of his ability to care
for his wife are indicated per APA guidelines. Antidepressant medication in conjunction with
depression-focused psychotherapy is recommended for first line initial/acute phase therapy per APA
guidelines. APA recommends use of SSRIs, SNRIs, mirtazapine, or bupropion as the most effective
agents for decreasing depressive symptoms. The best option for this patient is the SSRI Paxil 10mg PO
QAM because it will help him gain the weight he lost recently, will not cause insomnia, and is the only
SSRI that helps with sleep (sedating effects). I would start F.W. at a lower dose of 10mg PO QAM
(versus the adult recommended dose of 20mg PO QAM) because it is recommended to begin this
medication this way in elderly patients and to titrate up slowly. Although this medication is highly
protein bound and has more CYP interactions than SNRIs, it is safe with his current medications. I
would warn him of use of APAP while on this medication because is a commonly used CYP2D6
substrate and Paxil is a strong 2D6 inhibitor that can increase serum levels of APAP and potentially
cause toxicity. Paxil and other SSRIs and SNRIs can have an additive antiplatelet effect when combined
with ASA. It is recommended per APA guidelines to monitor bleeding risk but is not considered a
serious interaction or contraindication so I would not DC ASA at this time due to its cardio protective
effects and a strong PMHx and FHx of cardiac conditions. I would warn against combining this
medication with EtOH due to the potential All other available SSRIs for the treatment of MDD are
inappropriate for this patient because they can cause insomnia and weight loss and potentially
exacerbate his preexisting symptoms. SSRIs have a BBW for increased suicidal ideations that is
typically only seen in younger patients, but I would monitor for any signs of this on follow up. SNRIs
and Buproprion (Wellbutrin) are not a good option in this case as they are not recommended in patients
with hypertension or insomnia. Mirtazapine (Remeron) can help with weight gain and sleep but is not
recommended in patients with hyperlipidemia and is associated with anticholinergic effects, so it is also
not a good option for this patient or the elderly. MAOI’s are not indicated for initial treatment and are
only indicated for patients who are not responsive to other treatments. Mixed serotonergic agents such
as Trazadone, Nefazodone, and Vilazodone are also options for MDD but are not first line.
Antipsychotics are used to augment treatment but are not indicated at this time, as F.W. has not
displayed psychotic features at this time. An adequate trial to determine efficacy of MDD
pharmacotherapy treatment is generally 4-8 weeks to determine the efficacy of this drug but since he is
elderly SSRIs can take up to 12 weeks to take effect. Non-pharm treatments would include referral to
CBT to supplement MDD pharmacotherapy, patient education on good sleep hygiene, and referral to a
nutritionist if inadequate weight restoration on follow-up.
References
Major Depressive Disorder. In: Wells BG, DiPiro JT, Schwinghammer TL, DiPiro CV. eds. Pharmacotherapy Quick Guide New
York, NY: McGraw-Hill;
. http://accesspharmacy.mhmedical.com.suproxy.su.edu/content.aspx?bookid=2177&sectionid=165474230. Accessed October
04, 2017.

APA Treatment Guidelines – Major Depressive Disorder. PsychU. https://www.psychu.org/apa-treatment-guidelines-major-

depressive-disorder/. Published October 16, 2016. Accessed October 7, 2017.
Katheryn Soto PA 644 – TR 2 10/18/2017

PARoxetine [cited 2017 October 10] In: Access Pharmacy [internet] McGraw Hill c2017 Available from:
http://accesspharmacy.mhmedical.com.suproxy.su.edu/drugs.aspx?gbosID=131742