What is the first choice antidepressant for patients with ...



What is the first choice antidepressant for patients with renal impairment?Prepared by UK Medicines Information (UKMi) pharmacists for NHS healthcare professionals.Before using this Q&A, read the disclaimer at prepared: Nov 2017 Background Depression is a common psychiatric disorder which can be caused and exacerbated by chronic physical health problems [1,2]. Patients with chronic kidney disease, especially severe renal impairment (RI) have been shown to be at higher risk of depression [2]. Antidepressant prescribing rates are lower in patients on dialysis despite the increased prevalence of depression [3]. There is a lack of controlled trial data for the treatment of depression in RI and this, together with concern over antidepressant side effects, may contribute to reduced prescribing of antidepressants in RI [3]. The use of antidepressants in renal replacement therapies is not discussed here.AnswerMost antidepressants can be used with caution in RI since the majority are hepatically metabolised and do not significantly accumulate, even in severe RI [3-9]. The main issues surrounding prescribing antidepressants for patients with RI are much the same as for patients with normal renal function; the effects of age, comorbidities and the potential effects of concurrent medications need to be considered. In addition, patients with RI may be at increased risk of anticholinergic effects, bleeding and sedation associated with some antidepressants [5,10].In line with NICE guidance [1,2], the most appropriate antidepressant should be chosen based on:Any anticipated adverse events, for example side effects and discontinuation symptoms and potential interactions with concomitant medication or physical health problemsThe patient’s perception of the efficacy and tolerability of any antidepressants they have previously taken.NICE guidelines state that there is no evidence as yet supporting the use of specific antidepressants for patients with particular chronic physical health problems [2]. They recommend that when an antidepressant is to be prescribed, a SSRI is usually chosen first line as they are equally effective as other antidepressants but have a favourable side effect profile. Citalopram and sertraline are particularly recommended as they also have less propensity to interact compared with other SSRIs [1,2].This advice is not specific to RI.Table 1 contains a summary of the information from the manufacturer’s product information, Renal Drug Database and The Maudsley Prescribing Guidelines for a range of antidepressants. The Maudsley Prescribing Guidelines state that no agent is clearly preferred over another in RI. Sertraline and citalopram are suggested as reasonable choices although the QTc prolonging effects of citalopram should be considered. Electrolyte changes are common in established renal failure and are a risk factor for QTc prolongation and arrhythmia [5]. The Psychotropic Drug Directory assesses antidepressants in terms of risk in RI as follows [6]:Lower risk – agomelatine, mianserin, moclobemide, TCA’s, trazodone, vortioxetine Moderate risk – duloxetine, MAOIs, mirtazapine, reboxetine, SSRIs (most)Higher risk – venlafaxine, fluoxetine, sertraline.Both The Psychotropic Drug Directory and The Maudsley Prescribing Guidelines provide information on individual drugs where available [5,6]. The Psychotropic Drug Directory considers sertraline a higher risk antidepressant, compared with the recommendation in The Maudsley Guidelines; this is based on a study of 12 haemodialysis patients taking 25mg/day sertraline. All 12 showed signs of serotonin syndrome and 11 discontinued sertraline within 3 weeks [6]. The Renal Drug Database [4] suggests no renal dose adjustments are required for sertraline [4]. Other resources recommend lower starting doses and cautious titration in RI [9,11].The majority of information regarding the use of antidepressants relates to pharmacokinetic studies or to patients undergoing dialysis and there is limited data on clinical use in RI prior to dialysis. Reviews by Hedayati et al [3] and Nagler et al [9] provide information on most antidepressants in RI, including pharmacokinetic data, where available, and both reviews suggest that SSRIs be considered as a first choice although specific agents are not mentioned. Raymond et al [8] and Nagler et al [9], highlight that few studies have evaluated the clinical efficacy of antidepressants in RI but state that there is most evidence for the use of SSRI’s. Raymond et al., apply the principles of prescribing antidepressants for the general population to those with renal disease and suggest that newer drugs such as SSRIs, venlafaxine and mirtazapine are generally favoured over TCA’s and MAOIs due to their safety profiles, with choice of a particular agent based on adverse effects and interactions [8]. Hyponatraemia has been associated with all antidepressants, although it has been reported more frequently with SSRIs; reduced renal function is a risk factor for developing hyponatraemia [12,13].Particular caution may be required when switching between antidepressants as half-lives of individual agents may be increased in RI [4,6,7]. Wash out periods, where advised, may need to be extended to take this into account. The Maudsley Guidelines specifically recommend vigilance in monitoring for serotonin syndrome in patients with RI prescribed antidepressants [5]. Selective Serotonin Reuptake Inhibitors (SSRIs)SSRIs are often recommended as the agents of choice in RI [3,5,9,11] although there is a lack of robust evidence to support this recommendation and therefore it is mainly based on pharmacokinetic data and clinical experience [3,7,9]. Reviews by Nagler et al [9] and the Cochrane Collaboration [14] have demonstrated the paucity of information available on the use of antidepressants, including SSRIS, in RI and renal replacement therapies.SSRIs are predominantly hepatically metabolised and some SSRIs alter the kinetics of CYP450 enzymes [15-21]. In general SSRIs do not require a dose adjustment in RI, however as some metabolites are renally excreted, caution is required [4,15-19]. The half-life and plasma concentration of paroxetine have been shown to increase as renal function declines and lower starting doses are recommended by most sources [4,5,7,8,18]. Drug interactions may be a problem with the SSRIs that affect CYP450 enzymes. Fluoxetine, fluvoxamine and paroxetine in particular may interact with other medicines via this mechanism [1,21]. Fluoxetine is well tolerated in dialysis patients [7] but results of efficacy studies of fluoxetine in renal disease are conflicting [5]. Fluoxetine may not be the most appropriate first-line agent due to its extended half-life and interaction potential [1,5,7,21]. See notes above regarding citalopram and sertraline).SSRIs are associated with an increased bleeding risk which may be a concern in RI [3,8,12]. Tricyclic Antidepressants (TCAs)Historically, TCAs were the agents of choice in RI due to more experience of their use, but they have been superseded by the SSRIs due to safety concerns and adverse effects with TCAs [3,8]. Amitriptyline and dosulepin are effective but they are particularly dangerous in overdose and NICE [1- dosulepin only] and the BNF do not recommend their use in the treatment of depression [13]. Although most TCAs can be used cautiously in RI, as in patients with normal renal function, they are generally not recommended as first-line antidepressants. The majority of TCAs are hepatically metabolised and most do not alter the kinetics of enzymes in the CYP450 pathway [20-28]. Interactions with other medicines metabolised via the CYP450 pathway are therefore less likely than with the SSRIs, but numerous other interactions occur [11,20-28]. Lofepramine, of which approximately 50% is renally excreted, is contraindicated by its manufacturer in severe RI [6,26].TCAs’ antimuscarinic adverse effects may be more pronounced in RI, and all patients given TCAs should be monitored for urinary retention, confusion, sedation and postural hypotension [5]. Cardiac adverse effects, e.g. hypotension and arrhythmias, may also be a problem in patients with RI and co-existing cardiovascular disease [3,8]. Miscellaneous AntidepressantsThere is limited experience of the use of duloxetine in RI and it is contra-indicated by the manufacturer in patients with creatinine clearance (CrCl) <30mL/min [29]. Duloxetine is extensively metabolised by the CYP450 pathway to mainly inactive metabolites and it has been shown to accumulate in chronic kidney disease and dialysis patients [5,7,29]. Duloxetine has been associated with increases in blood pressure, and patients with hypertension or other cardiovascular disease or whose condition may be affected by an increase in blood pressure should have their blood pressure monitored [12]. Mirtazapine is extensively metabolised via the CYP450 pathway to active and inactive metabolites which are mainly excreted in the urine [20,30]. Clearance of mirtazapine is reduced in moderate to severe RI (CrCl <40mL/min) and the manufacturers advise that this should be taken into account when prescribing mirtazapine [6,30]. Mirtazapine has little antimuscarinic activity but is a potent inhibitor of histamine receptors and this accounts for its sedative properties [21,30]. Moclobemide is extensively metabolised by the liver, in part by CYP450 enzymes, to mainly inactive metabolites, which are renally excreted [20,31]. No dose alteration is required in RI as RI has not been shown to alter the elimination of moclobemide [6,31]. Moclobemide is claimed to have less risk of dietary and drug interactions than other MAOIs, but patients should still avoid consumption of large amounts of tyramine rich foods and should avoid taking sympathomimetics [13]. Reboxetine has been shown to be metabolised predominately by the CYP450 pathway in in vitro studies, to inactive metabolites, which are renally excreted [20,32]. Reboxetine is not thought to have any clinically significant effects on CYP450 enzymes [20,32]. Reboxetine’s half-life and plasma levels are approximately doubled in patients with RI [6]. The manufacturer recommends a 50% reduction in starting dose for patients with RI and avoiding its use in the elderly due to limited evidence in this patient group [32]. Venlafaxine is extensively metabolised via the CYP450 pathway to active metabolites which are mainly excreted in the urine [20,33]. The half-lives of venlafaxine and its metabolites have been shown to increase in RI [7,20]. The manufacturer recommends cautious use in RI and advises reducing the dose by 50% in severe RI (GFR <30mL/min) [33]. Venlafaxine has been shown to cause hypertension and monitoring of blood pressure is indicated for all patients taking venlafaxine but is especially important for those with pre-existing hypertension [7,12,33]. Venlafaxine also has an increased bleeding risk and it should be used cautiously in patients with cardiovascular disease [12,33]. Avoid using the XL preparations if the GFR is <30mL/min [5]. Agomelatine is one of the newer antidepressants and there is very little information available regarding its use in RI. Agomelatine is metabolised via the CYP450 pathway to inactive metabolites which are renally excreted [34]. No dosage modification in severe RI is recommended by the manufacturers but caution should be used due to the lack of clinical experience in this patient group [34].Trazodone is a tricyclic related drug and therefore has cautions similar to the TCAs [13]. Trazodone is extensively metabolised by the CYP450 pathway to active metabolites which are renally excreted [20,35]. In general, doses do not need to be reduced in RI but it is advisable to start with a low dose and increase the dose cautiously [4,5,35].Vortioxetine is a new antidepressant approved by NICE as a third line option for major depressive episodes [13]. The manufacturer of vortioxetine advises caution in severe renal impairment due to limited data [36]. Dose adjustment in any stage of RI is unlikely to be needed with vortioxetine [5,6,36].Due to the complexity of using lithium in RI, seek specialist advice before lithium is prescribed.SummaryData on the use of antidepressants in renal impairment are limited.The majority of antidepressants can be used in renal impairment with caution.The choice of the initial antidepressant is based on the same general principles as in normal renal function.Specific increased risks due to renal disease need to be considered.Start with a low dose, titrate slowly and monitor patients closely.Side effects may be enhanced in renal impairment.Extra caution may be needed when switching between antidepressants as half-lives may be extended.Lofepramine and duloxetine are contraindicated by their manufacturers in severe renal impairment.LimitationsThis Medicines Q&A is not designed to be a standalone resource on choice or dosing of antidepressants in renal impairment. Readers are advised to use standard drug dosing in renal disease resources to support decision making. This Q&A is intended for use in adult patients only. The use of antidepressants for indications other than depression is outside the scope of this Q&A. The use of antidepressants in renal replacement therapies is not discussed here.Table 1: Summary of information on the use of antidepressants in renal impairment from the manufacturer’s product information, Renal Drug Database and the Maudsley Prescribing Guidelines. (Details based on current editions and correct at the time of writing).Manufacturers' Information Renal Drug Database[4]The Maudsley Prescribing Guidelines [5]TCAsMonitor all patients given TCAs for urinary retention, confusion, sedation and postural hypotension.AmitriptylineNo information on dose adjustment available.[22]<10-50 mL/min dose as in normal renal function. Introduce gradually due to dizziness and postural hypotension.Withdraw treatment gradually.Dose as in normal renal function, but start with a low dose and increase slowly.Plasma level and ECG monitoring may be useful.Has been used to treat pain in renal disease.ClomipramineThe effects of RI on the pharmacokinetics of clomipramine have not been determined.[23]20-50 mL/min dose as in normal renal function. <10-20 mL/min start low and titrate according to response.20-50 mL/min dose as in normal renal function. <20 mL/min, effects unknown, start at a low dose and monitor.A case of clomipramine-induced interstitial nephritis and reversible acute renal failure has been reported.DoxepinUse with caution in patients with RI.[24]20-50 mL/min dose as in normal renal function. <10-20 mL/min start low and titrate according to response.Dose as in normal renal function. Haemolytic anaemia with renal failure has been reported.ImipramineCaution in severe RI.[25]In patients with severe RI, no change occurs in renal excretion of imipramine and its biologically active metabolites. However concentrations of the biologically inactive metabolites are elevated. The clinical significance of this is not known.[25]<10-50 mL/min dose as in normal renal function. <10-50 mL/min no specific dose adjustment necessary.Manufacturer advises caution in severe RI. Renal impairment and renal damage have been reported rarely.LofepramineLofepramine is contra-indicated in severe RI.[26]Lofepramine should be used with caution in RI.[26]10-50 mL/min dose as in normal renal function. <10 mL/min start low and titrate slowly.Contra-indicated by manufacturer in severe RI due to lack of data.10-50 mL/min dose as in normal renal function. <10 mL/min start with a small dose and titrate slowly.Manufacturer contra-indicates in severe RI. NortriptylineNo information available from the manufacturer.[27]10-50 mL/min dose as in normal renal function. <10 mL/min start with small dose.10-50 mL/min dose as in normal renal function. <10 mL/min start at a low dose.Plasma level monitoring recommended at doses >100mg/day. Worsening of GFR in elderly patients has been reported.TrimipramineNo information available from the manufacturer.[28]<10-50 mL/min dose as in normal renal function.Dose as for normal renal function.Elevated urea, acute renal failure and interstitial nephritis have been reported.SSRIsCitalopramDosage adjustment is not necessary in mild or moderate RI.[15]No information available for severe RI (CrCl <20 mL/min).[15]<10-50 mL/min dose as in normal renal function. Caution <10ml/min, reduced clearance in severe renal failure.Dose as for normal renal function.Caution if GFR <10ml/min due to reduced clearance.EscitalopramDosage adjustment is not necessary in mild or moderate RI.[16] Caution is advised in patients with severe RI (CrCl <30 mL/min).[16]30-50 mL/min dose as in normal renal function. <10-30mL/min start with a low dose and titrate slowly.Dose adjustment is not necessary in mild or moderate RI.Caution advised if <30mL/min; start with a low dose and increase slowly. Renal failure and reversible renal tubular defects have been reported.FluoxetineDialysis patients given fluoxetine 20mg/day for 2 months, showed no difference in levels of fluoxetine or norfluoxetine compared to controls with no RI.[17]Increased plasma concentrations may be observed in RI after repeated administration of fluoxetine.[17]10-50mL/min dose as in normal renal function.<10 mL/min use low dose, or on alternate days and increase according to response.Metabolites excreted renally; accumulation may occur in severe renal failure.20-50 mL/min dose as in normal renal function. <20 mL/min use a low dose or on alternate days and increase according to response.ParoxetineIncreased plasma concentrations occur in severe RI (CrCl < 30 mL/min). Caution is recommended and dosage should be restricted to the lower end of the dosage range.[18]30-50 mL/min dose as in normal renal function. <10-30 mL/min start with 20mg, titrate slowly.30-50 mL/min dose as in normal renal function. <10-30 mL/min start with 10mg (other sources say start at 20mg) and increase according to response.Rarely associated with Fanconi syndrome and acute renal failure.SertralineNo dosage adjustment is necessary in patients with RI. [19]<10-50 mL/min dose as in normal renal function. Dosing as for normal renal function.Sertraline has been used to treat dialysis-associated hypotension; however acute renal failure has been reported so use with caution.OthersAgomelatineNo change in pharmacokinetics observed in severe RI (n=8 single dose of 25mg) but cautious use is recommended in moderate or severe RI due to limited clinical data.[34]<10-50 mL/min dose as in normal renal function. Use with caution in RI and monitor patients closely.No data on use in renal disease.Manufacturer advises cautious use in moderate or severe RI.DuloxetineNo dosage adjustment is necessary for patients with mild to moderate RI (CrCl 30 to 80 mL/min).[29]Contra-indicated in severe RI (CrCl <30 mL/min).[29] 30-50 mL/min dose as in normal renal function, start with a low dose.<10-30 mL/min start at a very low dose and increase according to response.Contra-indicated by manufacturer <30mL/min due to increased plasma concentration and limited data.>30mL/min advise to start at a low dose and increase slowly.<30mL/min contra-indicated.A case of acute renal failure with duloxetine has been reported. MirtazapineClearance may be decreased in patients with moderate to severe RI (CrCl <40 mL/min). This should be taken into account when prescribing mirtazapine in this category of patients.[30]20-40 mL/min dose as in normal renal function.<10-20 mL/min start low, monitor closely.10-50 mL/min dose as in normal renal function.<10 mL/min start low, monitor closely.Mirtazapine has been used to treat pruritus caused by renal failure but is associated with kidney calculus formation.MoclobemidePatients with RI do not require dose adjustment.[31]<10-50 mL/min dose as in normal renal function. <10-50 mL/min dose as in normal renal function. An active metabolite was found to be raised in RI but was not thought to affect dosing.ReboxetineThe starting dose in RI should be 2mg BD which can be increased based on patients’ tolerance.[32]20-50 mL/min dose as in normal renal function.<10-20 mL/min start with 2mg BD and adjust according to response.GFR <20mL/min starting dose 2mg BD, adjust according to response.Half-life is prolonged as renal function decreases.TrazodoneNo dosage adjustment usually required in RI; monitor regularly.[35]Cautious use is recommended in severe RI.[35]20-50 mL/min dose as in normal renal function. 10-20 mL/min dose as in normal renal function; start with small doses and increase gradually.<10 mL/min start with small doses and increase gradually.20-50mL/min dose as in normal renal function.10-20 mL/min dose as in normal renal function; start with small doses and increase gradually.<10 mL/min start with small doses and increase gradually.VenlafaxineNo change in dosage is necessary for patients with GFR between 30-70 mL/minute; caution is advised.[33]In severe RI (GFR < 30 mL/min), reduce dose by 50%.[33]Because of inter-individual variability in clearance in RI patients, individualisation of dose may be desirable.[33]30-50 mL/min dose as in normal renal function. <10-30 mL/min reduce total dose by 50%. An ECG is required before treatment.Clearance is decreased and half-life prolonged in RI.Dosing advice differs.30-50 mL/min dose as in normal renal function or reduce by 50%.10-30 mL/min decrease dose by 50% and give once daily. <10mL/min decrease dose by 50% and give once daily but manufacturer advises avoiding in these patients.Avoid using the XL preparations if GFR <30mL/min. Rhabdomyolysis and renal failure have been reported rarely.VortioxetineNo dose adjustment is needed in RI.[36]Cautious use is recommended in severe RI.[36] 20<50 mL/min dose as in normal renal function. <20 mL/min dose as in normal renal function but use with caution.As per manufacturers advice; no dose adjustment needed in RI and end stage disease.AcknowledgementsRenal Pharmacist, Royal Devon and Exeter NHS Foundation TrustReferencesNational Institute for Health and Care Excellence [NICE].?Depression in adults: recognition and management. Clinical Guideline 90. Last updated April 2016. Accessed via on 26/09/2017. National Institute for Health and Care Excellence [NICE].?Depression in adults with a chronic physical health problem: recognition and management. Clinical Guideline 91, Published 2009. Accessed via HYPERLINK "" on 26/09/2017.Hedayati SS, Yalamanchili V and Finkelstein FO. A practical approach to the treatment of depression in patients with chronic kidney disease and end-stage renal disease. Kidney Int. 2012 Feb; 81(3):247-255.Ashley C and Dunleavy A. Editors. The Renal Drug Database. Radcliffe Publishing. Accessed via on 29/09/2017 and 30/11/2017 Monographs last reviewed Jun-Nov 2017.Taylor D, Paton C, Kapur S. Use of psychotropics in special patient groups: Renal Impairment. The Maudsley Prescribing Guidelines in Psychiatry 12th Edition. Wiley Blackwell; 2015; pp576-589.Bazire S. Renal Impairment, Antidepressants. Psychotropic Drug Directory. Aberdeen: HealthComm UK Limited; 2016; pp316-319.Baghdady NT, Banik S, Swartz SA, McIntyre RS. Psychotropic drugs and renal failure: translating the evidence for clinical practice. Adv Ther. 2009 Apr; 26(4):404-24. Raymond CB, Wazny LDHoncharik PL. Pharmacotherapeutic options for the treatment of depression in patients with chronic kidney disease. Nephrol Nurs J. 2008 May-Jun; 35(3): 257-263. EV, Webster AC, Vanholder R et al. Antidepressants for depression in stage 3-5 chronic kidney disease: a systematic review of pharmacokinetics, efficacy and safety with recommendations by European Renal Best Practice (ERBP). Nephrol Dial Transplant 2012. 0:1-10. Advance Access published Aug 1, 2012. Mitchell P, Harvey S. Depression and the older medical patient-When and how to intervene. Maturitas 2014,79:153-159. BC Provincial Renal Agency. Depression and Anxiety: The Role of Kidney Care Clinics. 2015. Accessed via on 26/09/2017.Clinical Knowledge Summary. Depression - Prescribing information. How should I monitor someone taking antidepressants? Last revised October 2015. Accessed via on 06/10/2017.Joint Formulary Committee. British National Formulary [online]. Antidepressant Drugs. Accessed via on 05/10/2017.Rayner L, Price A, Evans A, Valsraj K, Higginson IJ, Hotopf M. Antidepressants for depression in physically ill people. Cochrane Database of Systematic Reviews 2010, Issue 3. Art. No.: CD007503. DOI: 10.1002/14651858.CD007503.pub2. Accessed via on 26/09/2017.Summary of Product Characteristics. Cipramil Tablets. Lundbeck Ltd. Date of revision of text: Dec 2016. Accessed via: on 27/09/2017.Summary of Product Characteristics. Cipralex 5, 10 and 20mg film-coated tablets. Lundbeck Ltd. Date of revision of text: Sep 2013. Accessed via: on 27/09/2017.Summary of Product Characteristics. Prozac 20mg hard capsules and 20mg/5mL oral liquid. Eli Lilly and Company Ltd. Date of revision of text: Feb 2016. Accessed via: on 27/09/2017.Summary of Product Characteristics. Paroxetine 20mg tablets. Sandoz Ltd. Date of revision of text: Dec 2015. Accessed via: on 27/09/2017.Summary of product Characteristics. Lustral 100mg film coated tablets. Pfizer Ltd. Date of revision of text: Nov 2015. Accessed via: on 27/09/2017.Drugdex Drug Evaluations. Monographs for: amitriptyline, clomipramine, dosulepin,doxepin, imipramine, lofepramine nortriptyline, trimipramine, mianserin, trazodone, phenelzine, isocarboxazid,, tranylcypromine, moclobemide, citalopram, escitalopram, fluoxetine, fluvoxamine, paroxetine, sertraline, agomelatine, duloxetine, flupentixol, mirtazapine, reboxetine, venlafaxine. In: DRUGDEX System (electronic version). Thomson Micromedex, Greenwood Village, Colorado, USA. Accessed via on 06/10/2017.Preston CL (ed), Stockley's Drug Interactions. [online] London: Pharmaceutical Press. Accessed via on 06/10/2017.Summary of Product Characteristics. Amitriptyline tablets 10mg. Accord Healthcare. Date of revision of text: Apr 2017. Accessed via: on 27/09/2017.Summary of Product Characteristics. Clomipramine 10mg capsules. Generics UK T/A Mylan. Date of revision of text: Apr 2016. Accessed via: on 27/09/2017.Summary of Product Characteristics. Sinepin capsules 25mg. Marlborough Pharmaceuticals Ltd. Date of revision of text: Jan 2014. Accessed via: on 27/09/2017.Summary of Product Characteristics. Imipramine tablets 10mg. Actavis UK. Date of revision of text: Jun 2017. Accessed via: on 27/09/2017.Summary of Product Characteristics. Lofepramine 70mg tablets. Actavis UK. Date of revision of text: Jun 2017. Accessed via: on 27/09/2017.Summary of Product Characteristics. Nortriptyline tablets 10mg, 25mg. King Pharmaceuticals Ltd. Date of revision of text: Sep 2015. Accessed via: on 27/09/2017.Summary of Product Characteristics. Trimipramine capsules 50mg. Zentiva. Date of revision of text: Jun 2015. Accessed via: on 27/09/2017.Summary of Product Characteristics. Cymbalta hard gastro-resistant capsules 30mg, 60mg. Eli Lilly and Company Ltd. Date of revision of text: Jan 2017. Accessed via: on 27/09/17.Summary of Product Characteristics. Mirtazapine 30mg tablets. Sandoz Ltd. Date of revision of text: Apr 2015. Accessed via: on 27/09/2017.Summary of Product Characteristics. Moclobemide 300mg film coated tablets. Sandoz Ltd. Date of revision of text: May 2017. Accessed via: on 27/09/2017.Summary of Product Characteristics. Edronax 4mg tablets. Pfizer Ltd. Date of revision of text: Oct 2015. Accessed via: on 27/09/2017.Summary of Product Characteristics. Efexor XL 150mg hard prolonged release capsules. Pfizer Ltd. Date of revision of text: Jul 2016. Accessed via: on 27/09/2017.Summary of Product Characteristics. Valdoxan. Servier Laboratories Ltd. Date of revision of text: Jul 2017. Accessed via: on 27/09/2017.Summary of Product Characteristics. Molipaxin/Trazodone 150mg tablets. Zentiva. Date of revision of text: Apr 2015. Accessed via: on 27/09/2017.Summary of product Characteristics. Brintellix tablets 5, 10 and 20mg. Lundbeck Ltd. Date of revision of text: Jan 2017. Accessed via HYPERLINK "" on 27/09/2017.Quality Assurance Prepared byJill Forrest, based on earlier work by Tiffany Barrett, South West Medicines Information, University Hospitals Bristol NHS Foundation TrustDate PreparedNovember 2017Checked byJulia Kuczynska, South West Medicines Information, University Hospitals Bristol NHS Foundation TrustDate of checkJanuary 2018Search strategyEmbase (via NHS Evidence) - Search terms used:exp ANTIDEPRESSANT AGENT and (exp KIDNEY DYSFUNCTION OR exp KIDNEY DISEASE or KIDNEY FAILURE)exp DEPRESSION and (exp KIDNEY DYSFUNCTION OR exp KIDNEY DISEASE or KIDNEY FAILURE)Limit to: Human and English Language and Publication Year 2014-Current and (Human Age Groups Adult 18 to 64 years or Aged 65+ yearsMedline (via NHS Evidence) – Search terms used: (exp ANTIDEPRESSIVE AGENTS or exp DEPRESSIVE DISORDER) and (exp RENAL INSUFFICIENCY or exp KIDNEY DISEASES or exp ACUTE KIDNEY INJURY)[Limit to: English Language and Humans and Publication Year 2014-Current]In-house database/ resources The Renal Association: Royal College of Psychiatrists: ................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download