In managing side effects associated with psychotropic drugs, prescribers need to arm themselves with a menu of strategies and opt first for simpler solutions over adding or switching a medication, Rajnish Mago, MD, said at Psych Congress 2020.
In a virtual session he termed as a “call to action” on an often neglected component of prescribing, the editor of SimpleandPractical.com said that for each common side effect, strategies should be classified based on intensity as Level 1, 2, and 3 approaches. The most intensive Level 3 measures should be used only if side effects persist but stopping the offending medication would be problematic, said Dr. Mago, who teaches at SUNY Upstate Medical University, Syracuse, New York, and the University of Pennsylvania, Philadelphia.
Dr. Mago added that medical professionals often do not focus enough on common everyday side effects such as nausea, dry mouth, and excessive sweating. These might not be as medically serious as extreme side effects, but often are the issues that lead patients to stop taking a medication or fail to take an effective dose.
Two Prevalent Challenges
He reserved time at the end of the session to address the prevalent and much-discussed side effects of sexual dysfunction and weight gain. There is an approximately 25% prevalence of sexual dysfunction associated with antidepressant use where there is no other known cause. The problem may be more severe in women, but prescribers will need to ask women because they are less likely than men to report sexual side effects, Dr. Mago said.
Only about 10% of patients experiencing sexual dysfunction will see improvement simply by waiting 6 to 18 months. “Please don't keep telling patients it will get better, because usually it will not,” Dr. Mago said. More productive approaches, he suggested, might include drug holidays (effective for sertraline and paroxetine in 50% of cases, according to research), switching to a drug such as bupropion or mirtazapine with fewer sexual side effects, or adding for men a drug to treat erectile dysfunction where appropriate.
On the issue of weight gain, Dr. Mago had one primary message: “Those of you who are not prescribing metformin for metabolic side effects, please consider this. This is a greatly underutilized strategy.” For weight gain associated with second-generation antipsychotics, metformin has demonstrated even greater effectiveness than topiramate, he said. A 2016 study found that for patients who had gained more than 10% of their baseline weight, metformin resulted in an average weight reduction of 7.5%.
Metformin should be considered in the first few months of antipsychotic treatment where indicated, but it should not be used in the elderly or the medically ill, Dr. Mago said. Doses of extended-release metformin can start at 500 mg once a day, with increases to an optimal dose of 1000 mg twice a day. A daily multivitamin is advised because metformin can lead to vitamin B12 deficiency, Dr. Mago said.
Scale of Approaches
For each common side effect, Dr. Mago discussed starting with basic approaches to managing the effect before opting for more intensive strategies.
To manage nausea, the most common cause of treatment discontinuation in antidepressant trials, he suggested first titrating an antidepressant up over one week, or using sustained-release formulations or split dosing. Ginger root also is effective for combating nausea — “this is not an old wives' tale,” he said.
If these approaches do not produce results, Level 2 strategies such as prescription anti-nausea medications may be needed. Ondansetron has been widely used, but mirtazapine works on the same serotonin receptors and may be worth keeping in the menu of options, Dr. Mago said.
The goal always should remain to “have many options in your back pocket,” he said.
“Systematic Strategies for Managing Common Side Effects (Instead of Stopping or Switching the Medication).” Presented at Psych Congress 2020: Virtual; September 12, 2020.