Update on antidepressants during Covid-19

Fluoxetine & Sertraline
Many will be aware of some recent challenges accessing fluoxetine and sertraline.
PHARMAC is aware of the current supply issue affecting fluoxetine cap 20 mg with disruptions to supply of fluoxetine capsules and tablets in New Zealand is not a new issue. 

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• Mylan's Fluox brand is not currently available due to manufacturing issues
• Teva’s Arrow-Fluoxetine brand remains in the market to maintain continuity of supply. The Arrow-Fluoxetine caps have been on monthly dispensing since November 2019 and the tablets since late February 2020.

Sertraline Sertrona brand has no supply issues with both the supplier and ProPharma confirming availability
Antidepressants in Pregnancy - a friendly reminder from Dr Paul Daborn (Maternal Mental Health Psychiatrist)
Some GPs are still favouring fluoxetine, which was at one stage the preferred choice. There are risks associated with fluoxetine including earlier delivery, smaller for dates baby and, due to longer half-life (t1/2), more neonatal adaptation syndrome and problems.
Sertraline is the SSRI antidepressant of choice for pregnant women and may be used pre-conception through to the postnatal period and when breastfeeding.
There’s good evidence showing that discontinuing antidepressant medication during pregnancy risks a relapse of depression in up to 70% of women.
Try to expose the unborn baby to as few agents as possible by using the lowest effective dose. For sertraline this may be 50-150mg (rarely 200mg is required).
Current thinking is that there is:

• no increased risk of congenital abnormalities with first trimester exposure to sertraline.
• a modest increased risk of pre-term birth and low birth weight.
• a risk of neonatal adaptation syndrome, but sertraline is probably least problematical in this regard.

It's a good choice in breast feeding as less than 3% of maternal dose secreted into milk with metabolites often being undetectable in the baby.
In summary:

• Continue sertraline for pregnant women, do not change to another agent.
• Consider starting sertraline for depression in pregnancy or postnatally if breast feeding.

Nardil (Phenelzine tablets)
Phenelzine is one of two non-reversible monoamine oxidase inhibitor (MAOI) indicated for the treatment of depression.
Link Healthcare, the supplier of phenelzine tablets, has notified PHARMAC that they can no longer supply this medication in New Zealand. Nardil is the only Medsafe registered brand of phenelzine tablets in New Zealand. Link Healthcare expect all remaining stock of Nardil, to be depleted by mid-late May 2020
Implications

• People taking phenelzine will need to be changed to another antidepressant.
• Please ensure no new patients are started on phenelzine
• Please transition patients currently on phenelzine on to alternative treatments as soon as possible. Mental Health Subcommittee of the Pharmacology and Therapeutics Advisory Committee advise that tranylcypromine sulphate would be an appropriate alternative MAOI for patients, however:
  • treatment changes need to be individualised for each patient.
  • general practitioners should consult with a psychiatrist (e.g. Primary Care Psychiatrist) regarding treatment options and transition.
  • Tranylcypromine has a psychostimulant activity that phenelzine lacks - careful cross-titration is required
  • Approximate dose equivalence: phenelzine 15 mg ~ tranylcypromine 10 mg.​

​Dr Andrew Darby
Primary Care Psychiatrist

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