*note many side effects are dose-dependent – they increase with dose increases or they reemerge with a dose increase until tolerance develops again

If med is working: Reduce dose and stay on the tolerated dose before trying to increase it again, titrate slow moving forward vs Augment

If med is not working or side effect intolerable even at the lowest dose: Switch

*note many side effects are time-dependent – they start immediately upon dosing and upon each dose increase, but go away with time

wait, wait, wait…if pt willing (if not, address)

Dose dependent side effect

• Decrease the dose temporarily wait for side effect to subside before increasing it SLOWLY back up
• Blurry vision (anticholinergic effect): decrease dose, wait, switch if it does not get better
• Bruxism: decrease dose, cyclobenzaprine 2.5mg at bedtime, add Buspar 2.5mg BID, acrylic mouth guards
• Emotional blunting (increased serotonin can cause diminished dopamine release) – pt feeling like a “zombie” diminished ranged of accessible emotions eg. someone close to them dies and they’re unable to cry: decrease dose, add Abilify or Seroquel (you can also try Wellbutrin 100-200mg SR), or switch to Zoloft or Prozac
• Fatigue/sedation: move to bedtime
• GI distress: take medication with food, split dose to BID if extreme
• Insomnia: move to AM, use sleep aids temporarily, use trazodone
  *insomnia coupled with increased anxiety/activation/restlessness can indicate SSRI initiation syndrome vs manic flip and can be reason to STOP the medication
• Muscle spasms/clenching: baclofen 5mg or tizanidine 2mg or cyclobenzaprine 5mg HS
• Paresthesia “tingling”: consider pyridoxine (vit B6) 150mg daily
• REM Behavior Disorder (acting out dreams) management HERE
• Restless Leg management HERE
• Serotonin Syndrome (caution in use with other serotonergic agents, please note this is rare): stop added agent, decrease dose
• Sexual dysfunction HERE
• Sleepwalking management HERE
• Sweating: take medication exactly at the same time every day eg 9am or 9pm (have pt set phone alert). If that does not help consider clonidine 0.1-0.2mg qHS
• Yawning: switch to a different group of meds
• Tremor/jitters: reduce dose, consider propranolol 10-40mg daily if bothersome

Non dose dependent side effects

• Brain “zaps” Effexor/Paxil discontinuation: use Prozac 10mg x 5 days, then 10mg every 2 days for the next 10 days then stop
• Urinary incontinence: d/c meds or try benztropine 0.5-1mg qHS; 0.5 to 1 mg/day as a single dose. Titrate in 0.5 mg increments every 5 to 6 days based on response and tolerability. Usual dose: 1 to 2 mg/day (range: 0.5 to 6 mg/day) although some patients may need 4 to 6 mg/day; maximum: 6 mg/day)
• Urinary retention: d/c meds
• Weight gain and metabolic side effects HERE

Older patients:

• Caution with long term risk and patients >65 for fragility fractures; advise them to get a bone scan if other risk factors are present (done for women over 65, men over 70)
• Caution with GI bleeding, make sure they complete annual physical, ask about fatigue, stool color