Antidepressants

Depression is a very common medical disorder that affects every 1 in 5 individual in the U.S. It is often said that depression results from chemical imbalance in the brain, either too little or too much of certain chemicals in the brain. Factors that lead to chemical imbalance could be one or a combination of recent events, past issues, genetic vulnerability, medications, medical problems etc.

Antidepressants, as the name suggests treat depressants. About 50% of people who take antidepressant find their depression symptoms halved. The first antidepressant drug was Imipramine (Tofranil). It was marketed in 1958. Today, there are close to 30 antidepressants that are grouped into five categories. Each has different chemical structures to treat moderate to severe depression.

Types of antidepressants

There are five main types of antidepressants. They differ in the neurotransmitters they affect.

1. Monoamine oxidase inhibitors (MAOIs)

2. Serotonin and norepinephrine reuptake inhibitors (SNRIs)

3. Selective Serotonin Reuptake Inhibitors (SSRIs)

4. Tricyclic antidepressants (TCAs)

5. Atypical antidepressants

Under these five types of antidepressants, there are around 30 antidepressant medicines. They are grouped based on how they work. Each antidepressant is different and affects different systems of the brain to different degrees. Considering the difference to be as small as 3-4%, it can have an enormous impact on an individual to alleviate depression symptoms.

Patients respond to antidepressants differently. Some may respond to or tolerate one antidepressant and not respond to or tolerate another antidepressant. Each antidepressant has different use, adverse effects and drug interactions. Prescription of anti-depressants is based on the symptoms, patient's age, family history, drug tolerance, side effects and past response to antidepressants.

Monoamine oxidase inhibitors (MAOIs)

How MAOIs work: When depressed, the brain chemistry is impacted. The level of three neurotransmitters, norepinephrine, serotonin and dopamine is low. Collectively, these three are called monoamines. An enzyme called monoamine oxidase is linked to removing the three neurotransmitters from the brain.

Antidepressants such as MAOIs inhibit monoamine oxidase and allow more of the three neurotransmitters to remain in the brain. The levels of the chemicals rise. This elevates mood as there is improved brain cell communication.

MAOIs have been replaced by antidepressants that are far safer and cause fewer side effects. MAOIs carry the risk of considerable side effects and drug interactions.

The Food and Drug Administration has approved these MAOIs to treat depression.

• Isocarboxazid (Marplan)
  
• Phenelzine (Nardil)
  
• Selegiline (Emsam)
  
• Tranylcypromine (Parnate)
  

Of the four, Selegiline (Emsam) is a skin patch approved to treat major depressive disorder. The other three are available as oral medications.

Side effects of MAOIs

MAOIs carry the risk of considerable side effects and drug interactions. Hence, MAOIs are prescribed when other depressants fail to provide desired results.

Common side effects of MAOIs are dry mouth, nausea, diarrhea or constipation, headache, drowsiness, tiredness, weakness, insomnia, dizziness or lightheadedness, skin reaction at the patch site.

Other possible serious side effects include fainting, mental/mood changes, muscle stiffness, swollen ankles and legs, involuntary muscle jerks, shaking (tremor), low blood pressure, reduced sexual desire, sudden weight gain, eye pain, double/blurred vision, difficulty starting urine flow, muscle cramps, prickling or tingling sensation in the skin.

MAOIs interactions with other medicines

When two or more drugs interact, it can reduce the efficacy of the drug. Possibility of unexpected side effects is high. Knowing drug interactions is critical for your health. It is best to discuss with health care provider before taking MAOI anti-depressant medication.

MAOIs can cause serious reactions if taken with certain other drugs.

MAOI interaction with other antidepressants

• Tricyclic antidepressants
  
• Tetracyclic antidepressants
  
• SSRIs
  
• Other MAOIs
  
• Serotonin antagonists
  
• Mirtazapine
  
• Venlafaxine
  

MAOI interaction with asthma medicines

• Ephedrine and other asthma drugs
  
• Inhalants with albuterol, metaproterenol or other beta-adrenegic bronchodilators
  
• Theophylline

MAOIs interact with cold, cough, allergy, sinus, decongestant and hay fever medications. The medicines can be in the form of tablets, ointment, sprays or drops.

• Antihistamines
  
• Dextromethorphan
  
• Ephedrine
  
• Phenylephrine
  
• Oxymetazoline
  
• Phenylpropanolamine
  
• Pseudoephedrine
  

MAOIs interaction with diabetes medicines

• Insulin
• Oral hypoglycemic agents.
  

MAOIs interaction with medicines to treat low blood pressure.

• Dopamine
  
• Epinephrine
  
• Isoproterenol
  
• Metaraminol
  
• Methyldopa
  
• Norepinephrine
  

MAOIs interaction with medicines to treat high blood pressure.

• Guanadrel
  
• Hydralazine
  
• Methyldopa
  
• Reserpine
  
• Beta-blockers
  
• Calcium channel blockers
  
• Diuretics
  

MAOIs interaction with mood-stabilizer medicines

• Carbamazepine
  
• Lithium
  

MAOIs interaction with pain-killers and anesthetic medicines.

• Anesthetics (general)
  
• Anesthetics (local)
  
• Cyclobenzaprine
  
• Meperidine
  

MAOIs interaction with sedatives and tranquilizers

• Alcohol
  
• Barbiturates
  
• Buspirone
  
• Major tranquilizers
  
• Minor tranquilizers
  
• L-tryptophan
  

MAOIs interaction with stimulants and street drugs

• Amphetamines
  
• Benzedrine
  
• Benzphetamine
  
• Dextroamphetamine
  
• Methamphetamine
  
• Methylphenidate
  

MAOIs interaction with weight loss and appetite suppression medication

• Cylert
  
• Fenfluramine
  
• Phendimetrazine
  
• Phentermine and OTC medications
  
• Phenylpropanolamine
  

MAOIs interaction with other MAOI medicines

• Caffeine (coffee, tea, soda and chocolate)
  
• Disulfiram
  
• L-dopa
  

MAOIs interaction with food and beverages

MAOIs with certain foods and beverages can cause dangerous interactions. It is best to consult your doctor for a complete list of foods and beverages to be abstained from. Take for example tyramine, an amino acid which occurs naturally in the body and helps regulate blood pressure. When MAOI is recommended, foods and beverages with tyramine should be restricted as it can quickly reach dangerous levels and spike blood pressure.

• Foods with high levels of tyramine (an amino acid to regulate blood pressure) - Strong or aged cheese, cured meats, smoked or processed meats, sauces, soybeans and soybeans products, snow peas, broad beans and their pods, dried or overripe fruits, meat tenderizers, yeast-extract spreads, alcoholic beverages.
  
• Protein rich fruits (avocados, fava beans, Italian green beans or snow peas, sauerkraut and canned figs)
  
• Meat products
  
• Fish products
  
• Milk products
  
• Alcoholic beverages
  
• Improperly stored foods or stale foods.
  

MAOIs are not the first choice

MAOIs are prescribed only when all the other anti-depressants don't work. It's mainly due to the 'cheese effect'. The connection is established. Yes, those who ate products containing cheese while on an MAOI experienced severe headaches. Further, MAOI is not recommended for children or teenagers.

MAOI is given to people:

• When other antidepressants haven't worked
  
• Who cannot tolerate the side effects of other antidepressants
  
• Who have a family or personal history of using MAOI successfully
  
• With unusual depression symptoms
  

MAOI and psychotherapy

MAOI works best when paired with some form of psychotherapy. An antidepressant alone would not suffice to meet the behavioral, emotional or underlying mental health issues. A qualified psychotherapist can help in coping with the condition.

SNRIs type of anti-depressant

How SNRIs work: Serotonin and Norepinephrine Reuptake Inhibitors affect two important brain chemicals, serotonin and norepinephrine. Serotonin is regarded as a 'feel-good' chemical. It is associated with positive feelings of wellbeing. Norepinephrine is associated with alertness and energy. An imbalance can cause depression.

SNRIs block the reabsorption (recycling) of the neurotransmitters in the brain. Reabsorption is going back into the cells that released them. When reabsorption happens, the levels go down. When SNRIs block reabsorption, the levels of the two neurochemicals increase and helps improve and elevate mood, enhances the alertness of the person experiencing symptoms of depression.

This type of anti-depressant is also called dual reuptake inhibitors or dual-acting antidepressant as they affect two important brain chemicals-serotonin and norepinephrine. The Food and Drug Administration has approved these MAOIs to treat depression.

• Desvenlafaxine (Pristiq, Khedezla)
  
• Duloxetine (Cymbalta)
  
• Levomilnacipran (Fetzima)
  
• Venlafaxine (Effexor XR)
  

SNRIs interaction with other medications

Interactions between medicines can cause reactions which can be life-threatening. Before taking an anti-depressant, inform doctor of any/all medicines being taken. SNRIs interact with medicines like:

• Warfarin (Coumadin, Marevan)
  
• St.John's wort
  
• MAOIs
  
• Tricyclic antidepressants
  
• Triptans
  
• Anticoagulants
  
• Antihistamines
  
• Alcohol
  
• Theophyline
  
• Codeine
  
• Beta blocker medications for heart disease or high blood pressure
  
• Benzodiazepines
  
• Cisapride
  
• Carbamazepine (Tegretol)
  
• Thioridazine (Mellaril)
  
• Terfenadine (Seldane)
  
• Sumatriptin for migraine headaches
  
• Ketoconazole
  
• Trimadol
  
• Other antidepressants
  

Besides some medicines, intake of certain substances as given below, can increase the toxicity of SNRIs.

• Alcohol
  
• Drugs that depress the central nervous system
  
• Decongestants
  
• Medications used for insomnia
  

Side effects of SNRIs

Compared to other types of anti-depressants, SNRIs have fewer side effects. In most cases, the side effects go away after few days or weeks of taking SNRIs. Anti-depressant medications take four to six weeks to start working.

It is always best to inform the doctor of any side effect if experienced while taking any antidepressant. While taking an anti-depressant, it is not necessary for the patient to experience all the side effects. It may be any one or a few of these side effects.

• Mild nausea
  
• Headache
  
• Diarrhea
  
• Abdominal cramps
  
• Pain related to abdominal cramps
  
• Vomiting
  
• Constipation
  
• Dizziness
  
• Dry mouth
  
• Difficulty in sleeping
  
• Excessive sweating
  
• Sexual problems
  
• Loss of appetite
  
• Weight loss
  

Caution

Women who are pregnant or thinking of becoming pregnant and breastfeeding mothers should let the healthcare provider know while being prescribed an anti-depressant medication, including SNRIs.

Serotonin syndrome may occur when the levels of serotonin in the brain reaches high levels. It is triggered when an SNRI antidepressant is taken with another drug with high levels of serotonin (example – St.John's wort). Seek emergency medical help. The symptoms of severe serotonin level rise are very high fever, seizures, irregular heartbeat and unconsciousness.

Seek immediate medical attention, if while taking SNRIs, the patient:

1. Has abnormal bleeding

2. Has suicidal thoughts or behavior

3. Blood pressure levels rise (may increase when taking SNRIs)

4. Pressure of the fluid inside eye changes (narrow angle glaucoma)

Contraindication of SNRIs

Two SNRIs, namely Duloxetine and Milnacipran (approved to treat Fibromyalgia) is contraindicated in patients with uncontrolled narrow angle or angle-closure glaucoma. SNRIs can cause liver problems, including hepatitis. SNRIs are not recommended for people with liver problems and kidney problems (renal failure).

There is a high possibility of SNRIs affecting activities requiring mental or motor concentration. At least for the first few days or till such time the patient is accustomed to the effect, it is best to have family or friends or paid support.

Tricylic antidepressants (TCAs)

Also known as cyclic antidepressants or TCAs, this type of antidepressant is best suited for patients and is prescribed by doctor only when other drugs have failed to treat depression. TCAs are similar to SNRIs. TCAs increase levels of norepinephrine and serotonin, the two neurotransmitters and block the action of acetylcholine, another neurotransmitter. By restoring the balance in the brain Tricyclic antidepressants alleviate depression.

FDA approved Tricyclic antidepressants are:

• Amitriptyline
  
• Amoxapine
  
• Desipramine (Norpramin)
  
• Doxepin (Silenor)
  
• Imipramine (Tofranil)
  
• Nortriptyline (Pamelor)
  
• Protriptyline (Vivactil)
  
• Trimipramine (Surmontil)
  

Besides these, Maprotiline is a Tetracyclic antidepressant that is FDA approved to treat depression.

Side effects of Tricyclic antidepressants

40% of people taking antidepressants have side effects. Initially in most cases, the side effects may cause problem but would improve with time. Benefits of treatment outweigh the initial problems.

Tricyclic antidepressants are associated with many side effects. This is a reason why doctors prescribe other antidepressants with fewer side effects. Side effects are due to the interference of tricyclic antidepressants with autoimmune nervous system. Common side effects of TCAs are:

• Dry mouth
  
• Blurred vision
  
• Constipation
  
• Problems passing urine
  
• Feeling drowsy
  
• Feeling dizzy
  
• Sudden weight gain or weight loss
  
• Excessive sweating at night
  
• Skin rash
  
• Palpitation (Fast heart rhythm)
  

It is best to seek medical attention if the person experiences symptoms like:

• Trouble breathing
  
• Swelling of face, lips, tongue or throat
  
• Hives
  
• Thoughts of suicide
  
• Agitation and restlessness
  
• Seizures
  
• Fast heartbeat
  
• Nausea and vomiting
  

Drug interaction includes interaction of drugs with other drugs, interaction of drugs with food (drug-food interaction) and other substances. The interaction may increase or decrease the effectiveness of the drugs and/or its side effects. Sometimes, the interactions may lead to psychological sufferings.

Prior to starting treatment with any medication, including antidepressant, make a list of all the medications being taken and provide it to the health care provider.

• MAOIs
  
• Hypotensive agents (medicines used to treat blood pressure)
  
• Central nervous system depressants like alcohol, sedatives or hypnotics and barbiturates
  
• Anti psychotic agents
  
• Cimetidine, SSRIs, SNRIs, levodopa, anticoagulants
  
• Drugs that block acetylcholine
  
• Clonidine
  
• Sleeping pills
  
• Pain killers
  
• Tranquillizers
  
• Antihypertensive medicines
  
• Antihistamines
  
• Antifungal medicines
  

Caution

While taking TCAs it is best not to drink alcohol, as it can add to the side effects. People who have seizures, difficulty urinating, glaucoma or heart conditions (coronary heart disease) the symptoms can get worse.

SSRIs or Selective serotonin reuptake inhibitors

Of the different types of antidepressants for depression, SSRIs or Selective Serotonin Reuptake Inhibitors are most commonly prescribed. SRIs are relatively safe and have fewer side effects.

SSRIs ease symptoms of moderate to severe depression by increasing the levels of serotonin in the brain. Serotonin is one of the chemicals (neurotransmitter) that help to relay messages from one area of the brain to another. Serotonin is believed to influence a variety of psychological and other body functions. An imbalance in serotonin levels may influence mood and lead to depression. Low brain cell production of serotonin, a lack of receptor sites to receive the serotonin that is made, inability of serotonin to reach the receptor sites, shortage of tryptophan – chemical from which serotonin is made, any of these can lead to depression.

SSRIs are designed to boost serotonin levels. This enables production of new brain cells which in turn allows the depression to ease. SSRIs are called selective as they primarily affect serotonin and not other transmitters. SSRIs approved by the FDA for the treatment of depression are:

• Citalopram (Celexa)
  
• Escitalopram (Lexapro)
  
• Fluoxetine (Prozac)
  
• Fluvoxamine (Luvox, Luvox CR)
  
• Paroxetine (Paxil, Paxil CR)
  
• Sertraline (Zoloft)
  

SSRIs and drug interaction

SSRIs are subject to extensive oxidative metabolism (a chemical process wherein oxygen is used to make energy from carbohydrates) in the liver. Drug interactions with SSRI are either due to overdosing of the drug combined.

• Non-steroidal anti-inflammatory drugs (NSAIDs)
  
• Anti platelets (to prevent blood clots)
  
• Theophylline (to treat asthma)
  
• Medicines to treat Schizophrenia and psychosis
  
• Medicines to treat severe depression and bipolar disorder
  
• Medicines to treat migraines
  
• Decongestants
  
• Other antidepressants
  

Foods or substances to avoid while taking SSRIs

• Alcohol
  
• Diuretics
  
• St.John's wort
  
• Caffeine (Excessive consumption)
  
• Grape fruit
  
• Cheese (before or after taking pills)
  

SSRIs are not suitable for people with certain medical conditions. While an antidepressant medication is being prescribed, the health care provider should be informed if the patient has any of these medical conditions to weigh the benefits vs. risks.

• Bipolar disorder
  
• Hemophilia (Bleeding disorder)
  
• Type 1 diabetes or type 2 diabetes
  
• Epilepsy
  
• Narrow angle glaucoma
  
• Serious kidney, liver or heart problems
  

Side effects of SSRIs

The object of knowing side effects of any medication is to be aware of what to expect and to work out a strategy to continue medication and speed up recovery. Though SSRIs are the most commonly prescribed antidepressant, their side effects cannot be ignored.

All SSRIs tend to work in a similar way. But the active ingredient differs. Some people may experience side effects and some people may not. And even if experienced, common side effects of SSRIs are most likely to improve after few doses once the body adjusts to the medication. Talk to health care provider to know possible ways of reducing these side effects. For example, taking medication with food can reduce risk of nausea.

• Fatigue
  
• Weight loss
  
• Insomnia
  
• Headaches
  
• Nausea
  
• Pupil dilation
  
• Restlessness
  
• Nervousness
  
• Dizziness
  
• Diminished sexual desire
  
• Erectile dysfunction in men
  
• Difficulty achieving orgasm (men and women)
  

Caution

There are risks associated with taking any type of antidepressants during pregnancy. The medication does cross the placenta and are found in both amniotic fluid and breast milk. Associated risks are preterm birth, low birth weight, birth defects and delays in developmental milestones. The health care provider would recommend use of antidepressant during pregnancy based on the balance between risks and benefits. SSRIs have the best safety record. To treat depression during pregnancy SSRIs like Citalopram (Celexa), Fluoxetine (Prozac) and Sertraline (Zoloft) are recommended by health care providers.

Atypical antidepressants

How it works: Typically, these antidepressants do not fit into other types of antidepressants. Each atypical antidepressant is unique and works in a different way to treat depression. Atypical antidepressants are recommended for patients with major depression with inadequate responses or intolerable side effects during first-line treatment with SSRIs.

The link between the three main monoamine neurotransmitters in the brain i.e. dopamine, norepinephrine and serotonin and depression symptom is certain. Increase or decrease of specific neurotransmitter brings about specific symptoms which in turn suggest that depression can be assigned to specific neurochemical mechanism. Accordingly, doctors prescribe specific antidepressant drug that target symptoms-specific neurotransmitters to treat patient.

Atypical antidepressants work in this manner by effecting changes in brain chemistry. They change the levels of one or more neurotransmitters, such as dopamine, serotonin or norepinephrine. Changing the balance of these chemicals help brain cells send and receive messages, which in turn boosts mood and provide a sense of relaxation.

Atypical antidepressants approved by the FDA to treat depression are:

• Bupropion (Brand name:Wellbutrin, Forfivo XL, Aplenzin)
  
• Mirtazapine (Brand name: Remeron)
  
• Nefazodone
  
• Trazodone
  
• Vortioxetine (Brand name: Trintellix)
  

Side effects of atypical antidepressants

Some patients may not experience any side effect. Those who experience can feel assured that it may go away after a time. In case it persists, the health care provider may prescribe a different medication. Each atypical antidepressant is unique, side effects too vary.

• Anxiety
  
• Restlessness or agitation
  
• Confusion
  
• Constipation
  
• Dry mouth
  
• Headache
  
• Insomnia
  
• Increased and irregular heartbeat
  
• Nausea
  
• Sore throat
  
• Tremor
  

• Constipation
  
• Dizziness or lightheadedness
  
• Dry mouth
  
• Increased appetite
  
• Increased cholesterol
  
• Increased or decreased blood pressure
  
• Low white blood cell count
  
• Sleepiness
  
• Weakness
  
• Weight gain
  

• Blurred vision
  
• Confusion
  
• Constipation
  
• Dizziness or lightheadedness
  
• Dry mouth
  
• Headache
  
• Low blood pressure
  
• Nausea
  
• Excessive sleep
  
• Weakness
  

• Excessive sleep
  
• Headache
  
• Dry mouth
  
• Dizziness or lightheadedness
  
• Nausea
  
• Fatigue
  
• Diarrhea
  
• Constipation
  
• Insomnia
  
• Low blood pressure
  
• Feeling confused
  
• Blurred vision
  
• Irregular heartbeat
  

Caution

Atypical antidepressants can cause some problems in some circumstances. While atypical antidepressant is prescribed for treatment of depression, the patient should inform the healthcare provider of any health issues and related medicines being taken.

• Women who are pregnant or planning pregnancy should discuss the risks/benefits of taking atypical antidepressant. Never stop the medication suddenly and without informing the doctor as it poses great risks.
  
  
• Seek immediate medical attention if symptoms related to Serotonin syndrome occurs. When two medications that affect an increase in serotonin are combined, it can lead to Serotonin Syndrome. Symptoms include anxiety, agitation, sweating, confusion, tremors, restlessness, lack of coordination and a rapid heartbeat.
  
  
• Drinking alcohol or using illegal drugs while taking antidepressant medication may decrease the benefits, worsen the condition and increase adverse effects of the medication.
  
  
• Atypical antidepressant Bupropion should be avoided by patients with seizure disorder or an eating disorder like bulimia or anorexia.
  
  
• Mirtazapine is not approved for use in children. Also, Mirtazapine increases cholesterol levels.
  
  
• Nefazodone can aggravate liver disease.
  
  
• Trazodone is to be avoided by people with heart related ailments.
  
  
• Vortioxetine is linked to risk of bleeding.
  

Atypical antidepressant - Drug and food interaction

Certain drugs or substances may increase blood levels and toxicity.

• Alcohol
  
• Drugs for insomnia
  
• SSRIs
  
• TCAs
  
• MAOIs
  
• Beta Blockers
  
• Anti arrhythmic drugs
  
• Levodopa
  

• Alcohol
• Drugs for insomnia
  
• Anti arrhythmic drugs
  
• Phenothiazines
  
• TCAs
  
• MAOIs
  
• Warfarin
  
• Fluvoxamine
  
• Fluoxetine
  
• Paroxetine
  
• Rdioquin
  
• Quinolone antibiotics
  

• drugs taken for insomnia
  
• TCAs
  
• Thyroid medication
  
• Phenothiazines and Benzodiazepines
  

• Alcohol
  
• Drugs for insomnia
  
• Buspirone
  
• Carbamazepine
  
• Cisapride
  
• Cyclosporine
  
• Digoxin
  
• Pimozide
  
• Thioridazine
  
• Triazolam
  
• St.John's wort
  
• SSRIs
  
• TCAs
  
• Drugs that lead to abnormal heart rhythms
  
• Drugs to treat high cholesterol
  
• Buspirone
  
• Sibutramine
  
• Sumatriptan
  
• Drugs for migraine headache
  

• Alcohol
  
• Drugs taken for insomnia
  
• Clonidine
  
• Digoxin
  
• MAOIs
  
• Phenytoin
  
• Warfarin
  
• Antifungal agents
  
• Carbamazepine
  
• Phenothiazines
  
• Ritonavir
  
• SSRIs
  
• St.John's wort
  
• Drugs that cause abnormal heart rhythms
  

• Clozapine
  
• Desipramine
  
• Haloperidol
  
• Indinavir
  
• SSRIs
  
• Warfarin
  
• Cimetidine
  
• MAOIs
  
• St.John's wort
  

Painkillers

Painkillers are analgesic medications. Pain is experienced when the special nerve endings in that part of the injured body send pain messages to the brain. Painkilling medicines interfere with these messages either at the site of the injury, in the spinal cord or in the brain and block the pain. Painkillers are available in different forms. They can be swallowed as tablets, capsules or liquids. There are painkillers in the form of injection, suppositories, creams or an ointment.

Painkiller abuse is on the rise all over the world and the US is possibly the largest consumer of Painkillers. One of the reasons is the easy availability of OTC Painkillers and possibly owing to the drug induced exuberance or 'high' associated with the intake of some kind of narcotic painkillers. The following pages offer a complete insight about the different types of Painkillers and their effects.

Painkiller categories

Pain killer medications are broadly classified into two main groups:

Non-narcotic (non-opioids)
Narcotic (opioid)

Common Non-narcotic painkillers: Non narcotic painkillers include two types, namely Non steroidal anti inflammatory drugs (NSAIDs) and Acetaminophen.

NSAIDs:

Aspirin - Actual drug name : Acetylsalicylic Acid is one of the widest known/used drugs to manage pain and to some extent fevers. With its anti-coagulant properties Aspirin is used for lowering the risk of heart attack and strokes in low doses.

Dosage: For Pain management in Adults: 3 gm per day in divided doses.
Lowering of the risk of heart attack and strokes (Myocardial Infarction - Prophylaxis or Thromboembolic Stroke Prophylaxis): - Single dose between 75 and 325 mg.

Ibuprofen : Another potent Analgesic in the NSAID group, Ibuprofen is useful to treat mild to moderate pain and helps to relieve symptoms of arthritis (osteoarthritis, rheumatoid arthritis or juvenile arthritis), such as inflammation, swelling, stiffness, and joint pain. It is also used as an Antipyretic and for symptomatic treatment of menstrual cramps.

Dosage: For Pain management in Adults: 200 - 400 mg every 4 hours in a day if administered orally. 400 - 800 mg if administered intravenously over a period of 30 minutes every 6 hours.

Naproxen : This NSAID is effective to control pain, stiffness and inflammation associated with conditions like arthritis, ankylosing spondylitis, Tendonitis, bursitis and gout.

Dosage: For Pain management in Adults: 500 mg Naproxen twice daily or in divided doses subject to a maximum of 1 gm per day.

Aceclofenac: Aceclofenac is a NSAID that is commonly used for its analgesic and anti-inflammatory properties. It is typically prescribed to treat various conditions such as rheumatoid arthritis, osteoarthritis, ankylosing spondylitis and other inflammatory disorders. Aceclofenac works by inhibiting the production of prostaglandins, which are substances responsible for pain, swelling, and inflammation. It primarily targets the enzyme cyclooxygenase (COX), specifically COX-2, thereby reducing pain and inflammation.

Dosage : The dosage of aceclofenac may vary depending on the patient's age, condition, and response. It is typically administered orally as tablets or capsules, with or without food. The recommended initial dose for adults is usually 100 mg twice daily.

Diclofenac : This NSAID is useful for pain management when there is inflammation such as Arthritis, Dermatomyositis and Ankylosing Spondylitis.

Dosage: For Pain management in Adults: 50mg tablets 3 times a day subject to a maximum of 150mg per day.

Indomethacin : This drug is prescribed for fever, pain, stiffness and swelling especially for relieving symptoms of swelling and pain related to osteoarthritis, rheumatoid arthritis and ankylosing spondylitis. Indomethacin is effective also to treat acute shoulder pain and gouty arthritis.

Dosage: For Pain management in Adults: 25 - 50 mg every 8 hours subject to a maximum of 150 - 200 mg per day depending upon the severity of the pain.

Celecoxib: is used for rheumatoid arthritis, osteoarthritis, ankylosing spondylitis, juvenile arthritis and menstrual pain.
Dosage:For Pain management in Adults: 200 mg once per day.

Narcotic painkillers:

• Codeine
  
• Fentanyl
  
• Meperidine
  
• Morphine
  
• Oxycodone
  
• Tramadol
  
• Hydrocodone
  
• Hydromorphone
  

NSAIDs provide relief from pain associated with inflammation. They are commonly used for headaches, fever, dental pain, dysmenorrhea, bone pain, arthritis and muscle aches. If prescribed alone, NSAID relieves slight to moderate pain and for moderate to severe pain relief, NSAIDs are used in combination with opioids. Some NSAID can be purchased over-the-counter and does not require a prescription from a medical doctor. Do not use this class of drug immediately before or after Coronary Artery Bypass Graft (CABG). Generally NSAIDs are not advisable when Dengue fever is present as this class of analgesics may induce capillary leakage which can lead to hemoconcentration and serous effusions resulting in circulatory collapse.

Acetaminophen: is available under many trade names. e.g.; Tylenol, Panadol
Paracetamol

Being an Analgesic and an Antipyretic (drug to reduce fever), Paracetamol (Acetaminophen) is used to treat many conditions such as headaches, muscles aches, arthritis, backache, toothaches, colds and fever caused by infection. Acetaminophen is available in the form of chewable tablets, capsules, liquid as well as in the form of suppositories. Acetaminophen can be taken after or before food unless specifically directed by the doctor.

Contraindication: Certain prescription medications when taken along with Paracetamol can cause problems. Paracetamol is not to be used without recommendation from a doctor under any of these circumstances.

• Liver problems
  
• Liver failure
  
• Excessive drinking of alcohol
  
• Allergy to Acetaminophen

Paracetamol during pregnancy

Paracetamol is not to be used by pregnant women without recommendation from the doctor. Taking Paracetamol while breast feeding can harm a nursing baby as Paracetamol can pass into breast milk. Signs of allergic reaction to Paracetamol include hives, difficulty breathing, and swelling of the face, lips, tongue or throat. Without further delay seek medical help.

Dosage: For Adults: 500 mg tablets every four hours per day subject to a maximum of 4 gms.

Narcotic painkillers: When the OTC painkillers do not provide the much needed relief from pain, narcotic painkillers are prescribed by the doctor. Narcotic are powerful painkillers effective in relieving severe pain. If not taken correctly or as directed by the doctor, narcotic painkillers can have serious side effects.

Codeine

Codeine is used to treat mild to moderately severe pain. It is also used to reduce severe cough and diarrhea. Codeine is available in the form of a tablet, a capsule, and a solution (liquid). Codeine can be taken with or without food. Narcotic medications should never be combined with alcohol as it can lead to dangerous side effects or even death. If there is a history of hypersensitivity to Codeine, it should not be prescribed. Also, Codeine is not to be used under these circumstance:

• Respiratory depression
  
• Acute or severe bronchial asthma or hypercarbia
  
• Symptoms of paralytic ileus. (bowel obstruction)
  
• Raised intracranial pressure

Codeine during pregnancy

FDA has categorized Codeine in Category C. Pregnant women or women planning to conceive should inform the doctor before using Codeine. If potential benefits outweigh potential risks, Codeine may be recommended for use during pregnancy. Codeine can pass into breast milk and may harm a nursing baby. Mild side effects include dizziness, lightheadedness, headache, drowsiness, mood change, nausea, vomiting, constipation, stomach pain and difficulty urinating. Serious side effects include difficulty in breathing, palpitations, hives, change in vision and seizures.

Fentanyl

Fentanyl is prescribed to treat pain in cancer patients. Fentanyl is particularly used for 'breakthrough pain', pain that is not controlled by other medicines. Fentanyl is usually not prescribed for treating or relieving pain other than cancer related. Fentanil is available in the form of buccal tablet, buccal film, nasal spray, oral transmucosal lozenge, transdermal film extended release. Fentanyl is not for casual use as this drug is far more potent than Morphine. Do not use this medication to relieve mild, short-term, or sudden pain.

Fentanyl is contraindicated for select health conditions and circumstances. Those with a known history of substance abuse should keep away from Fentanyl. If MAOI has been taken within 14 days, Fentanyl should be avoided as it may cause seizures, hyperthermia, and hypertension and in serious cases loss of life.

• Intolerance to any of the drug component.
  
• Hypotension
  
• Hypersensitivity
  
• Head injury
  
• Myasthenia Gravis
  
• Hypovolemia

Fentanyl during pregnancy

FDA has categorized Fentanyl in Category C. Pregnant women or women planning to conceive should inform the doctor before using Fentanyl. There is a possibility of addiction or withdrawal symptoms in newborns if the pregnant mother takes Fentanyl during pregnancy.

Meperidine

Meperidine (or Pethidine as it is commonly known)is prescribed to ease moderate to severe pain as determined by the doctor. In particular, Meperidine is used to ease pain that is experienced before or during surgery, for pain during labor and delivery. In some cases, Meperidine is prescribed for pain occurring from chronic conditions like sickle cell anemia and some type of cancers. Meperidine is available in the form of tablets as well as oral solution. Meperidine can be taken with or without food or as directed by doctor.

Pethidine is contraindicated in patients who are hypersensitive to Pethidine and those who have received recently. Also, patients who have breathing problems, respiratory depression, paralytic ileus, severe infectious diarrhea should avoid Meperidine. Do not take Meperidine while taking medicines like ritonavir, sibutramine or sodium oxybate.

Meperidine during pregnancy: FDA has categorized Meperidine in Category C. As there is a high possibility of respiratory depression in newborns, Meperidine should not be used in pregnant woman.

Side effects may be mild or severe. Less serious effects of Meperidine include constipation, loss of appetite, headache, feeling weak, dry mouth, excessive sweating, and unusual itching, below normal urinating, loss of interest in sex.

Morphine

Morphine is used for severe pain, cough suppression and sometimes before surgery. In most cases, Morphine is prescribed when the patient requires relief from pain for longer than a few days. Morphine is available in the form of capsules, oral solution, syrup or tablets. It is advantageous to drink plenty of liquid while taking Morphine.

Contraindication

Morphine is contraindicated in patients who have undergone surgery unless Morphine was used before surgery.

• Don't use Morphine in case of allergic reaction to narcotic medicines or narcotic cough medicines that contain codeine, hydrocodone or dihydrocodeine.
  
• If prone to asthma attack or a bowel obstruction, Morphine is not to be used.
  
• Dangerous drug interaction is possible if Morphine is used within 14 days of using a MAO inhibitor.
  
• Morphine is contraindicated in case of an undiagnosed abdominal pain, injuries of the head, chest injuries or depressed respiration and if the person is unconscious.

Morphine during pregnancy

FDA has categorized Morphine as Category C. Pregnant women or women planning to conceive should inform doctor before using Morphine. There is a possibility of addiction or withdrawal symptoms in newborn if the pregnant mother takes Morphine during pregnancy. Morphine can pass into breast milk and may harm a nursing baby.

Morphine side effects

There can be mild and severe side effects of Morphine. Look out for these side effects and remember to discuss with the doctor without delay. Besides these in case of any unusual body response, seek medical attention without delay.

• Shallow breathing
  
• Slow heart rate
  
• Seizures
  
• Cold clammy skin
  
• Severe weakness
  
• Trouble swallowing
  
• Pale skin
  
• Easy bruising
  
• Weight loss
  
• Constipation
  
• Memory problems
  
• Disturbed sleeping patterns.

Oxycodone

Similar to Morphine, Oxycodone is used for severe pain, cough suppression and sometimes before surgery. In most cases, Oxycodone is prescribed when the patient requires relief from pain for longer than a few days. Oxycodone is available in the form of a pill and liquid form. Drink plenty of water to avoid constipation. Oxycodone like many other Narcotic Pain Killers can be dangerous if alcohol is consumed. It is contraindicated for Asthma patients or those who suffer from paralytic ileus.

Oxycodone during pregnancy The FDA has assigned category B for Oxycodone. Unless the potential benefits outweigh the risks, Oxycodone is not given to pregnant women as this narcotic drug is habit forming. Though Oxycodone is excreted into breast milk, the potential effects are not well-established.

Tramadol

Tramadol is prescribed to relieve pain and is recommended for short term use only. Tramadol is effective in managing pain for rheumatoid arthritis, fibromyalgia and restless legs syndrome. Tramadol is available in the form of tablets, capsules, liquid and injection form.

Contraindication: Tramadol is contraindicated in patients who are suffering from epilepsy, previous head injury as it can induce seizures. Tramadol should not be prescribed to those with allergic reaction to any narcotic drug. Tramadol should not be taken with other medications like muscle relaxants, anti nausea medicines and anti depressants as it can exacerbate other underlying conditions.

Tramadol during pregnancy

The FDA has categorized Tramadol under category C. There are significant chances of the unborn baby developing problems and hence pregnant woman should not use Tramadol. Further, as Tramadol can pass into breast milk and harm a nursing baby, it should not be used while breast feeding.

Tramadol side effects

Most common side effects of Tramadol are constipation, diarrhea, drowsiness, dry mouth or nausea. If these persist seek medical attention immediately. Some of the serious side effects of Tramadol include severe or mild headaches, difficulty with swallowing, sudden mood swings, seizures, blurred vision, ringing in the ears and colored stools. Contact your doctor or go to the nearest emergency hospital.

Hydrocodone

Hydrocodone - a narcotic analgesic is usually available in combination with other ingredients like Paracetamol which contributes to better effect in pain control. There are Hydrocodone combinations to relieve moderate to severe pain and some to relieve cough. Hydrocodone is available in the form of tablet, capsule, syrup, solution and extended-release capsule as well as extended-release suspension. A normal diet would suffice unless specifically directed by doctor while using Hydrocodone.

Contraindication

Hydrocodone is contraindicated in patients with hypersensitivity to Hydrocodone or any ingredient of the formulation. Those with CNS (Central nervous system) depression and severe respiratory depression should avoid hydrocodone.

Hydrocodone during pregnancy

Hydrocodone is categorized under C by the FDA. As there is certain amount of risk associated, Hydrocodone is prescribed for pregnant women only if the potential benefits outweigh potential risks. Some of the side effects include nausea, headache, chest constriction, irregular heartbeat, allergic reactions and trouble urinating.

Hydromorphone

Hydromorphone is used to treat longer bouts of pain that do not respond to OTC painkillers. Being stronger than Morphine, hydromorphone is preferred to regulate pain from injuries, surgery, cancer and severe migraine headaches. Hydromorphone is normally given through parenteral administration as other ways of administrations result in poor absorption.

Contraindication

Hydromorphone is contraindicated in these circumstances.

• Allergy to hydromorphone or any other opioid medicines or any other ingredient of this medication.
  
• Has acute asthma or any other breathing problem.
  
• Has acute respiratory problem or severe central nervous system depression
  
• Has pulmonary edema.

Hydromorphone during pregnancy

As per FDA classification, Hydromorphone falls under category C. Unless, the potential benefits outweigh potential risks, doctors will not prescribe hydromorphone for pregnant women. Nausea and vomiting are very common side effects that occur initially. Serious side effects of Hydromorphone include allergic reaction, hives, confusion, severe weakness, losing consciousness and seizures. Seek medical attention immediately without any delay.

FDA Pregnancy Categories Drugs are divided into many categories based on the given drug and its effects on the fetus or its mother during pregnancy:

• Category A: Safe during Pregnancy based on studies on human
  
  
• Category B: Reasonably Safe - based on Animal studies
  
  
• Category C: Animal studies indicate possible risk - but the benefits may necessitate the use despite the risks
  
  
• Category D: Not Safe for fetus
  
  
• Category X: Do NOT use during Pregnancy as the potential for serious side effects is high