What alternative antidepressants are effective for a patient with extensive small bowel resection, previously on Lexapro (escitalopram), who discontinued it without withdrawal symptoms, potentially due to impaired absorption in the setting of shortened small bowel syndrome?

From the Guidelines

For patients with short bowel syndrome and depression, I recommend considering medications with alternative routes of administration or those less dependent on small bowel absorption, such as bupropion or mirtazapine, due to the potential for poor absorption of oral medications in this population. The patient's lack of discontinuation symptoms after stopping Lexapro suggests poor absorption of the medication through her limited small bowel, which is consistent with the findings of the AGA clinical practice update on management of short bowel syndrome 1. When initiating any new antidepressant, it is essential to start at lower doses and monitor closely for efficacy and side effects, as absorption may be unpredictable. Some key points to consider when managing depression in patients with short bowel syndrome include:

• Using medications that are less dependent on small bowel absorption, such as bupropion, which is primarily metabolized by the liver
• Considering non-oral options, such as transdermal selegiline or esketamine nasal spray, for treatment-resistant depression
• Monitoring therapeutic drug levels, if available, to ensure adequate absorption and efficacy
• Implementing non-pharmacological approaches, such as cognitive behavioral therapy, which can be particularly valuable in patients with complex medical conditions where medication absorption is compromised. The American College of Physicians recommends that clinicians assess patient status, therapeutic response, and adverse effects of antidepressant therapy on a regular basis, beginning within 1 to 2 weeks of initiation of therapy 1. Additionally, the British Society of Gastroenterology guidelines suggest that tricyclic antidepressants and selective serotonin reuptake inhibitors may be effective second-line treatments for irritable bowel syndrome, but their use should be carefully considered due to potential side effects and interactions 1. Overall, a comprehensive approach to managing depression in patients with short bowel syndrome requires careful consideration of the patient's individual needs and medical history, as well as close monitoring of treatment efficacy and side effects.

From the FDA Drug Label

The FDA drug label does not answer the question.

From the Research

Patient Background

• The patient underwent extensive small bowel resection 13 years ago due to a twisted superior mesenteric artery, resulting in large portions of necrotic small bowel being removed.
• The patient is on lifelong Total Parenteral Nutrition (TPN) feeds, currently 5 days a week for 10 hours a day.
• The patient has depression and was taking Lexapro 20mg for 3 years, but recently stopped with no discontinuation symptoms.

Drug Absorption in Short Bowel Syndrome

• Studies have shown that drug absorption can be altered in patients with short bowel syndrome due to the reduced surface area of the small intestine 2, 3.
• The absorption of certain drugs, such as antimicrobial agents, digoxin, and oral contraceptives, can be reduced in patients with short bowel syndrome 2.
• However, some drugs, such as warfarin, tricyclic antidepressants, and metronidazole, can still be effectively absorbed in patients with short bowel syndrome 2.

Antidepressant Treatment in Short Bowel Syndrome

• There is limited research on the treatment of depression in patients with short bowel syndrome, but studies suggest that individualized dosing and therapeutic drug monitoring may be necessary to achieve therapeutic efficacy 3, 4.
• Some antidepressants, such as duloxetine and sertraline, have been shown to have reduced levels in patients with short bowel syndrome, while others, such as citalopram and escitalopram, may have increased levels due to intestinal adaptation 4.

Selective Serotonin Reuptake Inhibitors (SSRIs)

• SSRIs are commonly used to treat depression, but they can have varying side effect profiles and pharmacokinetics 5, 6.
• Some SSRIs, such as escitalopram and sertraline, have been shown to be less tolerated in the gastrointestinal tract, while others, such as mirtazapine, may have fewer side effects 5.
• When prescribing SSRIs, a risk-benefit analysis must be considered, taking into account the potential treatment effects, adverse effects, and dangers of the illness being treated 6.