From the Guidelines
Selective serotonin reuptake inhibitors (SSRIs) and most other antidepressants should be avoided when taking rasagiline due to the risk of serotonin syndrome. The safest antidepressant option to use with rasagiline is bupropion (Wellbutrin), which works primarily on dopamine and norepinephrine systems rather than serotonin 1. Typical starting doses are 150 mg daily, which can be increased to 300 mg daily if needed. A minimum washout period of 14 days is required when switching between rasagiline and serotonergic antidepressants. This recommendation is based on bupropion's mechanism of action, which has minimal effect on serotonin levels, thus reducing the risk of dangerous drug interactions with MAO-B inhibitors like rasagiline. Some key points to consider when prescribing antidepressants with rasagiline include:
- Concomitant administration of any of the SSRIs with any of the monoamine oxidase inhibitors (MAOIs) is contraindicated because of increased risk of serotonin syndrome 1
- Bupropion has a lower propensity for drug interactions compared to other antidepressants, making it a safer option to use with rasagiline
- Patients should still be monitored for potential side effects such as increased blood pressure, agitation, or insomnia
- Any combination of antidepressants with rasagiline should be supervised by a healthcare provider who can monitor for adverse effects and adjust treatment as needed. It's also worth noting that the evidence from the study on premature ejaculation 1 is not directly relevant to the question of which antidepressant is safe to use with rasagiline, as it discusses the use of SSRIs for a different indication. However, it does highlight the importance of considering the potential risks and benefits of different antidepressants, including the risk of serotonin syndrome when used with MAOIs like rasagiline.
From the Research
Safe Antidepressant Options with Rasagiline
When considering the use of antidepressants with rasagiline, a monoamine oxidase B (MAO-B) inhibitor, it is crucial to select an antidepressant that minimizes the risk of serotonin syndrome, a potentially life-threatening condition. The following points outline safe options and considerations:
- Mirtazapine: This antidepressant has a unique mechanism of action that may make it a safer choice when used with MAO-B inhibitors like rasagiline. However, there have been cases where mirtazapine, in combination with other serotonergic agents, has induced serotonin syndrome 2.
- Serotonin and Norepinephrine Reuptake Inhibitors (SNRIs): While SNRIs like venlafaxine and duloxetine can be effective, their use with MAO-B inhibitors requires caution due to the potential for increased serotonergic effects and serotonin syndrome 3.
- Selective Serotonin Reuptake Inhibitors (SSRIs): The combination of SSRIs and MAO-B inhibitors can result in increased serotonergic effects, leading to serotonin syndrome. However, some studies suggest that this combination can be well-tolerated if the recommended doses are not exceeded and the SSRI dose is kept at the lower end of the therapeutic range. Among SSRIs, citalopram and sertraline may be preferred 4.
- Case Reports and Studies: There have been case reports of serotonin syndrome associated with the combination of escitalopram and rasagiline 5, highlighting the need for careful monitoring and dose adjustment when combining these medications.
Key Considerations
- Dose Adjustment: Keeping the SSRI dose at the lower end of the therapeutic range may help minimize the risk of serotonin syndrome.
- Monitoring: Close monitoring for signs of serotonin syndrome is essential when combining antidepressants with rasagiline.
- Alternative Options: Considering alternative antidepressants with a lower risk of serotonin syndrome when used with MAO-B inhibitors may be necessary in some cases.