What anxiety medications can be given with Paxil (paroxetine)?

Anxiety Medications Compatible with Paxil (Paroxetine)

When prescribing anxiety medications alongside paroxetine (Paxil), citalopram/escitalopram are the preferred options due to their minimal drug interactions through the CYP450 system, making them safer to combine with paroxetine. 1

Understanding Paroxetine's Profile

Paroxetine (Paxil) is a selective serotonin reuptake inhibitor (SSRI) with the following characteristics:

• More anticholinergic than other SSRIs 1
• Potent inhibitor of CYP2D6 enzyme 1
• Associated with discontinuation syndrome 1
• Has been associated with higher risk of suicidal thinking compared to other SSRIs 1

Safe Medication Options to Combine with Paroxetine

First-Line Options:

• Citalopram (Celexa): Has the least effect on CYP450 isoenzymes compared to other SSRIs, making it safer to combine with paroxetine 1
• Escitalopram (Lexapro): Similar to citalopram with minimal drug interactions 1

Second-Line Options:

• Mirtazapine (Remeron): Well-tolerated option that promotes sleep, appetite, and weight gain 1
• Bupropion (Wellbutrin): Activating properties may be beneficial for patients with low energy; should not be used in agitated patients 1

Medications to Use with Caution

• Sertraline (Zoloft): While it has less effect on metabolism of other medications compared to other SSRIs, still exercise caution 1
• Benzodiazepines: May be considered but require careful monitoring for dependence and cognitive effects 1

Medications to Avoid

• Monoamine Oxidase Inhibitors (MAOIs): Absolutely contraindicated due to high risk of serotonin syndrome 1
• Fluvoxamine (Luvox): Has significant interactions with multiple CYP450 enzymes (CYP1A2, CYP2C19, CYP2C9, CYP3A4, and CYP2D6) 1
• Other serotonergic drugs: Use extreme caution with:
  • SNRIs (venlafaxine, duloxetine) 1
  • Tricyclic antidepressants 1
  • Tramadol, meperidine, methadone, fentanyl 1
  • Dextromethorphan, St. John's wort 1

Monitoring Recommendations

• Start any additional serotonergic medication at a low dose 1
• Increase doses slowly with careful monitoring, especially in first 24-48 hours after dosage changes 1
• Monitor for signs of serotonin syndrome: mental status changes, neuromuscular hyperactivity, autonomic hyperactivity 1
• Watch for symptoms of QT prolongation if combining with medications that affect cardiac conduction 1

Special Considerations

• Elderly patients: Lower doses are recommended due to slower metabolism 2
• Hepatic impairment: Reduced elimination requires dose adjustment 2
• Discontinuation: Taper slowly over 10-14 days to minimize withdrawal symptoms 1

Clinical Pitfalls to Avoid

• Serotonin syndrome: A potentially life-threatening condition that can occur when combining multiple serotonergic medications 1
• Drug-drug interactions: Paroxetine inhibits CYP2D6, which can increase blood levels of other medications metabolized by this enzyme 1
• Discontinuation symptoms: Can be severe with paroxetine; include dizziness, sensory disturbances, anxiety, irritability 1
• Initial anxiety exacerbation: SSRIs can temporarily worsen anxiety when first started 1

By carefully selecting compatible anxiety medications and monitoring for potential interactions, clinicians can safely augment paroxetine therapy when needed for patients with anxiety disorders.