Paroxetine


Thông tin thuốc gốc
Chỉ định và Liều dùng
Oral
Obsessive compulsive disorder
Adult: As paroxetine hydrochloride/mesilate conventional tab; oral susp: Initially, 20 mg daily preferably in the morning, may be gradually increased in 10 mg increments at intervals of at least 1 week according to individual response. Usual maintenance: 40 mg daily. Max: 60 mg daily.
Elderly: As paroxetine hydrochloride/mesilate conventional tab; oral susp: Max: 40 mg daily.

Oral
Generalised anxiety disorder
Adult: As paroxetine hydrochloride/mesilate conventional tab; oral susp: 20 mg daily preferably in the morning. Dose may be gradually increased in 10 mg increments at intervals of at least 1 week if response is inadequate. Max: 50 mg daily.
Elderly: As paroxetine hydrochloride/mesilate conventional tab; oral susp: Max: 40 mg daily.

Oral
Premenstrual dysphoric disorder
Adult: As paroxetine hydrochloride modified-release tab: Initially, 12.5 mg once daily preferably in the morning, may be increased to 25 mg once daily after an interval of at least 1 week if necessary. Doses may be given either continuously (daily throughout the menstrual cycle) or intermittently (during the luteal phase of the menstrual cycle).

Oral
Posttraumatic stress disorder
Adult: As paroxetine hydrochloride conventional tab/oral susp: Initially, 20 mg daily preferably in the morning, may be gradually increased in 10 mg increments at intervals of at least 1 week according to individual response. Max: 50 mg daily.
Elderly: As paroxetine hydrochloride conventional tab/oral susp: Max: 40 mg daily.

Oral
Social anxiety disorder
Adult: As paroxetine hydrochloride conventional tab/oral susp: 20 mg daily. Dose may be gradually increased in 10 mg increments if response is inadequate. Max: 50 mg or 60 mg daily. As paroxetine hydrochloride modified-release tab: Initially, 12.5 mg daily, may be increased in 12.5 mg daily increments at intervals of at least 1 week according to individual response. Max: 37.5 mg daily. All doses are given as a single daily dose preferably in the morning.
Elderly: As paroxetine hydrochloride conventional tab/oral susp: Max: 40 mg daily. As paroxetine hydrochloride modified-release tab: Initially, 12.5 mg daily, may be increased up to 37.5 mg daily.

Oral
Major depressive disorder
Adult: As paroxetine hydrochloride/mesilate conventional tab; oral susp: 20 mg daily. Dose may be gradually increased in 10 mg increments at intervals of at least 1 week if response is inadequate. Max: 50 mg daily. As paroxetine hydrochloride modified-release tab: Initially, 25 mg daily, may be increased in 12.5 mg daily increments at intervals of at least 1 week according to individual response. Max: 62.5 mg daily. All doses are given as a single daily dose preferably in the morning.
Elderly: As paroxetine hydrochloride/mesilate conventional tab; oral susp: Max: 40 mg daily. As paroxetine hydrochloride modified-release tab: Initially, 12.5 mg daily, may be increased up to 50 mg daily.

Oral
Panic disorder with or without agoraphobia
Adult: As paroxetine hydrochloride/mesilate conventional tab; oral susp: Initially, 10 mg daily, may be gradually increased in 10 mg increments at intervals of at least 1 week according to individual response. Recommended maintenance: 40 mg daily. Max: 60 mg daily. As paroxetine hydrochloride modified-release tab: Initially, 12.5 mg daily, may be increased in 12.5 mg daily increments at intervals of at least 1 week according to individual response. Max: 75 mg daily. All doses are given as a single daily dose preferably in the morning.
Elderly: As paroxetine hydrochloride/mesilate conventional tab; oral susp: Max: 40 mg daily. As paroxetine hydrochloride modified-release tab: Initially, 12.5 mg daily, may be increased up to 50 mg daily.

Oral
Moderate to severe vasomotor symptoms associated with menopause
Adult: As paroxetine mesilate cap: 7.5 mg once daily preferably at bedtime.
Special Patient Group
Pharmacogenomics:

Paroxetine is extensively metabolised by CYP2D6 isoenzyme to form glucuronide or sulfate conjugates. CYP2D6 polymorphisms may influence the metabolism, clinical efficacy, and safety of paroxetine.

CYP2D6 allele frequencies among individuals of different populations and ethnic backgrounds may be a considering factor that may cause potential uncertainty in genotyping and phenotype predictions. For example, CYP2D6*10 is common in Asians and CYP2D6*17 is common in people of Sub-Saharan African ancestry, while these alleles have considerably lower prevalence in other ethnic groups such as Caucasians of European ancestry. Moreover, Asian populations were also found to carry CYP2D6*14A allele. Thus, the alleles that should be tested may considerably vary for a given population.

CYP2D6 ultrarapid metabolisers
Carriers of duplications of functional alleles e.g. *1/*1xN, *1/*2xN, *2/*2xN. May have increased paroxetine metabolism as compared with extensive metabolisers, resulting in lower or undetectable plasma levels and increased risk of pharmacotherapy failure.
Clinical Pharmacogenetics Implementation Consortium (CPIC) recommends selecting an alternative drug not primarily metabolised or to a lesser extent by CYP2D6 (e.g. citalopram, sertraline).

CYP2D6 extensive metabolisers
Carriers of 2 normal function alleles, or 2 decreased function alleles, or 1 normal function and 1 no function allele, or 1 normal function and 1 decreased function allele e.g. *1/*1, *1/*2, *1/*4, *1/*5, *1/*9, *1/*41, *2/*2, *41/*41. May have normal paroxetine metabolism.
CPIC recommends initiating treatment with the recommended starting dose.

CYP2D6 intermediate metabolisers
Carriers of 1 decreased function and 1 no function allele e.g. *4/*10, *4/*41, *5/*9. May have reduced paroxetine metabolism as compared with extensive metabolisers, resulting in higher plasma concentrations and increased risk of adverse effects (e.g. insomnia, headache, sexual or gastrointestinal dysfunction).
However, CPIC considers initiating treatment with the recommended starting dose.

CYP2D6 poor metabolisers
Carriers of no functional alleles e.g. *3/*4, *4/*4, *5/*5, *5/*6. May have greatly reduced paroxetine metabolism as compared with extensive metabolisers, resulting in higher plasma concentrations and increased risk of adverse effects (e.g. insomnia, headache, sexual or gastrointestinal dysfunction).
CPIC recommends selecting an alternative drug not primarily metabolised by CYP2D6 (e.g. citalopram, sertraline). If paroxetine use is warranted, may consider 50% dose reduction of the recommended initial dose and titrate according to response.
Renal Impairment
Major depressive disorder; Obsessive compulsive disorder; Panic disorder with or without agoraphobia; Social anxiety disorder; Generalised anxiety disorder; Posttraumatic stress disorder; Premenstrual dysphoric disorder:

CrCl (mL/min) Dosage
Severe (<30) Use the lower end of the dosage range.
Hepatic Impairment
Major depressive disorder; Obsessive compulsive disorder; Panic disorder with or without agoraphobia; Social anxiety disorder; Generalised anxiety disorder; Posttraumatic stress disorder; Premenstrual dysphoric disorder: Use the lower end of the dosage range.
Cách dùng
May be taken with or without food. May be taken w/ meals to minimise GI upset.
Chống chỉ định
Pregnancy (as paroxetine mesilate cap). Concurrent use with or within 14 days after discontinuation of MAOIs (including linezolid and IV methylene blue). Concomitant use with pimozide, thioridazine.
Thận trọng
Patients with history of suicide-related events or pre-existing suicidal ideation, bipolar disorder, history of mania, pre-existing seizure disorder or conditions predisposing to seizures (e.g. brain damage, alcoholism), narrow-angle glaucoma or history of glaucoma, CV disease (e.g. recent history of MI, unstable heart disease), history of bleeding disorders or other conditions predisposing to bleeding, diabetes mellitus, volume depletion. Paroxetine mesilate cap: Not indicated for the treatment of any psychiatric conditions. Oral susp: Patients with high gastric pH or achlorhydria. Concomitant electroconvulsive therapy. Avoid abrupt withdrawal. Severe renal (CrCl <30 mL/min) and hepatic impairment. Debilitated patients. Elderly. Pregnancy and lactation. CYP2D6 ultrarapid and poor metabolisers.
Phản ứng phụ
Significant: Suicidal thoughts and behaviour, worsening of depression, mania or hypomania, akathisia or psychomotor restlessness, seizures, bleeding abnormalities (e.g. ecchymoses, purpura, epistaxis, haematomas, petechiae), anticholinergic effects, bone fractures, mild pupillary dilation, sexual dysfunction (e.g. impotence, ejaculatory disorder), withdrawal symptoms. Rarely, hyponatraemia (primarily in elders).
Cardiac disorders: Sinus tachycardia. Rarely, bradycardia.
Ear and labyrinth disorders: Tinnitus.
Eye disorders: Blurred vision.
Gastrointestinal disorders: Nausea, constipation, dry mouth, vomiting, diarrhoea.
General disorders and administration site conditions: Asthenia, fatigue, malaise, lethargy.
Investigations: Weight gain, increased cholesterol levels, transient changes in blood pressure. Rarely, elevated hepatic enzymes.
Metabolism and nutrition disorders: Decreased appetite.
Musculoskeletal and connective tissue disorders: Rarely, myalgia, arthralgia.
Nervous system disorders: Headache, dizziness, tremor, impaired concentration.
Psychiatric disorders: Insomnia, somnolence, agitation, abnormal dreams, aggression.
Renal and urinary disorders: Urinary retention or incontinence.
Respiratory, thoracic and mediastinal disorders: Yawning.
Skin and subcutaneous tissue disorders: Sweating, rashes, pruritus.
Vascular disorders: Postural hypotension.
Potentially Fatal: Serotonin syndrome, neuroleptic malignant syndrome (NMS)-like events, haemorrhage (e.g. gastrointestinal or gynaecological haemorrhage). Rarely, anaphylactoid reactions and angioedema.
Thông tin tư vấn bệnh nhân
This drug may impair judgment, thinking or motor skills, if affected, do not drive or operate machinery.
MonitoringParameters
Perform pregnancy tests for female patients prior to treatment initiation. Monitor renal function at baseline and as clinically indicated, LFTs, CBC as clinically indicated; serum Na in at-risk patients. Closely monitor for signs and symptoms of serotonin syndrome, clinical worsening, suicidality, or unusual behavioural changes especially at the start of therapy or during dose adjustments.
Quá liều
Symptoms: Somnolence, dizziness, nausea, tremor, tachycardia, confusion, vomiting, fever, involuntary muscle contractions, ECG changes, mydriasis, convulsions, ventricular dysrhythmias, hypertension, aggressiveness, syncope, hypotension, stupor, bradycardia, dystonia, rhabdomyolysis, hepatic dysfunction, manic reactions, myoclonus, acute renal failure, urinary retention, serotonin syndrome and coma. Management: Symptomatic and supportive treatment. Ensure adequate airway, oxygenation, and ventilation. Administer 20-30 g activated charcoal within a few hours of ingestion to decrease absorption. Frequently monitor cardiac rhythm and vital signs.
Tương tác
Increased risk of bleeding with aspirin, NSAIDs including COX-2 inhibitors, oral anticoagulants (e.g. warfarin), atypical antipsychotics (e.g. clozapine). May increase risk of hyponatraemia with diuretics. May increase blood glucose levels with pravastatin. May reduce plasma concentration and efficacy of endoxifen (active metabolite of tamoxifen). May reduce absorption of paroxetine oral susp with antacids, histamine H2-receptor antagonists, PPIs. Decreased plasma levels with fosamprenavir/ritonavir. Increased plasma levels of procyclidine, certain TCAs (e.g. clomipramine, nortriptyline, desipramine), phenothiazines (e.g. perphenazine), risperidone, atomoxetine, certain class 1C antiarrhythmics (e.g. propafenone, flecainide), metoprolol. May increase plasma concentrations with cimetidine.
Potentially Fatal: Increased risk of serotonin syndrome with other serotonergic agents (e.g. triptans, TCAs, fentanyl, lithium, tramadol, pethidine, buspirone, amphetamines, tryptophan) and agents which impair metabolism of serotonin (e.g. MAOIs including linezolid, IV methylene blue). Increased plasma levels of thioridazine and pimozide thus increasing the risk of QTc interval prolongation.
Food Interaction
Increased risk of serotonin syndrome with St. John’s wort.
Tác dụng
Description: Paroxetine selectively inhibits serotonin reuptake from the brain synapse, thereby stimulating serotonin activity in the brain.
Onset: Depression: Within 1 week; Anti-obsessional and anti-panic effects: Up to several weeks.
Pharmacokinetics:
Absorption: Readily and completely absorbed from the gastrointestinal tract. Increased peak concentration with food. Time to peak plasma concentration: 5.2-8.1 hours (immediate-release tab, susp); 6 hours (range: 3-8 hours [cap]); 6-10 hours (modified-release tab).
Distribution: Widely distributed throughout body tissues. Crosses placenta and enters breast milk. Volume of distribution: 8.7 L/kg (3-28 L/kg). Plasma protein binding: Approx 93-95%.
Metabolism: Undergoes extensive first-pass metabolism in the liver mainly via oxidation and methylation by CYP2D6 isoenzyme to form polar glucuronide and sulfate conjugates.
Excretion: Mainly via urine (approx 64% as metabolites, 2% as unchanged drug); faeces (approx 36% as metabolites, <1% as unchanged drug). Elimination half-life: Approx 21 hours (immediate release tab); 15-20 hours (modified-release tab).
Đặc tính

Chemical Structure Image
Paroxetine

Source: National Center for Biotechnology Information. PubChem Database. Paroxetine, CID=43815, https://pubchem.ncbi.nlm.nih.gov/compound/Paroxetine (accessed on Apr. 28, 2020)

Bảo quản
Modified-release tab; cap: Store between 20-25°C. Protect from light and humidity. Conventional tab: Store between 15-30°C. Oral susp: Store ≤25°C.
Phân loại MIMS
Phân loại ATC
N06AB05 - paroxetine ; Belongs to the class of selective serotonin reuptake inhibitors. Used in the management of depression.
References
Hicks JK, Bishop JR, Sangkuhl K et al. Clinical Pharmacogenetics Implementation Consortium (CPIC) Guideline for CYP2D6 and CYP2C19 Genotypes and Dosing of Selective Serotonin Reuptake Inhibitors. CPIC Guidelines. 2015 Aug;98(2):127-134. doi: 10.1002/cpt.147. Accessed 14/10/2019

Hicks JK, Bishop JR, Sangkuhl K et al. Supplement to: Clinical Pharmacogenetics Implementation Consortium (CPIC) Guideline for CYP2D6 and CYP2C19 Genotypes and Dosing of SSRIs. CPIC Guidelines. Accessed 14/10/2019

Annotation of CPIC Guideline for Paroxetine and CYP2D6. Pharmacogenomics Knowledgebase (PharmGKB). https://www.pharmgkb.org/. Accessed 14/10/2019.

Annotation of DPWG Guideline for Paroxetine and CYP2D6. Pharmacogenomics Knowledgebase (PharmGKB). https://www.pharmgkb.org/. Accessed 14/10/2019.

Anon. Paroxetine. Lexicomp Online. Hudson, Ohio. Wolters Kluwer Clinical Drug Information, Inc. https://online.lexi.com. Accessed 14/10/2019.

Brisdelle Capsule (Sebela Pharmaceuticals Inc.). DailyMed. Source: U.S. National Library of Medicine. https://dailymed.nlm.nih.gov/dailymed/. Accessed 14/10/2019.

Buckingham R (ed). Paroxetine. Martindale: The Complete Drug Reference [online]. London. Pharmaceutical Press. https://www.medicinescomplete.com. Accessed 14/10/2019.

Clinical Pharmacogenetics Implementation Consortium (CPIC) Guideline for CYP2D6 and CYP2C19 Genotypes and Dosing of Selective Serotonin Reuptake Inhibitors. Clinical Pharmacogenetics Implementation Consortium (CPIC). https://cpicpgx.org/. Accessed 14/10/2019.

Joint Formulary Committee. Paroxetine. British National Formulary [online]. London. BMJ Group and Pharmaceutical Press. https://www.medicinescomplete.com. Accessed 14/10/2019.

Paxil - Tablet, Film Coated; Suspension (Apotex Corp). DailyMed. Source: U.S. National Library of Medicine. https://dailymed.nlm.nih.gov/dailymed/. Accessed 14/10/2019.

Paxil CR - Tablet, Film Coated, Extended Release (Apotex Corp). DailyMed. Source: U.S. National Library of Medicine. https://dailymed.nlm.nih.gov/dailymed/. Accessed 14/10/2019.

Pexeva Tablet, Film Coated (Sebela Pharmaceuticals Inc.). DailyMed. Source: U.S. National Library of Medicine. https://dailymed.nlm.nih.gov/dailymed/. Accessed 14/10/2019.

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