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A 42-year old Caucasian man comes to the office for follow-up. He was diagnosed with depression two months ago, and has been undergoing treatment with fluoxetine ever since. The patient states that he is feeling better, and his sleep has improved. He is more optimistic, but he is worried because he is losing weight. His appetite continues to decrease despite treatment. He does not smoke or use illicit drugs, but he drinks alcohol on weekends. He works as a sales representative. Examination reveals no abnormalities. The patient is 5™11" tall, and weights 156 pounds. He lost 12 pounds in the last four months. Which of the following will be the most appropriate next step in the management of this patient?
A) Refer the patient to the nutritionist.
B) Start a work-up to rule out malignancy.
C) Stop fluoxetine; start bupropion.
D) Stop fluoxetine; start mirtazapine.
E) Continue fluoxetine; observe and reevaluate in one month.
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search out his CA pancreas.
heavily associated with depression.
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There are many plausible causes of this patient™s weight loss. It can be a feature of depression, when there is loss of appetite or anorexia. It may be a marker of an undiagnosed malignancy, which could coexist with depression. Lastly, it may be drug-induced.
In this case, the patient™s depressed condition seems to be improving with medication; however, his medication may be causing his lack of appetite and persistent weight loss. Fluoxetine causes anorexia in 4 to 11% of the cases, and in one third or more, will cause weight loss. Prolonged use (more than 6 months) can lead to weight gain in a small group of patients. Most antidepressants are related to weight gain, such as tricyclic antidepressants (TCA), especially amitriptyline or imipramine. Some selective serotonin reuptake inhibitors (SSRIs) can also increase weight. Examples are: paroxetine, citalopram and sertraline. Mirtazapine, a new tetracyclic agent, is also well known for its side effect of increasing appetite and weight.
(Choice C) Bupropion is related to decreased appetite and weight loss.
(Choice A) There is no urgent need for a nutritional referral since the patient™s weight loss can be explained by his lack of appetite, depression and drug therapy.
(Choice B) The patient™s weight loss is due to a decreased intake that is most probably due to fluoxetine use; therefore, changing the antidepressant is the most appropriate next step in this patient™s management. Furthermore, starting studies to rule out malignancy will provoke more anxiety and probably worsen the depression and loss of appetite in this patient.
(Choice E) Fluoxetine must be stopped, because it is the most probable cause of the patient™s current symptoms. Fortunately, this drug is one of the SSRIs that can be replaced without a high risk of having a "rebound effect."
Educational Objective:
Weight loss can be a side effect of antidepressants, especially bupropion and, less frequently, fluoxetine. Weight gain is a more common complication, especially with mirtazapine, paroxetine, sertraline, citalopram, imipramine and amitriptyline. The use of antidepressants must be tailored to each patient™s characteristics.
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yaar 2 monhts h/p depression and loosing weight by 4 months.
trouble of weight loss is prior to developing depression.
i m confused. Aa?
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thnx dear.
good question.
