Dr. Bob's Psychopharmacology Tips

SSRI maximum doses

Date: Mon, 15 May 1995 22:13:39 +0059 (EDT)
From: scole@world.std.com (Stanley Cole)
Subject: SSRI maximum doses

On Mon, 15 May 1995, Sergio Henao wrote:

It has been said in this group that patients sometimes respond to SSRI doses beyond the usually recomended ones. For instance, sertraline has been given in doses of up to 600 mg a day with success. I checked with some of my colleagues (psychopharmacologists) in Houston and they never heard of it and would not recomend it. In view of this I decided to call the medical information department at the manufacturing company. Their physician told me that for that particular drug the response curve has been flat and for this reason they would not recomend or support going beyond 200.

Glenn Davis at Henry Ford told me there were old cases of patients who required very high doses of neuroleptics because of metabolism by overgrown bacteria in the gut and that single doses of neomycin to wipe out the abnormal flora restored the absorption of the drug.

BTW, for medicolegal reasons, the drug company always refuses to recommend doses higher that the FDA labeling.

From: Kevin Miller <MillerKB@wpogate.slu.edu>
Date: Wed, 17 May 1995 02:17:05 -0400
Subject: SSRI maximum doses

I've used sertraline to 300 mg/day and paroxetine to 60 mg/day without difficulty. My best indicator of response above the maximum recommended dose is a partial response at doses up to the maximum. I find if improvement continues with increases in dose, increases above the recommended maximum are well tolerated.

Date: Tue, 16 May 1995 05:49:35 -0700 (PDT)
From: eliot.gelwan@channel1.com (Eliot Gelwan)
Subject: SSRI maximum doses

I am familiar with a patient with AIDS (CMV, CNS toxoplasmosis, etc.) who reported only minimal to negligible relief at fluoxetine 80 mg qd. When the patient increased (on his own) to 100 mg qd, he reported more relief. Specifically, he reported that he then awoke in the morning with severe depression which decreased rapidly within 30 minutes to two hours (although he dozed in the early afternoon). The attending (internal medicine/infectious diseases) was (and remains) uncomfortable with more than 60 mg qd, although is re-considering in light of the absence of problematic side effects, reliability of the patient, and remarkable psychological resilience of this patient who has had a full-blown AIDS diagnosis for more than four years.

Date: Wed, 19 Jul 1995 18:48:19 -0700 (PDT)
From: Ivan Goldberg <psydoc@psycom.net>
Subject: SSRI maximum doses

I have treated patients with OCD and Borderline Personality Disorder with doses of Prozac in the 400 mg/day range. None showed symptoms of the serotonin syndrome.

From: PMBrig@aol.com (Peter M. Brigham, MD)
Date: Mon, 30 Oct 1995 22:00:05 -0500
Subject: SSRI maximum doses

On Sat, Oct 28, 1995, jkp@world.std.com wrote:

Jonathan Shay reports that his Viet Nam vets routinely need 40-60 mg of fluoxetine. Maybe the PTSD population generally does. (Overlap with substance abuse [might also be a factor].)

I have one robustly healthy guy -- non-drug abuser, non-traumatized -- who needs 60 mg of fluoxetine, but only one.

I wonder if those who generally use lower doses usually just switch SSRIs rather than increasing beyond a certain point...

Date: Tue, 31 Oct 1995 21:54:55 +0001 (EST)
From: scole@world.std.com (Stanley Cole)
Subject: SSRI maximum doses

My experience like Peter's is of a significant number of patients needing high doses of fluoxetine (so far 120 mg is the highest I have had to go). I have done levels on most of these folks and they were with one exception modest. While levels do not correlate with effect, these indicate that these patients are either not absorbing the medication or are very rapid metabolizers. One sees the same phenomenon with most other medications. We also know that in the pool of so called treatment resistant patients, at least half have had inadequate dosing. The rule of thumb for dosing has always been to increase to the point of response or intolerable side effects. The was the myth that grew up around fluoxetine that 20 mg was the magic number, as long as you waited up to 6-12 weeks, but it isn't always so.

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