What antidepressants do not cross-react with sertraline?

Fråga: What antidepressants do not cross-react with sertraline? A patient has developed facial edema and rash during sertraline treatment.

Sammanfattning: Cross-reactivity often occurs within the same antidepressant group and therefore a change of drug class is recommended. Based on the current reports of adverse effects it seems SNRIs could be an alternative. TCAs could also be a reasonable choice based on its pharmacodynamic properties.

Svar: Angioedema has often been reported to appear in combination with urticaria and is believed to be a type 1 hypersensitivity reaction. Angioedema in combination with urticaria can appear as an adverse effect with all antidepressants, but they generally resolve after discontinuation of the drug (1). Cutaneous reactions in general as an adverse reaction to sertraline have been discussed in several previous Drugline documents (19883, 15130, 13726, 22929).

Angioedema alone as an adverse reaction has been reported for all SSRIs, SNRIs, TCAs and tetracyclics, but only one case-report has been published this far (1). The case concerned a 64-year-old woman who developed swelling of her tongue and constriction of her throat six hours after her first dose paroxetine, her symptoms cleared without any treatment (2). There are a few reports on allergic reactions to fluoxetine and angioedema associated with fluvoxamine (3, 4). In the Swedish register of adverse reactions there are several reports on angioedema associated with antidepressants.

Cross-reactivity between different SSRIs has been described, despite the fact that SSRI have different chemical structures (5, 6). When patients develop adverse cutaneous reactions it is therefore advised that the next antidepressant is chosen from a different drug class (7, 8). There are currently no studies on the cross-reactivity between SSRI and other antidepressants such as SNRI, TCAs, mirtazapine and monoamine oxidase inhibitors (MAO-inhibitors). The role of excipients such as titanium dioxide as an allergenic substance has been discussed in a previous Drugline document (Drugline 15130) but patients who react to titanium dioxide often also react to many other drug classes.

TCAs with dimethylated amine (amitryptiline, doxepin, trimipramine, clomipramine and imipramine) primarily block serotonin reuptake but they also block cholinergic and histaminic receptors. The antihistaminic properties of TCAs have been suggested to explain the low number of reports on urticaria under treatment with TCA (9).

In the Swedish database of adverse effects (BiSi), there are similar numbers of angioedema and anaphylactic reactions associated with different SSRIs (sertraline, fluoxetine, fluvoxamine), TCAs, mirtazapine, and SNRIs (bupropion, duloxetine and venlafaxine), with bupropion as the most frequently associated with angioedema and anaphylactic reactions. Warnock JK, Morris DW. Adverse cutaneous reactions to antidepressants. Am J Clin Dermatol 2002;3(5):329-39 Mithani H, Hurwitz TA. Paroxetine-induced angioedema and tongue swelling. J Clin Psychiatry 1996 Oct;57(10):486 Paxil (paroxetine). Compendium of pharmaceuticals specialities. 31st ed. Ottawa, Ontario, Canada: Canadian Pharmaceutical Association; 1996:1111-3 Luvox (fluvoxamine maleate). Compendium of pharmaceuticals specialities. 31st ed. Ottawa, Ontario, Canada: Canadian Pharmaceutical Association; 1996: 808-9 Warnock CA, Azadian AG. Cross-sensitivity between paroxetine and sertraline. Ann Pharmacother 2002 Apr;36(4):631-3 Beauquier B, Fahs H. Secondary dermatologic effects of serotonin reuptake inhibitor antidepressants: hypothesis of cross-reacting. Encephale 1998 Jan-Feb;24(1):62-4 (Article in French) Krasowska D, Szymanek M, Schwartz RA, Myslinski W. Cutaneous effects of the most commonly used antidepressant medication, the selective serotonin reuptake inhibitors. J Am Acad Dermatol 2007 May;56(5):848-53 Warnock JK, Knesevich JW. Adverse cutaneous reactions to antidepressants. Am J Psychiatry 1988 Apr;145(4):425-30 Tan EK, Grattan CE. Drug-induced urticaria. Expert Opin Drug Saf 2004 Sep;3(5):471-84