Table 2

Actual messages in e-prescribing software—antidepressants

Trigger drugShort warningText displayed if prescribers presses the more buttonAlternative medications shown
AmitriptylineWarning—high risk of anticholinergic reactions and sedation in the elderly … more‘Amitriptyline (as well as doxepin) should not be used as first-line antidepressant therapy in elderly patients because of strong anticholinergic and sedative properties. In addition, cardiac toxicity is more likely to occur in the presence of underlying cardiac disease. Amitriptyline and doxepin may cause significant orthostatic hypotension in older adults even in lower dosages, thereby increasing the risk of falls and fractures. Although nortriptyline or desipramine may be used if a TCA is required, alternatives such as sertraline or citalopram generally are preferred as they may be safer in elderly patients.’

  • Sertraline

  • Citalopram Escitalopram

  • Mirtazepine

  • Buproprion

DoxepinWarning—high risk of anticholinergic reactions and sedation in the elderly … more‘Doxepin (as well as amitriptyline) should not be used as first-line antidepressant therapy in elderly patients because of strong anticholinergic and sedative properties. In addition, cardiac toxicity is more likely to occur in the presence of underlying cardiac disease. Doxepin, and amitriptyline may cause significant orthostatic hypotension in older adults even in lower dosages, thereby increasing the risk of falls and fractures. Although nortriptyline or desipramine may be used if a TCA is required, alternative antidepressants such as sertraline or citalopram generally are preferred as they may be safer in elderly patients.’

  • Sertraline

  • Citalopram, Escitalopram

  • Mirtazepine

  • Buproprion

Fluoxetine (daily)Warning—prolonged half-life in elderly, high ADR risk … more‘Although the daily administration of fluoxetine in healthy older adults has been shown to be safe and effective in clinical trials, concern exists because of the prolonged half-life of fluoxetine and nor-fluoxetine especially in more medically complex elderly patients. In addition, a risk of producing excessive CNS stimulation, sleep disturbances, and increasing agitation exists especially with daily fluoxetine. Fluoxetine may also cause multiple drug interactions. Safer alternatives such as sertraline or citalopram exist.’

  • Sertraline

  • Citalopram, Escitalopram

  • Mirtazepine

  • Buproprion

  • ADR, adverse drug reaction; CNS, central nervous system; TCA, tricyclic antidepressant.