Table 2 Evidence for antidepressant treatment of depression during HCV Therapy and drug interactions with DAAs
From: Psychiatric treatment considerations with direct acting antivirals in hepatitis C
Level of evidence for depression treatment | Antidepressant (route of metabolism) | Known or potential interactions with DAAs | Comments |
|---|---|---|---|
Level 1 | Escitalopram (CYP2C19, 3A4 >> 2D6) | No interaction observed with boceprevir [37] 35% ↓ escitalopram AUC with telaprevir [38] | Boceprevir: no dose adjustment required. Telaprevir: May need to titrate escitalopram dose according to clinical response. |
Level 2 | Citalopram (CYP2C19, 3A4 >> 2D6) | Potential for ↓ antidepressant concentrations based on escitalopram interaction data. | Monitor and titrate dose according to clinical response. |
Paroxetine* (CYP2D6) | No interaction expected based on known pharmacologic characteristics. | Monitor and titrate dose according to clinical response. | |
Level 4 | Bupropion (CYP2B6), Fluoxetine (CYP2D6) | No interaction expected based on known pharmacologic characteristics. | Monitor and titrate dose according to clinical response. |
|  | Sertraline (CYP2B6 > 2C9/19, 3A4, 2D6, UGT1A1 - possible), Mirtazapine (CYP2D6, 1A2, 3A4), Venlafaxine (CYP2D6 > CYP3A4) | Potential for ↑ sertraline, mirtazapine, venlafaxine concentrations (clinical significance unknown). | Use with caution; monitor and titrate dose according to clinical response. |
Potential for ↑ desvenlafaxine concentrations (clinical significance unknown). | Monitor and titrate antidepressant dose according to clinical response. | ||
Tricyclic antidepressants i.e. Desipramine (CYP2D6>>UGT), Imipramine (CYP2D6, 1A2, 2C19, 3A > UGT), Trazodone** (CYP2D6> CYP3A) | Potential increase in TCA concentrations resulting in dizziness, hypotension and syncope. | Use with caution with DAAs, lower TCA doses are recommended. | |
Nortriptyline (CYP2D6) | No interaction expected based on known pharmacologic characteristics. | Monitor and titrate dose according to clinical response. | |
Avoid (exceptional circumstances only) | Duloxetine (CYP1A2, 2D6) | Duloxetine: risk of hepatotoxicity. | Duloxetine is contraindicated in liver disease. |
Nefazodone (CYP3A4) | Nefazodone: potential for ↑ nefazodone and/or DAA concentrations; also risk of hepatotoxicity. | Nefazone was discontinued in the United States and Canada in 2003 due to hepatotoxicity concerns. Avoid use in liver disease. | |
|  | St. John’s Wort (hypericum perforatum); induces CYP3A4 and P-gp [40]. | Potential for ↓ DAA concentrations. | St. John’s Wort is contraindicated with boceprevir [19] and telaprevir [18]. |