SSRI and PPI in primary care

[bananas85]

As a PCP, I see a lot of my patients on PPI (specifically omeprazole) and SSRI (specifically Lexapro). How do psychiatrists manage this? How long after discontinuing PPI does it take for the Cyp inhibition to resolve.

What other PPI is recommended? Protonix?

Is measuring a Lexapro level appropriate? If so what is an appropriate level.

Thank you

---

Members don't see this ad.

 

[Merovinge]

As a PCP, I see a lot of my patients on PPI (specifically omeprazole) and SSRI (specifically Lexapro). How do psychiatrists manage this? How long after discontinuing PPI does it take for the Cyp inhibition to resolve.

What other PPI is recommended? Protonix?

Is measuring a Lexapro level appropriate? If so what is an appropriate level.

Thank you

Omeprazole is specifically a large concern with citalopram, even moreso when people used to routinely be on 60mg. The main issue with a high level is not psychiatric, if pts are becoming psychiatrically toxic on the SSRI we can assess for that easily enough. The main issue is QTc prolongation. My VA attending had a guy prescribed omeprazole after having been on citalopram and his QTc got over 600.

Lexapro is somewhat less bad but the pt should just be on any other PPI that is appropriate and covered by the insurance, omeprazole I think is by far the biggest offender of CYP 2C19 inhibitation and it is not a class effect of PPI's themselves.

So no need for SSRI level, check the EKG and generally just get away from CYP 2C19 inhibition if the celexa/lexapro has helped the patient. If they must remain on the 2C19 inhibitor then talk to psychiatry about switching SSRI.

Edit - Good on you for asking about this, I see a lot of PCPs AND psychiatrists miss it!

 

[PistolPete]

Good post. I've never thought about omeprazole being a problem and prolonging QTc. This is why I hang around these boards, you always pick up stuff!

 

[nexus73]

if the lexapro is working just use a different ppi

 

[Blitz2006]

Great question

Found a good paper that addresses this issue, in the last couple paragraphs:

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3532688/

So I guess if someone is on PPI, should avoid Celexa/Lexapro...good to know.

 

[Merovinge]

Great question

Found a good paper that addresses this issue, in the last couple paragraphs:

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3532688/

So I guess if someone is on PPI, should avoid Celexa/Lexapro...good to know.

This has not been my experience, I believe pantoprazole is generally safe with the Celexa/Lexapro compounds.

https://www.ncbi.nlm.nih.gov/pubmed/8930576

 

[cbrons]

https://crediblemeds.org/blog/pantoprazole-now-conditional-tdp-risk-list/

Sent from my SM-N910P using SDN mobile

 

[Seroquelled]

So is the issue elevated levels of lexapro/celexa or is it hypomagnesemia? Or the combo?

 

[Merovinge]

So is the issue elevated levels of lexapro/celexa or is it hypomagnesemia? Or the combo?

To be clear I am not arguing anything about PPI's as a class and hypomagnesemia, that's out of my wheelhouse. Above the discussion was the specific intersection between PPIs with CYP2C19 inhibition and higher citalopram/escitalopram levels leading to prolonged QTc. That interaction should be avoided when possible and if not possible dosages of the SSRI should be adjusted downward with EKG monitoring; switching to pantroprazole is an easy way to avoid it, switching the SSRI is a less-easy but possible way.