Augment or Switch

Augmentation or Switching

There are no clear guidelines to provide guidance when considering switching medication for anxiety. It is reasonable to consider recommendations for depression. Factors to consider in choosing between switching vs. augmenting for depression are as follows:

According to 2016 CANMAT guidelines consider switching antidepressants when:

• it is the first antidepressant
• there are poorly tolerated side effects to the first antidepressant
• no response to (<25% improvement to the first antidepressant
• there is more time to wait for a response (less severe, less functional impairment)
• patient prefers to switch

CANMAT recommends considering adjunctive medication when:

• there have been 2 or more antidepressant trials
• the initial antidepressant is well tolerated
• there is a partial response (>25% improvement) to the initial antidepressant
• there are specific residual symptoms or side effects to the original antidepressant that can be targeted
• there is less time to wait for a response (more severe, more functional impairment)
• patient prefers to add on another medication

Augmentation

Please go to Increase or Augment

Switching

1. Consider switching to another medication approved for that disorder by Health Canada
   • please see Choosing an Antidepressant
2. If initial medication was an SSRI, and side effects are not the reason to switch, consider switching instead to an SNRI such as Venlafaxine and attempt to gradually dose to 225 mg if tolerated in order to see if patient needs noradrenergic effects seen at this dose (it is mostly a serotonergic medication at lower doses).
3. For Obsessive-Compulsive disorder consider switching to clomipramine if patient did not respond to adequate trials of an SSRI at higher doses and venlafaxine for  at least 8 weeks each at the maximum tolerable dose.
4. If unable to tolerate SSRI or SNRI consider Psychotherapy or for GAD and Social Anxiety Disorder a trial of pregabalin