Because Prozac is metabolized principally by the liver, depressed or alcoholic patients with liver disfunction should be given either a lower dose of Prozac (or any other SSRI antidepressant) or none at all. A liver that is already overtaxed will take significantly more time to metabolize the drug. Regular monitoring of liver funtioning is necessary. Researchers have discovered that patients with normal livers require no more than three days before the amount of Prozac in the body diminishes to one-half, while patients with cirrhosis of the liver need over a week—7.6 days—to reach the same point. In addition, the study found that Prozac’s metabolite, norfluoxetine, also took several days longer to be flushed out of the system when liver disease was present.

What about marijuana, cocaine, LSD, or other similar drugs? These illegally obtained mood-altering drugs are all completely contraindicated for patients taking Prozac—and this would be true even if they were legal. Taken with or without Prozac, these drugs can cause uncontrolled highs, severe depression, and psychotic states in some people. For patients already prone to these reactions, the risk is high if an antidepressant drug like Prozac is added.

*115\22\4*

Prozac is especially helpful for patients with major depression, dysthymia (the milder version of major depression), and obsessive-compulsive disorder, as well as for patients who lack energy, feel listless, and chronically function below par, symptoms typically seen in subclinical depression. In addition, psychiatrists who have read individual claims of Prozac’s usefulness in treating bulimia and other disorders can probably feel safe prescribing Prozac to individual patients with these symptoms.

The FDA has completed some of its evaluations, and Prozac is now approved for major depression, obsessive-compulsive disorder, and bulimia. Despite its popularity, Prozac should be prescribed with care and not simply handed out to anyone who wants it.

What are the effects of Prozac on kidney function? Because the kidneys are responsible for the elimination of Prozac, an impaired and hence less efficient kidney may cause the drug to accumulate in the body. For this reason, patients with renal disease, as evidenced by high BUN or serum creatinine, including those undergoing hemodialysis, should take smaller than normal doses of Prozac. (Again, the same recommendation holds for patients with kidney disease who are receiving other SSRIs for their depression. Regular monitoring is required and nephrologists should be consulted.)

Can diabetics safely use Prozac if depressed? The use of Prozac in diabetic patients may alter the blood sugar control. Hypoglycemia, an abnormally low amount of glucose in the blood, has been reported in diabetic patients taking Prozac, and discontinuing therapy has occasionally produced hyperglycemia, an abnormally high concentration of sugar in the blood.

There is insufficient data to prove that Prozac alone can cause all of these changes in blood sugar, and so most diabetic patients may be treated safely with Prozac. However, when initiating therapy with Prozac and later when discontinuing its use, it is important to keep a close watch on blood glucose levels and adjusts insulin three to four times a day accordingly. My depressed diabetic patients have done extremely well on long-term Prozac.

*96\22\4*

No. Monoamine oxidase inhibitors (MAOIs) and Prozac just don’t mix. A few patients who have taken both drugs simultaneously have fed severe reactions mat include confusion, sweating, shivering, muscle spasms, tremors, and restlessness, as well as symptoms of rigidity, hyperthermia, rapid fluctuations of pulse and blood pressure, extreme agitation, delirium, coma, and in eight cases, death. Even patients who stopped taking Prozac and then immediately started up on an MAOI have had these reactions.

A patient who wants to switch to Prozac from an MAOI must allow fourteen days to elapse after discontinuing MAOI treatment before the MAOI is completely out of the system. Only then can Prozac be safely tried.

A patient who wants to go in the other direction, ceasing treatment with Prozac and beginning treatment with an MAOI, must wait even longer. Because Prozac and its major breakdown product, norfluoxetine, remain in the body for a long time, a minimum of five weeks is needed after discontinuing Prozac before MAOI treatment can commence.

*75\22\4*

Prozac is a member of a new class of antidepressants with a different mechanism of action than previous antidepressant drugs. Although equal to past antidepressants in effectiveness, it is uniquely not lethal in overdose, nor is it toxic to the cardiovascular system compared to the older drugs. It is also easier to take, since its side effects are so much milder.

A lot of patients walk in asking for Prozac, whether they need it or not Prozac has received more publicity than any other previously used psychiatric drug in America and abroad, and this unprecedented media attention has helped catapult Prozac to its current level of popularity. Seldom in the past did anyone I met at a dinner party question me about Tofranil or Nardil (although they did ask many times about lithium when its effectiveness as a treatment for manic depression first became known to the media). Now people ask about Prozac. Unlike other drugs, many of which are equally effective, Prozac has become a well-known, frequently requested remedy. Just as the most medically untutored know that a headache can be cured with aspirin, people who feel a little down today or want a personality “lift” are quick to discover that friends, family and the local GP have a single recommendation: Prozac. Sad to say, the media have oversold Prozac to the general public and to psychiatrists and other doctors. In my experience and in the experience of many of America’s leading psychopharmacologists, the myth of Prozac’s ability to cause a total personality metamorphosis has, more often than not, led to disappointment

*54\22\4*

Many patients who stop taking Prozac on their own do so because they find the side effects of slight nausea and insomnia unbearable or are too impatient to wait for early side effects to recede. Patients who are prone to hysterical reactions or those who are phobic about taking pills are often doomed to discontinue Prozac or any other medication from the outset.

The main complaints that cause patients to discontinue treatment are, in order of frequency, nausea, nervousness, insomnia, anxiety, tremor, headache, drowsiness, diarrhea, dizziness, sweating, and dry mouth.

The numbers and percentages for each of these categories are small. Nausea, the most common adverse reaction associated with stopping treatment, caused between 3% and 4% of the people tested to stop taking the drug. Nervousness and insomnia influenced another 2% to 3% to discontinue treatment. Not one of the other side effects involved in ending treatment affected more than 2% of those tested.

*34\22\4*