Review/Guide, Oct/17: "Fluoxetine" (Prozac)

This paper looks at fluoxetine/Prozac -- its indications, mechanism of action, administration, adverse effects, contraindications, monitoring and toxicity.

Here's the section on adverse effects (which is quite depressing!), followed by the link to the full paper:

Adverse Effects

Most common side effects reported by adults include Insomnia, nausea, diarrhea, anorexia, dry mouth, headache, drowsiness, anxiety, nervousness, yawning, decreased libido, decreased arousal (seen as decreased lubrication in women and decreased erectile function in men), bruising, bleeding (rarely), hyperhidrosis, also keep in mind if this may be due to underlying mania/psychosis, seizures (rarely), induction of mania, rare activation of suicidal ideation and behavior (especially in teenagers), weight gain/loss, decreased orgasm (anorgasmia and ejaculation latency), muscle weakness, tremors, and pharyngitis.

The 5HT2C antagonism is what is thought to contribute to the anxiety, insomnia, and agitation that patients perceive with fluoxetine. Patient's may even have a panic attack with the administration with fluoxetine. Thus it is the clinician's responsibility to educate patient.

Most side effects are immediate and go away with time. Thus, it is best to wait for the side effects to subside before altering treatment. Most side effects are dose-dependent and time-dependent. It is important to be cautious of emergence of agitation or activation, which may indicate a bipolar state, which may require the addition of a mood stabilizer or an atypical antipsychotic. Fluoxetine can be activating, thus if insomnia is present, consider giving it early in the morning. Additionally, one may reduce dose if side effects are too distressing for the patient. The patient should be cautioned about side effects, if they persist, after a few weeks, switching to a different antidepressant may be indicated.

It is best to try another antidepressant before relying on augmentation strategies to minimize polypharmacy and encourage adherence to psychotropic medications. Trazodone, mirtazapine, or a hypnotic may be used for insomnia. Mirtazapine may also be used for agitation or gastrointestinal side effects. Benzodiazepines may be used for anxiety. Bupropion or a phosphodiesterase inhibitor (i.e., Sildenafil) may be used for sexual dysfunction. Bupropion may also be indicated for cognitive slowing or apathy seen with fluoxetine.

https://www.ncbi.nlm.nih.gov/books/NBK459223/#article-21850.s1