Objective: In elderly patients, orthostatic hypotension (OH) and postprandial hypotension (PPH) are very common conditions associated with severe consequences such as falls or syncope. Nortriptyline and paroxetine may have adverse effects on OH and PPH because of a-adrenergic blockade properties; however, the precise effects of these medications in very old depressed patients are not clear. Particularly data of the effects on postprandial blood pressure (BP) changes are limited. The purpose of this study is to describe the effects of nortriptyline and paroxetine on orthostatic- and postprandial BP in elderly patients aged 70 years or older.
Design: Double-blind, randomized parallel design with nortriptyline or paroxetine therapy.
Materials and Methods: In 21 depressed patients, aged 71-92 years (mean age 82 years) with major depressive or dysthymic disorders (DSM IV criteria), orthostatic and postprandial BP changes were measured before and during 4 weeks of therapy. BP was measured beat-to-beat by an automatic Finapres device (FINger Arterial PRESsure) during standardized standing- and mealtests. Nortriptyline was given as 25 mg for 1 week, 50 mg for 1 week, and 75 mg for 2 weeks, and therapy with paroxetine 10 mg for 2 weeks and 20 mg for 2 weeks. Identical capsules for nortriptyline and paroxetine were used. Depression severity was evaluated by the Hamilton Rating Scale for Depression and the Montgomery Asberg Depression Rating Scale. BP changes were analyzed by two-way repeated measures ANOVA with simple contrast to examine the effect of time, therapy, and time-by-therapy interaction on postprandial- and orthostatic changes during each test.
Results: Nortriptyline and paroxetine both ameliorated depression severity (p<0.01). PPH was present in 67% of the patients before therapy with a maximum decline in systolic BP of –24.7 ± 2.2 (SEM) mmHg in the nortriptyline group and –23.2 ± 4.7 mmHg in the paroxetine group. PPH was not aggravated during nortriptyline or paroxetine. OH was present in 24% of the patients before therapy, and in 50% during nortriptyline compared to 18% during paroxetine. Nortriptyline resulted in larger and longer decreases in systolic BP after standing (-20.4 mmHg, p<0.05). Paroxetine did not affect BP changes after standing.
Conclusion: PPH and OH were very common in elderly depressed patients before the start of antidepressants. Nortriptyline (75 mg daily) worsened orthostatic decreases in systolic BP, but left postprandial BP responses unchanged. Paroxetine 20 mg did not affect orthostatic or postprandial BP changes. Therefore, based on the effects on BP, paroxetine might be preferred above nortryptylline as antidepressant therapy in elderly depressed patients.
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