Depression Symptoms Treatment

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Question. I have obsessive compulsive disorder and panic disorder. I was recently prescribed Luvox. I have had no adverse reactions, and my doctor insists that I up the dosage. On the Internet, I discovered that Luvox reacts with nicotine. I am a smoker and I wonder how they interact. I have noticed some benefit to taking Luvox and would like to increase the dose, but not at the risk of the unknown. Do you have any further information?

Answer. I am not sure quite what you discovered on-line, but my own literature search and a call to the makers of the Nicotrol patch turned up no reports of any adverse reactions with the combination of Nicotrol patch and Luvox-type medications (termed SSRIs, and including Luvox, Prozac, Zoloft, and Paxil). This, of course, does not prove that adverse reactions can’t occur

Since Luvox is a relatively new agent, it is certainly possible that you have uncovered a problem not reported in the literature yet (or reported to the makers of Nicotrol). There are some issues surrounding nicotine, antidepressants and depression that you may be picking up on-line. First of all, there have been some reports of depressive bouts occurring in patients who have a history of depression and who have suddenly quit smoking “cold turkey.” I have not seen this reported with OCD or panic disorder, but I wouldn’t discount the possibility.

It is also true that nicotine in various forms can induce or activate the enzyme system in the liver that breaks down some antidepressant drugs, including some tricyclics like imipramine. Since the metabolic route for fluvoxamine (Luvox) is not well-described, it is theoretically possible that nicotine (either smoked or via patch) might affect the metabolism of Luvox. Indeed, I know of one report showing that smokers have a 23% reduction in fluvoxamine levels compared to nonsmokers (van Harten et al, Clinical Pharmacology & Therapeutics, 1992;52:427-35).

Conversely, it is known that Luvox inhibits an enzyme system in the liver called 1A2. This is the same system induced by nicotine. It is theoretically possible that Luvox might raise nicotine levels by inhibiting the 1A2 system, but it is not known (at least by me, or the makers of Nicotrol) which enzyme system breaks down nicotine. In short, I have no information suggesting that you would be at any significant risk by using Luvox with nicotine, but I cannot absolutely rule out the possibility. I can tell you that 25 mg of Luvox is unlikely to be very helpful for OCD, as I’m sure your doctor would agree. Most likely, a slow, careful increase in the dose would be safe, with or without nicotine. A slow increase is usually better tolerated in patients who have panic disorder, in any case.

By the way, I strongly recommend you get some behavioral therapy to help you quit smoking gradually, and not rely on the patch. The manufacturer agrees with this comprehensive approach.