Question: Dear Doctor

my name is XXXXXXX and I am a researcher in Cognitive Science. I am writing to ask for advice regarding my grandmother’s health condition. She is currently suffering from interstitial lung disease (probably pulmonary fibrosis). I’m going to give you her medical history first and then ask my questions:

She’s 84 years old. She lives in the Czech Republic with my grandfather.
As a child, she contracted typhus and tuberculosis.
As an adult, she was an occasional smoker for about 20 years (a couple of cigarettes per week). She hasn’t smoked for about 30-40 years now.
For the last 15 years, she has been medicated with a low dose of Nitrofurantoin (taken every day) because of perpetual urinary tract infections.
3 years ago she was diagnosed with pulmonary fibrosis and medicated with Prednisone, which helped alleviate most of the symptoms. For the last 6 months she has been off this medication.
After the diagnosis of pulmonary fibrosis, the doctor prescribed a different antibiotic - nifuratelum (MacMirror), which she now takes daily.
1 month ago, she was diagnosed with Alzheimer’s disease and prescribed with DOSPELIN (DONEPEZIL-HYDROCHLORIDE) 10mg and ASENTRA (setraline) 50mg. Since last week, she has taken 100mg of setraline.

Three days ago, she started experiencing a very severe attack of dry cough, identical to or even worse than what she experienced when she was diagnosed with fibrosis. Based on this study (https://www.dovepress.com/the-relationship-of-ssri-and-snri-usage-with-interstitial-lung-disease-peer-reviewed-fulltext-article-CIA#T1) I suspect that setraline might be the possible cause of the current symptom worsening.

I have three questions:

1) Would you recommend stopping setraline and replacing SSRI with MAOI such as Moclobemide (Aurorix)? Moclobemide is available in the Czech Republic. Setraline has helped my grandmother a lot. She was so sad and miserable all the time and now she’s feeling so much better. I don’t want to deprive her of the wonderful effects of anti-depressants but at the same time I don’t want to risk worsening her fibrosis.
I have already told my grandmother to take only 50mg in case setraline is truly the causal factor.

2) Was the pulmonary treatment correct? I’ve read that corticosteroids should not be prescribed for fibrosis any longer because they’re not effective. In fact, they cause greater mortality than placebo in this disease (https://www.atsjournals.org/doi/full/10.1164/ajrccm.185.5.587). Instead, there are better, newer medications such as pirfenidone (https://www.mayoclinic.org/diseases-conditions/pulmonary-fibrosis/diagnosis-treatment/drc-0000). I think we should take grandmother to a differet doctor.

3) Do you have any other recommendations?

Thanks a lot!

Best regards,
XXXXXXX Jilek

Dear Dr Spaho,

thank you for your detailed and helpful answer. I have called my grandmother's neurologist but he and all other neurologists from the clinic are on holiday this week. The nurse contacted the neurologist for me directly, however, he claimed that setraline should not cause pulmonary fibrosis so they won't change medication anyway...

My granmother's GP can prescripe any type of anti-depressants, however, she doesn't have sufficient knowledge to do so, neither does her Pneumologist. We are going to consult a new Pneumologist but it will take weeks if not months before she gets there. It will also take the same amount of time to get to a different neurologist. It's a sad state of healthcare in my country.

As I want to help my grandmother quickly before the setraline does any more damage to her lungs, while not interrupting her treatment for Alzheimer's, I'm going to ask her GP to prescribe a new anti-depressant.

She received setraline not only for depression, but also for OCD-like symptoms and aggressive behaviour towards my grandfather. She also received quetiapine to control the aggressive behaviour, however, since it worsened her instability (she began to fall down), it was stopped. Nevertheless, the setraline "miraculously" eliminated all aggressive behaviour - that's why I think that continuing with anti-depressants is a good idea.

You recommended Citalopram and valproate as possible alternatives. Although I don't understand the underlying chemistry, I would like to steer clear of any SSRI's given her condition as they may also affect pulmonary fibrosis in a negative way.

You mentioned that MAOI drugs could also be of benefit. I think it would be best to ask my grandmother's GP to prescribe her with a suitable MAOI anti-depressant. I think moclobemide in particular might be good.

1) Theoretically speaking, If I brought my grandmother to your clinic, would you prescribe her with Moclobemide/some other MAOI? If so, what dosage?

2) What's the best way to stop setraline (she's on 50mg daily now) and start moclobemide/MAOI? Does there need to be a pause between the stopping of setraline and starting of moclobemide/MAOI?

3) Are there any possible interactions between moclobemide/MAOI and the other drugs my grandmother is taking? (nifuratelum, donepezil-hydrochloride, levothyroxine natricum)

Thanks!