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Year 3 Pharmacology > A Practical Guide to Anti-Depressants and Mood Stabilisers > Flashcards

A Practical Guide to Anti-Depressants and Mood Stabilisers Flashcards

1
Q

Aim in the treatment of depression?

A

Complete resolution of symptoms

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2
Q

1st line treatment for depression?

A

Usually SSRIs; subsequent choices depend on a no. of factors

Anti-depressants may also be given in combination

NOTE - there is no step by step flow chart

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3
Q

Common factors affecting drug choice for depression?

A

What has worked for this patient previously

Indications

Patient’s comorbidities and risk factors

Patient preference

Safety in pregnancy / breastfeeding

Treatment of specific symptoms, e.g: insomnia or psychosis

Risk of overdose

Patient’s willingness to adhere to monitoring and other restrictions

Dose frequency

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4
Q

Efficacy of anti-depressants?

A

Normally take 2-6 weeks to work; consider ECT when a quicker response, that what is achieved with anti-depressants, is required

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5
Q

How to start anti-depressants?

A

Start at a low dose and titrate up, to avoid initiation side effects

NOTE - speed of titration depends on side effects VS the need for a quick response

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6
Q

Treating older patients for depression?

A

Try to avoid polypharmacy

Use lower doses in older patients (usually 1/2 the adult dose)

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7
Q

Cautions for anti-depressants in younger patients?

A

Rarely, can cause agitation leading to suicidal ideation and behaviour

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8
Q

How long does treatment for depression continue for?

A

Continue for:
• 6-12 months after full resolution of symptoms of the 1st episode
• 12-24 months for a recurrence
• Indefinitely, if a 3rd episode has occurred

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9
Q

Treatment of bipolar disorder?

A

Mainstay are mood stabilisers, e.g: lithium, anti-convulsants, anti-psychotics

Lamotrigine is good for bipolar depression

Valproate is good for mania / hypomania

Generally, avoid anti-depressants in bipolar unless short-term for a depressive episode; DO NOT GIVE ANTI-DEPRESSANTS WITHOUT A MOOD STABILISER IN BIPOLAR

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10
Q

Why are anti-depressants not given without a mood stabiliser in bipolar?

A

Can cause switching to mania / hypomania or mood instability

Even if they not cause elevated mood, they are not as effective as mood stabilisers for bipolar depression

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11
Q

Examples of Selective Serotonin Reuptake Inhibitors (SSRIs)?

A

Fluoxetine, sertraline, citalopram, escitalopram, paroxetine

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12
Q

Uses of SSRIs?

A

Usually:
• 1st line in depression
• 1st line if an anti-depressant is required in bipolar

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13
Q

Side effects of SSRIs?

A

GI upset

Anxiety, agitation

Insomnia (taken in the morning to reduce this)

Sexual dysfunction

Hyponatraemia in older patients

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14
Q

Side effects of discontinuation of SSRIs?

A

GI upset, anxiety, agitation, insomnia, myoclonus

NOTE - discontinuation side effects are worse with paroxetine than the other SSRIs; it is rarely used now

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15
Q

How to avoid discontinuation side effects of SSRIs?

A

Taper the drug over weeks

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16
Q

Cautions with SSRIs?

A

Increased risk of GI bleeding if taken with NSAIDs

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17
Q

Situations where different SSRIs are preferred?

A

Sertraline is safest in patients with cardiac issues

Citalopram is safest in epilepsy

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18
Q

Specific issues with citalopram?

A

Assoc. with long QTc interval

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19
Q

Examples of TCAs?

A

Amitriptyline, imipramine

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20
Q

Why are TCAs not used as 1st line for depression?

A

Due to cardiac side effects

They are dangerous in OD

NOTE - they are as effective as SSRIs

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21
Q

Side effects of TCAs?

A

Sedation (taken at night for this reason), confusion, dizziness

Anti-muscarinic effects

Sexual dysfunction

Rarely, cardiac arrhythmias may occur (lofepramine has a lower cardiac risk)

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22
Q

When should use of TCAs be avoided?

A

Cardiac problems

Older people

Suicidal intent

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23
Q

Uses of TCAs other than for depression?

A

Neuropathic pain

OCD

Anxiety disorders

Migraine prophylaxis

Nocturnal enuresis

Cataplexy

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24
Q

Examples of NaSSA (noradrenergic and specific serotonergic anti-depressant)?

A

Mirtazapine

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25
Q

Uses of mirtazapine?

A

May be used 1st line if patient also has insomnia and/or poor appetite

Often used when an SSRI has not worked

Relatively safe for those with cardiac issues

NOTE - mirtazapine has a good anxiolytic effect

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26
Q

Side effects of mirtazapine?

A

Sedation (taken at night for this reason)

Hunger and weight gain

Constipation

Dizziness, falls

Dry mouth

Unusual / vivid dreams

Rarely - blood dyscrasias, seizures

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27
Q

Examples of SNRIs (serotonin and noradrenaline reuptake inhibitors)?

A

Venlafaxine, duloxetine

28
Q

Uses of SNRIs?

A

Not usually 1st line due to greater risk of side effects than SSRIs but often used when SSRI and/or mirtazapine have not worked

Venlafaxine is very good combined with mirtazapine, when monotherapy has not worked

NOTE - duloxetine can also be used for neuropathic pain or bladder instability

29
Q

Side effects of SNRIs?

A

As for SSRIs

Hypertension

Cardiac arrhythmias

Insomnia (taken in the morning for this reason)

Discontinuation side effects are as for SSRIs

30
Q

Types of MAO inhibitors?

A

Irreversible MAOIs
• Phenelzine
• Tranylcypromine
• Isocarboxazid

Reversible MAOIs:
• Moclobemide (less side effects but also less effective)

31
Q

Uses of MAOIs?

A

Very effective anti-depressants; only used in treatment resistant depression (this is because MAOIs require adherence to dietary and medication restrictions)

Rarely used in BPAD, due to high risk of switching to mania

32
Q

Side effects of MAOIs?

A

Postural hypotension, drowsiness, insomnia, fatigue

Nausea, constipation

Rarely, HYPERTENSIVE CRISIS

33
Q

Issues with tyramine in assoc. with MAOIs?

A

Tyramine is a potent releaser of norepinephrine, which causes raised BP

Normally, MAO breaks down norepinephrine and, if MAO-A is inhibited and a high tyramine meal is taken, norepinephrine can accumulate, leading to a HYPERTENSIVE CRISIS

34
Q

Foods with a high tyramine content?

A

Cheese

Alcoholic drinks, esp. red wine (this inc. alcohol free beer)

Dried / smoked / fermented meats

Stock cubes, pate, marmite, bovril, black pudding, large amounts of caffeine, broad bean pods, soy, tofu

35
Q

Drugs that interact with MAOIs?

A

SSRIS / SNRIs

Tyrptophan

TCAs

Mirtazapine

Phenylephrine

Some opioids

Dextromethorphan

36
Q

Symptoms of hypertensive crisis?

A

Headache

SoB

Nosebleeds

Anxiety

37
Q

Complications of hypertensive crisis?

A

Arrhythmias, stroke, seizures, death

38
Q

Management of hypertensive crisis?

A

Phentolamine infusion

39
Q

Examples of SARIs (serotonin 2 antagonist / reuptake inhibitors)?

A

Trazodone

40
Q

Uses of SARIs?

A

Often used as an anti-depressant when sedation is required

AND/OR

To augment other anti-depressants

41
Q

Side effects of SARIs?

A

GI upset

Dizziness, sedation (taken at night for this reason), fatigue

Headache

Hypotension / syncope

In-coordination

Oedema

Blurred vision

Priapism

42
Q

Uses of lithium carbonate?

A

Most effective treatment for BPAD

Also used as an adjunct to anti-depressants in treatment of resistant depression

43
Q

Side effects of lithium carbonate?

A

GI upset

Dry mouth

Feeling of weakness / shakiness

Sedation (taken at night for this reason)

Weight gain

Fine tremor

Polydipsia and polyuria

Ankle swelling

Renal impairment

Cardiac arrhythmias

Hypothyroidism and hypoparathyroidism

44
Q

Drugs that interact with lithium carbonate?

A

NSAIDs, ACEIs, ARBs, diuretics (more so with thiazides than loops)

45
Q

Ix before initiation of lithium?

A

U&Es, TFTs

ECG

46
Q

Ix during and following initiation of lithium?

A

Lithium levels (12 hours after last dose) and U&Es every 5 days; this is continued until Li level is stable within the therapeutic range

Every 3 months - Li level and U&Es

Every 6 months - TFTs

If dehydrated from physical illness, generally unwell or if the patient has signs of toxicity, check Li level and U&Es

47
Q

How is hypothyroidism due to Li treated?

A

Usually with levothyroxine, rather than stopping Li

48
Q

Warning signs of Li toxicity?

A

GI upset

Blurred vision

Coarse tremor

Drowsiness

Ataxia

49
Q

Signs of severe Li toxicity?

A

Confusion, LoC, seizures, coma, death

50
Q

Causes of Li toxicity?

A

Increased dose

Dehydration (physical illness, lack of fluid intake, alcohol, hot weather, exercise)

Drug interactions

Reduction in salt intake

51
Q

Management of Li toxicity?

A

Stop Li

IV fluids

Monitor renal function

In severe cases, dialysis may be required

52
Q

Uses of semisodium valproate?

A

Effective as an anti-convulsant in bipolar mania / hypomania

53
Q

Mechanism of action of semisodium valproate?

A

Blocks voltage-activated Na+ channels, increasing GABA levels

54
Q

Side effects of semisodium valproate?

A

Sedation and fatigue

Tremor

Dizziness

GI upset and weight gain

Rarely - hepatotoxicity, pancreatitis, increased in suicidal behaviour

55
Q

In whom should semisodium valproate not be prescribed?

A

Avoid in women of childbearing age, as it is highly TERATOGENIC (causing neural tube defects)

56
Q

Ix with semisodium valproate prescription?

A

Platelet count and LFTs prior to initiation

57
Q

Uses of lamotrigine?

A

Anti-convulsant used in the treatment and prophylaxis of bipolar depression

NOTE - it blocks voltage-activated Na+ channels

58
Q

Side effects of lamotrigine?

A

Rash (advise to see doctor ASAP if this occurs)

GI upset

Sedation (not common), fatigue and insomnia

Dizziness

Ataxia

Rarely - SJS, blood dyscrasias

NOTE - titrate slowly over 6 weeks to reduce risk of rash and SJS

59
Q

Examples of atypical anti-psychotics?

A

Olanzapine

Risperidone

Quetiapine

Clozapine

60
Q

Uses of atypical anti-psychotics?

A

For manic / hypomanic and depressed mood states in BPAD

Combine with an anti-depressant in psychotic unipolar depression

Adjunct to an anti-depressant in unipolar depression without psychotic symptoms

61
Q

Side effects of atypical ADs (except apiprazole)?

A

Sedation

Weight gain (mainly due to increased hunger)

Metabolic syndrome

EPSE (extra-pyramidal side effects)

Constipation

QTc prolongation

Neuroleptic malignant syndrome

NOTE - used more often than typical anti-psychotics, esp. in mood disorders

62
Q

Side effects of apiprazole?

A

Insomnia

GI upset and constipation

Agitation

Akathisia

Orthostatic hypotension

Headache

63
Q

Ix with atypical anti-psychotics?

A

Check the following prior to initiation:
• BP and weight
• Lipids, BG, FBC, U&Es, LFTs
• ECG

Then check yearly, or more often depending on results and other risk factors

64
Q

Examples of typical anti-psychotics?

A

HALOPERIDOL

Chlorpromazine

65
Q

Uses of typical anti-psychotics?

A

Treatment and prophylaxis of both manic / hypomanic and depressed mood states in BPAD

Combine with an anti-depressant in psychotic unipolar depression

Adjunct to an AD even in unipolar depression without psychotic symptoms

66
Q

Side effects of typical anti-psychotics?

A

EPSE

Sedation

Dizziness

QTc prolongation

Hyperprolactinaemia

Neuroleptic malignant syndrome

Year 3 Pharmacology (5 decks)

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