Anti-Depressant Drugs

Question 1

Name the 6 SSRI anti-depressant drugs

Answer 1

1) Fluoxetine (prozac)
2) Fluvoxamine
3) Paroxetine (paxil)
4) Sertraline (zoloft)
5) citalopram (cymbalta)
6) escitalopram (lexapro)

Question 2

Name one super high yield fact about each of the 6 SSRI anti-depressants

Answer 2

1) fluoxetine –> has a “once a week formula”; longest half life; safe in kids and pregnant women
2) Fluvoxamine –> mostly used for OCD
3) Paroxetine –> sedation, constip, wt gain SE + *short half life leading to bad W/D
4) Sertraline –> highest risk for GI disturbances
5) Citalopram –> *fewest D-D interactions; possibly fewer sexual side effects
6) escitalopram –> enantiomer of citalopram; few side effects; expensive

Question 3

What are the first signs of serotonin syndrome and what is the key sign and how do we treat it?

Answer 3

1st signs: flushing and diarrhea
key sign: myoclonic jerks
treatment: calcium channel blocker (nifedipine)

Question 4

What is the biggest side effect of an SSRI? and how can it be treated?

Answer 4

25-30% have a sexual side effect that does not usually resolve… it can be treated by adding bupropion

Question 5

How long should you be off of an SSRI before switching to a MAOI?

Answer 5

AT LEAST 2 weeks… BUT if you’re using fluoxetine wait at least 6 weeks because it has a really long half life!

Question 6

What are the 2 SNRIs you should know?

Answer 6

1) venlafaxine (effexor)

2) duloxetine (cymbalta)

Question 7

What ELSE (besides depression) can you use the SNRI drugs for?

Answer 7

Venlafaxine –> also treats GAD and possibly even ADHD (watch out for uncontrolled HTN)… LOW side effect profile

Duloxetine –> also treats neuropathic pain or fibromyalgia… need to check on liver enzymes and don’t go above 40mg on dosing as this can prolong QT

Question 8

What are the other 3 “random” anti-depressants that you should know about and what are their MOA’s/uses?

Answer 8

1) Bupriopion - NE-DA re-uptake inhibitor (“NEDA” boner… but watch out for seizures… lack sexual side effects)
2) Trazodone/Nefazodone - 5-HT atagonist/agonist… main use for refractory depression and also helps with insomnia… no sleep changes like with other SSRIs… can cause priapism however
3) Mirtrazapine (remeron) - alpha2 receptor antagonist; useful for refractory depression and weight gain (*especially good for elderly)… watch out for agranulocytosis

Question 9

What should you keep in mind when prescribing an SSRI or duloxetine (think about metabolism)?

Answer 9

virtually all SSRIs are CYP450 inhibitors… so they can increase the levels of warfarin –> an increase in bleeding events

Question 10

What are the 4 tertiary amine TCAs to know?

Answer 10

“ACID”

1) amitriptyline
2) clomipramine
3) impipramine
4) doxepin

Question 11

What is one fun fact about the 4 “ACID” TCAs?

Answer 11

amitriptyline –> also used for chronic pain and insomnia
clomipramine –> good for OCD
Imipramine –> has an IM form; good for panic disorders
doxepin –> also used for chronic pain and as a sleep aid

Question 12

What are the 2 secondary TCAs?

Answer 12

1) nortriptyline

2) Desipramine

Question 13

What is high yield about Nortriptyline?

Answer 13

It is least likely to cause orthostatic hypotension!

Question 14

What are the 2 “tetracyclic antidepressants”?

Answer 14

1) amoxepine - may cause EPS; similar SE profile as typical antipsychotics
2) maprotiline - higher rates of seizure, arrythmia, and fatality on overdose

Question 15

How do we treat TCA overdose?

Answer 15

sodium Bicarbonate!

Question 16

What are the 3 TCAs that can also treat chronic pain

Answer 16

1) amitriptyliniie
2) nortriptyline
3) doxepin

Question 17

What are the 3 major complications of TCAs?

Answer 17

the 3 C’s

1) cardiotoxicity
2) convulsions aka seizures
3) coma

Question 18

What do TCAs have so many side effects?

Answer 18

they interact with many drugs but more importantly they have a lack of specificty with other receptors

Question 19

What side effects are do to specific receptor interactions with TCAs?

Answer 19

1) anti-histamine properties –> sedation, wt gain
2) anti-adrenergic –> cardio SE: orthostatic hypotension, reflex tachycardia, QT prolongation
3) anti-muscarinic (aka anti-cholinergic) –> blurry vision, urinary retention, dry mouth, exacerbation of narrow angle glaucoma*
4) pro serotonin properties –> ED in guys/ anorgasmia in females

*MOST lethal in overdose… so MUST assess about suicidal attempts/thoughts

Question 20

What are the 4 MAOIs to know?

Answer 20

1) phenelzine
2) tranylcypromine
3) isocarboxazid
4) selegiline

Question 21

When are MAOIs typically used more often?

Answer 21

Usually more effective in treating atypical depression

Question 22

What 2 coniditions should be concerned about with a patient on an MAOI?

Answer 22

1) HTN crisis… inform them about avoiding tyramine containing foods
2) 5-HT syndrome… make sure they’re avoiding OTC cough medicine and other drugs (ie bupropion etc)

Question 23

What are some common SE with MAOIs?

Answer 23

1) orthostatic hypotension is the MOST common
2) drowsiness
3) wt gain
4) sleep dysfunction
5) those with pyridoxine deficiency can have a parasthesia
* rule = start low and go slow*

Question 24

What foods ought to be avoided in a patient on an MAOI/

Answer 24

foods high in tyramine… red wine, cheese, fava beans, cured meats…

Question 25

What are some other conditions that can be treated by anti-depressants?

Answer 25

OCD: fluvoxamine and clomipramine
Social phobias: SSRIs, TCAs
GAD: SSRI, SNRI (esp venlafaxine)
PTSD: SSRI
Neuropathic pain: amitrip, nortrip, and duloxetine (cymbalta)
Migraine headaches: amitryptiline
smoking cessation: bupriopion
Insomnia: mirtrazapine and amitriptyline