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Pharm Summer > Antidepressant Agents > Flashcards

Antidepressant Agents Flashcards

1
Q

Major Depressive or Unipolar Disorder:

lifetime prevalence?

A

5-20%

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2
Q

Major Depressive or Unipolar Disorder consists of core depressive symptoms plus “_______ symptoms”

A

vegetative (ie abnormal sleep/motor activity)

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3
Q

Major Depressive or Unipolar Disorder:

Pts are most responsive to?

A

Usually responds specifically to electroconvulsive therapy (ECT) or antidepressants

Pharmacotherapy» psychotherapy

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4
Q

Dysthmia= is a _____ form of depression

A

milder**–> generally no long-term responses to drug therapy but pharmacotherapy is superior to placebo

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5
Q

Dysthymia:

higher in males or females?

A

3x higher in females

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6
Q

Bipolar Disorder 1=

A

Cyclic, episodes of mania (bipolar I)

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7
Q

Bipolar 2=

A

hypomania, depressed mood

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8
Q

Psychotic Sx can be present in Bipolar 1 or 2?

A

Elevated, expressive, or irritable mood –> psychotic symptoms can be present in bipolar I

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9
Q

Factors favoring treatment with an antidepressant (list 4)

A

Presence of agitation or problems with sleep or appetite

Moderate to severe symptoms

History of response to antidepressant therapy

Patient preference

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10
Q

For treatment resistant depression, what are some medication options?

A

first–> try switching meds, or combining antidepressants

Buspirone (anti- anxiety), or atypical antipsychotics ( i.e. aripiprazole-olanzapine-quetiapine), OR
Lamotrigine or Lithium (mood stabilizers)

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10
Q

Symptoms of Depression At least 5 of 9 for at least 2 weeks: SIGECAPS

A

Sleep* – too much or too little*

Interest – decreased  loss of interest in life – anhedonia

Guilt – increased  feelings of worthlessness

Energy* – decreased*

Concentration - decreased

Appetite – increased or decreased –> >5% change in body weight in 1 month*

Psychomotor agitation/retardation*

Suicidal ideation – thoughts about death or suicide

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10
Q

Monoamine Theory of Depression:

what is the initial observation?

A

Reserpine (used as anti-hypertensive) depleted brain NE and 5HT –> induced depression
**Effective antidepressant drugs shared property of enhancing availability of NE-5HT in synapse

–overall lacking support

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10
Q

Shift in Focus of Hypotheses for Depression:
Dysregulation=
synaptic changes=

A

Dysregulation of pre-and post-synaptic control of NE-5HT neurotransmission

Synaptic changes produced by antidepressants then lead to alterations of gene expression

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10
Q

An adequate trial of medication for treatment of depression generally would be:

A

4-8 weeks

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10
Q

A 25-year-old woman has a long history of depressive symptoms accompanied by body aches and pain secondary to a car accident 2 years ago. Physical and laboratory tests are unremarkable. Which of the following drugs might be useful in this patient?

Amitriptyline (TCAD)
Fluoxetine (SSRI)
Sertraline (SSRI)
Mirtazapine (α2 antagonist)
Duloxetine (SNRI)
A

Amytriptiline= cheaper, and good for neuropathic pain

and Duloxetine

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10
Q

Newer agent for Treatment resistant depression that is an NMDA receptor antagonist is known as _______

A
  • *S-ketamine
  • -> recently approved for intranasal tx, unknown mechanism. BUT it’s expensive: $1200 for 4 weeks, administered 2x a week/for 4 weeks
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10
Q

New drug for post-partum depression which is a Positive allosteric modulator (PAM) is known as _______

A

Brexanolone (Zulresso)

=a neuroactive steroid (NAS) that binds to a different subunit (δ) on GABA-A receptor than benzodiazepines (α)

IV infusion over 60 hours with medical supervision - significant improvement in symptoms at 60 hrs - maintained 30 days

Sedation and sudden loss of consciousness possible

Cost of drug alone currently $34,000

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10
Q

List some acute S/E of SSRIs

A

Acute effects –often diminish over time)

Nausea-diarrhea [5HT3] (increase 5HT effects in GI tract)

Activation-insomnia (commonly)

Restlessness [5HT2] (akathisia), somnolence possible

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10
Q

List some delayed onset S/E of SSRIs

A

Weight gain

Sexual dysfunction [5HT3]

Cognitive blunting

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10
Q

SSRIs fatality rate?

Withdrawal Sx?

A

Very low likelihood of fatalities in OD

w/drawal–>Flu-like or neurologic symptoms –> severity related to half-life (shorter > longer

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10
Q

Which SSRI will result in greater withdrawal sx? [paroxetine or fluoxetine?

A

[paroxetine > fluoxetine])

shorter half life» longer

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10
Q

SNRI’s S/E: list

A

**Venlafaxine - Duloxetine

Hypertension, anxiety, nausea, somnolence, sweating, dizziness, sexual dysfxn

**More rapid appearance of withdrawal symptoms than SSRIs, except paroxetine

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10
Q

Norepinephrine Dopamine Reuptake Inhibitors (NDRIs): list 1 example of a med & it’s S/E

A

Bupropion!

Dizziness, dry mouth, tremor, insomnia, anxiety, aggravation of psychosis

**Potential for seizures at high doses

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10
Q

Trazadone:

-major S/E?

A

Drowsiness

–Overdose –>minor problems only

25
Q

Mirtazapine: S/E?

A

Somnolence

Increased appetite –> **weight gain (great for Pts who are cant sleep and cant eat )

**mirtazapine= good for Pts who cant eat and cant sleep

26
Q

T/F: TCAs have declining use

A

T! poor side effect profile, declining use, 2nd-3rd line agents

27
Q

Which TCA causes greater sedation: amitriptyline or desipramine?

A

Sedation: Lassitude, fatigue, sleepiness [Amitriptyline > Desipramine]

28
Q

Which TCA causes the MOST antimuscarinic effects?

A

Amitriptyline > Desipramine-Nortriptyline]

Blurred vision, constipation, dry mouth, urinary hesitancy, fuzzy thinking

Higher doses–> aggravation of narrow angle glaucoma, paralytic ileus, urinary retention, delirium

29
Q

TCAs:

cardiac S/E?

A

Orthostatic hypotension (α1 blockade)

EKG abnormalities (quinidine-like effects) –> arrhythmias –> sudden death in OD

30
Q

TCAs: neurologic S/E?

A

Tremor, paresthesias, can see seizures in OD

Metabolic-endocrine: Weight gain histamine blocking action, sexual disturbances

31
Q

A Pt OD on Amitriptyline and is now experiencing arrhythmias. What would you give him for immediate tx?

A

sodium bicarb

32
Q

MAOIs S/E: list ex’s

A

**Postural hypotension (chronic increase in false NT)

Milder anti-cholinergic effect

Sedation (phenelzine)

CNS stimulation (tranylcypromine)

Liver damage

**Seizures, shock, hyperthermia in overdose

33
Q

Which agent would be a poor choice in a 70-year-old with depressive symptoms due the drug having significant alpha-1 receptor antagonism, thus having a higher risk for falls due to orthostatic hypotension?

Fluoxetine (SSRI)
Amitriptyline (TCAD)
Bupropion (NDRI)
Phenelzine (MAOI)
Sertraline (SSRI)
A

Amitriptyline (TCAD)

34
Q

S-Ketamine causes ______ BP after administration. It’s contraindicated IF Pt has ______

A

Increased BP

Contraindicated if AV malformation or history of intracerebral hemorrhage

Controlled substance [CIII] with potential for dependence and abuse

35
Q

Fluoxetine is comparable to the tricyclic antidepressant amitriptyline in:

Producing orthostatic hypotension
Causing dry mouth and blurred vision
Producing life-threatening EKG changes
Alleviating the symptoms of depression

A

Alleviating the symptoms of depression

36
Q

Most antidepressant agents have an _____ CNS depressant effect when used with other sedatives

A

additive

37
Q

MAOIs + decongestants or with foods high in Tyramine (beer-wine-cheese)=

A

HYPERTENSIVE CRISIS

**Results from acute increase in NE release

38
Q

SSRIs + MAOIs=

A

serotonin syndrome**

–occurs with just MAOIs

39
Q

Pt presents with rapid changes in mental status (confusion), and HTN and tachycardia–>

A

**serotonin syndrome

Also occurs w/ SSRIs or MAOIs + opioid analgesics [meperidine-tramadol] or antitussive [ dextromethorphan]

40
Q

DDIs:

SSRIs–> ______ of P450 drug metabolizing enzymes

A

**inhibition

w/ Fluoxetine / paroxetine or fluvoxamine

Less concern with sertraline and citalopram

Can decrease efficacy of drugs requiring activation by CYP2D6 (codeine – tramadol)

41
Q

Why should you worry about prescribing an elderly Pt on an SSRI with St. John’s Wort?

A

Possible induction of P450 drug metabolizing enzymes

Reports of serotonin syndrome in elderly patients taking St. John’s Wort and SSRIs

42
Q

A 26-year-old man is receiving pharmacotherapy for a psychiatric disorder. He comes to the emergency room with elevated blood pressure, sweating, headache, and vomiting. His companion tells the physician that the patient became ill at a party where he ate triple-cheese pizza and was drinking Guinness beer. The patient is most likely taking a drug from which therapeutic class?

Serotonin selective reuptake inhibitors
Tricyclic antidepressants
Monoamine oxidase inhibitors
Serotonin norepinephrine reuptake inhibitors

A

MAOIs

43
Q

Ex’s of atypical antipsychotics that can be used for tx resistant depression:

A

aripiprazole-olanzapine-quetiapine)

44
Q

To be effective in acute and chronic pain management, tramadol and codeine must be converted to an active form by CYP2D6. Cases of inadequate pain control have occurred when these agents were administered to patients who were being treated with:

Fluoxetine
Amitriptyline
Bupropion
Escitalopram

A

fluoxetine

45
Q

SSRIs are much less effective than tricyclic antidepressants in the management of:

Bulimia
Chronic pain of neuropathic origin
Generalized anxiety disorder
Obsessive-compulsive disorder
Premenstrual dysphoric disorder
A

Chronic pain of neuropathic origin

46
Q

SSRIs / Heterocyclic agents / TCADS: describe the pharmocokinetics

A

Incomplete absorption, significant 1st pass effect

High protein binding/lipid solubility (high Vd)

**Wide interpatient variations in Cp for a given dose

47
Q

MAOIs:

T/F–> inhibition is irreversible

A

True!! Inhibition is irreversible – continues after drug no longer detectable (2 weeks)

Best to monitor platelet MAO inhibition for determination of duration of MAOI drug effect

48
Q

first line tx for depression=

A

**Generic SSRIs are usually first line:
Sertraline – Fluoxetine –Citalopram=Escitalopram

SNRIs (esp. Venlafaxine)–> May be more effective. Side effects > SSRIs

Bupropion: Equal efficacy, Less weight gain and sexual side effects

49
Q

Wellbutrin is NOT effective for tx of ______ depression

A

anxious

50
Q

Mirtazapine might be a good choice for treatment of depression in patients who complain of:

Sexual dysfunction
Insomnia
Weight gain
Constipation

A

insomnia

51
Q

Bupropion:

  • Is not sedating
  • Does not cause weight gain
  • Is contraindicated in patients with seizure disorder
  • All of the above
A

ALL

know this for exam

52
Q

_____ is the most rapid and effective (70-90%) tx for SEVERE ACUTE depression

A

ECT –> Can be life-saving if patient is suicidal

Usually 6-12 treatments at a frequency of 2-3 per week

53
Q

ECT:

list ADRs

A

Medical–>cardiopulmonary events, fractures, orodental injuries, headache

Cognitive–> acute confusion, retrograde and anterograde amnesia

54
Q

Anterograde amnesia=

A

while drug is in your system you don’t form memories

55
Q

A 36-year-old woman presents with symptoms of major depression that are unrelated to a general medical condition, bereavement, or substance abuse. She is not currently taking any prescription or over-the-counter medications. Drug treatment is to be initiated with sertraline. In your information to the patient, you would tell her:

Sertraline may take 2 weeks or longer for onset of Antidepressive effect

It is preferable that she take the drug in the morning

Some nausea and GI upset may be present

She should notify you if she anticipates using other prescription drugs

All the above

A

ALL

56
Q

Which of the following statements concerning the side effects and toxicities of antidepressant drug use is FALSE?

Concomitant use of SSRIs and MAOIs may result in a serotonin syndrome.

SSRIs (e.g., fluoxetine) can induce hypomania in patients with bipolar disorder.

Tricyclic antidepressants (e.g., amitriptyline) have a lower incidence of anticholinergic side effects than SSRIs.

Inhibitors of dopamine and norepinephrine reuptake (e.g., bupropion) have been observed to cause anxiety and restlessness due to their mild stimulant action.

None of the above

A

Answer= Tricyclic antidepressants (e.g., amitriptyline) have a lower incidence of anticholinergic side effects than SSRIs.

-B- watch out with SSRIs with Pts you may suspect bipolar

D- true

57
Q

Regarding the clinical use of antidepressants, which statement is accurate?

Chronic use of SSRIs (venlafaxine) increases the activity of hepatic drug-metabolizing enzymes

In the treatment of major depressive disorders, citalopram is usually more effective than paroxetine

MAOIs can be effective in depressions with attendant anxiety, phobic features, and hypochondriasis

Weight gain often occurs during the first few weeks in patients taking SSRIs

A

MAOIs can be effective in depressions with attendant anxiety, phobic features, and hypochondriasis

SSRIs decrease activity of hepatic drug-metabolizing enzymes

-citalopram and paroxetine are equally efficacious

D- may lose weight initially due to all the S/E

58
Q

A recently widowed 76-year-old female patient was treated with a benzodiazepine for several weeks (appropriate?) after the death of her husband, but she did not like the daytime sedation it caused even at low dosage. Living independently, she has no major medical problems but appears rather infirm for age and has poor eyesight. Because her depressive symptoms are not abating, you decide on a trial of an antidepressant medication. Which would be the most appropriate choice for this patient?

Amitriptyline
Trazodone
Mirtazapine
Phenelzine
Citalopram
A

citalopram

Pharm Summer (2 decks)

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