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Antidepressant medications Flashcards

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1
Q

How do antidepressants work?

A

Block reuptake pump (serotonin transporter OR NE transporter)
This leads to increased levels of neurotransmitters in snyapse

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2
Q

What causes receptors to down-regulate?

A

Increased level of SERT or NT in synapse

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3
Q

What do antidepressants impact?

A

Gene expression

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4
Q

When are MAOIs CI’d?

A 
SSRIs
SNRIs
TCAs
Sympathomimetics
Levadopa (d/t risk of HTN crisis)
Foods containing tyramine
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5
Q

When are MAOIs used?

A

MDD

Treatment resistant depression

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6
Q

Why are MAOIs not used anymore?

A

Newer safer options

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7
Q

How do we counsel patients on MAOIs?

A

Signs of HTN crisis, foods to avoid

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8
Q

What pumps do TCAs work on?

A

Serotonin
NE
Dopamine

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9
Q

What receptors do TCAs work on?

A

Muscarinic cholinergic
Histamine-1
Alpha-1

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10
Q

Where do TCAs block sodium channels?

A

Heart and brain (OD potential)

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11
Q

What are TCA OD sx?

A

Cardiac arrhymthias
Hypotension
Seizures
Coma Death

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12
Q

When do we avoid TCAs?

A

Patients with current suicidal ideations or h/o suicidal ideations or attempts

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13
Q

What is the MOA of MAOIs?

A

Nonselective and irreversible inhibitor of:
MAO A: serotonin and NE
MAO B: dopamine

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14
Q

Are TCAs considered “me too” drugs?

A

No

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15
Q

What levels should be checked with TCAs?

A

Blood levels for toxicity (not TDM)

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16
Q

What happens if there is abrupt withdrawal of TCAs?

A

Cholinergic rebound

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17
Q

What is the MOA for SSRIs?

A

Selective and potent inhibition of serotonin reuptake

Minor actions on other receptors, which accounts for differences in agents

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18
Q

What are TCAs?

A 
Amitriptyline
Nortriptyline
Imipramine
Desipramine
Doxepin
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19
Q

What are MAOIs?

A

Phenelzine
Tranylcypromine
Selegiline

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20
Q

Which TCA is the most anticholinergic?

A

Amitriptyline

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21
Q

What is the management of acute phase agitation, anxiety, panic attacks, akathisia, “jitteriness syndrome”?

A

New onset: Decrease SSRI/SNRI to lower dose, titrate more slowly

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22
Q

What SEs do serotonin cause in the limbic cortex?

A 
Agitation
Anxiety
Panic attacks
Akathisia
Jitteriness syndrome
Insomnia
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23
Q

What is the management of acute phase insomnia?

A

Take dose in morning

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24
Q

What SEs does serotonin cause in the brainstem?

A

Nocturnal awakenings/sleep disturbances

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25
Q

What is the management of nocturnal awakenings/sleep disturbances?

A

Decrease dose, take dose in AM

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26
Q

What are the SEs of serotonin in the spinal cord?

A

Sexual dysfunction

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27
Q

What is the management of acute phase sexual dysfunction?

A

Waiting 2-8 weeks for spontaneous remission
Decrease dose
Switching to a different SSRI/non-SSRI antidepressant

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28
Q

What are the SEs of serotonin on the hypothalamus or brainstem?

A

HA
Nausea/vomiting
Reduced appetite
Wt loss

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29
Q

What is the management of acute phase HA?

A

Watch and monitor, consider APAP PRN

May consider switching to a different agent

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30
Q

What are the SEs of serotonin on the GI tract?

A

GI distress - increased bowel motility, cramps, and diarrhea

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31
Q

What are the management strategies for acute phase N/V?

A

The most commonly cited reasons for stopping antidepressant therapy in the first thirty days of treatment
Take with food
Can decrease dose, or try a different agent

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32
Q

What are the management strategies for acute phase reduced appetite, wt loss, and GI distress?

A

Take medication dose with food

Can decrease dose, or try a different agent

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33
Q

How do we manage acute phase dizziness, drowsiness and sedation?

A

Take dose in evening/near bedtime

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34
Q

Which SSRIs cause wt gain?

A

Mirtazapine > paroxetine (packs it on)

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35
Q

What should we do if a pt gains wt on an SSRI?

A

Switch to another SSRI or SNRI

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36
Q

What drugs are given with SSRIs for sleep disturbances?

A

Trazodone/Mirtazapine commonly used

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37
Q

What drug do we switch to if the pt experiences apathy, fatigue, and lethargy?

A

Bupropion > fluoxetine > SSRIs

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38
Q

What is the management of long term sexual dysfunction?

A

Switching to a different SSRI/non-SSRI
Try Bupropion, Mirtazapine, Trazodone
Paxil/Lexapro cause MORE sexual dysfunction

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39
Q

What are less common SEs of SSRIs?

A

Diarrhea
Hyponatremia in elderly
Prolonged bleeding - caution with antiplatelet agents, anticoagulants or NSAIDs

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40
Q

How do we treat SSRI diarrhea?

A

Try another agent

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41
Q

Which drugs cause hyponatremia?

A

SSRIs > SNRIs > Bupropion, mirtazapine

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42
Q

What is the treatment of SSRI prolonged bleeding?

A

Switch to mirtazapine or bupropion

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43
Q

How do SSRIs and SNRIs prolong bleeding time?

A

Decrease intra-platelet 5-HT stores and increase the risk of bleeding = monitor

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44
Q

What are WD sx of SSRIs?

A 
Fatigue
Lethargy
Flu-like sx
Dizziness
HA
Nausea
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45
Q

What do we do if a pt accidentally discontinues their SSRI?

A

Restart previous dose, and taper more slowly over several weeks to months

46
Q

What do we do in the event of serotonin syndrome?

A

Serotonin agents must be stopped and supportive care initiated
Pt should be monitored for improvement and sx of WD

47
Q

What are a lot of antidepressants metabolized by?

A

2D6 and 3A4

48
Q

Which SSRIs have minimal CYP450 interactions?

A

Lexapro

49
Q

What are pharmacogenomic considerations of SSRIs?

A

Different medications work differently for different people

50
Q

What are SSRIs?

A

Prozac
Paxil
Celexa
Lexapro

51
Q

Which SSRI has the longest half-life?

A

Prozac

52
Q

Why is prozac administered in the morning?

A

Activating effect

53
Q

What patients do we consider prozac in?

A

Pts with fatigue, low-energy, non-compliance (weekly dosing available)

54
Q

Which SSRI is preg cat D?

A

Paxil

55
Q

Which SSRI is more sedating than the others?

A

Paxil

56
Q

Which SSRI causes the most weight gain?

A

Paxil

57
Q

What is paxil associated with?

A

More constipation and cholinergic rebound with abrupt WD

58
Q

What can paxil be used for?

A

Vasomotor sx of menopause

59
Q

Which SSRI has the highest QT prolongation?

A

Celexa

60
Q

What is the dosing of Celexa in elderly/hepatic impairment?

A

20mg/d

61
Q

Which is the most tolerable antidepressant?

A

Lexapro

62
Q

What are SNRIs called?

A

Designer TCAs

63
Q

What is the MOA of SNRIs?

A

Activity on serotonin, NE and some dopamine

64
Q

Which drugs are SNRIs?

A

Venlafaxine
Duloxetine
Desvenlafaxin

65
Q

What activity does SNRIs lack?

A

Significant anticholinergic, antihistamine, and alpha-1 blocking activity

66
Q

How does Venlafaxine act as an SSRI?

A

When used at lower doses

67
Q

What are the SEs of venlafaxine?

A

Sweating
Tachycardia
Palpitations
At high doses = increased BP

68
Q

What is venlafaxine used for?

A

Neuropathy

Hot flashes

69
Q

When do we avoid duloxetine?

A

Hepatotoxicity

70
Q

What is duloxetine indicated for?

A

Pain and fibromyalgia

71
Q

How do we take a patient off of duloxetine?

A

Taper - severe withdrawal

72
Q

Does desvenlafaxine need to be titrated?

A

No

73
Q

What is the desvenlafaxine dose?

A

50mg QD

74
Q

What is desvenlafaxine?

A

Active metabolite of venlafaxine

75
Q

What class is bupropion?

A

NE and DA Reuptake blocker

76
Q

What SE is low in bupropion?

A

Sexual side effect potential

77
Q

What are the common SE of bupropion?

A 
Agitation
Insomnia
Anxiety
Diminished appetite
Wt loss
78
Q

What is bupropion CI’d with?

A 
Hx of seizure
Eating disorders (anorexia/bolemia)
79
Q

Is bupropion an activating or blocking antidepressant?

A

Activating

80
Q

What is bupropions dose-related SE?

A

Seizure

81
Q

What rxns can bupopion cause?

A

Neuropsychiatric rxn

82
Q

What class is mirtazapine in?

A

Alpha 2 antagonist

83
Q

What does the mirtazapine MOA lead to indirectly?

A

Increased release of both NE and serotonin

84
Q

What are common SEs of mirtazapine?

A 
Sedation
Wt gain
Increased appetite
Dizziness
Dry mouth
Constipation
85
Q

What is mirtazapine good for?

A

Depression
Insomnia
Appetite stimulation/help cause wt gain

86
Q

What is the relationship of mirtazapines dose and sedation?

A

Inverse

87
Q

What is the onset of mirtazapine vs SSRIs

A

Mirtazapine faster than SSRIs

88
Q

What is the MOA of trazadone and nefazadone?

A

Block serotonin postsynaptically (more than reuptake)

89
Q

What SE associated with SSRIs are decreased in nefazodone/trazodone?

A

Sexual dysfunciton
Insomnia
Anxiety

90
Q

What toxicity is associated with nefazodone?

A

Hepatotoxicity

91
Q

What is trazodone typically used for?

A

Sedative - must use HD for antidepressant effect

92
Q

What are the most common SE for Trazodone?

A 
Sedation
Orthostasis
HA
Nausea
Priapism
93
Q

What is the MOA of Viibryd (Vilazodone)?

A

SPARI
Partial serotonin agonist + SRI
Lower risk of serotonin syndrome

94
Q

What combination of drugs is similar to Viibryd?

A

Paxil + buspirone

95
Q

How should Viibryd be tajeb?

A

With food - high incidence of GI SE

96
Q

What is the MOA of Trintellix (vortioxetine)?

A

Tri = 3 mechanisms

SSRI + serotonin agonist + serotonin antagonist

97
Q

What is the preferred method when switching/changing antidepressants?

A

Cross taper

98
Q

When is a direct switch acceptable when switching antdepressants?

A

SRI agents

99
Q

How long do MAOIs need a wash out?

A

2 weeks

5 weeks for prozac

100
Q

How do we prevent WD sx?

A

Gradual tapering over several weeks

101
Q

What is the starting and usual dose for prozac?

A

20

20-60

102
Q

What is the starting and usual dose for Paxil?

A

20

20-60

103
Q

What is the starting and usual dose for sertraline?

A

50

50-200

104
Q

What is the starting and usual dose for fluvoxamine?

A

50

100-300

105
Q

What is the starting and usual dose for celexa?

A

20

20-40

106
Q

What is the starting and usual dose for lexapro?

A

10

10-20

107
Q

What are the starting and usual dose for effexor?

A

37.5 -75

75-375

108
Q

What is the starting and usual doses for bupropion?

A

100-150

300-400

109
Q

What is the starting and usual dose for mirtazapine?

A

15

15-45

110
Q

What is the starting and usual dose for duloxetine?

A

30-60

60-120

Psych (9 decks)

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