Antidepressant medications Flashcards
What class of drug is Citalopram?
SSRI
++ doses over 600mg can cause QT prolongation
What class of drug is Dapoxetine?
SSRI (used for premature ejaculation, not depression)
What class of drug is Escitalopram (Lexapro, lexam, esipram, cilopam)?
SSRI
++ Doses over 300mg can cause QT prolongation
What class of drug is Fluoxetine (prosac, lovan, zactin, fluotex)?
SSRI
What class of drug is Fluvoxamine?
SSRI
What class of drug is Paroxetine?
SSRI
What class of drug is Sertraline?
SSRI
What class of drug is Vortioxetine?
SSRI (acts in the CNS only)
What is the basic MOA of SSRIs?
Decrease serotonin reuptake
What is the clinical presentation of someone with acute serotonergic syndrome from SSRI or MAOI poisoning?
Acute serotonergic syndrome (when taken with other serotonergic drugs). Neuromuscular excitation, hyperthermia, altered conscious state.
Neuromuscular excitation = hyperreflexia, clonus, ocular clonus, myoclonus, shivering, hypertonia, rigidity.
++ (600mg) Citalopram and (300mg) Escitalopram can cause QT prolongation and torsades de pointes
++ Citalopram, escitalopram, and fluoxetine can cause mild bradycardia
What are the investigations required in SSRI poisoning?
ECG where the patient is taking Citalopram or Escitalopram.
Management of SSRI poisoning.
Activated charcoal within two hours where dose is greater than 50x the defined daily dose,
or Activated charcoal within 4 hours where dose is over 600mg and 300mg for Citalopram and Escitalopram respectively.
IV fluids for hypotension
Diazepam and cyproheptadine (oral)
Diazepam and Midazolam (IV)
Continuous ECG monitoring for Citralopram (>800 with charcoal, >600 without charcoal.) and Escitalopram (>400 with charcoal, >300 without charcoal).
Management of QT interval prolongation
Correct magnesium deficiency:
Magnesium sulfate 50% 5-10ml IV over 30-60mins)
If deficient, fix potassium
If deficient, fix calcium
What is the dosage of potassium in QT prolongation with potassium deficiency?
ORAL: Potassium chloride 14-16mmol orally every 2-4 hours
IV: 10-20mmol potassium chloride IV over 1-2 hours (premixed infusion bag)
What is the dosage of calcium in QT prolongation with calcium deficiency?
Calcium gluconate 10% 10-20ml IV over 10-30 mins
repeat until levels normalised
Management of torsades de pointes
Magnesium sulfate 50% (8mmol) 4ml IV over 10-15 mins.
Isoprenaline 20micrograms IV every 2-3 minutes to maintain heart rate above 90BPM
What is the primary MOA of tricyclic antidepressants
TCAs inhibit reuptake of noradrenaline and serotonin into presynaptic terminals. Although unrelated to the therapeutic effects of the TCAs, they also block cholinergic, histaminergic, alpha1-adrenergic and serotonergic receptors. Clomipramine has a greater effect on serotonin transport than other TCAs.
What class of drug is Amitriptyline?
TCA
What class of drug is Clomipramine?
TCA
What class of drug is Dosulepin (Dothiepin)?
TCA
What class of drug is Doxepin?
TCA
What class of drug is Imipramine?
TCA
What class of drug is Nortriptyline?
TCA
What is the dose toxicity of TCAs
Less than 5mg/kg - usually non-toxic
Between 5-20mg/kg - sedation and anticholinergic effects
Over 20mg/kg - severe toxicity (coma, seizures, major cardiovascular toxicity)
What is the clinical presentation of TCA poisoning?
Symptoms start at 2h. Severe complications at 6h.
- CNS effects:
Decreased consciousness, respiratory depression and coma.
seizures - CV effects:
Hypotension (alpha-adrenoreceptor blockade)
Sinus tachycardia (Alpha-adrenoreceptor blockade and anti-cholinergic effects)
QRS widening and arrhythmia (Sodium channel blockade) - Anticholinergic toxidrome:
Mydriasis, warm dry skin, sinus tachy, dry mouth.
Urinary retention and reduced bowel sounds.
Delirium that can persist for 24-48 hours
What are the ECG changes in TCA poisoning
QRS widening (<200ms)
Broad complex tachycardia
Dominant R wave in aVR (more than 3mm in height and an R:S ratio of 2:1)
What investigations are required in TCA poisoning?
ECG
Blood gas
Serum potassium (patients treated with alkalinisation)
What is the treatment for TCA poisoning?
Activated charcoal
If seizures - intubate + IV benzodiazepine
Sodium bicarbonate for wide QRS
+++Quinidine and Procainamide are strictly contraindicated
What class of drug Phenelzine?
MOAI (irreversible non-selective)
What class of drug Tranylcypromine (parnate)?
MAOI (irreversible non-selective)
What class of drug Moclobemide?
MOAI (reversible selective)
Why do you have to be cautious when prescribing Phenelzine and tranylcypromine MOAI?
Because they have a narrow therapeutic index and doses marginally above the therapeutic dose can be toxic.
What is the dose toxicity of Phenelzine and Tranylcypromine?
1-2mg/kg - mild to moderate toxicity
2-4mg/kg - severe toxicity
> 4mg/kg - death
+++Measurement of serum MAOI concentration is not useful as it does not correlate with toxicity
What is a dietary consideration for patients taking Phenelzine and Tranylcypromine?
Tyramine containing foods should be avoided
Cheese, wine, preserved meats, yeast products.
Causes tyramine reaction (severe headache and hypertension)
What is the clinical presentation of Phenelzine and Tranylcypromine (irreversible, non-selective MAOI) poisoning?
Symptom onset 6-12 hours after ingestion, but can be delayed up to 24h, and last from 1-4 days.
Serotonergic syndrome
Investigations for Phenelzine and Tranylcypromine (irreversible, non-selective MAOI) poisoning?
FBC UEC Serum creatine kinase Blood gas ECG Coagulation profile CT brain - Haemorrhage
Treatment for Phenelzine and Tranylcypromine (irreversible, non-selective MAOI) poisoning?
Decontamination with activated charcoal within 2 hours
Benzodiazepine for seizures
Cold IV therapy for hyperthermia
Noradrenaline for hypotension
Glyceryl nitrate for hypertension (short acting because it fluctuates)
Treatment for arrhythmias associated with serotonergic syndrome
+++ Do not use beta blockers
What class of drug is Desvenlafaxine (pristiq, desfax, desven)?
SNRI
What class of drug is Duloxetine?
SNRI
What class of drug is Venlafaxine?
SNRI
What conditions should SNRIs be used only with caution
Bipolar (causes manic episodes)
Cardiac disease (causes palpitations
Concurrent use of other serotonergic drugs
What is the normal dose of Desvenlafaxine?
50mg Oral
What is the normal dose of Duloxetine (Cymbalta, duloxecor, tixol)?
Anxiety: 30mg per day to start, increase 30mg daily to a maximum of 120mg
Depression 60mg daily
Painful diabetic peripheral neuropathy 60mg per day
(30mg if CrCl<30)
What is the normal dose of Venlafaxine?
75mg once daily, if required increase to 150mg
What is the normal dose of Citralopram?
Start at 20mg once daily, increasing to 40mg after 2-4 weeks.
If old start on 10mg daily and increase to 20mg if needed (because of decreased CYP2C19 function)
What is the normal dose of Escitalopram
10mg once daily. Increase to a maximum of 20mg after 2-4 weeks if needed
If elderly or hepatic impairment 5mg daily increasing to 10mg after 2-4 weeks if needed.
What is the normal dose of Fluoxetine
Major depression - 20mg daily increasing to 60mg if needed
OCD - 20mg daily increasing to 60-80mg if needed. dosage can be split between morning and evening.
Premenstrual dysphoric disorder - 20mg daily
10mg daily / 20mg bidaily in patients with hepatic impairment
No more than 40mg daily in elderly patients
+++don’t use in breastfeeding because of long half-life
What is the normal dose of Fluvoxamine
50mg per day increasing to 100-300mg daily as needed.
Doses >150mg should be given in 2-3 doses
What is the normal dose of Paroxetine (paxitine, roxet, aropax, exetine)?
Generalised anxiety disorder - 10mg daily increasing to 20mg after a week if needed
Major depression- 20mg daily increasing to 50mg if needed
OCD- 20mg daily increasing to 50mg if needed
Elderly patients or CrCl<30 - initial dose of 10mg daily, increase to a maximum of 40mg
What is the normal dose of Sertraline (zoloft, setrona, eleva)?
Major depression - 50mg daily increasing to 200mg if needed
OCD - 50mg once daily increasing to 200mg if needed
Panic disorder / social phobia - 25mg once daily increasing to 50mg if needed
Premenstrual dysphoric disorder - 50mg daily
What is the normal dose of Amitriptyline (endep, entrip)?
Major depression - 25-75mg oral increasing by 25-50mg every 2-3 days to 75-150mg daily (max 300mg). Give maintenance dose at night.
What is the normal dose of Clomipramine?
Major depression - 25-75mg oral increasing by 25-50mg every 2-3 days to 75-150mg daily (max 300mg). Give maintenance dose at night.
Panic disorder - 25mg per day increasing to to 50-150mg
What is the normal dose of Dosulepin (dothep)?
Major depression - 25-75mg oral increasing by 25-50mg every 2-3 days to 75-150mg daily (max 300mg). Give whole dose at night.
What is the normal dose of Doxepin (deptran)?
Major depression - 25-75mg oral increasing by 25-50mg every 2-3 days to 75-150mg daily (max 300mg). Give as divided dose or all at night.
What is the normal dose of Imipramine?
Major depression - 25-75mg oral increasing by 25-50mg every 2-3 days to 75-150mg daily (max 300mg). Give maintenance dose at night.
Panic disorder - 25mg per day increasing to to 50-150mg
What is the normal dose of Nortriptyline (allegron, nortriTABS)?
Major depression - 25-75mg oral increasing by 25-50mg every 2-3 days to 75-150mg daily (max 150mg). Divided dose, or all at night.
What is the normal dose of Phenelzine?
15mg per day in 2-3 doses. If response is inadequate after 1-4 weeks increase by 15mg every 1-2 weeks to 60mg daily. (max 90mg)
What is the normal dose of Tranylcypromine (parnate, parpromine)?
10mg per day (2x doses).
If insufficient response after 2 weeks increase by 10mg daily every 1-3 weeks to 30-40mg (max 60mg)
What class of drug is Reboxetine?
Noradrenaline reuptake inhibitor
What are things to be cautious of in the use of the NaRI drug, Reboxetine?
Seizures (lowers seizure threshold)
cardiovascular disease (causes orthostatic hypotension)
Urinary retention (can cause and exacerbate urinary retention)
Bipolar (can cause manic episodes)
What is the normal dose of Reboxetine?
4mg per day in two doses. Increase as needed after 3 weeks to 10mg daily (max 12mg)
What class of drug is Agomelatine?
Melotonin agonist and 5HT2c receptor antagonis
What is the normal dose of Agomelatine (valdoxan)?
25mg before sleep. Increase to 50mg if needed after 2 weeks
What class of drug is Mianserin (lumin)?
Tetracyclic antidepressant / alpha-2-antagonist
What class of drug is Mirtazapine?
Tetracyclic antidepressant / alpha-2-antagonist
What are the contraindications for Mirtazapine (Axit, Mirtanza, Milivin, Avanza) and Mianserin (lumin)?
Treatment with MAOIs in the last 14 days
What is the normal dose of Mianserin?
30-60mg per day increasing by 10-20 every 2-3 days if necessary up to 60-90mg (max 120mg)
What is the normal dose of Mirtazapine
15mg at night. Increasing to 30-45 as needed (max 60mg)
What class of drug is Bupropion (Zyban)?
Noradrenaline-dopamine reuptake inhibitor.
Used mostly in smoking cessation
What are the contraindications for Bupropion?
History of seizures
CNS tumour
Bulimia & anorexia
Alcohol withdrawal & benzo withdrawal due to increased risk of seizures.
What are the buzzwords for fluoxetine (Prozac)?
Only antidepressant which is first line in children and adolescents.
Longest half life (16h)
Good ADR profile
What Antidepressant is first line for children and adolescents?
Fluoxetine (Prozac)
Which SSRI has the longest half life?
Fluoxetine (Prozac)
What are the buzzwords for Sertraline (Zoloft)?
First line in adults.
Good to give with comorbid CV disease
Safe for pregnancy
What are the buzzwords for Paroxetine (Aropax)?
Contraindicated in pregnancy. Causes foetal pulmonary hypertension.
Which SSRI is contraindicated in pregnancy?
Paroxetine (Aropax) because it causes foetal pulmonary hypertension
What are the buzzwords for Fluvoxamine (Luvox)?
Strong sedation
Used in OCD
What are the buzzwords for Citalopram (Cipramil) and escitalopram (Lexapro)
First line for anxiety
Cause QT prolongation
What are the buzzwords for venlafaxine (efexor)?
Causes the most sexual dysfunction
What are the buzzwords for Desvenlafaxine (Pristiq)?
Good for vasomotor symptoms (flushing)
What are the buzzwords for Duloxetine (Cymbalta)?
Also used for chronic pain and fibromyalgia
What are the buzzwords for Mirtanzapine (Avanza)
Lots of sedation (50% of patients)
Lots of weight gain (30% of patients)
Good in elderly. First line for elderly patients along with sertraline.
What are the buzzwords for Mianserin?
Sedation
Agranulocytosis (needs FBC before treatment and monitoring of WCC)
