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Antidepressant medications Flashcards

1
Q

What class of drug is Citalopram?

A

SSRI

++ doses over 600mg can cause QT prolongation

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2
Q

What class of drug is Dapoxetine?

A

SSRI (used for premature ejaculation, not depression)

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3
Q

What class of drug is Escitalopram (Lexapro, lexam, esipram, cilopam)?

A

SSRI

++ Doses over 300mg can cause QT prolongation

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4
Q

What class of drug is Fluoxetine (prosac, lovan, zactin, fluotex)?

A

SSRI

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5
Q

What class of drug is Fluvoxamine?

A

SSRI

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6
Q

What class of drug is Paroxetine?

A

SSRI

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7
Q

What class of drug is Sertraline?

A

SSRI

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8
Q

What class of drug is Vortioxetine?

A

SSRI (acts in the CNS only)

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9
Q

What is the basic MOA of SSRIs?

A

Decrease serotonin reuptake

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10
Q

What is the clinical presentation of someone with acute serotonergic syndrome from SSRI or MAOI poisoning?

A

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

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11
Q

What are the investigations required in SSRI poisoning?

A

ECG where the patient is taking Citalopram or Escitalopram.

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12
Q

Management of SSRI poisoning.

A

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).

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13
Q

Management of QT interval prolongation

A

Correct magnesium deficiency:
Magnesium sulfate 50% 5-10ml IV over 30-60mins)

If deficient, fix potassium

If deficient, fix calcium

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14
Q

What is the dosage of potassium in QT prolongation with potassium deficiency?

A

ORAL: Potassium chloride 14-16mmol orally every 2-4 hours

IV: 10-20mmol potassium chloride IV over 1-2 hours (premixed infusion bag)

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15
Q

What is the dosage of calcium in QT prolongation with calcium deficiency?

A

Calcium gluconate 10% 10-20ml IV over 10-30 mins

repeat until levels normalised

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16
Q

Management of torsades de pointes

A

Magnesium sulfate 50% (8mmol) 4ml IV over 10-15 mins.

Isoprenaline 20micrograms IV every 2-3 minutes to maintain heart rate above 90BPM

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17
Q

What is the primary MOA of tricyclic antidepressants

A

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.

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18
Q

What class of drug is Amitriptyline?

A

TCA

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19
Q

What class of drug is Clomipramine?

A

TCA

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20
Q

What class of drug is Dosulepin (Dothiepin)?

A

TCA

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21
Q

What class of drug is Doxepin?

A

TCA

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22
Q

What class of drug is Imipramine?

A

TCA

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23
Q

What class of drug is Nortriptyline?

A

TCA

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24
Q

What is the dose toxicity of TCAs

A

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)

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25
What is the clinical presentation of TCA poisoning?
Symptoms start at 2h. Severe complications at 6h. 1. CNS effects: Decreased consciousness, respiratory depression and coma. seizures 2. CV effects: Hypotension (alpha-adrenoreceptor blockade) Sinus tachycardia (Alpha-adrenoreceptor blockade and anti-cholinergic effects) QRS widening and arrhythmia (Sodium channel blockade) 3. Anticholinergic toxidrome: Mydriasis, warm dry skin, sinus tachy, dry mouth. Urinary retention and reduced bowel sounds. Delirium that can persist for 24-48 hours
26
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)
27
What investigations are required in TCA poisoning?
ECG Blood gas Serum potassium (patients treated with alkalinisation)
28
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
29
What class of drug Phenelzine?
MOAI (irreversible non-selective)
30
What class of drug Tranylcypromine (parnate)?
MAOI (irreversible non-selective)
31
What class of drug Moclobemide?
MOAI (reversible selective)
32
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.
33
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
34
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)
35
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
36
Investigations for Phenelzine and Tranylcypromine (irreversible, non-selective MAOI) poisoning?
``` FBC UEC Serum creatine kinase Blood gas ECG Coagulation profile CT brain - Haemorrhage ```
37
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
38
What class of drug is Desvenlafaxine (pristiq, desfax, desven)?
SNRI
39
What class of drug is Duloxetine?
SNRI
40
What class of drug is Venlafaxine?
SNRI
41
What conditions should SNRIs be used only with caution
Bipolar (causes manic episodes) Cardiac disease (causes palpitations Concurrent use of other serotonergic drugs
42
What is the normal dose of Desvenlafaxine?
50mg Oral
43
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)
44
What is the normal dose of Venlafaxine?
75mg once daily, if required increase to 150mg
45
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)
46
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.
47
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
48
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
49
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
50
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
51
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.
52
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
53
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.
54
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.
55
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
56
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.
57
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)
58
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)
59
What class of drug is Reboxetine?
Noradrenaline reuptake inhibitor
60
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)
61
What is the normal dose of Reboxetine?
4mg per day in two doses. Increase as needed after 3 weeks to 10mg daily (max 12mg)
62
What class of drug is Agomelatine?
Melotonin agonist and 5HT2c receptor antagonis
63
What is the normal dose of Agomelatine (valdoxan)?
25mg before sleep. Increase to 50mg if needed after 2 weeks
64
What class of drug is Mianserin (lumin)?
Tetracyclic antidepressant / alpha-2-antagonist
65
What class of drug is Mirtazapine?
Tetracyclic antidepressant / alpha-2-antagonist
66
What are the contraindications for Mirtazapine (Axit, Mirtanza, Milivin, Avanza) and Mianserin (lumin)?
Treatment with MAOIs in the last 14 days
67
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)
68
What is the normal dose of Mirtazapine
15mg at night. Increasing to 30-45 as needed (max 60mg)
69
What class of drug is Bupropion (Zyban)?
Noradrenaline-dopamine reuptake inhibitor. Used mostly in smoking cessation
70
What are the contraindications for Bupropion?
History of seizures CNS tumour Bulimia & anorexia Alcohol withdrawal & benzo withdrawal due to increased risk of seizures.
71
What are the buzzwords for fluoxetine (Prozac)?
Only antidepressant which is first line in children and adolescents. Longest half life (16h) Good ADR profile
72
What Antidepressant is first line for children and adolescents?
Fluoxetine (Prozac)
73
Which SSRI has the longest half life?
Fluoxetine (Prozac)
74
What are the buzzwords for Sertraline (Zoloft)?
First line in adults. Good to give with comorbid CV disease Safe for pregnancy
75
What are the buzzwords for Paroxetine (Aropax)?
Contraindicated in pregnancy. Causes foetal pulmonary hypertension.
76
Which SSRI is contraindicated in pregnancy?
Paroxetine (Aropax) because it causes foetal pulmonary hypertension
77
What are the buzzwords for Fluvoxamine (Luvox)?
Strong sedation | Used in OCD
78
What are the buzzwords for Citalopram (Cipramil) and escitalopram (Lexapro)
First line for anxiety | Cause QT prolongation
79
What are the buzzwords for venlafaxine (efexor)?
Causes the most sexual dysfunction
80
What are the buzzwords for Desvenlafaxine (Pristiq)?
Good for vasomotor symptoms (flushing)
81
What are the buzzwords for Duloxetine (Cymbalta)?
Also used for chronic pain and fibromyalgia
82
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.
83
What are the buzzwords for Mianserin?
Sedation | Agranulocytosis (needs FBC before treatment and monitoring of WCC)

Psych matrix (49 decks)

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