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Antidepressant medications Flashcards

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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
Q

What is the clinical presentation of TCA poisoning?

A

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
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26
Q

What are the ECG changes in TCA poisoning

A

QRS widening (<200ms)

Broad complex tachycardia

Dominant R wave in aVR (more than 3mm in height and an R:S ratio of 2:1)

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27
Q

What investigations are required in TCA poisoning?

A

ECG
Blood gas
Serum potassium (patients treated with alkalinisation)

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28
Q

What is the treatment for TCA poisoning?

A

Activated charcoal

If seizures - intubate + IV benzodiazepine

Sodium bicarbonate for wide QRS

+++Quinidine and Procainamide are strictly contraindicated

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29
Q

What class of drug Phenelzine?

A

MOAI (irreversible non-selective)

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30
Q

What class of drug Tranylcypromine (parnate)?

A

MAOI (irreversible non-selective)

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31
Q

What class of drug Moclobemide?

A

MOAI (reversible selective)

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32
Q

Why do you have to be cautious when prescribing Phenelzine and tranylcypromine MOAI?

A

Because they have a narrow therapeutic index and doses marginally above the therapeutic dose can be toxic.

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33
Q

What is the dose toxicity of Phenelzine and Tranylcypromine?

A

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

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34
Q

What is a dietary consideration for patients taking Phenelzine and Tranylcypromine?

A

Tyramine containing foods should be avoided

Cheese, wine, preserved meats, yeast products.

Causes tyramine reaction (severe headache and hypertension)

35
Q

What is the clinical presentation of Phenelzine and Tranylcypromine (irreversible, non-selective MAOI) poisoning?

A

Symptom onset 6-12 hours after ingestion, but can be delayed up to 24h, and last from 1-4 days.

Serotonergic syndrome

36
Q

Investigations for Phenelzine and Tranylcypromine (irreversible, non-selective MAOI) poisoning?

A 
FBC
UEC
Serum creatine kinase
Blood gas
ECG
Coagulation profile
CT brain - Haemorrhage
37
Q

Treatment for Phenelzine and Tranylcypromine (irreversible, non-selective MAOI) poisoning?

A

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
Q

What class of drug is Desvenlafaxine (pristiq, desfax, desven)?

A

SNRI

39
Q

What class of drug is Duloxetine?

A

SNRI

40
Q

What class of drug is Venlafaxine?

A

SNRI

41
Q

What conditions should SNRIs be used only with caution

A

Bipolar (causes manic episodes)
Cardiac disease (causes palpitations
Concurrent use of other serotonergic drugs

42
Q

What is the normal dose of Desvenlafaxine?

A

50mg Oral

43
Q

What is the normal dose of Duloxetine (Cymbalta, duloxecor, tixol)?

A

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
Q

What is the normal dose of Venlafaxine?

A

75mg once daily, if required increase to 150mg

45
Q

What is the normal dose of Citralopram?

A

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
Q

What is the normal dose of Escitalopram

A

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
Q

What is the normal dose of Fluoxetine

A

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
Q

What is the normal dose of Fluvoxamine

A

50mg per day increasing to 100-300mg daily as needed.

Doses >150mg should be given in 2-3 doses

49
Q

What is the normal dose of Paroxetine (paxitine, roxet, aropax, exetine)?

A

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
Q

What is the normal dose of Sertraline (zoloft, setrona, eleva)?

A

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
Q

What is the normal dose of Amitriptyline (endep, entrip)?

A

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
Q

What is the normal dose of Clomipramine?

A

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
Q

What is the normal dose of Dosulepin (dothep)?

A

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
Q

What is the normal dose of Doxepin (deptran)?

A

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
Q

What is the normal dose of Imipramine?

A

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
Q

What is the normal dose of Nortriptyline (allegron, nortriTABS)?

A

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
Q

What is the normal dose of Phenelzine?

A

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
Q

What is the normal dose of Tranylcypromine (parnate, parpromine)?

A

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
Q

What class of drug is Reboxetine?

A

Noradrenaline reuptake inhibitor

60
Q

What are things to be cautious of in the use of the NaRI drug, Reboxetine?

A

Seizures (lowers seizure threshold)

cardiovascular disease (causes orthostatic hypotension)

Urinary retention (can cause and exacerbate urinary retention)

Bipolar (can cause manic episodes)

61
Q

What is the normal dose of Reboxetine?

A

4mg per day in two doses. Increase as needed after 3 weeks to 10mg daily (max 12mg)

62
Q

What class of drug is Agomelatine?

A

Melotonin agonist and 5HT2c receptor antagonis

63
Q

What is the normal dose of Agomelatine (valdoxan)?

A

25mg before sleep. Increase to 50mg if needed after 2 weeks

64
Q

What class of drug is Mianserin (lumin)?

A

Tetracyclic antidepressant / alpha-2-antagonist

65
Q

What class of drug is Mirtazapine?

A

Tetracyclic antidepressant / alpha-2-antagonist

66
Q

What are the contraindications for Mirtazapine (Axit, Mirtanza, Milivin, Avanza) and Mianserin (lumin)?

A

Treatment with MAOIs in the last 14 days

67
Q

What is the normal dose of Mianserin?

A

30-60mg per day increasing by 10-20 every 2-3 days if necessary up to 60-90mg (max 120mg)

68
Q

What is the normal dose of Mirtazapine

A

15mg at night. Increasing to 30-45 as needed (max 60mg)

69
Q

What class of drug is Bupropion (Zyban)?

A

Noradrenaline-dopamine reuptake inhibitor.

Used mostly in smoking cessation

70
Q

What are the contraindications for Bupropion?

A

History of seizures
CNS tumour
Bulimia & anorexia
Alcohol withdrawal & benzo withdrawal due to increased risk of seizures.

71
Q

What are the buzzwords for fluoxetine (Prozac)?

A

Only antidepressant which is first line in children and adolescents.

Longest half life (16h)

Good ADR profile

72
Q

What Antidepressant is first line for children and adolescents?

A

Fluoxetine (Prozac)

73
Q

Which SSRI has the longest half life?

A

Fluoxetine (Prozac)

74
Q

What are the buzzwords for Sertraline (Zoloft)?

A

First line in adults.

Good to give with comorbid CV disease

Safe for pregnancy

75
Q

What are the buzzwords for Paroxetine (Aropax)?

A

Contraindicated in pregnancy. Causes foetal pulmonary hypertension.

76
Q

Which SSRI is contraindicated in pregnancy?

A

Paroxetine (Aropax) because it causes foetal pulmonary hypertension

77
Q

What are the buzzwords for Fluvoxamine (Luvox)?

A

Strong sedation

Used in OCD

78
Q

What are the buzzwords for Citalopram (Cipramil) and escitalopram (Lexapro)

A

First line for anxiety

Cause QT prolongation

79
Q

What are the buzzwords for venlafaxine (efexor)?

A

Causes the most sexual dysfunction

80
Q

What are the buzzwords for Desvenlafaxine (Pristiq)?

A

Good for vasomotor symptoms (flushing)

81
Q

What are the buzzwords for Duloxetine (Cymbalta)?

A

Also used for chronic pain and fibromyalgia

82
Q

What are the buzzwords for Mirtanzapine (Avanza)

A

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
Q

What are the buzzwords for Mianserin?

A

Sedation

Agranulocytosis (needs FBC before treatment and monitoring of WCC)

Psych matrix (49 decks)

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