Antidepressant meds Flashcards
Antidepressants
General
Most antidepressants have similar efficacy in treating depression so your choice of antidepressant should be based on side effect profile and comorbidities
Lots of antidepressants work on multiple neurotransmitters
Start low and go slow
Peds patients typically start at ½ starting dose for 7 days then increase
All antidepressants have a BLACK BOX WARNING for increase suicidal ideation in patients under 25yo
Follow up closely with these patients
neurotransmitters
Serotonin Side Effects
Nausea, vomiting, diarrhea
Headaches, dizziness
Inducing mania/hypomania
Increased bleeding risk (serotonin receptors on platelets)
Typically presents as easy bruising
No need to hold medications prior to surgery
Bone fractures (up to 76% increased risk with SSRIs)
Seuxal Dysfunction - decfreased libido, delayed or inability to climax (F>M)
Serotonin Syndrome
And possible meds
EMERGENCY - potentially fatal
2+ serotonergic medications simultaneously
Serotonin Syndrome “Shivers”
S - Shivering
H - Hyperreflexia and Myoclonus
I - Increased Temperature
V- Vital Sign instability( increase BP, HR, RR)
E- Encephalopathy (altered LOC)
R - Restlessness
S - Sweating
Discontinuation Syndrome
Best and worst offender
Advise patients to never abruptly stop medications
NOT medically dangerous but uncomfortable
Typically will taper off medications over several weeks OR cross taper onto new medication
Reduce dose by 25% per week over 4 weeks
Paxil = WORST
Prozac = LEAST
Discontinuation syndrome
Sx
F - Flu-like symptoms
I - Insomnia
N - Nausea
I - Imbalance
S - Sensory Disturbances
H - Hyperarousal
SSRI
Fluoxetine (Prozac)
SSRI
Dose - 10mg - 60mg, weekly form 90mg
FDA indications- MDD (age 8+), OCD (age 7+), panic disorder, bulimia, PMDD
Off label- PTSD, social anxiety
Monitoring-no routine monitoring
Side Effects- general SSRI SE, SSRI most likely to cause insomnia and anxiety
Has longest half live (active metabolite T1/2 is 2+ weeks) of any SSRI which can make it self-tapering (no discontinuation syndrome)
Can be stimulating (cause insomnia, anxiety, and decreased appetite) so is a good option for someone who needs activation (fatigue, concentration issues, etc)
Paroxetine (Paxil)
SSRI
Dose: 10mg - 40mg
FDA indications- MDD, OCD, panic disorder, social anxiety, GAD, PTSD, PMDD, menopausal hot flashes
Off label- premature ejaculation
Monitoring- no routine monitoring
Side Effects- general SSRI SE, SSRI most likely to cause weight gain, sexual side effects, sedation
Pregnancy category D, so avoid if possible in women of child-bearing age
Half live of less than 24 hours, bad rebounds symptoms if stopped abruptly
Sertraline (Zoloft)
SSRI
Dose: 50mg - 300mg
FDA indications- MDD, OCD (age 6+), panic disorder, PTSD, PMDD, social anxiety
Off label- GAD
Monitoring- no routine monitoring
Side Effects- general SSRI SE, SSRI most likely to cause nausea
Sometimes called squirt-raline due to GI SE
Escitalopram (Lexapro)
SSRI
Dose: 10mg - 20mg
FDA indications- MDD (age 12+), GAD
Off label- OCD, PTSD, social anxiety, panic disorder, PMDD
Monitoring- no routine monitoring
Side Effects- general SSRI SE
Enantiomer of citalopram (S enantiomer is the pure active form and R en antiomer has anticholinergic properties which causes more side effects)
Considered the cleanest SSRI meaning it has the fewest SE
Selective Norepinephrine Reuptake Inhibitors
Blocks serotonin and norepinephrine reuptake transports to increase both in synaptic cleft
Venlafaxine (Effexor)
SNRI
Dose: 37.5mg - 225mg
FDA indications- MDD, social anxiety disorder, GAD, panic disorder
Off label- PTSD, PMDD, vasomotor symptoms of menopause, diabetic peripheral neuropathy
Monitoring- periodic BP
Cost- cheap
Side Effects- anorexia, dizziness, dry mouth, sweating, sexual side effects, nervousness, hypertension, hyponatremia (in volume depleted)
Has significant discontinuation syndrome even with the XR formulation, titrate off very slowly or consider using fluoxetine taper
Desvenlafaxine (Pristiq)
SNRI
Dose: 50mg - 200mg
FDA indications- MDD
Off label- fibromyalgia, vasomotor symptoms of menopause, GAD, social anxiety disorder, panic disorder, PTSD, PMDD
Monitoring- periodic BP
Cost- not as cheap as other antidepressants
Side Effects- hypertension, nausea, dizziness, insomnia, excessive sweating, sexual side effects
No clear advantage of using desvenlafaxine over venlafaxine
Duloxetine (Cymbalta)
SNRI
Dose: 20mg - 120mg (typically BID)
FDA indications- MDD, GAD (ages 7+), diabetic peripheral neuropathic pain, fibromyalgia, chronic MSK pain
Off label- other neuropathic or chronic pain disorders, other anxiety disorders, stress urinary incontinence
Monitoring- LFTs is suspect liver disease, periodic BP
Cost- cheap
Side Effects- liver disorders, nausea, dry mouth, insomnia, fatigue, HA, sexual side effects, urinary hesitation, urinary retention
Very useful in patients with comorbid pain syndromes or with stress urinary incontinence
Levomilnacipran (Fetzima)
SNRI
Dose: 20mg - 120mg
FDA indications- MDD
Off label- fibromyalgia, anxiety disorders, vasomotor symptoms with menopause, diabetic peripheral neuropathy, chronic MSK pain
Monitoring- periodic BP and pulse
Cost- expensive
Side Effects- nausea, vomiting, constipation, sweating, increased HR, urinary hesitation, urinary retention
Nausea may be severe enough for titration
Increased rate of side effects and cost make this drug a second line SNRI
Bupropion (Wellbutrin)
NDRI
Dose: comes in IR and XL version. 75mg - 450mg
FDA indications- MDD, seasonal affective disorder, smoking cessation (Zyban)
Off label- ADHD, sexual dysfunction, bipolar depression
Side effects- seizure, agitation, insomnia (take in morning to reduce), HA, nausea, vomiting, tremor, tachycardia, NE effects make this med stimulating making it particularly useful in patients with fatigue and poor concentration associated with depression
Lack of sexual side effects and weight gain make it very useful in patients suffering these SE from other meds or are worried about this SE
Can reduce seizure threshold
so don’t give in bulimic patients and be very careful in patients with alcohol use disorder and electrolyte disorders
New Drug: Auvelity, dextromethorphan-bupropion for MDD
Nonmedication Antidepressant Tx
CBT
https://www.mind.org.uk/information-support/drugs-and-treatments/talking-therapy-and-counselling/cognitive-behavioural-therapy-cbt/
CBT alone is just as effective as antidepressants and antidepressants alone are just as effective as CBT
Best results with both CBT and medication
Nonmedication Antidepressant Tx
Light Box Therapy
Indications- no FDA approval but indicated for seasonal affective disorder and non-seasonal depression
Side effects- eye strain, HA, mania in bipolar patients (uncommon)
Light boxes emit full spectrum light with the standard minimum intensity of 10,000 lux (similar to light experienced if standing outside for 30 minutes
Decreases melatonin production
Nonmedication Antidepressant Tx
ECT-electrocompulsive therapy
FDA indications- treatment resistant or severe depression (either unipolar or bipolar), catatonia
Off-label indications- psychotic depression, severe schizophrenia, suicidality, neuroleptic malignant syndrome
Side effects- acute confusion, memory loss, tension HA (30%), nausea, jaw pain
Induces a generalized seizure which has antidepressant/antipsychotic effects via unknown mechanism
Treatments given 3x/wk, response usually within 3-6 treatments, average number of treatments = 7-10
High remission rate however relapse is common with out maintenance treatment
Most effective treatment for depression
https://medicine.umich.edu/dept/psychiatry/programs/neuromodulation/electroconvulsive-therapy
Nonmedication Antidepressant Tx
TMS-transcranial magnetic stimulation
FDA indications- depression that has not responded to 1 prior antidepressant, OCD, migraine pain
Off-label indications- post- stroke depression, Parkinson’s disease, Alzheimer’s disease, PTSD, chronic pain
Side effects- scalp discomfort, seizures (uncommon), hearing loss (uncommon
Modulates activity in cortical regions
In theory, left dorsolateral prefrontal cortex in underactive in depression
Treatments are given 5x/wk with response usually beginning after 20 treatment
https://ufhealthjax.org/psychiatry/transcranial-magnetic-stimulation.aspx
Escalation of treatment resistant depression
Level I: Begin with an adequate trial of a first-line antidepressant (usually a generic formulation of an SSRI or SNRI)
Level II: Switch to another first-line antidepressant (some favor switching to a different type of medication, eg, mirtazapine)
Level III: Patented antidepressants, combinations and adjuncts or older antidepressants (ie, TCAs or MAOIs)
Level IV: Neuromodulation strategies (TMS or ECT), ketamine infusions or intranasal esketamine
Level V: VNS or unproven or experimental strategies
Mirtazapine (Remeron)
Alpha-2 Receptor Antagonists (NaSSA)
MOA- serotonin antagonist and alpha-2 adrenergic antagonist
Dose: 7.5mg to 45mg
FDA indications- MDD
Off label- panic disorder, PTSD, GAD, insomnia, appetite stimulant
Monitoring- weight
Cost- cheap
Side Effects- somnolence, increased appetite, weight gain, agranulocytosis or severe neutropenia (rare)
Its tendency to cause stimulant appetite and sedation makes it a great choice for some patients (insomnia, cachexia, etc) but a terrible option for others (eating disorders, body dysphoric disorder)
If patient has too much sedation at starting dose, consider increasing dose as it has more noradrenergic activity relative to antihistaminergic activity at higher doses
Trazodone
Serotonin-2 Antagonist-Reuptake Inhibitors (SARIs)
MOA- serotonin reuptake inhibitor, alpha-1 adrenergic antagonist, serotonin receptor antagonist
Dose: 25mg to 300mg
FDA indications- MDD
Off label- insomnia, anxiety
Monitoring- no routine monitoring
Cost- cheap
Side Effects- drowsiness, dry mouth, lightheadedness, orthostatic hypotension, priapism (TrazoBone)
Mostly used for insomnia due to its sedating qualities
Vilazodone (Viibryd)
SSRI and 5HT1A Partial Agonist
MOA- serotonin reuptake inhibitor and serotonin partial agonist
Dose: 10mg to 40mg
FDA indications- MDD
Off label- OCD, other anxiety disorders
Monitoring- no routine monitoring
Cost- expensive
Side Effects- diarrhea, nausea, vomiting, insomnia, hyponatremia
Must be taken with food
Fewer Sexual side effects
Vortioxetine (Trintellix)
SSRI and Serotonin (5-HT) Receptor Modulator
MOA- multimodal antidepressant: antagonist, partial agonist, and agonist of different serotonin receptors
Dose: 5-20mg
FDA indications- MDD
Off label- GAD, other anxiety disorders
Monitoring- no routine monitoring
Cost- expensive
Side Effects- GI side effects, sexual side effects
Helps with cognitive functioning in depression
May have less sexual side effects than other SSRI
Brexpiprazole (Rexulti)
Atypical antipsychotics
MOA- dopamine D2 and serotonin partial agonist and antagonist
Dose: 0.5mg to 4mg
FDA indications- schizophrenia, depression adjunct
Off label- too new to tell
Monitoring- fasting glucose, lipids
Cost- expensive
Side Effects- weight gain, akathisia, somnolence, tardive dyskinesia, impulse control problems, pathologic gambling
Is actually an antipsychotic
Is only used as an adjunct for depression meaning it is not a monotherapy
Esketamine (Spravato)
MOA- NMDA receptor antagonist
FDA indications- treatment resistant major depression (in conjunction with an oral antidepressant)
Off label- pain, migraine
Monitoring- must be monitored after dose for 2 hours (cannot be taken at home)
Cost- expensive
Side Effects- sedation, dissociation, elevated BP, cognitive impairment, hypertensive crisis
Recently approved for treatment resistant major depression, even more recently approved for use in emergency room for urgent depressive episode or suicidal ideation
Intranasal spray (IV formulation is Ketalar)
Complicated dosing with different phases (induction and maintenance)
TCAs
MOA- serotonin and NE reuptake inhibitor which causes its therapeutic effects, but it also blocks histamine and muscarinic receptors and effects Na and Ca channels which account for its side effects and toxicity
FDA indications- MDD
Off label- many different TCAs have different off label indications, too many to discuss here
Monitoring- ECG if history of cardiac disease, Nortriptyline requires plasma levels
Cost- cheap
Side Effects- sedation, dry mouth, constipation, weight gain, sexual side effects, urinary hesitation, blurred vision, arrhythmias, QT prolongation
Clomipramine is FDA approved for OCD
Not as commonly used due to toxicity and side effects
Can easily cause overdose
TCA Overdose
Avoid use in patients with past suicide attempts or suicidal ideation
