Antidepressants Flashcards
Unipolar vs. Bipolar
- Before medicating differentiate between the two diagnosis
- Complete family and personal history
- ANTIDEPRESSANTS ARE NOT INDICATED FOR BIPOLAR DISORDER
- CAN PRECIPITATE MANIA AND HYPOMANIA
- AD’s will not alleviate bipolar depressive symptoms
Selecting the Correct Antidepressant
- Discuss: tolerability, safety, effectiveness, cost, age, family hx, drug-drug interactions, comorbids, symptoms
- Initiate treatment with SSRI or SNRI (sometimes can do mirtazapine or bupropion
- Newer agents can be more expensive and lack broad experience
- First generation TCAs and MAOI’s may offer similar/greater effectiveness BUT with less receptor specificity and more toxicity and side effects
SSRI’s
3 points
5 drugs and points to each
FSCEP
- NOT indicated for mild depression
- IS indicated for mod-severe depression
- SSRI’s not interchangeable
FSCEP
most energizing to least energizing
- fluoxetine
- unique 5HT2c action (not short term anxiety)
- slightly lower onset of action compared to other SSRI
- can cause insomnia (bc most energizing) - sertraline
- dopamine transport inhibitor
- sigma-1 receptor binding
- often used with bupropion - citalopram
- QT prolongation
- do not use with bradycardia, hypokalemia, hypomagnesemia, CHF, recent MI, or other QT-prolonging drugs - escitalopram
- low risk of QT prolongation
- No CYP450 interactions
- considered to be best tolerated SSRI
- lower doses usually effective - paroxetine
- some anticholinergic effects
- useful when anxiety is strong component
Specific Indications for SSRI’s
CV Disease
sertraline
Specific Indications for SSRI’s
Adolescents
fluoxetine, sertraline, escitalopram
Specific Indications for SSRI’s
Underweight
paroxetine
Specific Indications for SSRI’s
Overweight
fluoxetine
Specific Indications for SSRI’s
Psychomotor slowing
fluoxetine
Specific Indications for SSRI’s
Insomnia
paroxetine
Specific Indications for SSRI’s
Somnolence
fluoxetine, sertraline
Specific Indications for SSRI’s
Elderly
citalopram
Avoid indications for SSRI’s
overweight
paroxetine
Avoid indications for SSRI’s
QT prolong or torsades risk
citalopram
Avoid indications for SSRI’s
Agitation or Insomnia
fluoxetine
Avoid indications for SSRI’s
Elderly
paroxetine (bc has some anticholinergic effects)
Avoid indications for SSRI’s
Pregnancy
ALL
Adverse Effects of SSRI’s
GI Effects: NAUSEA (especially with paroxetine and sertraline), abd pain, decreased appetite, dry mouth
Weight loss or gain
Restlessness/Agitation
Fatigue/Drowsiness
Sexual Dysfunction
SI
Skin Rash/Photosensitivity
QT Prolongation (citalopram)
Headache and Tremor
Adverse Effects of SSRI’s
GI Effects: NAUSEA (especially with paroxetine and sertraline), abd pain, decreased appetite, dry mouth
Weight loss or gain
(paroxetine highest risk of gain)
(sertraline small loss in acute phase of tx)
(fluoxetine modest loss bc app suppressant)
Restlessness/Agitation
Fatigue/Drowsiness
Sexual Dysfunction (anorgasmia, decreased libido, impotence, delayed ejaculation) (paroxetine highest rate of sexual dysfunction) (citalopram loss of libido and higher level of sexual dysfunction than sertraline) (fluoxetine less likely to have sexual dysfunction than paroxetine and sertraline)
SI
Skin Rash/Photosensitivity
QT Prolongation (citalopram)
Headache and Tremor
Drug Interactions with SSRI’s
MAOI’s (phenelzine or isocarboxazid):
- Serotonin Syndrome: usually when two serotonin increasing drugs used at one time like SJW, tramadol, meperidine, dextromorphan
- Neuroleptic Malignant Syndrome (fatal) (hyperthermia, rigidity and autonomic dysregulation)
» Do not use within 14 days of each other
Drugs that increase coag time:
- antiplatelets, anticoagulants (GI BLEED)
- aspirin, NSAIDs
- warfarin
TCA and Lithium
- can elevate levels of these drugs
Serotonin Syndrome Signs
- Hallmark sign: Clonus (involuntary rapid muscle contractions and relaxation) or tremor
- Mental status changes
- neuromuscular changes
- autonomic changes: diarrhea, fever, flushing, sweating
Usually after an increase in dosages
Usually within 6 hours
SNRI’s
Drugs: venlafaxine, duloxetine, desvenlafaxine
2ND LINE
Avoid in:
hypertension (increase BP)
agitation or insomnia
alcoholism (liver damage)
SNRI Side Effects
GI: nausea and constipation
CV: increased BP, tachycardia, arrythmias
Neuro: dizzy, fatigue, headache, insomnia, diaphoresis, blurred vision, dysruria
SEXUAL DYSFUNCTION: 40%
** SNRI’s need to be titrated down over 4 week period***
Drugs that cause Sexual Dysfunction
Yes —-
SSRI’s
SNRI’s
No —
Wellbutrin
Mirtazapine
SPARI’s (lesser than SSRI’s)
Wellbutrin
- usually added but sometimes monotherapy
- potentially activating
»_space; use for psychomotor slowing, fatigue, hypersomnia, because it is energizing and stimulating
»_space; use with overweight bc of reason above - Used with smoking cessation
- often used as SSRI’s add on
- use for sexual dysfunction concerns (used for anhedonia)
»_space; markedly less sexual dysfunction side effects
Side Effects:
Seizure is biggest concern
TCA’s
Drugs: triptylines and others (-ines)
2ND LINE
Indications similar to SSRI / SNRI
Beers list
Most dangerous SE: cardiotoxicity
- causes significant QT prolong and lowers seizure threshold
Mirtazapine
Atypical Antidepressant (2nd or 3rd line)
- Considered an alpha 2 agonist
- Does not inhibit reuptake
- Less energizing, histamine effect, NO SIGNIFICANT DRUG INTERACTIONS, can be used as add-on
Consider for:
- anxiety, agitation, insomnia, underweight, sexual dysfunction
Avoid in:
- overweight, hyperlipidemia
SPARI’s
Drugs: vortioxetine, vilazodone, nefazodone
- Lesser sexual dysfunction than SSRI
- Leads to heavier GI side effects COMMON NAUSEA
Consider for:
- overweight, sexual dysfunction concerns, psychomotor slowing
Avoid in:
??
MAOI’s
Drugs: phenelzine, isocarboxazid, tranylcypromine
3RD LINE
but 1ST choice in atypical depression …
- Avoid with high tyramine foods
….
MAOI’s Drug Interactions
MAJOR DRUG INTERACTIONS
- indirect-acting sympathomimetic agents
- TCA’s and SSRI’s
- Antihypertensive drugs
- Meperidine
- ALL MAOI’s administered orally??
When should you switch Antidepressants?
Partial Response - FIRST MAXIMIZE DOSAGE OF AGENT - Switch to another medication - ADD 2ND DRUG IF NEEDED: Buspirone, Bupropion, Mirtazapine >>> DO NOT ADD MAOI's or TCA's to SSRI'S
When Partial Response Continues
- Try meds with different MOA
mirtazapine, venlafaxine, desvenlafaxine, duloxetine
combo usually better than mono if partial response
Common Mistakes When Prescribing Antidepressants
- Inadequate dosing or initial dose too high
- Inadequate trial 4-8 weeks
- Inadequate follow up to check for SE
- Fail to switch med or augment
- Does not select best medication for comorbids and symptoms
- No consideration for psychotherapy
- Does not treat to full remission
- Does not adequately education on limitations, SE, length of treatment
What happens when you give a bipolar antidepressants
hypomania or mania
1st and 2nd line treatment
1st: SSRI
2nd: SNRI, TCA
3rd: MAOI
Other Indications of SSRI’s
panic disorder OCD PTSD premenstrual dysphoric disorder anxiety disorders
CYP 450 Chart for SSRI
Which are more likely to have interactions
escitalo citalo sert ^ lowest incidence of drug interactions parox fluo ^ higher incidence of drug interactions + if given codeine based meds they can have higher pain (also applies to morphien, hydromorphone and morphine?) 2D6
E Cant Start Popping Flies
Other Indications of SNRI’s
Pain related to depression
fibromyalagia
neuropathy
duloxetine FDA approved for fibromyalgia, GAD, diabetic peripheral neuropathy, chronic musculoskeletal pain
velafaxine FDA approved to treat social anxiety, panic disorder and GAD
Dosing for Fluoxetine and Citalopram
Fluoxetine: 20-80mg q am START at 20 and increase q 3sh weeks (can be divided into BID) d/c gradual
Citalopram 20-40 q am START at 20 can increase q 1 week (max dose for CYP and Elderly is 20) d/c gradual
First Line and what to augment with in partial response
SSRI, BUP, MIRT, SNRI
augment with (dont give two SSRI) SSRI, SNRI, BUP, BUS, MIRT,
NOT MAOI’s or caution with TCA’s
