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pharm exam 3 > Antidepressants > Flashcards

Antidepressants Flashcards

1
Q

Unipolar vs. Bipolar

A
  • 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
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2
Q

Selecting the Correct Antidepressant

A
  • 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
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3
Q

SSRI’s

3 points
5 drugs and points to each

FSCEP

A
  • NOT indicated for mild depression
  • IS indicated for mod-severe depression
  • SSRI’s not interchangeable
    FSCEP

most energizing to least energizing

  1. fluoxetine
    - unique 5HT2c action (not short term anxiety)
    - slightly lower onset of action compared to other SSRI
    - can cause insomnia (bc most energizing)
  2. sertraline
    - dopamine transport inhibitor
    - sigma-1 receptor binding
    - often used with bupropion
  3. citalopram
    - QT prolongation
    - do not use with bradycardia, hypokalemia, hypomagnesemia, CHF, recent MI, or other QT-prolonging drugs
  4. escitalopram
    - low risk of QT prolongation
    - No CYP450 interactions
    - considered to be best tolerated SSRI
    - lower doses usually effective
  5. paroxetine
    - some anticholinergic effects
    - useful when anxiety is strong component
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4
Q

Specific Indications for SSRI’s

CV Disease

A

sertraline

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5
Q

Specific Indications for SSRI’s

Adolescents

A

fluoxetine, sertraline, escitalopram

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6
Q

Specific Indications for SSRI’s

Underweight

A

paroxetine

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7
Q

Specific Indications for SSRI’s

Overweight

A

fluoxetine

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8
Q

Specific Indications for SSRI’s

Psychomotor slowing

A

fluoxetine

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9
Q

Specific Indications for SSRI’s

Insomnia

A

paroxetine

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10
Q

Specific Indications for SSRI’s

Somnolence

A

fluoxetine, sertraline

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11
Q

Specific Indications for SSRI’s

Elderly

A

citalopram

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12
Q

Avoid indications for SSRI’s

overweight

A

paroxetine

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13
Q

Avoid indications for SSRI’s

QT prolong or torsades risk

A

citalopram

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14
Q

Avoid indications for SSRI’s

Agitation or Insomnia

A

fluoxetine

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15
Q

Avoid indications for SSRI’s

Elderly

A

paroxetine (bc has some anticholinergic effects)

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16
Q

Avoid indications for SSRI’s

Pregnancy

A

ALL

17
Q

Adverse Effects of SSRI’s

A

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

18
Q

Adverse Effects of SSRI’s

A

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

19
Q

Drug Interactions with SSRI’s

A

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

20
Q

Serotonin Syndrome Signs

A
  • 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

21
Q

SNRI’s

A

Drugs: venlafaxine, duloxetine, desvenlafaxine

2ND LINE

Avoid in:
hypertension (increase BP)
agitation or insomnia
alcoholism (liver damage)

22
Q

SNRI Side Effects

A

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***

23
Q

Drugs that cause Sexual Dysfunction

A

Yes —-
SSRI’s
SNRI’s

No —
Wellbutrin
Mirtazapine
SPARI’s (lesser than SSRI’s)

24
Q

Wellbutrin

A
  • usually added but sometimes monotherapy
  • potentially activating
    &raquo_space; use for psychomotor slowing, fatigue, hypersomnia, because it is energizing and stimulating
    &raquo_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)
    &raquo_space; markedly less sexual dysfunction side effects

Side Effects:
Seizure is biggest concern

25
Q

TCA’s

A

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

26
Q

Mirtazapine

A

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

27
Q

SPARI’s

A

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:
??

28
Q

MAOI’s

A

Drugs: phenelzine, isocarboxazid, tranylcypromine

3RD LINE
but 1ST choice in atypical depression …

  • Avoid with high tyramine foods
    ….
29
Q

MAOI’s Drug Interactions

A

MAJOR DRUG INTERACTIONS

  • indirect-acting sympathomimetic agents
  • TCA’s and SSRI’s
  • Antihypertensive drugs
  • Meperidine
  • ALL MAOI’s administered orally??
30
Q

When should you switch Antidepressants?

A 
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

31
Q

Common Mistakes When Prescribing Antidepressants

A
  • 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
32
Q

What happens when you give a bipolar antidepressants

A

hypomania or mania

33
Q

1st and 2nd line treatment

A

1st: SSRI
2nd: SNRI, TCA
3rd: MAOI

34
Q

Other Indications of SSRI’s

A 
panic disorder
OCD
PTSD
premenstrual dysphoric disorder
anxiety disorders
35
Q

CYP 450 Chart for SSRI

Which are more likely to have interactions

A 
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

36
Q

Other Indications of SNRI’s

A

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

37
Q

Dosing for Fluoxetine and Citalopram

A

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

38
Q

First Line and what to augment with in partial response

A

SSRI, BUP, MIRT, SNRI

augment with (dont give two SSRI)
SSRI, SNRI, BUP, BUS, MIRT,

NOT MAOI’s or caution with TCA’s

pharm exam 3 (14 decks)

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