Antidepressants Flashcards
when was fluoxetine first introduced
1980s
why did the introduction of SSRIs revolutionize the treatment of depression
had wider therapeutic index and fewer side effects than MAOIs and TCAs which were the only meds previously available
is any one class of antidepressant more effective than any other
no–> shown in STAR*D trial
why is paroxetine generally not recommended first line
very potent
most severe withdrawal symptoms if stopped abruptly
what side effect are we trying to prevent with the diet restriction required with MAOIs
hypertensive crisis
why is the max dose of escitalopram 20mg
risk of QTc prolongation at higher doses
antidepressants with more serotonergic action may help more with which symptoms of depression
cognitive symptoms such as rumination
antidepressants with more norepinephrine reuptake action may help more with which symptoms of depression
more of the behavioural symptoms like anhedonia and low mood
list common side effects of antidepressants
nausea
headache
GI issues
most will self resolve within 1-2 weeks
is excessive sweating common in those on SSRI/SNRIs?
can be
mechanism not understood–> likely related to 5HT receptors or NE reuptake inhibition
severe cases have been reported
what medication can you add if someone is having excessive sweating on ADs
benztropine, clonidine or terazosin may be helpful
can try switching to another SSRI
on which AD is sweating most likely to occur? least likely?
sweating is most likely to occur with paroxetine and least likely to occur with escitalopram
in the elderly, falls are more common in which ADs? less likely?
more likely to fall if on SNRIs or TCAs
less likely on SSRIs
what blood monitoring is particularly important in elderly people on ADs
monitoring of sodium levels–> risk of hyponatremia
what effect do ADs have on sleep efficiency
almost all DECREASE sleep efficiency
will also increase number of awakenings, worsen PLMS and RLS, can worsen parasomnias and increase stage 1 sleep
what effect do ADs have on REM sleep
almost all will:
increase REM latency
suppress REM
delay REM onset
what placebo response is generally seen in studies of ADs
strong placebo response up to 30-40% in MDD (but this does not explain all of the efficacy of SSRIs/SNSRIs)
is paroxetine safe for kids and teens
no
have any antidepressants been approved for kids and teens in canada
no
which aspects of sexual function are most commonly affected by SSRIs
libido and sexual interest–occasionally
ejaculation and orgasm–frequently
erection(potency) in males–rarely affected
agonism at what receptors are thought to cause sexual dysfunction with SSRIs
5HT2A and 5HT2C agonism
specifically spinal cord 5HT2A receptor agonism
*serotonergic nerve terminals also target dopamine and norepinephrine pathways in the brain and inhibit their activity and these pathways are involved in desire and arousal phases of the sexual response cycle
name two ADs that are MORE likely to cause sexual dysfunction
escitalopram and paroxetine
list 5 ADs that are LESS likely to cause sexual dysfunction
buproprion
agomelatine
mirtazapine
vilazodone
vortioxetine
list 5 medication that can be added to an existing AD regimen to address issues related to sexual dysfunction
buproprion
bupsirone
cyproheptadine
mirtazapine
sildenafil
what is cyproheptadine
a 5HT2 ANTagonist
has antihisaminergic and adrenolytic properties
may help with AD induced sexual dysfunction
how might you prescribe buproprion if being used to help address AD related sexual dysfunction
can add buproprion SR 150mg PRN prior to sexual activity or as a daily adjunct
in the most recent YoDA-C study, was there benefit in adding fluoxetine to CBT in kids and teens with depression
did NOT find benefit for this
*thus recommendation is that meds should never be first line treatment for C&A depression
what is the mechanism of action generally of SSRIs
blocks reuptake of serotonin, increasing levels in the space between neurons
ALL SSRIs are first line for which disorders
ALL are first line for MDD and panic disorder
which 4 SSRIs are first line for SAD
escitalopram
fluvoxamine
paroxetine
sertraline
list the 3 SSRIs that are first line for GAD
escitalopram
paroxetine
sertraline
which SSRIs are first line for OCD
all EXCEPT for citalopram
which SSRIs are first line for PTSD
fluoxetine
paroxetine
sertraline
which two SSRIs are recommended in situations of MDD + heart disease
sertraline
citalopram
in what type of dementia are SSRIs first line and why
ALL are first line for fronto-temporal dementia–> treats impulsivity
other than depressive and anxiety disorders, fluoxetine is also studied in what other conditions?
IED (effective)
bulimia
cataplexy
name two SSRIs that are approved in pregnancy and breastfeeding
sertraline
citalopram
name the ONLY SSRI recommended for bipolar II depression
sertraline
name an SSRI that has shown efficacy in treating BPSD
citalopram
(CitAD trial)
venlafaxine is first line for what disorders
MDD
GAD
SAD
PTSD
panic
(2nd line for OCD and bipolar II depression)
name the only first line med for perimenopausal depression
desvenlafaxine
venlafaxine has noradrenergic activity above what dose
above 225mg per day
venlafaxine should be avoided in what medical condition
glaucoma
duloxetine should be avoided in what medical conditions (health canada warning)
renal and hepatic impairment
duloxetine is first line for which conditions
MDD and GAD
which is the most noradrenergic of the SNRIs
levomilnacipran
why should buproprion be reconsidered in those with a seizure history
lowers seizure threshold
above what dose does buproprion start to lower seizure threshold
above 400mg per day
what antipsychotics does buproprion interact with
risperidone, abilify
due to CYP 2D6 inhibition
buproprion is contraindicated in which patients
eating disorder patients
is there a risk of GI bleed with buproprion
no–> also only minimal risk of SIADH and QTc prolongation
list possible side effects of buproprion
prominent headache
irritability
restlessness
insomnia
dry mouth
nausea
tremor
rare psychosis
seizures
can buproprion be used for ADHD
third line
buproprion can be used to help treat what often comorbid condition (especially in those with schizophrenia)
smoking cessation
is buspirone recommended for panic disorder
no
what is the mechanism of action of agomelatine
melatonin receptor agonist
agomelatine is first line for which conditions
MDD and GAD
what AD has the most GI side effects
vilazodone
TCAs are indicated for what types of illnesses (other than depression)
funcitional illnesses (i.e IBS, fibromyalgia, functional dyspepsia)
should you use TCAs fro bipolar depression
no–risk of manic switch
why are all TCAs second line in MDD
side effects
what is the least anticholinergic and best tolerated if the TCAs
nortriptyline
(amitriptyline is the most anicholinergic)
clomipramine is first line for what condition
OCD
name a TCA that can be used to treat childhood enuresis
imipramine
list the MAOis
moclobemide
phenelzine
selegiline
name the only antidepressant included in the sleep guidelines (for insomnia)
doxepin
name two tyramine rich foods to be avoided when taking MAOis
aged cheese
wine
list some side effects associated with MAOIs
hypotension
dizziness
dry mouth
GI upset
urinary hesitancy
headache
sexual side effects
weight gain
myoclonic jerks
edema
psychosis
why must you be careful is co-prescribing fluoxetine and risperidone
can increase plasma concentration of risperidone by 2-3 fold through CYP2D6 inhibition
