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Pharm 2 > Antidepressants > Flashcards

Antidepressants Flashcards

1
Q

DSM-5 Diagnostic Criteria – Major Depressive Episode (MDD)

A

Major
Depressive
Episode
Depressed
mood
Weight change
Sleep disturbances
Agitation/retardation
Fatigue
Guilt
Decreased
concentration
Suicidal ideation Loss of interest
or pleasure

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2
Q

Symptoms present most
of the day, nearly every day
Symptoms present > – weeks
and represent a change from
previous functioning

A

2

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3
Q

Must have > – symptoms

A

5

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4
Q

DSM-5 Diagnostic Criteria – MDD
(4)

A
  • symptoms cause clinically
    significant distress or
    impairment in social,
    occupational, or other
    important areas of functioning
  • not attributable to the
    physiological effects of a
    substance or another medical
    condition
  • not better explained by
    another psychiatric illness
  • has never been a manic
    episode or a hypomanic
    episode
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5
Q

Monoamine
Hypothesis of
Depression
* Depression due to

A

deficiency of
monoamine neurotransmitters (NT)
– norepinephrine
– serotonin

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6
Q

Monoamine
Hypothesis of
Depression
Evidence
– Depletion of NT induces depression
(2)

A

– Antidepressants increase levels of NT
– Onset of antidepressant activity
(decrease in depressive symptoms) is
correlated with down-regulation of
receptors

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7
Q

Oral Side Effects Associated with
Antidepressants
* Common
(2)

A

– Xerostomia (96%)
– Dysguesia (65%)

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8
Q

Oral Side Effects Associated with
Antidepressants
* Less Common

A

– Hypersalivation, stomatitis,
dysphagia, bruxism, glossiitis,
tardive dyskinesia, hairy
tongue, salivary gland
enlargement, tongue edema,
gingivitis, halitosis, ulcers, jaw
stiffness, candidiasis, sinusitis,
erythema multiforme, Steven-
Johnson syndrome, gumline
erosion, periodontal disease,
tooth disease

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9
Q

Monoamine Oxidase Inhibitors
(MAO-I)
(2)

A
  • phenelzine (Nardil)
  • tranylcypromine
    (Parnate)
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10
Q

Monoamine Oxidase Inhibitors
* drug-drug and
drug-food interactions
(2)

A

– hypertensive crisis
– serotonin syndrome

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11
Q

Common Side Effects of MAO-I
(7)

A
  • Dry mouth
  • Nausea, diarrhea or constipation
  • Headache
  • Drowsiness or Insomnia
  • Dizziness or lightheadedness
  • Weight gain
  • Sexual dysfunction
  • Significant morbidity and mortality associated
    with overdose
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12
Q

Hypertensive Crisis
* Defined by diastolic blood pressure > – mmHg
* Potentially fatal reaction characterized by:
(8)

A

120

– Occipital headache – may radiate frontally
– Palpitation
– Neck stiffness or soreness
– Nausea and/or vomiting
– Sweating
– Dilated pupils, photophobia
– Tachycardia or bradycardia
– Chest pain

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13
Q

Suggested Tyramine Dietary
Modifications for MAO-I
* Foods to AVOID
(6)

A

– Dried, aged, smoked,
fermented, spoiled, or
improperly stored meat,
poultry and fish
– Broad bean pods
– Aged cheeses
– Tap and nonpasteurized beers
– Marmite, sauerkraut
– Soy products/tofu

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14
Q

Suggested Tyramine Dietary
Modifications for MAO-I
* Foods ALLOWED
(5)

A

– Fresh or processed meat,
poultry and fish
– All other vegetables
– Processed and cottage
cheese, ricotta cheese,
yogurt
– Canned or bottled beers and
alcohol
– Brewer’s and baker’s yeast

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15
Q

Warnings:
Do not use if you are now taking a
prescription

A

monoamine oxidase inhibitor
(MAOI) (certain drugs for depression,
psychiatric or emotional conditions, or
Parkinson’s disease), or for 2 weeks after
stopping the MAOI drug. If you do not know
if your prescription drug contains an MAOI,
ask a doctor or pharmacist before taking this
product

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16
Q

Hypertensive Crisis –
Drug Interactions to AVOID
(4)

A
  • Decongestants
  • Stimulants
  • Antidepressants with
    NRI activity
  • Appetite suppressants
    with NRI activity
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17
Q
  • Decongestants
    (4)
A

– phenylephrine
– ephedrine (ma huang,
ephedra)
– pseudoephedrine
– oxymetazoline

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18
Q
  • Stimulants
    (2)
A

– amphetamines
– methylphenidate

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19
Q
  • Antidepressants with
    NRI activity
    (3)
A

– TCA
– SNRI (venlafaxine,
desvenlafaxine,
duloxetine)
– bupropion, mirtazapine

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20
Q
  • Appetite suppressants
    with NRI activity
    (1)
A

– phentermine

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21
Q

Serotonin Syndrome
(3)

A
  • Addition or increase of
    known serotonergic agent to
    an established medication
    regimen
  • Other etiologies (infectious,
    metabolic, substance abuse
    or withdrawal) have ruled
    out.
  • Antipsychotic has not been
    started or increased prior to
    the onset of sign/symptoms
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22
Q

Serotonin Syndrome
* Three of more of the
following symptoms:

A

– Agitation
– Diaphoresis
– Diarrhea
– Fever
– Hyperreflexia
– Incoordination
– Mental status changes
(confusion, hypomania)
– Myoclonus
– Shivering
– Tremor

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23
Q

Serotonin Syndrome –
Drug Interactions to AVOID
(4)

A
  • Antidepressants
  • Other TCA structure
    drugs
  • Pain Medication
  • Cough Suppressants
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24
Q
  • Antidepressants
    (4)
A

– SSRI
– TCA (clomipramine)
– SNRI
– Mirtazapine

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25
Q
  • Other TCA structure
    drugs
    (2)
A

– Cyclobenzaprine
– Carbamazepine

26
Q
  • Pain Medication
    (5)
A

– Meperidine
– Tramadol ✔
– Methadone
– Propoxyphene
– Fentanyl

27
Q
  • Cough Suppressants
    (1)
A

– Dextromethorphan

28
Q

MAO-I: Summary
Advantages
(1)

A
  • May be useful in
    treatment refractory
    depression
29
Q

MAO-I: Summary
Disadvantages
(7)

A
  • Tolerability
  • Significant risk of
    morbidity and
    mortality associated
    with overdose
  • Oral side effect – dry
    mouth
  • Dietary restrictions
  • Significant drug
    interaction risk
  • Hypertensive crisis
  • Serotonin syndrome
30
Q

Tricyclic Antidepressants (TCA)
(2)

A
  • Tertiary TCA
    – amitriptyline (Elavil)
  • Secondary TCA
    – nortriptyline (Pamelor)
31
Q

Side Effect Profile of TCA
(4)

A
  • cardiac conduction disturbances - QTc prolongation
  • seizures
  • sexual dysfunction
  • significant risk of morbidity and mortality associated with
    overdose
32
Q

Drug Interactions with TCA

A
  • TCA + CNS Depressants (ex. opioid pain
    medication) = additive CNS depressant effects
33
Q

TCA: Summary
Advantages
(2)

A
  • May be useful in
    treatment refractory
    depression
  • More commonly used
    for chronic pain
    (diabetic peripheral
    neuropathic pain,
    fibromyalgia, chronic
    musculoskeletal pain)
    and insomnia
34
Q

TCA: Summary
Disadvantages
(4)

A
  • Tolerability
  • Significant risk of morbidity
    and mortality associated
    with overdose
  • Oral side effect – dry
    mouth
  • Overall high side effect
    burden – including weight
    gain, sedation and sexual
    dysfunction
  • Significant risk for drug
    interactions (additive CNS
    depressant effects)
35
Q

Selective Serotonin Reuptake
Inhibitors (SSRI)
(5)

A
  • fluoxetine (Prozac)
  • paroxetine (Paxil, Paxil CR,
    Pexeva)
  • sertraline (Zoloft)
  • citalopram (Celexa)
  • escitalopram (Lexapro)
36
Q

Mechanism of Action and
Side Effect Profile of SSRI
(2)

A

– minimal to no effect on
H1, M1 or alpha1
receptors
– side effect profile - GI
upset, headache,
insomnia, restlessness,
anxiety, weight gain,
sexual dysfunction

37
Q

Side Effects Important in Dentistry
(2)

A
  • Increased risk for
    bleeding and bruising
  • Bruxism
38
Q

Drug Interactions with NSAID
* Pharmacodynamic
interactions
(2)

A

– SSRI – decrease
platelet aggregation
* INCREASED RISK FOR
BLEEDING

39
Q

Drug Interactions with Opioid Medications
(codeine, hydrocodone and oxycodone)
(4)

A
  • Pharmacokinetic interaction
  • Drugs that INHIBIT CYP450 2D6
    PREVENT the metabolism of
    codeine, hydrocodone and
    oxycodone to an active medication.
  • OUTCOME: pain relieving effects
    are REDUCED
  • Antidepressants
    – Paroxetine (Paxil)
    – Fluoxetine (Prozac)
40
Q

SSRI: Summary
Advantages
(4)

A
  • (+) safety associated
    with overdose
  • Recommended 1st line in
    all depression treatment
    algorithms
  • (+) safety profile in
    patients with medical
    illnesses
  • Relatively well tolerated
41
Q

SSRI: Summary
Disadvantages
(4)

A
  • Tolerability
  • Oral side effect –
    bruxism, increased
    risk for bleeding
  • Long term side effects
    – weight gain and
    sexual dysfunction
  • Significant risk for drug
    interactions
42
Q

Side Effect Profile -
Venlafaxine and Duloxetine
* Side effect profile
(2)

A

– no effect on H1, M1 or
alpha1 receptors
– side effect profile -
nausea, elevated BP,
weight gain, sexual
dysfunction

43
Q

SNRI: Summary
Advantages
(4)

A
  • (+) Safety profile in
    overdose
  • Recommended 1st line in
    all depression treatment
    algorithms
  • Used to treat depression
    and pain (diabetic
    peripheral neuropathic
    pain, fibromyalgia, chronic
    musculoskeletal pain)
  • Relatively well tolerated
44
Q

SNRI: Summary
Disadvantages
(4)

A
  • Tolerability
  • No specific oral side
    effects
  • Long term side effects –
    weight gain and sexual
    dysfunction
  • Low risk for drug
    interactions
45
Q

Side Effect Profile of
Bupropion
* contraindications
(3)
* caution use in —
* no effect on (3)receptors
* side effect profile -
(3)

A

– seizure history
– history of significant head trauma
– anorexia or bulimia

psychosis

H1, M1 or alpha1

– insomnia, seizures (less common)
– low risk of sexual dysfunction
– low risk of weight gain

46
Q

Drug Interactions with Opioid Medications
(codeine, hydrocodone and oxycodone)
(4)

A
  • Pharmacokinetic interaction
  • Drugs that INHIBIT CYP450 2D6
    PREVENT the metabolism of
    codeine, hydrocodone and
    oxycodone to an active medication.
  • OUTCOME: pain relieving effects
    are REDUCED
  • Antidepressants
    – Paroxetine (Paxil)
    – Fluoxetine (Prozac)
    – Bupropion (Wellbutrin)
47
Q

NDRI - Bupropion: Summary
Advantages
(5)

A
  • Recommended 1st line in
    depression treatment
    algorithms
  • Low risk of sexual
    dysfunction
  • Low risk risk for weight
    gain
  • Used for smoking
    cessation
  • Relatively well tolerated
48
Q

NDRI - Bupropion: Summary
Disadvantages
(4)

A
  • Tolerability
  • No specific oral side
    effects
  • Potential for seizures
    associated with
    overdose
  • Significant risk for drug
    interactions
49
Q

Side Effect Profile of Mirtazapine
(3)

A
  • no effect on M1 or alpha1 receptors
  • (+) effect on H1 receptors
  • side effect profile
    – Sedation
    – dry mouth
    – weight gain
    – low risk of sexual dysfunction
50
Q

Presynaptic Alpha2 Antagonist - Mirtazapine:
Summary
Advantages
(3)

A
  • (+) Safety profile in
    overdose
  • Recommended 1st
    line in depression
    treatment
    algorithms
  • Low risk for sexual
    dysfunction
51
Q

Presynaptic Alpha2 Antagonist - Mirtazapine:
Summary
Disadvantages
(4)

A
  • Tolerability
  • Oral side effect –
    dry mouth
  • Long term side
    effects - weight
    gain, sedation
  • Low risk for drug
    interactions
52
Q

Goals of Antidepressant Therapy
(7)

A
  • REMISSION = resolution of depression
    symptoms
  • Improve functioning
  • Reduce risk of relapse
  • Increase quality of life
  • Decrease depression morbidity
  • Decrease depression mortality
  • Decrease healthcare costs
53
Q

Definitions of Response and Remission
% Reduction in Score
Remission
Response
Partial Response
Nonresponse

A

≥75%
50% - 74%
25% - 49%
<25%

54
Q

Selection of Antidepressant Therapy
Empiric selection of antidepressant therapy:
(5)

A
  • past history of AD response
  • family history of AD response
  • concurrent disease states/drug therapy
  • adverse effect profile
  • cost
55
Q

Selection of Antidepressant Therapy
* Treatment Guidelines (APA 2019)
(5)

A
  • Psychotherapy can be used alone for mild-moderate
    depression
  • Pharmacotherapy can use used alone for mild-
    moderate depression
  • Pharmacotherapy +/- psychotherapy for moderate-
    severe depression
  • SSRI, SNRI, bupropion and mirtazapine are
    recommended as 1st line therapy
  • Only complimentary therapy recommended 1st line is
    St. John’s wort (CANMAT 2016, VA/DoD 2016)
56
Q

Efficacy
of AD
(3)

A
  • All antidepressants demonstrate equivalent
    efficacy - 70%.
  • onset - days to weeks (depending on type of
    symptom)
  • therapeutic trial - 6-8 weeks
57
Q

Nonremission is Common
* —% remission
* —% response with residual symptoms
* –% partial response
* –% nonresponse
* –% intolerant

A

35–45
10–20
15
25
7–15

58
Q

Symptom Remission
first week (3)

A
  • Decreased Anxiety
  • Improvement in Sleep
  • Improvement in Appetite
59
Q

Symptom Remission
1-3 Weeks (3)

A
  • Increased Activity,
    Sex Drive, Self-care,
    and Memory
  • Thinking and Movements
    Normalize
  • Sleeping and Eating
    Patterns Normalize
60
Q

Symptom Remission
2-4 Weeks (3)

A

Relief of Depressed
Mood
* Less Hopeless/
Helpless
* Thoughts of Suicide
Subside

61
Q

Maintenance Antidepressant
Therapy
* first episode -
* second episode -
* > 2 episodes -
* elderly patients -

A

continue AD for 9-12 months
continue AD for 5 years
continue AD for lifetime
consider continuing AD
for longer; maybe indefinitely

62
Q
A

Pharm 2 (13 decks)

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