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BCPS > Antidepressants > Flashcards

Antidepressants Flashcards

1
Q

First line antidepressants

A

SSRI
SNRI
Bupropion
Mirtazapine
Vortioxetine

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2
Q

Adequate trial of antidepressant

A

4-8 weeks

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3
Q

Remission definition

A

3 weeks with no symptoms of depressed mood & anhedonia, and no more than 3 remaining symptoms of depression

Remission = goal of therapy

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4
Q

Onset of effectiveness

A

2-4 weeks: improvement in physical symptoms (energy, sleep)

-If partial response at 4 weeks, need longer trial

4-6 weeks: full effect

8 weeks: response

12 weeks: remission

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5
Q

Maintenance of therapy

A

Once reached remission (at least 12 weeks!) continue for another 6-9 months

If risk factor for recurrent depression, treat for 2 years or longer
(frequent recurrent episodes, severe episodes, chronic episodes, presence of comorbid psych condition, residual symptoms)

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6
Q

1A2 sub, inhib, inducer

A

Substrate:
Duloxetine

Inducer:
Cannabis, tobacco

Inhibitor:
Caffeine, fluvoxamine

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7
Q

2C19 sub, inducer, inhib

A

Substrate:
Citalopram
Escitalopram
Fluoextine
Imipramine
Viladozone

Inducer:
St Johns wort

Inhibitor
Amitriptyline
Cannabis
Fluoxetine
Fluvoxamine
Imipramine

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8
Q

2D6 sub, inhibitor

A

Substrate:
Amitriptyline
Desipramine
Duloxetine
Fluoxetine
Imipramine
Nefazodone
Nortriptyline
Trazodone
Venlafaxine
Vortioxetine

Inhibitor
Bupropion
Cannabis
Duloxetine
Fluoxetine
Paroxetine
Sertraline

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9
Q

3A4 sub, inducer, inhib

A

Substrate
Citalopram
Escitalopram
Levomilnacipran
Nefazodone
Trazodone
Venlafaxine
Vilazodone

Inducer
St Johns wort

Inhib
Fluvoxamine
Nefazodone

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10
Q

SSRI with longest half life

A

fluoxetine (1-4 days)

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11
Q

Most activating SSRIs

A

Fluoxetine
Sertraline

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12
Q

Most sedating SSRIs

A

Paroxetine
Fluvoxamine

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13
Q

Most common ADR of SSRI

A

GI upset
Insomnia
Restlessness
Headache
Sexual dysfunction (>=50% of ppl)

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14
Q

Intervention for SSRI induced sexual dysfunction

A
  1. Wait and see
  2. Add bupropion
  3. Lower SSRI dose
  4. Add PDE-5 inhibitor in men
  5. Weak data, but add buspirone or mirtazapine
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15
Q

Serotonin syndrome

A

3 clusters of symptoms:
-Neuromuscular hyperactivity (myoconlus, rigidity, tremors)
-Altered Mental Status (agitation, confusion, hypomania)
-Autonomic instability (hyperthermia, diaphoresis)

Hunter criteria used to identify

Treatment:
1. D/C offending agent
2. Supportive measures
3 Give cyproheptadine; a benzo for myoclonus; antiseizure meds; nifedipine for HTN

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16
Q

Other serotonergic meds to increase risk of serotonin syndrome

A

MAOIs
Dextromethorphan
Meperidine
Tramadol
Sympathomimetics
Linezolid
Lithium
TCAs
SNRIs

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17
Q

Withdrawal of SSRI

A

Flu-like symptoms (nausea, chills)
Neurologic symptoms (paresthesias, insomnia, anxiety, electric shock sensations)

Gradual dose reduction needed even for long half life

18
Q

Citalopram ADR

A

QTc prolongation, especially doses > 40mg

FDA now limits daily dose to <= 40mg

20mg max if hepatic impairment, >60, 2C19 poor metabolizer, or 2C19 inhibitor

19
Q

Renal adjustment needed for these SNRIs

A

Desvenlafaxine
Levomilnacipran

Avoid duloxetine in severe renal impairment

20
Q

SNRI for hepatic insufficency

A

Desvenlafaxine - bypasses CYP metabolism

21
Q

SNRIs and hypertension

A

Usually mild and not clinically significant UNLESS uncontrolled HTN

22
Q

SNRI with orthostatic hypotension

A

Levomilnacipran
Desvenlafaxine

23
Q

Vilazodone (viibryd) CI

A

History of seizure

24
Q

Vortioxetine (trintellex) unique MOA

A

SSRI +
-serotonin 1A agonist
-serotonin 1B partial agonist
-serotonin 3 antagonist
-serotonin-1D antagonist
-serotonin-7 antagonist

Improves cognitive function

Lower risk of sexual dysfunction

25
Q

Trazodone unique ADR

A

Priapism (medical emergency)

26
Q

Nefazodone BBW

A

Liver toxicity

Must monitor LFTs

2-3rd line agent

27
Q

Mirtazapine sedative effect, other ADRs

A

Sedating at lower doses
Insomnia at higher doses

weight gain (inc. appetite), constipation, asthenia

28
Q

Bupropion unique ADR

A

Increased risk of seizures

29
Q

Bupropion seizure risk management

A
  1. Avoid use in all susceptible patients
  2. Do not give >150mg/dose or >450mg/day
  3. Avoid dose titrations more often than every 4 days (XR, SR) or 3 days (IR)
30
Q

Bupropion + Dextromethorphan

A

Combination for treatment of depression

31
Q

Tertiary amine TCAs

A

Amitriptyline
Imipramine

More potent for serotonergic reuptake inhibition

32
Q

Secondary amine TCAs

A

Nortriptyline
Desipramine

More selective for norepinephrine reuptake inhibition
Less anticholinergic

33
Q

TCA in overdose

A

Cardiotoxic - causing prolonged QTc and TdP, seizures

Do not give to actively suicidal patient

34
Q

TCA ADRs

A

Anticholinergic (amitriptyline)
Sedation (amitriptyline)
Orthostatic hypotension (imipramine)
Cardiotoxic (amitriptyline & imipramine)

35
Q

Avoid TCAs in these populations

A

Cardiac disease
Seizure disorder
Actively suicidal

36
Q

Nonselective MAOIs

A

Isocarboxazid
Phenelzine
Tranylcypromine

37
Q

MAOIs + tyramine

A

Potential for hypertensive crisis

Avoid aged cheese, preserved meats, wine, beer

38
Q

Gepirone

A

New antidepressant

Take with food

QTc prolongation

No sexual dysfunction side effect

39
Q

Antidepressants and suicidality

A

ALL carry BBW for increased risk of suicide in children, adolescents, young adults up to 24.

Highest risk at initiation or dose adjustment – since physical symptoms improve first, more energy to act out.

Do not avoid treatment due to risk of suicide

40
Q

SGA with FDA approval for adjust to antidepressants

A

Aripiprazole
Brexpiprazole
Cariprazine
Quetiapine ER

Almost all used

41
Q

Treatment resistant depression

A
  1. Olanazpine + fluoxetine
  2. Esketamine (onset within hours)

BCPS (27 decks)

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