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Pharmacology II > Antidepressants > Flashcards

Antidepressants Flashcards

1
Q

to diagnose a major depressive episode one of these is required:

A
  • depressed mood
  • apathy/loss of interest
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2
Q

to diagnose a major depressive episode four or more of these is required:

A
  • weight/appetite changes
  • sleep disturbances
  • psychomotor
  • fatigue
  • guilt/worthlessness
  • executive dysfunction
  • suicidal ideation
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3
Q

symptoms must present how often to dx a major depressive episode

A
  • most of the day, nearly every day
  • 2 weeks or more and represent a change from previous functioning
  • must have 5 symptoms or more
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4
Q

what are the DSM-5 diagnostic criteria for MDD

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 hypomanic episode
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5
Q

what is the monoamine hypothesis of depression

A
  • depression due to deficiency of monoamine NT such as norepinephrine and serotinin
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6
Q

what is the evidence for the monoamine hypothesis of depression

A
  • depletion of NT induces depression
  • 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

what is the name brand for amitriptyline

A

elavil

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8
Q

what is the brand name for nortriptyline

A

pamelor

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9
Q

what is the receptor pharmacology, side effects, life threatening side effects, oral side effects of amitriptyline and nortriptyline

A
  • SRI, NRI, H1 antagonist, M1 antagonist, alpha-1 antagonist
  • SE: sedation, weight gain, dry mouth, blurred vision, constipation, dizziness, OH, sexual dysfunction
  • life threatening SE: CV- QTc prolongation, seizures
  • oral SE: dry mouth
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10
Q

are amitriptyline and nortriptyline safe in overdose, are they first line therapy and do they have a high risk for drug interactions

A

-no
- no
-yes

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11
Q

what is the daily dose and primary mechanism of amitriptyline

A
  • 50-300mg
  • mixed NE and 5HT reuptake inhibition
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12
Q

what type of medication is amitriptyline

A

heterocyclic tertiary amine

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13
Q

what is the dosage and primary mechanism for nortriptyline

A
  • 50-150mg
  • NE > 5HT reuptake inhibition
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14
Q

what type of medication is nortriptyline

A

heterocyclic secondary amine

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15
Q

what are the SSRIs

A
  • fluoxetine (prozac)
  • sertraline (zoloft)
  • paroxetine (Paxil, pexeva)
  • citalopram (celexa)
  • escitalopram (lexapro)
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16
Q

what is the dosage and primary mechanism for fluoxetine

A

10-80mg
- 5HT&raquo_space;»> NE reuptake inhibition

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17
Q

what is the dosage and primary mechanism for sertraline

A

50-200mg
- 5HT&raquo_space;»> NE reuptake inhibition

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18
Q

what is the dosage and primary mechanism for paroxetine

A

10-40mg
- 5HT&raquo_space;»> NE reuptake inhibition

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19
Q

what is the dosage and primary mechanism for citalopram

A

-20-40mg
- 5HT&raquo_space;»> NE reuptake inhibition

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20
Q

what is the dosage and primary mechanism for escitalopram

A

10-20mg
- 5HT&raquo_space;»> NE reuptake inhibition

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21
Q

what are the SNRIs

A
  • venlafaxine (effexor)
  • duloxetine (cymbalta)
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22
Q

what is the dosage and primary mechanism for venlafaxine

A

37.5-225mg
- 5HT > NE&raquo_space; DA reuptake inhibition

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23
Q

what is the dosage and primary mechanism for duloxetine

A

-30-120mg
- 5HT = NE reuptake inhibition

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24
Q

what are the monoamine oxidase inhibitors (MAOI)

A
  • phenelzine (nardil)
  • tranylcypromine (parnate)
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25
what is the dosage and primary mechanism for phenelzine
- 15-90mg - nonselective MAO A and B inhibition
26
what is the dosage and primary mechanism for tranylcypromine
10-60mg - nonselective MAO A and B inhibition
27
what are the atypical antidepressants
- buproprion (wellbutrin, fortivo) - mirtazapine (remeron)
28
what is the dosage and primary mechanism for buproprion
- 150-450mg - NE and DA reuptake inhibition
29
what is the dosage and primary mechanism for mirtazapine
-15-45mg - alpha2-NE - 5HT2 presynaptic antagonist - 5HT2/3 postsynaptic antagonist
30
what is the considerations with esketamine
administer intranasally under the supervision of a healthcare provider for treatment resistant depression in adults
31
what are the considerations for brexanolone
administered as a continuous IV infusion over 60 hours for the treatment of post partum depression in adults
32
what are the most common oral side effects associated with anti depressants and what is the incidence of each
- xerostomia (96%) - dysgeusia (65%)
33
what are the less common oral side effects of anti depressants
- hypersalivation - stomatitis - dysphagia - bruxism - glossitis - tardive dyskinesia - hairy tongue - salivary gland enlargement - tongue edema - gingivitis - halitosis - ulcers - jaw stiffness - candidiasis - sinusisit - erythema multiforme - steven johnson syndrome - gumline erosion - periodontal disease - tooth disease
34
what are the considerations with MAO-I drugs
- drug- drug and drug-food interactions - hypertensive criss - serotonin syndrome
35
what are the common side effects with MAO-I drugs
- dry mouth - most common - nausea, diarrhea, or consipation - headache - drowsiness or insomnia - dizziness or lightheadedness - weight gain - sexual dysfunction - significant morbidity and mortality associated with overdose **
36
what is the definition of hypertensive criss
diastolic BP over 120mmHg
37
hypertensive crisis potentially fatal reaction characterized by
- occipital headache- may radiate frontally - palpitation - neck stiffness or soreness - neausea and/or vomiting - sweating - dilated pupils, photophobia - tachycardia or bradycardia - chest pain
38
what are the foods to avoid with MAO-I
- dried, aged,smokes, fermented, spoiled or improperly stored meat, poultry and fish - broad bean pods - aged cheeses - tap and nonpasteurized beers - marmite, sauerkraut - soy products- tofu
39
what food are allowed with MAO- I
- fresh or processed meat, poultry, fish - all other vegetables - processed and cottage cheese, ricotta cheese, yogurt - canned or bottled beers and alcohol - brewers and bakers yeast
40
what is the warning with MAO-I with other drugs
do not use NyQuil with is or for 2 weeks after stopping MAOI drug
41
what are the drugs to avoid with hypertensive crisis
- decongestants: phenylephrine, ephedrine, pseudoephedrine*, oxymetazoline - stimulants: amphetamines, methyphenidate - antidepressants with NRI activity: TCA, SNRI, buproprion, mirtazapine - appetite suppressants with NRI activity: phetermine
42
what is serotonin syndrome
- addition or increase of known serotonergic agent to an established medication regimen - other etiologies have ruled out - antipsychotic has not been started or increased prior to the onset of signs/symptoms
43
serotonin syndrome dx requires three or more of the following symptoms:
- agitation - diaphoresis - diarrhea - fever - hyperreflexia - incoordination - mental status change (confusion, hypomania) = myoclonus - shivering - tremor
44
what are the drug interactions to avoid with serotonin syndrome
- antidepressants: SSRI, TCA, SNRI, mirtazapine - other TCA structure drugs: cyclobenzaprine, carbamazepine - pain medication: meperidine, tramadol*, methadone, propoxyphene, fentanyl - cough suppressants: dextromethrophan**
45
what are the advantages and disadvantages of MAO-I drugs
- advantages: may be useful in treatment refractory depression - disadvantages: tolerability: significant risk of morbidity and mortality associated with overdose. oral side effects of dry mouth. dietary restrictions. significant drug interaction risk: hypertensive crisis and serotonin syndrome
46
what is the side effect profile of TCAs
- cardiac conduction disturbances - QTc prolongation - seizures - sexual dysfunction - significant risk of morbitity and mortality with overdose
47
what are the drug interactions with TCA
- TCA + CNS depressants = additive CNS depresant effects
48
what are the advantages of TCAs
- may be useful in treatment of refractory depression - more commonly used for chronic pain (diabetic peripheral neuropathy, fibromyalgia, chronic musculoskeletal pain and insomnia)
49
what are the disadvantages of TCAs
- significant risk of morbidity and mortality associated with overdose - oral side effect- dry mouth - overall hig side effect burden- including weight gain, sedation and sexual dysfunction - significant risk for drug interactions
50
what is the mechanism of action of SSRIs
minimal to no effect on H1, M1 or alpha 1 receptors
51
what is the SE profile for SSRIs
-GI upset - headache - insomnia - restlessness - anxiety - weight gain - sexual dysfunction
52
what are the side effects of SSRIs in dentistry
- increased risk for bruising and bleeding - bruxism
53
what are the drug interactions with SSRIs
- pharmacodynamic interactions: SSRIs decrease platelelt aggregation- increased risk for bleeding - pharmacokinetic interaction: drugs that inhibit CYP450 2D6 prevent the metabolism of codeine, hydrocodone and oxycodone to an active medication. resulting in pain relieving effects are reduced -antidepressants: paroxetine and fluoxetine
54
what are the advantages of SSRIs
- positive safety associated with overdose - recommended 1st line in all depression treatment algorithms - safety profile in patients with medical illness - relatively well tolerated
55
what are the disadvantages of SSRIs
- tolerability - oral side effect- bruxism, increased risk for bleeding - long term side effects- weight gain and sexual dysfunction - significant risk for drug interacitons
56
what is the side effect profile for vanlafaxine and duloxetine
- nausea - elevated BP - weight gain - sexual dysfunction
57
what are the advantages of SNRIs
- safety profile in overdose - recommended 1st line in all depression treatment algorithms - used to treat depression and pain (diabetic peripheral neuropathy, fibromyalgia, chronic musculoskeletal pain) - relatively well tolerated
58
what are the disadvantages of SNRIs
- tolerability - no specific oral side effects - long term side effects- weight gain and sexual dysfunction - low risk for drug interactions
59
what are the contraindications for burproprion
- seizure history** - history of signficant head trauma - anorexia or bulimia - caution use in psychosis
60
what is the MOA and side effect profile of burproprion
- no effect on H1, M1 or alpha 1 receptor - side effects: insomnia, seizures (less common), low risk of sexual dysfunction, low risk of weight gain
61
what are the drug interactions for buproprion
- with opiods - pharmacokinetic interaction - drugs that inhibit CYP450 2D6 prevent the metabolism of hydrocodone, oxycodone and codeine to an active medication. outcome: pain relieving effects are reduced - antidepressants: paroxetine, fluoxetine, buproprion
62
what are the advantages of buproprion
- recommended 1st line agent in depression treatment algorithms - low risk of sexual dysfunction - low risk for weight gain - used for smoking cessation - relatively well tolerated
63
what are the disaddvantages of buproprion
- tolerability - no specific oral side effects - potential for seizures associated with overdose - significant risk for drug interactions
64
what is the MOA for mirtazapine
presynaptic alpha2 antagonist
65
mirtazapine has no effect on_____ receptors
M1 or alpha 1
66
mirtazapine has a positive effect on _____
H1 receptors
67
what is the side effect profile for mirtazapine
- sedation - dry mouth - weight gain - low risk for sexual dysfunction
68
what is the advantages of mirtazapine
- safety profile in overdose - recommended 1st line in depression treatment algorithms - low risk for sexual dysfunction
69
what are the disadvantages of mirtazapine
- tolerability - oral side effect- dry mouth - long term side effects- weight gain, sedation - low risk for drug interactions
70
what are the goals of antidepressant therapy
- remission- resolution of depression symptoms* - improve functioning* - reduce risk of relapse* - increase quality of life - decrease depression morbidity - decrease depression mortality - decrease healthcare costs
71
remission is a _____ reduction in score
75% or more
72
response is a _____ reduction in score
50-74%
73
partial response is a _____ reduction in score
25-49%
74
nonresponse is a _____ reduction in score
less than 25%
75
what is the empiric selection of antidepressant therapy
- past history of AD response - family history of AD repsonse - concurent disease states/drug therapy - adverse effect profile - cost
76
what are the treatment guidelines for antidepressants from the APA
- psychotherapy can be used alone for mild-moderate depression - pharmacotherapy can be used alone for mold-moderate depression - pharmacotherapy +/- psychotherapy for moderate- severe depression - SSRI, SNRI, buproprion, mirtazapine are recommended as 1st line therapy - only complimentary therapy recommended 1st line is st johns wort
77
all antidepressants demonstrate equivalent efficacy of:
70%
78
how long in onset for ADs
days to weeks depending on type of symptom
79
what is the therapeutic trial duration for Ad drugs
6-8 weeks
80
what is the percentage of remission
35-45%
81
nonremission is:
common
82
what are the symptom remissions in the first week
- decreased anxiety - improvement in sleep - improvment in appetite
83
what are the symptom remissions in 1-3 weeks
- increased activity, sex drive, self care, and memory - thinking and movements normalize - sleeping and eating patterns normalize
84
what are the symptom remissions in 2-4 weeks
- relief of depressed mood - less hopeless/helpess - thoughts of suicide subside
85
first episode how long for AD therapy
9-12 months
86
second episode how long AD therapy
5 years
87
more than 2 episodes how long AD therapy
lifetime
88
for elderly patients consider AD therapy for:
longer, maybe indefinitely
89

Pharmacology II (11 decks)

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