Brainscape's Knowledge GenomeTM


Top Flashcards (Certified)
All Flashcards

Pharm- Antipsychotics > Antidepressants > Flashcards

Antidepressants Flashcards

1
Q

Etiology of MDD

A

Changes in?
norepinephrine (NE)
serotonin (5-HT)
dopamine (DA)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

Treatment Goals of MDD

A

Reduce symptoms of acute depression
Facilitate patient’s return to pre-morbid functioning
Prevent further episodes of depression
Hospitalization

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

Hospitalization should be based on what 4 factors?

A

Suicide risk
Physical state of health
Support system
Presence of psychotic features

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

Acute Phase of treatment for MDD

A

Lasting from 6-8 weeks

Goal: Remission of symptoms

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

Continuation phase of treatment for MDD

A

Lasting from 4-9 months(in addition to acute phase)

Goal: Eliminate residual symptoms and prevent relapse

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

Maintenance Phase of treatment for MDD

A

Lasting at least 12-36 months

Goal: Prevent recurrence

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

Choice of Agent is based on what for antidepressants?

A 
Patient’s history of response
Pharmacogenetics (hx of familial response)
Subtype of depression
Concurrent medical history
Potential for drug-drug interactions
Adverse events profile
Drug cost
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

What is the response to antidepressants?

A

Approx. 65-70% of patients with varying types of depression improve with drug therapy
Well-documented placebo effect
Adverse effects may occur immediately
Resolution of symptoms may take 2-4 weeks (or longer!)
Adherence is essential to a successful outcome

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

What are the 5 classes of antidepressants

A 
Tricyclic Antidepressants (TCAs)
Monoamine oxidase inhibitors (MAOIs)
Selective serotonin reuptake inhibitors (SSRIs)
Mixed 5-HT and NE reuptake inhibitors
Miscellaneous
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

What is the black box warning found on all antidepressants?

A

regarding ↑’d risk of suicidality in young adults

(18-24 years), during initial stages of treatment

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

TCA MOA

A 
Block muscarinic (M1), adrenergic (α1), histamine (H1) receptors
All potentiate activity of NE and 5-HT via reuptake blockade
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

TCA Pharmacokinetics

A

Well-absorbed; low bioavailability due to high 1st –pass metabolism in liver
T ½ about 24 hours (allows for QD dosing)
Highly lipophilic–> wide distribution throughout the body
Highly protein bound
hepatically metabolized

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

TCA Adverse Effects

A 
Tachycardia
Orthostatic hypotension
Cardiac rhythm changes (i.e., QRS prolongation, ST depression, flattened or inverted T waves)
Weight gain 
Sedation
decrease seizure threshold
sexual dysfunction****
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

What is really important to know about TCA’s?

A

narrow theraputic index

Fatal in overdose  cardiac conduction abnormalities (i.e., torsades de pointes)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

Tertiary amine TCAs

A

More pronounced anticholinergic, antihistaminergic, and hypotensive effects
Avoid in elderly due to postural hypotension  risk of fall and other cardiovascular effects

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

TCA Contraindications? (6)

A

Patients with benign prostate hyperplasia
Patients with closed-angle glaucoma
Patients with cardiac disease
Baseline ECG (require for all)
Patients with hepatic impairment
Elderly patients
Particularly sensitive to antiACh effects
At ’d risk of TCA-induced cognitive toxicity (mild confusion to delirium)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
17
Q

TCA Drug interactions

A

Avoid use with other drugs that affect CYP450 system
May increase vasopressor response to direct-acting sympathomimetics (i.e., phenylephrine, epinephrine, NE)
Additive adverse effects with other agents with serotonergic, antiACh, sedative, or hypotensive properties

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
18
Q

3 MAO-I medications

A

Phenelzine (Nardil®) (nonselective)
Tranylcypromine (Parnate®)
Selegiline transdermal patch (Emsam®)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
19
Q

Tranylcypromine (Parnate®)

A

Non-selective inhibition of MAO-A and MAO-B

Rare to see due to ADE

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
20
Q

Selegiline transdermal patch (Emsam®)

A

Selective MAO-B inhibitor at 6 mg/24 hr patch (approx. 10 mg PO)
Non-selective inhibition at 9 mg- and 12 mg-per 24 hr patch

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
21
Q

MAO-I MOA

A

Block metabolism of NE, 5-HT, and DA via inhibition of MAO enzyme
NE and 5-HT: metabolized by MAO-A
DA and Tyramine: metabolized by MAO-A and MAO-B

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
22
Q

MAO-I pharmokinetics

A

Rapidly absorbed
Maximum MAO inhibition at 14 days
T ½ of 1-4 hrs
Clinical effects seen for up to 14 days after discontinuation

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
23
Q

MAO-I Adverse Effects

A 
Orthostatic hypotension		-  Dizziness
Mydriasis				-  Edema
Piloerection				-  Insomnia
Tremor					-  Anorgasmia
Excessive daytime sleepiness
Weight gain
hepatic dysfunction
hypertensive crisis
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
24
Q

Hypertensive Crisis that is an ADR in MAO-I

A

Occurs after ingestion of tyramine containing foods or drugs  dietary restriction
Tyramine = pressure amine; metabolized in gut by MAO enzymes
Causes release of NE from presynaptic sites
Signs and symptoms: hypertension, occipital headache, neck stiffness, diaphoresis, heart palpitations, nausea, vomiting
Medical emergency

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
25
MAO-I drug interactions
Washout period of 14 days necessary when switching from an MAOI to another antidepressant or from another antidepressant to an MAOI (5 week washout when switching from fluoxetine to an MAOI) Serotonin syndrome with other antidepressants
26
What are 6 SSRI medications used?
``` Fluoxetine (Prozac®) Sertraline (Zoloft®) Paroxetine (Paxil®) Citalopram (Celexa®) Escitalopram (Lexapro®) Fluvoxamine (Luvox®) – FDA approved for only OCD ```
27
SSRI's
1st line therapy for MDD Favorable safety profile No evidence to suggest one SSRI more efficacious than another Indicated for other psychiatric comorbidities Anxiety disorders (i.e., OCD, PTSD, general anxiety
28
MOA of SSRI's
Inhibit reuptake of 5-HT   5-HT activity in neuronal synapse Low affinity for histaminergic, cholinergic, and α-adrenergic receptors
29
Pharmacokinetics of SSRI's
T ½ = approx. 24 hrs for sertraline, paroxetine, citalopram, and escitalopram T ½ = 7+ days for fluoxetine (and active metabolite norfluoxetine) 4-5wks to get to steady state Hepatic impairment significantly interferes with metabolism Measurement of serum concentrations does not correlate with clinical outcome
30
SSRI's adverse effects
Nausea - Headache Sleep disturbances - Agitation/anxiety Sexual dysfunction - Tremor Less sedating and cause less weight gain than TCAs or MAOIs Serotonin syndrome with other serotonergic agents
31
Discontinuations Syndrome of SSRI's
Potential for withdrawal symptoms with abrupt discontinuation of short-acting SSRIs Symptoms: vivid dreams, nightmares, tremor, dizziness, crying spells, nausea, poor concentration Occurs as early a 1-4 days or up to 25 days after discontinuation Taper dose slowly over a period of 7-10 days
32
Fluoxetine Drug interactions
5-week washout after discontinuation before starting an MAOI (2-week washout for all other SSRIs)
33
Sertraline Drug interactions
Weak inhibitor of CYP2D6 at low doses; becomes more potent at higher doses (still weaker than fluoxetine and paroxetine) No known clinically significant drug interactions
34
Citalopram and escitalopram Drug interactions
Possible dose dependent inhibition of CYP2D6 | No known clinically significant drug interactions
35
Fluvoxamine Drug interactions
Potent inhibitor of CYP1A2 | Weak inhibitor at CYP2C9
36
3 Mixed 5-HT/NE Reuptake Inhibitors
Venlafaxine (Effexor®) Duloxetine (Cymbalta®) Desvenlafaxine (Pristiq®) active metabolite of effexor
37
Venlafaxine
Extended-release (XR) formulation considered a 1st line agent for MDD No significant adverse affects or cardiac affects 3 divided doses
38
Venlafaxine MOA
Potent 5-HT/NE reuptake inhibitor 5-HT reuptake inhibition 3-5 fold higher than NE reuptake inhibition at doses < 200 mg/day Weak DA reuptake inhibitor
39
Venlafaxine Pharmacokinetics
Well-absorbed Minimal plasma protein binding T ½ = 5-11 hrs (longer with XR formulation) Substantial 1st pass metabolism via CYP2D6
40
Venlafaxine Adverse effects
Side effect profile similar to SSRIs Common side effects Nausea, constipation, sedation, dry mouth, insomnia, dizziness, sweating, sexual dysfunction Discontinuation syndrome **not for someone with uncontrolled HTN**
41
Drug interactions for Venlafaxine
Weak inhibitor of CYP2D6 Little or no inhibition of other CYP enzymes Can potentially accumulate when combined with CYP2D6 inhibitors; use cautiously Serotonin syndrome
42
Duloxetine (5)
Balanced reuptake inhibitor if 5-HT and NE FDA indicated for MDD, diabetic neuropathy and fibromyalgia Adverse effect profile similar to venlafaxine (but no dose related  in BP) Metabolized at CYP2D6 and CYP1A2 T ½ = 12 hrs
43
Desvenlafaxine
Studies show no additional benefit above 50 mg/day with an increase in adverse effects at higher doses Adverse effect profile similar to venlafaxine No comparison studies with any other antidepressants
44
Buproprion/Wellbutrin
Most potent neurochemical action is DA reuptake inhibition (increase DA activity) Very low reuptake inhibition of NE No appreciable effect of reuptake of 5-HT
45
Buproprion/Wellbutrin indications
Depression: Wellbutrin® (immediate-release, SR, XL) | Smoking cessation: Zyban® (bupropion SR)
46
Buproprion/Wellbutrin Adverse effects
Use with caution with drugs known to  seizure threshold Use with an MAOI contraindicated Very low inhibition of CYP 2D6 Use with agents metabolized via CYP2D6 should be used with caution
47
Nefazodone MOA
Both a 5-HT2 antagonist and 5-HT reuptake inhibitor | Negligible affinity for cholinergic, histaminergic, dopaminergic receptors
48
Nefazodone Adverse effects and black box warning
Black box warning related to cases of life-threatening hepatic failure Common adverse events: light-headedness, dizziness, dry mouth, nausea, asthenia, orthostatic hypotension, sedation Potent CYP3A4 inhibitor Not a 1st line agent
49
Trazodone immediate release
Use as antidepressant has decreased due to adverse effects (i.e., orthostatic hypotension, dizziness, sedation) Usual dosage range: 150-300 mg/day Commonly used as a sedative at does of 50-100 mg HS Rare cases of priapism, QTc prolongation
50
Trazodone extended release
Oleptro® Starting dose: 150 mg once daily at bedtime Increase by 75 mg/day every 3 days to a maximum of 375 mg/day. Side-effect profile similar to immediate- release trazodone
51
Mirtazapine
Remeron® Selective, presynaptic α2-receptor antagonist Enhancement of NE transmission by α2-autoreceptor blockade  stimulation of α2-adrenoreceptors  ’d 5-HT firing T ½ = 20-40 hrs
52
Mirtazapine adverse effect and drug interactions
``` Adverse Effects Sedation Dry mouth Constipation Increased appetite Weight gain ``` Drug interactions Other sedating agents MAOIs
53
Vilazodone
Viibryd®- dual 5-HT activity | maintenance dose of 40 mg once daily with food
54
Vilazodone Adverse effects
Adverse Effects: Common: diarrhea, nausea, dizziness, dry mouth, insomnia, vomiting, and decreased libido, dry mouth Rare: May cause new or worsening cataracts with long-term use
55
Levomilnacipran
Fetzima® - SNRI Twofold greater potency for norepinephrine relative to serotonin reuptake inhibition Higher selectivity for norepinephrine reuptake inhibition compared with venlafaxine and duloxetine
56
Levomilnacipran side effects
Side effects in clinical trials include nausea, constipation, and sweating Primarily excreted by the kidneys Role in treatment of depression unknown –only studied versus placebo
57
Vortioxetine
Brintellix® - Serotonin re-uptake inhibitor and agonist | Most common adverse reactions: nausea, constipation and vomiting
58
Vortioxetine drug interactions
Strong inhibitors of CYP2D6: Reduce dose by half Strong CYP Inducers: Consider increasing dose Role in treatment of depression unknown
59
St. John’s wort
Herbal product – not regulated by the FDA Found to be safe and effective for treatment of mild-to-moderate depression significant drug interactions Potent CYP3A4 inducer
60
What is Electroconvulsive Therapy (ECT)
Small current used to induce a seizure 30 to 60 seconds in duration Patients are sedated and neuromuscular blocking agents used to prevent muscle contractions Course: 6-12 treatments (2-3 times/week)
61
ECT indications?
high suicide risk rapid physical decline drug non-response or intolerability history of prior response to ECT
62
Contraindications and limitations of ECT
Contraindications: no absolute contraindications Limitations/AEs: high relapse rate, impairments in memory and neurocognitive function, treatment- emergent mania, headache, nausea, muscle aches
63
Elderly Populations
Depression often mistaken for another disorder (i.e., dementia) Depressed mood may be less prominent than other symptoms (i.e., loss of appetite, cognitive impairment, sleeplessness, anergia, anhedonia) Somatic complaints frequent Increased suicide attempts SSRIs 1st line Start LOW and go SLOW
64
Pregnancy Population
Risks and benefits must always be carefully weighed New evidence for potential respiratory distress and withdrawal syndrome in neonates whose mothers took SSRIs during pregnancy Risks of untreated depression? ECT can be used safely during pregnancy Sertraline and paroxetine appear in low concentrations in breast milk
65
3 ways to evaluate the response of treatment
Target signs and symptoms Quality-of-life issues Tolerability of the agent
66
Evaluation of target signs and symptoms (4)
Non-response: 50% ↓ in baseline symptoms | Remission: return to baseline functioning
67
Antidepressants: General Dosing Information (4)
Lag time before start of therapy and onset of clinical response  can lead to noncompliance Onset of activity usually takes 1-2 weeks Improvement in energy, appetite, sleep disturbances 3-4 weeks usually required before mood- elevating response seen Adequate trial: 6-8 weeks at a maximum dosage
68
Treatment Resistant Depression
Definition = remission not achieved after 2 optimal antidepressant trials (6-8 weeks)
69
2 approaches used for treatment of resistant depression
Switching | Augmentation with another antidepressant, lithium, T3 (triiodothyronine), atypical antipsychotic, ECT, psychotherapy

Pharm- Antipsychotics (2 decks)

Brainscape helps you reach your goals faster, through stronger study habits.
© 2025 Bold Learning Solutions. Terms and Conditions