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Antidepressants Flashcards

1
Q

What is the general MOA of antidepressants?

A

blocks reuptake pump of serotonin or norepinephrine which leads to increased neurotransmitter concentration in the synapse

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2
Q

What does an increase in neurotransmitters do to the receptors?

A

It causes down regulation of the receptors

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3
Q

What other impact do antidepressants have besides the ones on neurotransmitters?

A

They have an impact on gene expression

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4
Q

What is the oldest class of antidepressants?

A

MAO inhibitors

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5
Q

What are MAOIs contraindicated with?

A

SSRIs, SNRIs, TCAs, sympathomimetics, and levodopa due to risk of HTN crisis

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6
Q

What are MAOIs used for?

A

MDD and treatment resistant depression

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7
Q

What risk is increased when you combine MAOIs with tyramine containing foods?

A

HTN crisis

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8
Q

What primary activity do TCAs have?

A

They work on serotonin, norepinephrine, and dopamine

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9
Q

What secondary activity do all TCAs have?

A

muscarinic, histamine-1, and alpha-1 activity

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10
Q

What are the overdose side effects of TCAs?

A

cardiac arrhythmias (possible arrest), hypotension, seizures, coma, and death

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11
Q

Which patient population should you not use TCAs in?

A

patients with suicidal ideation of hx of suicidal ideation or attempts

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12
Q

True or false: All TCA’s have the same side effect profiles

A

False

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13
Q

Which TCA has the most anticholinergic side effects?

A

amitriptyline

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14
Q

Which TCA is the least sedating?

A

Desipramine

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15
Q

Which TCA has the least GI side effects?

A

Clomipramine

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16
Q

What are blood levels used for in TCA?

A

As an aid to determine toxicity. Not used for effectiveness

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17
Q

What is the MOA of SSRIs?

A

selective and potent inhibition of serotonin reuptake

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18
Q

What are the major side effects of SSRIs action on the 5HT2A and 2C receptors in the limbic cortex?

A

agitation, anxiety, panic attacks, jitteriness syndrome, and insomnia

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19
Q

How do you combat the limbic cortex side effects?

A

decrease the SSRI/SNRI to lower dose and titrate more slowly and take dose in the morning.

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20
Q

What are the major side effects of SSRIs action on the 5HT2A receptors in the brainstem?

A

nocturnal awakenings/sleep disturbances

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21
Q

How do you combat the brainstem side effects?

A

decrease dose and take in the morning

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22
Q

What is the major side effect of SSRIs action on the 5HT2A receptors in the spinal cord?

A

Sexual dysfunction

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23
Q

How do you combat the spinal cord side effects?

A

wait 2-8 weeks to see if it spontaneously resolves. Switch to a different SSRI or non-SSRI antidepressant

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24
Q

What are the major side effects of SSRIs action on the 5HT3 receptors in the hypothalamus?

A

headache, N/V, reduced appetite, and weight loss

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25
How do you combat the hypothalamus side effects?
watch/monitor, consider prn APAP, take with food, decrease dose and titrate slowly, may switch agents
26
What is the most commonly cited reason for stopping antidepressant therapy in the first thirty days?
N/V
27
What are the major side effects of SSRIs action on the 5HT3 and 5HT4 receptors in the GI tract?
GI distress: increased motility, cramps, and diarrhea
28
How do you combat the GI side effects?
take with food, decrease dose and titrate slowly, may switch agents
29
What are other commonly cited side effects of SSRIs?
sweating, tremor, flushing, dizziness, drowsiness, and sedation
30
How do you combat the other common side effects of SSRIs?
take dose in the evening close to bedtime
31
What are the long-term side effects of SSRIs?
weight gain, sleep disturbances, apathy, fatigue, lethargy, and sexual dysfunction
32
Rank the SSRIs and SNRIs on their ability to cause weight gain
Mirtazapine > paroxetine > other SSRIs = SNRIs
33
What add on therapies are used for SSRI induced insomnia?
mirtazapine or trazadone
34
What antidepressant is superior if patient is suffering from apathy, fatigue, and lethargy secondary to SSRIs?
bupropion
35
Which agents are least likely to cause sexual dysfunction?
bupropion, mirtazapine, and trazadone
36
Which agents are most likely to cause sexual dysfunction?
paroxetine and escitalopram
37
Which SSRI side effect is most common in elderly patients?
hyponatremia
38
Rank the agents in order of most likely to cause hyponatremia to least likely
SSRIs > SNRIs > bupropion > mirtazapine
39
What side effects of SSRIs should we use caution in with antiplatelet agents, anticoags, or NSAIDs?
prolonged bleeding
40
How do SSRIs and SNRIs cause prolonged bleeding?
may decrease intra-platelet 5-HT stores
41
What are alternative options for the bleeding risk?
bupropion and mirtazapine
42
What happens if a patient experiences withdrawal symptoms from abrupt SSRI discontinuation?
restart previous dose, and taper more slowly over several weeks to months
43
What are the symptoms of SSRI withdrawal?
FINISH 1. flu-like symptoms 2. insomnia 3. nausea 4. imbalance 5. sensory disturbance 6. hyperarousal
44
How do you treat serotonin syndrome?
serotonergic agents must be stopped, and supportive care initiated. Monitor patient for improval and withdrawal symptoms
45
What is a potential treatment option for serotonin syndrome?
cyproheptadine (5HT-2a antagonist)
46
What are the manifestations of serotonin syndrome?
HR, sweating, HTN, N/V/D, akathisia, tremor, altered mental status, clonus, muscular hypertonicity, and hyperthermia
47
True or false: different medications work differently for different people
true
48
Which SSRI has the longest half-life (about 9 days)
fluoxetine
49
Which patients should we consider fluoxetine for?
patients with fatigue, low-energy, and non-compliance (weekly dosing option)
50
Which SSRI is the most tolerated from a side effect standpoint?
sertraline
51
What are the side effects of sertraline?
diarrhea, decreased appetite, sweating, sexual dysfunction, and tinnitus
52
Which SSRI is pregnancy category D?
paroxetine
53
What two side effects are more prevalent with paroxetine?
weight gain and sedation
54
What two side effects are associated with abrupt withdrawal of paroxetine?
constipation and cholinergic rebound
55
What is one use of paroxetine that is not shared with other SSRIs?
vasomotor symptoms of menopause
56
Which SSRI has the highest risk for QTc prolongation?
citalopram
57
What is the max dose of citalopram in elderly patients or in patients with hepatic impairment?
20 mg/day
58
What is considered the most tolerable antidepressant based on side effect profile?
escitalopram
59
Which antidepressant has the least amount of drug interactions?
escitalopram
60
What is the nickname for the SNRIs?
designer TCAs
61
What activity to SNRIs have?
serotonin, norepinephrine, and dopamine
62
What do the SNRIs lack when compared to TCAs?
significant anticholinergic, antihistaminic, and alpha-1 blocking activity
63
What is special about venlafaxine's MOA?
it acts like an SSRI at lower doses and displays SNRI actions at higher doses
64
What are the most common off-label uses of venlafaxine?
neuropathy and hot flashes
65
What are the side effects of venlafaxine?
Same as SSRIs except more sweating, tachycardia, and palpitations
66
What side effect is seen with higher doses of venlafaxine?
high blood pressure
67
In which patients should you avoid duloxetine in?
liver dysfunction due to hepatotoxicity
68
What is another use of duloxetine besides depression?
pain associated with fibromylagia
69
Due to severe withdrawal what is required in all patients stopping duloxetine?
taper
70
What is the active metabolite of venlafaxine?
desvenlafaxine
71
What is the dose of desvenlafaxine?
50 mg daily
72
Does desvenlafaxine need to be titrated?
no, it displays SNRI effects throughout the dosing range
73
What is the MOA of bupropion?
norepinephrine and dopamine reuptake blocker
74
What are the most common side effects of bupropion?
agitation, insomnia, anxiety, diminished appetite, and weight loss
75
In which patient population is bupropion contraindicated?
patients with a hx of seizures, anorexia, or bulimia
76
Why is bupropion sometimes used in combination with other antidepressants?
it augments their effects
77
What FDA warning was placed on bupropion?
neuropsychiatric reactions
78
What is the MOA of mirtazapine?
central alpha-2 antagonist or noradrenergic and specific serotonergic antidepressant - indirectly increases serotonin and norepinephrine
79
What are the common side effects of mirtazapine?
sedation, weight gain, increased appetite, dizziness, dry mouth, and constipation
80
What is mirtazapine a good agent for?
depression, insomnia, and appetite stimulation
81
Describe the relationship between mirtazapine dosing and sedation
inverse relationship: lower doses = more sedation
82
What is different about mirtazapine compared to SSRIs?
faster onset of action
83
What is the MOA of trazodone?
blocks 5HT2 postsynaptically
84
What is the benefit of trazodone compared to SSRIs
diminished ability to cause sexual dysfunction, insomnia, and anxiety
85
What is trazodone used more often for?
augmentation in the treatment of depression
86
What side effect is trazodone used for?
sedative effects
87
What are the side effects of trazodone?
sedation, orthostasis, HA, nausea, and priapism
88
What is the MOA of vortioxetine (Trintellix)?
SSRI + 5-HT1a agonist + 5-HT3 antagonist
89
What is the MOA of vilazodone (Viibryd)?
4-HT1a partial agonist + SRI
90
What is the benefit of vilazodone's dual MOA?
it possesses a lower risk for serotonin syndrome
91
What drug combination is similar to vilazodone?
paroxetine + buspirone
92
What side effect has a high incidence in patients taking vilazodone?
GI side effects
93
How do you combat the GI side effects of vilazodone?
take with food
94
Which class of antidepressant needs a washout period?
MAOIs
95
How do you prevent withdrawal or symptomatic relapse in patients stopping an antidepressant?
taper over several weeks
96
What factors contribute to taper strategy?
half-life, dose, duration of therapy, cost, and patient preference
97
What are the major counseling points for antidepressant?
1. AEs may occur initially; time limited 2. symptom resolution may not occur for 2-4 weeks or longer 3. adherence is essential
98
What is the BBW on brexanolone?
risk of excessive sedation or sudden loss of consciousness during administration
99
What is the MOA of NMDA receptor antagonist?
N-methyl-d-aspartate receptor antagonist
100
How is ketamine (NMDA antagonist) given?
IV infusion
101
What is ketamine used for?
Severe, treatment resistant MDD
102
What are the side effects of ketamine?
emergent psychosis, auditory and visual hallucinations
103
In what patient population is ketamine contraindicated in?
in patients with psychotic disorders
104
What is esketamine used for?
treatment resistant depression
105
How is esketamine given?
intranasally
106
What must be evaluated before starting esketamine?
blood pressure
107
What is the common psych side effect of esketamine?
anxiety
108
What are the serious side effects of esketamine?
increased blood pressure and dissociative disorder
109
What class of antidepressants is most studied in pregnancy?
SSRIs
110
What SSRI is preferred in pregnancy?
sertraline

Psych (3 decks)

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