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Antidepressants Flashcards

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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
Q

How do you combat the hypothalamus side effects?

A

watch/monitor, consider prn APAP, take with food, decrease dose and titrate slowly, may switch agents

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26
Q

What is the most commonly cited reason for stopping antidepressant therapy in the first thirty days?

A

N/V

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27
Q

What are the major side effects of SSRIs action on the 5HT3 and 5HT4 receptors in the GI tract?

A

GI distress: increased motility, cramps, and diarrhea

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28
Q

How do you combat the GI side effects?

A

take with food, decrease dose and titrate slowly, may switch agents

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29
Q

What are other commonly cited side effects of SSRIs?

A

sweating, tremor, flushing, dizziness, drowsiness, and sedation

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30
Q

How do you combat the other common side effects of SSRIs?

A

take dose in the evening close to bedtime

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31
Q

What are the long-term side effects of SSRIs?

A

weight gain, sleep disturbances, apathy, fatigue, lethargy, and sexual dysfunction

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32
Q

Rank the SSRIs and SNRIs on their ability to cause weight gain

A

Mirtazapine > paroxetine > other SSRIs = SNRIs

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33
Q

What add on therapies are used for SSRI induced insomnia?

A

mirtazapine or trazadone

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34
Q

What antidepressant is superior if patient is suffering from apathy, fatigue, and lethargy secondary to SSRIs?

A

bupropion

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35
Q

Which agents are least likely to cause sexual dysfunction?

A

bupropion, mirtazapine, and trazadone

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36
Q

Which agents are most likely to cause sexual dysfunction?

A

paroxetine and escitalopram

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37
Q

Which SSRI side effect is most common in elderly patients?

A

hyponatremia

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38
Q

Rank the agents in order of most likely to cause hyponatremia to least likely

A

SSRIs > SNRIs > bupropion > mirtazapine

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39
Q

What side effects of SSRIs should we use caution in with antiplatelet agents, anticoags, or NSAIDs?

A

prolonged bleeding

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40
Q

How do SSRIs and SNRIs cause prolonged bleeding?

A

may decrease intra-platelet 5-HT stores

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41
Q

What are alternative options for the bleeding risk?

A

bupropion and mirtazapine

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42
Q

What happens if a patient experiences withdrawal symptoms from abrupt SSRI discontinuation?

A

restart previous dose, and taper more slowly over several weeks to months

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43
Q

What are the symptoms of SSRI withdrawal?

A

FINISH

  1. flu-like symptoms
  2. insomnia
  3. nausea
  4. imbalance
  5. sensory disturbance
  6. hyperarousal
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44
Q

How do you treat serotonin syndrome?

A

serotonergic agents must be stopped, and supportive care initiated. Monitor patient for improval and withdrawal symptoms

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45
Q

What is a potential treatment option for serotonin syndrome?

A

cyproheptadine (5HT-2a antagonist)

46
Q

What are the manifestations of serotonin syndrome?

A

HR, sweating, HTN, N/V/D, akathisia, tremor, altered mental status, clonus, muscular hypertonicity, and hyperthermia

47
Q

True or false: different medications work differently for different people

A

true

48
Q

Which SSRI has the longest half-life (about 9 days)

A

fluoxetine

49
Q

Which patients should we consider fluoxetine for?

A

patients with fatigue, low-energy, and non-compliance (weekly dosing option)

50
Q

Which SSRI is the most tolerated from a side effect standpoint?

A

sertraline

51
Q

What are the side effects of sertraline?

A

diarrhea, decreased appetite, sweating, sexual dysfunction, and tinnitus

52
Q

Which SSRI is pregnancy category D?

A

paroxetine

53
Q

What two side effects are more prevalent with paroxetine?

A

weight gain and sedation

54
Q

What two side effects are associated with abrupt withdrawal of paroxetine?

A

constipation and cholinergic rebound

55
Q

What is one use of paroxetine that is not shared with other SSRIs?

A

vasomotor symptoms of menopause

56
Q

Which SSRI has the highest risk for QTc prolongation?

A

citalopram

57
Q

What is the max dose of citalopram in elderly patients or in patients with hepatic impairment?

A

20 mg/day

58
Q

What is considered the most tolerable antidepressant based on side effect profile?

A

escitalopram

59
Q

Which antidepressant has the least amount of drug interactions?

A

escitalopram

60
Q

What is the nickname for the SNRIs?

A

designer TCAs

61
Q

What activity to SNRIs have?

A

serotonin, norepinephrine, and dopamine

62
Q

What do the SNRIs lack when compared to TCAs?

A

significant anticholinergic, antihistaminic, and alpha-1 blocking activity

63
Q

What is special about venlafaxine’s MOA?

A

it acts like an SSRI at lower doses and displays SNRI actions at higher doses

64
Q

What are the most common off-label uses of venlafaxine?

A

neuropathy and hot flashes

65
Q

What are the side effects of venlafaxine?

A

Same as SSRIs except more sweating, tachycardia, and palpitations

66
Q

What side effect is seen with higher doses of venlafaxine?

A

high blood pressure

67
Q

In which patients should you avoid duloxetine in?

A

liver dysfunction due to hepatotoxicity

68
Q

What is another use of duloxetine besides depression?

A

pain associated with fibromylagia

69
Q

Due to severe withdrawal what is required in all patients stopping duloxetine?

A

taper

70
Q

What is the active metabolite of venlafaxine?

A

desvenlafaxine

71
Q

What is the dose of desvenlafaxine?

A

50 mg daily

72
Q

Does desvenlafaxine need to be titrated?

A

no, it displays SNRI effects throughout the dosing range

73
Q

What is the MOA of bupropion?

A

norepinephrine and dopamine reuptake blocker

74
Q

What are the most common side effects of bupropion?

A

agitation, insomnia, anxiety, diminished appetite, and weight loss

75
Q

In which patient population is bupropion contraindicated?

A

patients with a hx of seizures, anorexia, or bulimia

76
Q

Why is bupropion sometimes used in combination with other antidepressants?

A

it augments their effects

77
Q

What FDA warning was placed on bupropion?

A

neuropsychiatric reactions

78
Q

What is the MOA of mirtazapine?

A

central alpha-2 antagonist or noradrenergic and specific serotonergic antidepressant - indirectly increases serotonin and norepinephrine

79
Q

What are the common side effects of mirtazapine?

A

sedation, weight gain, increased appetite, dizziness, dry mouth, and constipation

80
Q

What is mirtazapine a good agent for?

A

depression, insomnia, and appetite stimulation

81
Q

Describe the relationship between mirtazapine dosing and sedation

A

inverse relationship: lower doses = more sedation

82
Q

What is different about mirtazapine compared to SSRIs?

A

faster onset of action

83
Q

What is the MOA of trazodone?

A

blocks 5HT2 postsynaptically

84
Q

What is the benefit of trazodone compared to SSRIs

A

diminished ability to cause sexual dysfunction, insomnia, and anxiety

85
Q

What is trazodone used more often for?

A

augmentation in the treatment of depression

86
Q

What side effect is trazodone used for?

A

sedative effects

87
Q

What are the side effects of trazodone?

A

sedation, orthostasis, HA, nausea, and priapism

88
Q

What is the MOA of vortioxetine (Trintellix)?

A

SSRI + 5-HT1a agonist + 5-HT3 antagonist

89
Q

What is the MOA of vilazodone (Viibryd)?

A

4-HT1a partial agonist + SRI

90
Q

What is the benefit of vilazodone’s dual MOA?

A

it possesses a lower risk for serotonin syndrome

91
Q

What drug combination is similar to vilazodone?

A

paroxetine + buspirone

92
Q

What side effect has a high incidence in patients taking vilazodone?

A

GI side effects

93
Q

How do you combat the GI side effects of vilazodone?

A

take with food

94
Q

Which class of antidepressant needs a washout period?

A

MAOIs

95
Q

How do you prevent withdrawal or symptomatic relapse in patients stopping an antidepressant?

A

taper over several weeks

96
Q

What factors contribute to taper strategy?

A

half-life, dose, duration of therapy, cost, and patient preference

97
Q

What are the major counseling points for antidepressant?

A
  1. AEs may occur initially; time limited
  2. symptom resolution may not occur for 2-4 weeks or longer
  3. adherence is essential
98
Q

What is the BBW on brexanolone?

A

risk of excessive sedation or sudden loss of consciousness during administration

99
Q

What is the MOA of NMDA receptor antagonist?

A

N-methyl-d-aspartate receptor antagonist

100
Q

How is ketamine (NMDA antagonist) given?

A

IV infusion

101
Q

What is ketamine used for?

A

Severe, treatment resistant MDD

102
Q

What are the side effects of ketamine?

A

emergent psychosis, auditory and visual hallucinations

103
Q

In what patient population is ketamine contraindicated in?

A

in patients with psychotic disorders

104
Q

What is esketamine used for?

A

treatment resistant depression

105
Q

How is esketamine given?

A

intranasally

106
Q

What must be evaluated before starting esketamine?

A

blood pressure

107
Q

What is the common psych side effect of esketamine?

A

anxiety

108
Q

What are the serious side effects of esketamine?

A

increased blood pressure and dissociative disorder

109
Q

What class of antidepressants is most studied in pregnancy?

A

SSRIs

110
Q

What SSRI is preferred in pregnancy?

A

sertraline

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