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Pharmacology > Antidepressants and antianxiety medication > Flashcards

Antidepressants and antianxiety medication Flashcards

1
Q

Most sedating SSRI

A

Paroxetine

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2
Q

Reason for paroxetine’s sedating effect

A

High H1 affinity

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3
Q

SSRI with the highest rate of discontinuation symptoms

A

Paroxetine

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4
Q

SSRIs with the highest rates of drug interactions

A

Fluoxetine
Fluvoxamine
Paroxetine

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5
Q

SSRI which causes the most short term anxiety and agitation

A

Fluoxetine

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6
Q

SSRI which causes the most short term weight loss

A

Fluoxetine

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7
Q

SSRI which has the least drug interactions

A

Citalopram

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8
Q

SSRI which is most often used with elderly patients due to its lower risk of interactions

A

Citalopram

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9
Q

SSRI which has the most evidence for safe use post-MI

A

Sertraline

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10
Q

SSRI which is most often used for children and adolescents

A

Fluoxetine

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11
Q

Most common side effect of SSRIs

A

GI side effects

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12
Q

SSRI which causes the most GI upset

A

Fluvoxamine

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13
Q

SSRIs which cause the least sexual dysfunction

A

Vortioxetine

Fluvoxamine

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14
Q

SSRI which is the most anticholinergic

A

Paroxetine

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15
Q

Medication which should be co-prescribed if a patient is taking an SSRI and NSAID

A

Protein pump inhibitor

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16
Q

Drugs where SSRIs should be avoided where possible

A

NSAIDs
Warfarin
Aspirin
Triptans

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17
Q

SSRI which does not need to be gradually reduced when stopping

A

Fluoxetine

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18
Q

SSRI discontinuation symptoms

A 
Restlessness
Insomnia, vivid dreams
Unsteadiness/dizziness
Sweating
GI symptoms - pain, cramps, diarrhoea, vomiting
Paraesthesia, shock-like symptoms
Flu-like symptoms
Crying spells
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19
Q

Half life of citalopram

A

33 hours

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20
Q

Half life of escitalopram

A

30 hours

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21
Q

Half life of fluoxetine in early use

A

1-3 days

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22
Q

Half life of fluoxetine with prolonged use

A

4-6 days

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23
Q

Half life of fluvoxamine

A

17-22 hours

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24
Q

Half life of paroxetine

A

22 hours

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25
Q

Half life of sertraline

A

26 hours

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26
Q

Mechanism of action of MAOIs

A

Block the monoamine oxidase enzyme, which breaks down different neurotransmitters

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27
Q

Where MAO A is found

A

Placenta, gut, liver

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28
Q

Where MAO B is found

A

Brain, liver, platelets

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29
Q

Neurotransmitters MAO A breaks down

A

Serotonin, noradrenaline, dopamine, tyramine

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30
Q

Neurotransmitters MAO B breaks down

A

Phenylethylamine, methylhistamine, tryptamine, dopamine, tyramine

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31
Q

Types of MAOIs

A

Reversible or irreversible, selective for MOA A or MOA B, or non-selective

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32
Q

Irreversible and selective inhibitors of MAO B

A

Selegiline (no longer selective at high doses)

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33
Q

Reversible and selective inhibitor of MAO A

A

Meclobemide

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34
Q

Most common adverse effects

A

Dry mouth, nausea, diarrhoea, constipation, insomnia, dizziness/light-headedness

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35
Q

Cause of MAOI cheese reaction

A

Tyramine is a monoamine found in different foods which displaces noradrenaline from neurons, causing hypertension. When MAO doesn’t break down tyramine it can build up and cause a hypertensive reaction

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36
Q

Foods to avoid due to risk of cheese reaction

A 
Cheese (except cream cheese and cottage cheese)
Broad beans
Alcohol
Banana peels
Bean curd
Sauerkraut
Yeast extracts (e.g. marmite)
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37
Q

First generation TCAs (tertiary amines)

A 
Amitriptyline
Lofepramine
Imipramine
Dosulepin
Doxepin
Clomipramine
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38
Q

Second generation TCAs (secondary amines)

A

Nortriptyline
Desipramine
Amoxapine

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39
Q

Most dangerous TCAs in overdose

A

Amitriptyline

Dosulepin - possibly the most dangerous

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40
Q

Common side effects of TCAs

A 
Drowsiness
Dry mouth
Blurred vision
Constipation
Urinary retention
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41
Q

Features of overdose of TCAs

A 
Sedation/coma
Seizures
Hypertension (early) then hypotension
Tachycardia
Broad complex dysrhythmias
Increased anticholinergic side effects
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42
Q

ECG features of TCA overdose

A

Increased QRS - >100ms in lead II
Terminal R wave >3mm in aVR
Sinus tachycardia

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43
Q

Specific treatments for overdose of TCAs

A

IV sodium bicarbonate
Hyperventilation
IV lidocaine
Avoid 1a (procainamide) and 1c (flecainide) antiarrhythmics, beta-blockers and amiodarone

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44
Q

Drug interactions of TCAs

A

Cytochrome p450 inhibitors can lead to toxicity as TCAs are highly metabolised by cytochrome p450
Cytochrome p450 inducers can lead to treatment failure
MAOIs - contraindicated with some TCAs due to serotonin syndrome like reactions
QTc prolonging drugs

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45
Q

Mechanism of action of TCAs

A

Block the serotonin transporter and the noradrenaline transporter which leads to elevated synaptic concentrations of serotonin and noradrenaline
Weak affinity for the dopamine transporter
Antagonists of multiple receptors including 5-HT2
Inhibit sodium channels leading to their cardiotoxicity in overdose

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46
Q

Interaction of TCAs with warfarin

A

TCAs increase warfarin levels - high risk of bleeding

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47
Q

Interaction of TCAs with clonidine

A

TCAs decrease clonidine levels - risk of hypertension

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48
Q

Interaction of TCAs with MAOIs

A

Increase serotonin levels via synergistic serotonergic enhancement - increased risk serotonin syndrome like reaction
Decrease tyramine entry - reduced risk cheese reaction

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49
Q

Interaction between TCAs and levodopa

A

Reduces absorption of levodopa and so lowers efficacy

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50
Q

Active metabolite of amitriptyline

A

Nortriptyline

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51
Q

Active metabolite of clomiprimine

A

Desmethyl-clomipramine

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52
Q

Active metabolite of dosulepin

A

Desmethyldosulepin

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53
Q

Active metabolite of doxepin

A

Desmethyldoxepin

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54
Q

Active metabolite of imipramine

A

Desipramine

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55
Q

Active metabolite of lofepramine

A

Desipramine

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56
Q

Active metabolite of fluoxetine

A

Norfluoxetine

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57
Q

Active metabolite of mirtazapine

A

Demethyl-mirtazapine

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58
Q

Active metabolite of trazadone and nefazodone

A

mCPP

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59
Q

Active metabolite of venlafaxine

A

O-desmethyl-venlafaxine

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60
Q

Start dose of citalopram for depression

A

10-20mg/day

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61
Q

Maximum citalopram dose for depression

A

40mg/day

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62
Q

Start dose of escitalopram for depression

A

5-10mg/day

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63
Q

Maximum escitalopram dose for depression

A

20mg/day

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64
Q

Start dose of sertraline for depression

A

50mg/day

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65
Q

Maximum sertraline dose for depression

A

200mg/day

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66
Q

Start dose of fluoxetine for depression

A

20mg/day

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67
Q

Maximum fluoxetine dose for depression

A

60mg/day

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68
Q

Start dose of paroxetine for depression

A

20mg/day

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69
Q

Maximum dose of paroxetine for depression

A

50mg/day

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70
Q

Start dose of vortioxetine for depression

A

5-10mg/day

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71
Q

Maximum vortioxetine dose for depression

A

20mg/day

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72
Q

Start dose of venlafaxine for depression

A

75mg/day in divided doses

73
Q

Maximum venlafaxine dose for depression

A

375mg/day

74
Q

Start dose of mirtazapine for depression

A

15mg/day

75
Q

Maximum mirtazapine dose for depression

A

45mg/day

76
Q

Start dose of moclobemide for depression

A

300mg/day in divided doses

77
Q

Usual dose of moclobemide for depression

A

Up to 600mg/day

78
Q

TCA discontinuation symptoms

A

Flu-like symptoms
Insomnia
Excessive dreaming

79
Q

MAOI discontinuation symptoms

A

Agitation
Ataxia and movement disorders
Insomnia
Vivid dreams

80
Q

Discontinuation symptoms associated with agomelatine

A

Nil

81
Q

Minimum effective dose of citalopram

A

20mg/day

82
Q

Minimum effective dose of fluoxetine

A

20mg/day

83
Q

Minimum effective dose of fluvoxamine

A

50mg/day

84
Q

Minimum effective dose of paroxetine

A

20mg/day

85
Q

Minimum effective dose of sertraline

A

50mg/day

86
Q

Minimum effective dose of mirtazapine

A

30mg/day

87
Q

Minimum effective dose of venlafaxine

A

75mg/day

88
Q

Minimum effective dose of duloxetine

A

40-60mg/day

89
Q

Minimum effective dose of agomelatine

A

25mg/day

90
Q

Minimum effective dose of moclobemide

A

300mg/day

91
Q

Minimum effective dose of trazadone

A

150mg/day

92
Q

Starting dose of fluvoxamine

A

50-100mg/day

93
Q

Maximum dose of fluvoxamine

A

300mg/day

94
Q

Starting dose of agomelatine

A

25mg/day

95
Q

Maximum dose of agomelatine

A

50mg/day

96
Q

Starting dose of trazodone

A

150mg/day in divided doses

97
Q

Maximum dose of trazodone

A

300mg/day generally

600mg/day in hospital inpatients

98
Q

Non selective MAO A and MAO B inhibitors (all irreversible)

A

Hydrazine
Phenelzine
Tranylcypromine
Hydracarbazine

99
Q

Antidepressant that can be given sublingually

A

Fluoxetine liquid

100
Q

Antidepressants that can be given buccally

A

Selegiline

Amitriptyline

101
Q

Antidepressants that can be given IV

A 
Citalopram
Escitalopram
Mirtazapine
Amitriptyline
Clomipramine
Ketamine
102
Q

IM antipsychotic which has been shown to have antidepressant effects

A

Flupentixol

103
Q

Antidepressant that can be given transdermally

A

Selegiline

104
Q

Antidepressants that exist as suppositaries

A

Amitriptyline
Clomipramine
Imipramine
Trazodone

105
Q

TCA side effects

A 
Antimuscarinic - dry mouth, urinary retention
Weight gain
Sedation
Sexual dysfunction
Cognitive impairment
Arrhythmias
Black hairy tongue
Tremor
Altered LFTs
Paralytic ileus
NMS
106
Q

Active metabolite of sertraline

A

Desmethylsertraline

107
Q

Dose at which antianxiety effects of trazadone appear compared to antidepressant effects

A

Antianxiety effects occur at lower doses

108
Q

Number of times a day buspirone is given

A

3

109
Q

Active metabolite of buspirone

A

1-pyrimidinylpiperazine

110
Q

Impact of bupropion on seizures

A

Dose related risk of seizures

Worse with instant release preparations

111
Q

Treatment combinations with good evidence for treatment resistant depression

A

SSRI or venlafaxine PLUS mirtazapine or mianserin

112
Q

Treatment combination for treatment resistant depression known as ‘California rocket fuel’

A

SNRI and mirtazapine

113
Q

Enantiomers present in citalopram

A

R and S

114
Q

Enantiomer present in escitalopram

A

Pure S enantiomer

115
Q

Benefit to using escitalopram rather than citalopram

A

R enantiomer of citalopram has antihistaminic properties - using escitalopram removes these
Citalopram has inconsistent therapeutic action due to the R enantiomer and dose often needs to be increased, but can’t due to QTc prolongation - using escitalopram lower doses can often be used and there are no higher dose restrictions to avoid prolonging the QTc

116
Q

Main clinical use for buspirone

A

Generalised anxiety disorder

117
Q

Hormone given to treat depression

A

Thyroid hormone

118
Q

TCA which is most preferable with elderly patients

A

Lofepramine

119
Q

Age group who clear TCAs fastest

A

Children/adolescents

120
Q

SSRI most selective for serotonin reuptake

A

Citalopram

121
Q

SSRI with the longest half life

A

Fluoxetine

122
Q

SSRI active metabolite with the longest half life

A

Norfluoxetine

123
Q

Antidepressant which shows autoinduction

A

Paroxetine

124
Q

Mechanism by which TCAs delay their own absorption

A

Anticholinergic effects

125
Q

Time after stopping SSRI when discontinuation symptoms have usually started

A

By day 5

126
Q

Discontinuation symptom specific to paroxetine

A

Suicidal ideation

127
Q

SSRI which causes the most sexual dysfunction

A

Paroxetine

128
Q

SSRI which causes the most weight gain

A

Paroxetine

129
Q

First line antidepressant for patients with diabetes

A

Fluoxetine

130
Q

Drugs to avoid with MAOIs

A 
SSRIs
SNRIs
TCAs - clomipramine and imipramine only
Opioids
St John's Wort
Triptans
OTC cold medication - dextromethorphan and chlorpheniramine
131
Q

SSRI which can be used to help prevent discontinuation symptoms from venlafaxine and clomipramine

A

Fluoxetine

132
Q

TCA which shows the highest rates of anticholinergic side effects

A

Imipramine

133
Q

Time frame to develop antidepressant related hyponatraemia

A

Usually within the first 30 days

134
Q

Antidepressant which most improves sleep wake cycles in major depression

A

Agomelatine

135
Q

Alternative name for dosulepin

A

Dothiepin

136
Q

Most sedating tricyclics

A

Amitriptyline

Dothiepin

137
Q

Effect on receptors of chronic administration of tricyclics

A

Causes down-regulation of beta-adrenergic receptors

138
Q

TCA with the most stimulant effect

A

Desipramine

139
Q

Medication of choice to treat a hypertensive crisis caused by combination of MAOI and tyramine containing food

A

Alpha adrenergic antagonist e.g. phentolamine, chlorpromazine

140
Q

Antidepressants known for causing weight gain

A

TCAs

Mirtazapine

141
Q

TCA with the highest antihistaminergic activity

A

Doxepin

142
Q

SSRI which should be used with the most caution post-MI

A

Citalopram

143
Q

Effect of bupropion on weight

A

Moderate sustained weight loss

144
Q

Specific side effect of mianserin that requires regular monitoring

A

Bone marrow suppression

145
Q

Side effect associated with venlafaxine and bupropion which can be helped by alpha and beta blockers

A

Sweating

146
Q

Common side effects of MAOIs

A 
Postural hypotension
Insomnia
Peripheral oedema
Restlessness
Nausea
Dizziness
Sexual dysfunction
Sweating
Tremor
147
Q

Antidepressant associated with closed angle glaucoma

A

Paroxetine

148
Q

Principle cause of death in TCA overdose

A

Cardiac arrhythmia

149
Q

SSRI which is present to high concentrations in breast milk

A

Fluoxetine

150
Q

Risk factors for antidepressant induced hyponatraemia

A

Old age
Female sex
Low BMI
Concomitant use of diuretics

151
Q

Antidepressant which can cause dependence

A

Tranylcypromine

152
Q

Antidepressant which can directly influence gene transcription through nuclear receptors

A

Tri-iodothyronine

153
Q

Medical condition where the use of MAOIs is contraindicated

A

Phaeochromocytoma

154
Q

Antidepressant with good efficacy in patients with atypical depression

A

Phenelzine

155
Q

Antidepressants least likely to precipitate mania in a patient with bipolar disorder

A

Bupropion

Sertraline

156
Q

Blood test required before starting agomelatine

A

LFTs

157
Q

Timing of LFTs required in patients taking agomelatine

A

Baseline

3, 6, 12, and 24 weeks after starting treatment

158
Q

Antidepressants to consider in patients who have developed antidepressant related hyponatraemia

A

Nortriptyline
Lofepramine
MAOIs

159
Q

Likely mechanism of action of SSRI discontinuation syndrome

A

Temporary deficiency in the brain of one or more essential neurotransmitters associated with mood

160
Q

Antidepressants known as dual action antidepressants

A

Venlafaxine

Duloxetine

161
Q

Impact of smoking on duloxetine plasma levels

A

Reduced by up to 50%

162
Q

Mechanism behind the increased risk of bleeding with SSRIs

A

SSRIs inhibit the serotonin transporter which is responsible for the uptake of serotonin into platelets
Depleted platelet serotonin leads to inability to form clots
SSRIs increase gastric acid secretion which acts as an irritant to the gastric mucosa, increasing the risk of GI bleeding

163
Q

Antidepressant most associated with waves of withdrawal symptoms

A

Venlafaxine

164
Q

SSRI with the shortest half life

A

Fluvoxamine

165
Q

Most serotonergic TCA

A

Clomipramine

166
Q

Reversible inhibitor of MAO that does not react with tyramine

A

Moclobemide

167
Q

Antidepressant treatment combination known as California rocket fuel for its effects in treatment resistant depression

A

Mirtazapine and venlafaxine

168
Q

Antidepressant suggested for patients with hyponatraemia

A

Agomelatine

169
Q

Mechanism of action of the delayed onset part of antidepressant medication action

A

Down regulation of HT1A autoreceptors in the post-synaptic neurons

170
Q

Antidepressant classes which cause an increased risk of postpartum haemorrhage

A

All classes

171
Q

Antidepressant causing the least sexual dysfunction

A

Agomelatine

172
Q

Time to wait after stopping a MAOI before starting another antidepressant (particularly an SSRI)

A

2 weeks

173
Q

Least sedating TCAs

A

Imipramine
Lofepramine
Nortriptyline

174
Q

Main side effects of buspirone

A 
Dizziness
Headache
Excitement
Nausea
Dry mouth
175
Q

Most notable side effect of ketamine

A

Dissociation

176
Q

TCA which causes the most weight gain

A

Doxepin

177
Q

Antidepressant associated with raised cholesterol levels

A

Mirtazapine

178
Q

Antidepressant discontinued due to risk of severe liver damage

A

Nefazodone

179
Q

Antidepressants least influenced by pharmacokinetic factors

A

MAOIs

Pharmacology (34 decks)

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