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Brain and Behavior Drugs > Antidepressants and mood stabilizers > Flashcards

Antidepressants and mood stabilizers Flashcards

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1
Q

What is the black box warning on all antidepressants?

A

For all antidepressants, there is a black box warning that they
increase the risk of suicidal thinking and behavior in children, adolescents, and young adults with major depressive disorder (MDD) and other
psychiatric disorders.

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2
Q

What are MAOIs used as antidepressants?

A

Phenelzine and tranylcypromine

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3
Q

MAOI: MOA

A 
Irreversibly
inhibits
monoamine
oxidase (MAO),
the enzyme that
breaks down
monoamine
neurotransmitters (including
serotonin,
norepinephrine,
and dopamine).
These
endogenous
chemicals play
an integral part
in the
pathophysiology
of depression.
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4
Q

MAOIs: Indications

A 
first-line
treatment for
atypical
depression;
anxiety; Major
Depressive
Disorder after
other tx options
have failed
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5
Q

MAOIs: Side Effects

A

orthostatic hypotension,
sedation, sexual
dysfunction

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6
Q

MAOIs: Contraindications

A

Serotonin syndrome or tyramine-induced hypertensive crisis could occur.

Contraindicated: coadministration
of methyldopa, other classes of
antidepressants (require a 14-day washout, 5 weeks for
fluoxetine), sympathomimetics, meperidine,
dextromethorphan, appetite suppressants,
carbamazepine, triptans

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7
Q

What is serotonin syndrome? How is this different than neuroleptic malignant syndrome?

A

Administration of multiple serotonergic agents (MAOIs,
SSRIs, SNRIs, etc.) can result in Serotonin Syndrome
due to additive effect. Sx include diarrhea,
restlessness, hyperreflexia, autonomic instability,
hyperthermia, rigidity, and delirium. (Note similarity to
Neuroleptic Malignant Syndrome; hyperreflexia is a
distinguishing feature of serotonin syndrome.)

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8
Q

What is tyramine-induced hypertensive crisis?

A

Tyramine is
a potent releaser of norepinephrine, which causes
vasoconstriction and thus elevated BP. Tyramine is
normally degraded by MAOa; when MAOa is inhibited by
MAOIs, small amounts of dietary tyramine can result in a hypertensive crisis. Sx include nausea, vomiting,
occipital headache, stiff neck, and sweating.
Contraindicated: aged or fermented meats, sausages,
and salami; pickled herring; lima bean pods; aged
cheeses; tap beer and other non-pasteurized beers; red
wine; concentrated yeast extract; sauerkraut; soybeans

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9
Q

SSRIs?

A

Citalopram, escitalopram, fluoxetine, fluvoxamine, paroxetine, sertraline.

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10
Q

SSRIs: MOA

A 
blocks
presynaptic
resorption of
already-released
serotonin (→
increased
serotonin levels)
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11
Q

SSRIs: Indications?

A 
Major
Depressive
Disorder;
various anxiety
disorders
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12
Q

SSRIs: Side Effects?

A 
a. GI: nausea and loose
bowel movements;
typically resolve after the
1st week of therapy
b. Sexual: decreased
libido, delayed
ejaculation,
anorgasmia
c. Paroxetine assos
with weight gain.
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13
Q

SSRIs: Metabolism

A

a. Metabolism: hepatic
b. Half-life: fluoxetine has the longest (~2 weeks),
fluvoxamine and paroxetine have the shortest. SSRIs
with shorter half-lives are more likely to induce a
discontinuation syndrome composed of flu-like
symptoms, irritability, dizziness, and vivid dreams.

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14
Q

SSRIs: Drug Interactions

A

Drug-drug interactions: all SSRIs are
contraindicated with pimozide. They should be used
with caution if prescribing other serotonergic drugs due
to the risk of serotonin syndrome.

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15
Q

SNRIs?

A

Venlafaxine, desvenlafaxine, duloxetine

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16
Q

SNRIs: MOA

A 
blocks the
reuptake of
presynaptic
serotonin and
norepinephrine.
(Dose-dependent
– at lower doses
these drugs
function as SSRIs;
at higher doses
they block the
reuptake of
norepinephrine as
well.)
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17
Q

SNRIs: Indications

A 
Major
Depressive
Disorder;
various anxiety
disorders;
neuropathic
pain
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18
Q

SNRIs: Side Effects

A 
a. GI: nausea and loose
bowel movements;
typically resolve after the
first week of therapy
b. Sexual: decreased
libido, delayed
ejaculation,
anorgasmia; incidence
is around 50%
c. HTN: blood pressure
monitoring is
recommended as drugs
can cause a dosedependent
increase in
diast. BP
19
Q

SNRIs: Drug Interactions

A

a. Drug-drug interactions: use with caution if
prescribing other serotonergic drugs due to the risk
of serotonin syndrome

20
Q

SNRIs: Metabolism

A

b. Metabolism: hepatic (mostly by CYP450 system)

c. Duloxetine is a moderate CYP450 inhibitor.

21
Q

Tricyclic antidepressants?

A

Amitriptyline, nortriptyline, imipramine

22
Q

Tricyclic antidepressants: MOA

A 
a. Blocks serotonin
and norepinephrine
transporters →
increased conc’n of
serotonin +
norepinephrine in
synaptic cleft
b. Blocks histamine
receptors and
muscarinic
acetylcholine
receptors with high
affinity
23
Q

Tricyclic antidepressants: Indications

A 
Major Depressive
Disorder; chronic
pain; headaches
(prophylaxis and
treatment); nocturnal
enuresis (imipramine)
24
Q

Tricyclic antidepressants: Side effects

A 
a. Anticholinergic: blurred vision,
constipation, dry mouth, orthostatic
hypotension, sedation, urinary
retention
b.Cardiovascular: tachycardia,
prolonged QT interval
c. Overdoses are often lethal;
patients require cardiac monitoring
in the ICU setting
25
Q

Tricyclic antidepressants: Drug Interactions

A

Use with caution if prescribing
other serotonergic drugs due
to the risk of serotonin
syndrome

26
Q

Atypical antidepressants?

A

Bupropion, mirtazapine, amoxapine, trazodone

27
Q

Bupropion: MOA

A 
Unicyclic
antidepressant; inhibits
reuptake of dopamine
\+ norepinephrine;
preferred over SSRIs
by many patients b/c of
its lack of sexual side
effects
28
Q

Mirtazapine and Amoxapine: MOA

A

Increases concentrations of
norepinephrine and
serotonin.

29
Q

Trazodone: MOA

A

Increases serotonergic
activity via poorly
understood
mechanism(s)

30
Q

Bupropion: Indications

A

Major Depressive
Disorder; Seasonal
Affective Disorder;
smoking cessation

31
Q

Mirtazapine, amoxapine, trazodone: Indications

A 
More sedating than
other antidepressants.
Often used to treat
insomnia in addition to
Major Depressive
Disorder.
32
Q

Bupropion: Side Effects

A 
i. Common – constipation, HA,
nausea, anxiety, insomnia
ii. Severe – seizures (c/i in patients
with eating disorders or epilepsy);
psychosis
33
Q

Mirtazapine and amoxapine: Side Effects

A

i. Common – weight gain, sedation

ii. Severe – agranulocytosis (rare)

34
Q

Trazodone: Side Effects

A 
i. Common – anticholinergic sx
(dizziness, dry mouth, orthostatic
hypotension, sedation)
ii. Severe – priapism (true urologic
emergency)
35
Q

Metabolism of atypical antidepressants? Drug interactions?

A 
Metabolism: Hepatic.
Avoid co-admin with MAOIs
due to risk of hypertensive
crisis.
Buproprion: Use with caution
with other dopaminergic agents such as L-dopa.
36
Q

The classic example of mood stabilizing drug?

A

Lithium

37
Q

Lithium: MOA

A 
alters cation
transport across
cell membranes in
nerve/muscle cells
→ influences
reuptake of
serotonin +/-
norepinephrine
38
Q

Lithium: Indication

A

Bipolar disorder

39
Q

Lithium: Side Effects and treatments of side effects

A 
Very effective but also very toxic
with a narrow therapeutic window
a. Common (transient): cognitive
slowing, GI upset,
polyuria/polydipsia, tremor
b. Severe: cardiac conduction
delays, diabetes insipidus,
Ebstein’s anomaly,
hypothyroidism
c. Moderate toxicity:
i. Sx – twitching, slurred speech,
lethargy, hyperreflexia, vertigo, GI
upset
ii. Tx – supportive measures (stop
lithium, fluids, etc.)
d. Severe toxicity:
i. Sx – seizures, stupor, coma, CV
collapse, death
ii.Tx – hemodialysis
40
Q

What is the workup down prior to prescribing lithium?

A

CBC with diff, EKG (esp >40 yo and/or heart dz), CMP, TSH, pregnancy test, BUN/Cr

Why? 
Benign leukocytosis
Cardiac arrhythmias
Hypernatremia
Hypothyroidism
Ebstein's anomlay, triscupsid regurgitation
Diabetes insipidus
41
Q

Lithium: Metabolism

A

a. Metabolism: 100% renally

excreted

42
Q

Lithium: Drug Interactions

A 
b. Drug-drug interactions: coadministration
of NSAIDs
(except salicylates and
sulindac), diuretics (especially
thiazides), or ACE inhibitors
is dangerous due to the risk
of lithium toxicity
43
Q

Anticonvulsants?

A

Valproate, carbamazepine, lamotrigine.

Brain and Behavior Drugs (14 decks)

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