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PCL470 > Antidepressants I > Flashcards

Antidepressants I Flashcards

1
Q

Affective Disorders (DSM-V) include:

A
  • general anxiety disorders (GAD)
  • post-traumatic stress disorders (PTSD)
  • panic disorders, phobias
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2
Q

Types of Depression (DSM-V)

A
  1. major depressive disorder (MDD) or unipolar depression
    - clinical depression (no manic episodes); recurring major depressive episodes
    - treated by antidepressants
  2. bipolar disorder (“manic depression”
    - periods of depression alternating with periods of mania
    - treated by mood-stabilizers
  3. dysthymia (“persistent depressive disorder”)
  4. SAD
  5. postpartum depression
  6. adjustment disorder with depression/stress response syndrome
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3
Q

MDD facts (etiology, prevalence, comorbidity)

A

etiology: exact mechanisms unknown, 30-40% heritability, complex polygenic mechanism (genetics x env)

prevalence: 17% of US adults will be affected at least once, females affected twice as frequently as males, leading cause of disability, large economic cost, suicide is second leading cause of death in 15-29 year olds

comorbidity: chronic pain, stroke, CV disease, cancer

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4
Q

Broad range of symptoms DSM-V: Major Depression

A
  • depressed mood (sad, empty, helpless, worried)
  • anhedonia
  • irritability
  • low self-esteem
  • feelings of hopelessness, worthlessness, and guilt
  • decreased ability to concentrate and think
  • decreased or increased appetite
  • weight loss or weight gain
  • insomnia or hypersomnia
  • low energy, fatigue, or increased agitation
  • decreased interest in pleasurable stimuli (food, sex, social int, etc)
  • recurrent thoughts of death and suicide

must have at least 5 of these symptoms for longer than a 2 week period

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5
Q

currently available treatments for depression

A
  • psychotherapy
  • chemical antidepressants
  • electroConvulsive therapy (ECT)
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6
Q

chemical antidepressants (overview)

A

all have similar efficacies and only work in 50-70% of patients with MDD
- therapeutic response is delayed (min 2-4 weeks before benefit)
- adverse side effects can limit usage

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7
Q

Monoamine Hypothesis of Depression

A

Abnormalities in serotonin (5HT), NE, and DA neurotransmission (deficiency)

(likely not mutually exclusive with neurotrophic hypoth)

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8
Q

Reserpine

A

BP med used in 1950s evoked depression by blocking VMAT

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9
Q

VMAT

A

vesicular monoamine transporter
- packages all monoamines

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10
Q

monoamines

A

DA, NE, 5-HT, melatonin, histamine

  • all derived from amino acids in similar synthetic processes
  • regulate: mood, sleep, appetite, peristalsis, arousal, sexual function, cognition, reward, motivation, aggression (sometimes with opposing effects)
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11
Q

monoamines act on what kinds of receptors

A

metabotropic GPCRS

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12
Q

location of production: DA, 5HT, NE

A

soma of producing neurons in:
- DA: VTA and substantia nigra
- 5HT: raphe nucleus
- NE: locus coerulus

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13
Q

Neurotrophic Hypothesis

A

Changes in nerve growth factors (BDNF) signalling play a role in cell survival and synaptic plasticity.

  • loss of neurotrophic growth factors leads to neuronal atrophy and death
    (BDNF activates TRK-B receptors leading to increased survival and growth)
  • possibly due to decrease in monoamine levels (NE and 5HT) and increased glucocorticoid levels (chronic stress)
  • antidepressants increase BDNF in brain

(likely not mutually exclusive with monoamine hypoth)

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14
Q

Major antidepressant drugs

A
  1. monoamine oxidase inhibitors (MAOIs)
  2. Tricyclic (TCAs)
  3. selective serotonin re-uptake inhibitors (SSRIs)
  4. serotonin-norepinephrine re-uptake inhibitors (SNRIs)
  5. atypical antidepressants
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15
Q

Different mechanism of actions of antidepressants

A
  1. block enzymatic degradation by monoamine oxidase (MOA) - MAOIs
  2. block re-uptake into the presynaptic terminal by inhibition of transporters (SERT and NERT) - TCAs, SSRIs, SNRIs
  3. inhibition of presynaptic autoreceptors
  4. binding specific postsynaptic receptors (5HT2)
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16
Q

Other clinical uses for antidepressant drugs

A
  • PTSD (SSRIs)
  • Anxiety (SSRIs and SNRIs)
  • Panic disorder (TCAs, MAOIs, SSRIs)
  • OCD (SSRIs)
  • enuresis (TCA)
  • chronic pain (TCAs and SSRIs)
  • eating disorder - bulimia (SSRIs)
  • smoking cessation (Bupropion)
  • Sedative (Trazodone)
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17
Q

Antidepressant side effects by the receptor they bind

(5HT, NE, DA, H1, Musc Ach, Alpha Adren)

A

Blockade of:
5HT - GI disturbances, anxiety (dose dependent), sexual dysfunction

NE - tremors, tachycardia

DA - psychomotor activation, anti parkinsonian effects, psychosis, increased attention and concentration

H1 - sedation, drowsiness, weight gain, hypotension

Muscarinic Ach - blurred vision, dry mouth, sinus tachycardia, constipation, urinary retention, memory dysfunction

alpha adrenergic - postural hypotension, reflex tachycardia, dizziness

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18
Q

Mechanism of action of MAOIs

A

increase synaptic availability of NE and 5HT by blocking their catabolism
- inhibit MAO enzymes (MAO-A and/or MAO-B)

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19
Q

Difference between MAO-A and -B

A

Monoamine oxidase A mainly breaks down tyramine, NE, 5HT and DA

MAO B mainly targets DA

20
Q

Problems and most common side effects with MAOIs

A
  • toxicity problems and potentially lethal food and drug interactions
  • MAIN: Orthostatic hypotension and weight gain
  • OTHER: headache, drowsiness, dry mouth, hypertension, sexual dysfunction (highest in irreversible MAOIs), increased tyramine can cause hypertension, increased circulation of bioamines (can’t combine with SSRI or SNRI) and NARROW therapeutic range
21
Q

phenelzine and tranylcypromine

A

Antidepressants - MAO A and B inhibitor
- have worse side effect profile than other MAOIs

22
Q

moclobemide

A

Antidepressant - MAO A inhibitor

23
Q

MAOIs and Tyramine

A

If taking MAOIs avoid foods high in tyramine - could be lethal
Increase in tyramine and decrease in MAO (breaks down monoamines) you get increased NE:
- hypertensive crisis
- headaches, intracranial bleeding, stroke

24
Q

Which foods have tyramine

A
  • most cheese
  • smoked/cured/dried/preserved meats and fish
  • fava beans, overripe avocados, fruits
  • chianti wines and beers with yeast
  • chocolate and coffee
25
Q

MAOIs are ____ line of treatment if ____

A
  • last
  • patient does not respond to SSRI and SNRI
26
Q

Imipramine

A

first TCA from 1950s
- prototype
- anti-cholinergic used to treat bedwetting
- strong 5HT and NE reuptake inhib

27
Q

besides depression, TCAs are also used to treat

A

chronic pain conditions
phobic and panic
OCD

28
Q

TCAs summary

A
  • second line treatment after SSRIs
  • block 5-HT and NE reuptake
  • immediate side effects, therapeutic effects in 2-3 weeks
  • narrow therapeutic range, risk of suicide by overdose
  • high protein binding and hepatic metabolism
29
Q

TCAs: mechanism of action

A
  1. block reuptake of 5HT and NE by inhibiting SERT and NET
  2. densensitive presynaptic autoreceptors (promotes further release of 5HT and NE)
  3. reduce central beta adrenergic receptor responsiveness and density
  4. antagonizes cholinergic, histaminergic, and alpha-adrenergic receptors
30
Q

Desipramine

A

More effective at treating neuropathic pain
- weaker anticholinaergic action
- stronger NE and 5HT properties

31
Q

Amitriptyline

A
  • highly anti-cholinergic
  • high alpha-adrenergic blocking properties
  • SEDATIVE
32
Q

TCAs: side effects

A

ANTAGONISTIC ACTION: anti- histamine and anti-cholinergic

through antagonist action: dry mouth, constipation, blurred vision, urinary retention, confusion (from blocking cholinergic receptors)

  • CNS toxicity, sexual dysfunction, cardiac toxicity (can cause lethal cardiac arrhythmias), overdose
33
Q

TCA overdose three Cs

A

convulsions, coma, cardiac arrhythmias

34
Q

Currently available SSRIs

A

fluoxetine, sertraline, paroxetine, citalopram, escitalopram, fluvoxamine

35
Q

SSRIs: used to treat

A

used in MDD, GAD, PTSD, OCD, Panic disorders, bulimia

36
Q

SSRIs: mech of action

A

Selectively inhibit SERT and block reuptake of serotonin into presynaptic terminal
also downregulates autoreceptors

37
Q

SSRIs: side effects

A
  • safest AD
  • in short-term can cause nausea, GI upset, diarrhea
  • long-term can cause sexual dysfunction in 30-40% patients
38
Q

Why is there a delayed onset of therapeutic action with SSRIs

A

Receptor desensitization, upregulation/downregulation, increase trophic factors, increased neuro- and synapto- genesis

39
Q

Venlafaxine

A
  • weak inhibitor of NET, greater affinity for SERT
  • used for severe depression
40
Q

Duloxetine

A
  • balanced effect on 5HT and NE
  • increasingly used for chronic pain over TCAs
41
Q

SNRIs

A

block NET as well as SERT

42
Q
  1. Trazodone
  2. Buproprion
  3. Mirtazapine
A

Atypical antidepressants
1. Blocks H1 receptor
2. blocks NE and DA reuptake (also used in smoking cessation)
3. blocks pre-synaptic alpha2 adrenergic receptors and increase synaptic 5HT and NE

43
Q

Why should you NOT combine MAOIs, TCAs, SSRIs

A

side effects can be fatal:
- must have a waiting period between changing meds to allow body to return to naive state

44
Q

Are SSRIs better at treating anxiety or depression? SNRIs?

A

SSRIs better for anxiety
SNRIs better for MDD

45
Q

Pharmacological properties of antidepressants

A
  • most had rapid oral absoprtion, peak plasma levels in 2-3 hours, and are tightly bound to plasma proteins, undergo hepatic metabolism and renal clearance
  • most all inhibit CYP enzymes (2D6, 3A4, 1A2, 2C19)
  • Never combine TCAs and SSRIs (long half lives)

PCL470 (14 decks)

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