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Hunts BD > Antidepressants lecture > Flashcards

Antidepressants lecture Flashcards

1
Q

How long to titrate dose

A

7 to 10 days

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2
Q

How long is each dose trial

A

4 to 6, but at least 4 weeks

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3
Q

How long do you keep someone on a dose if its working?

A

6+ months

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4
Q

Slightly more effective antidepressants?

A

Paroxetine, escitalopram, venlafaxine, mirtazapine, vortioxetine, amitripyline

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5
Q

1st gen?

A

MAOI, TCA, TeCAs

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6
Q

2nd gen?

A

-2nd gen MC
SSRI, SNRI, atypical, serotonin modulators, ketamine

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7
Q

SSRIs

MOA, Dosing, CI, SE, metabolism, why do we use them

A

we use them because
well tolerated good efficacy. 1st line for MDD
MOA- decreases pump of serotonin reuptake which makes more serotonin in the synapse
Dose- QAM
Metabolized in liver
CI- Allergy or MAOI in last two weeks

SE- GI upset (N/D, anorexia), Sleep change (up or down), Neuro (dizzy, HA), Sexual dusfunction (ED, libido down, anorgasmia), anxiety increases, SI increases

other SE- prolonged QT, wt gain, bleeding, orthostatic hypotension, serotonin syndrome

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8
Q

Name the SSRIs

A

Sertraline, ciralopram, escitalopram, fluoxetine, paroxetine, fluvoxamine

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9
Q

Longest half life of SSRIs-

A

Prozac (Fluoxetine) 3 d
If a pt wants to start a MAOI, they have to wait 5 weeks for prozac long half life

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10
Q

When can you expect serotonin syndrome to occur?

A

within 24 of starting them on a new med. often within 6 hours.

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11
Q

signs of serotonin syndrome? how do you know its serotonin syndrome?

A

no labs! clinical dx.
Give them benzodiazepines, hydrate
Signs and symptoms: diarrhea, increased bowel sounds, agitation, hyperreflexia, dry mucous membranes, autonomic instabliity, hyperthermia, HTN, tremor, clonus, seizure, death

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12
Q

Sertraline

SE? who gets it?

A

MC GI upset, diarrhea
likely for insomnia
Less prolonged QT
Most well tolerated
For pregnant

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13
Q

Citalopram/Escitalopram

A

escitalopram is an isomer of citalopram.
-MC prolonged QT
-easier on liver. least inhibition of hepatic cytochrome enzymes.
-minimal SE profile

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14
Q

FluvoxAMine

A

shortest half life (15 hrs)
somnolence (drowsy). good for sleep
Most drug interactions (DDI) of 2 cytochromes

**AM meaning you see the morning, sleep through the night
most drug interactions! associate someone about to sleep, and they take all of their pills beforehand

shortest half life because it is the opposite of fluvoxETine

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15
Q

FluoxETine

A

prozac
longest half life (3 d)
insomnia
anxiety
CI tamoxifen

*ET like the alien with a bra walking around at night
anxiety and insomnia because its opposite of fluoxAMine

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16
Q

Paroxetine

A

anticholinergic SE
orthostatic hypotension
wt gain
sexual dusfunction
DDI (2 cytochrome systems)
CI tamoxifen

17
Q

SNRIs - are they used 1st line?

A

yes, just as much as SSRIs
or 2nd line if can’t tolerate SSRI

18
Q

SNRI

MOA, dosing, CI, side effects, metabolism

A

blocks reuptake of 5-HT, and norephinephrine, increases levels in the synapse

qd
kidneys and liver
CI- within 2 weeks of MAOI, allergy, angle closure glaucoma
SE - not as much weight gain as SSRI
GI (N/V/D), dry mouth, constipation, sleep (up or down), HA&dizzy, sexual dysfunction (ED may be less), anxiety, SI, diaphoresis, hypertension, serotonin syndrome

19
Q

SNRIs name them

A

**Venlafaxine
Desvenlafaxine
Duloxetine **
Milnacipran
Levomilnacipran

20
Q

Venlafaxine

A

SNRI
SE:
Elevated BP
higher N/V
higher SI

think of a vanilla vaccine

you push out some while its upside down (hypertension)
N/V b/c the vanilla doesn’t sit right with the stomach
higher SI because its terrible to only have vanilla

21
Q

Desvenlafaxine

A

synthetic metabolite of venlafaxine
SE:
Less HTN & less SE than venlafaxine

“des” = dis as in away or less
vanilla vaccine

22
Q

Duloxetine

A

SNRI
Hepatic cytochrome inhibition so more likely to have DDIs
least hypertensive SE
chronic pain indication

Dual - ox - time
Dual because both NE and serotonin
Ox that is standing in the way of drugs (liver cytochrome inhibition)
Imagine stopwatch with two modes. one mode is a slow stream of water and the other mode is ox mode - take on liver metabolism and pain

23
Q

Milnacipran/Levomilnacipran

A

SNRI
pseudo-anticholinergic effects (urinary ret, const, dry mou)
used more for pain relief than MDD

** Milk na- sip- ran
When you drink too much milk you get thirsy (drying)
warm Milk is soothing, associate with pain relief

24
Q

Atypical Anti

A

2nd line if fail SSRI
1st line in only special cases
Bupropion, Mirtazapine,

25
Q

Buproprion

MOA

A

Atypical
MOA- dopamine-NE reuptake inhibitor, antagoniszes nicotinic
for a smoker that can’t take SSRI

SE- dry mouth, insomnia, nausea, seizures more likely

indicated: tobacco cessation, don’t want wt gained from SSRIs, or sexual dysfunct from SSRIs

CI: epilepsy patients, eating disorder (who need to gain weight), or 2 weeks within MAOI
lots of DDI.

  • A blue tailed skinny cigarrette plane
  • Skinny Dildo plane
26
Q

Mirtazapine

A

MOA- Antagonizes alpha 2, 5HT2, 5HT3, which causes incr rel. of serotonin and NE

SE dry mouth, drowsiness, huge weight gain, appetitie incr, sexual dysfunction (less than SSRI), SI.

Less orthostatic hypotension.

indicated for someone with insomnia b/c it causes drowsiness. its good for someone who is too skinny.

fewer DDIs than buproprion

“My Taz Apples”
-Tazmanian devil is a cartoon. he eats tons of apples because he has a big appetite. after eating so many apples he feels full and sleepy. plus all the sugar makes him thirsty.
There’s a small stream in the background indicating less orthostatic hypotension.

27
Q

Serotonin Modulators

tell me the names and the MOA, the dosing, CI, and SE for all, metabolism

A

2nd line for who can’t tolerate SSRIs
Nefazodone
Trazodone
Vilazodone
Vortioxetine

QD or BID
Liver
CI within 2 weeks of MAOI

SE- headache, diarrhea, nausea. SI, serotonin syndrome less than SSRI

28
Q

Nefazodone

A

like trazodone, it antagonizes 5 HT receptor, incr rel of serotonin

BBW hepatotoxcity (liver disease or elevated liver enzymes)
SE: HA, agitation, dizzy, drowsiness, insomnia, xerostomnia, hypotension

no sexual side effects
less GI upset
less weight gain

  • nefarious (for liver toxicity)
  • the bad boy who gets laid, is in shape, and isn’t running off to the bathroom
29
Q

Trazodone

A

MOA
SE:
sedation, nausea, dry mouth, fatigue, constipation, sexual dysfunction
Rare- Priapism, cardiac arrythmia
Weight NEUTRAL,
no sexual side effects (or less)

“Trail - Zone”
-hook up on the trail (priapism), weight neutral because you can both walk & rest.
the trail is relaxing = sedation
the trail is up a rugged mountain so cardiac arrythmia

30
Q

Vilazodone

A

SE: HA, diarrhea, nausea, sexual dysfunction
MOA: partial agonist of 5HT receptors
fast onset
less sexual dysfunction

Picture a luxurious villa zone where you go to relax and unwind. Vilazodone, like staying in a villa, helps elevate your mood quickly.
It’s a foreign spanish villa.
Diarrhea/N from the foreign food.

31
Q

Vortioxetine

A

serotonin modulator
dizzy, N/V/D/C
fast onset
less sexual dysfunction

*vortex whirlpool that makes you dizzy and the other symptoms
fast rapids so fast onset
with a banana

32
Q

Ketamine

general. how long? who is it indicated for? what does it do for the patient?

A

CI: psychotic symptoms
-Indicated for severe refactory depression w/o psychosis
-who failed ECT

given as IV (ketamine)
given as nasal spray (esketamine)

rapid robust improvement in depression that fades in two weeks

short term therapy only due to neurotoxicity in the long term
-can induce psychotomimetric effects (induce psychosis)
-outpatient clinics w/ restricted distribution system
-if used patients will eventually be switched to antidepressants or antipsychotics for the long term

33
Q

Ketamine

specific

A

MOA- opioid AMPA (glutamate agaonist), NMDA antagonist

SE- psychomimetic, HTN, tachycard, anxiety, dizzy, HA
Long term - abuse/addiction, neurotoxicty, bladder toxic, hepatotoxic
CI: anureism, AV malform, ICH, can’t increase BP
DDI- CNS depressants like opiates

34
Q

MAOI

MOA? drug names?

A

MAOa breaks down serotonin and NE
MAOb works with MAOa to break down dopamine

Tranylcypromine
Phenelzine
Isocarboxazid
Selegiline

a is the one in charge while b is second in command

35
Q

MAOI

indications

A

Extensive side effects, DDIs, and dietary restrictions
Usually only for treatment-resistant or atypical depression

36
Q

MAOI

CI , DDI, SE

A

SI- CVD, pheochromocytoma, liver/kidney impair, 2 weeks within other serotonergic drugs. Selegiline is less CI than other MAOIs

DDI numerous
SE- hypotension, GI upset, urinary hesitancy, HA, myoclonic jerks, edema, SI, Hypertensive crisis (180/120) when consuming tyramine

Tyramine- aged cheese, soy sauce, cured measts, tap beer, tofu, sauerkraut (selegiline less so)

37
Q

TCAs

names, indication, MOA for types

A

2nd line for depression due to side effects
-treats anxiety, pain
MOA inhibits reuptake of 5-HT and NE

Tertiary amines incr serotonin more
-amitriptyline, doxepin, imipramine, clomipramine, trimipramine

Secondary amines incr NE more
-nortriptyline, desipramine, protriptyline

secondary : mem * Norepi Drive Pack for notrip, desipram, protrip

tertiary mem * mom ADICT (ammi, doxe, imi, clim, tri)

38
Q

TCAs

dose, CI, SE

A

low doses!
CI: 2 weeks of MAOI, in acute recovery of an MI
SE: anticholinergic, sexual dysfunction, diaphoresis, tremor, wt gain, incr appetite, SI, cardiotoxicity (prolonged QT), fatal overdose

nortriptyline and desipramine have best tolerability.

think desi pram is a stroller and nortrip is a trip up north. they complement each other well so they both have good side effect profiles

39
Q

TeCAs

A

similar to TCAs
have an extra cyclic ring
refractory or atypical depression only

Maprotiline- MOA - block reup NE 5-HT
Amoxapine- MOA - block reup NE. block dopamine receptors.

SE is less anticholinergic SE but more histamine like than TCAs, still have SI

Hunts BD (10 decks)

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