Antidepressants lecture

Question 1

How long to titrate dose

Answer 1

7 to 10 days

Question 2

How long is each dose trial

Answer 2

4 to 6, but at least 4 weeks

Question 3

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

Answer 3

6+ months

Question 4

Slightly more effective antidepressants?

Answer 4

Paroxetine, escitalopram, venlafaxine, mirtazapine, vortioxetine, amitripyline

Question 5

1st gen?

Answer 5

MAOI, TCA, TeCAs

Question 6

2nd gen?

Answer 6

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

Question 7

SSRIs

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

Answer 7

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

Question 8

Name the SSRIs

Answer 8

Sertraline, ciralopram, escitalopram, fluoxetine, paroxetine, fluvoxamine

Question 9

Longest half life of SSRIs-

Answer 9

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

Question 10

When can you expect serotonin syndrome to occur?

Answer 10

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

Question 11

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

Answer 11

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

Question 12

Sertraline

SE? who gets it?

Answer 12

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

Question 13

Citalopram/Escitalopram

Answer 13

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

Question 14

FluvoxAMine

Answer 14

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

Question 15

FluoxETine

Answer 15

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

Question 16

Paroxetine

Answer 16

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

Question 17

SNRIs - are they used 1st line?

Answer 17

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

Question 18

SNRI

MOA, dosing, CI, side effects, metabolism

Answer 18

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

Question 19

SNRIs name them

Answer 19

**Venlafaxine
Desvenlafaxine
Duloxetine **
Milnacipran
Levomilnacipran

Question 20

Venlafaxine

Answer 20

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

Question 21

Desvenlafaxine

Answer 21

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

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

Question 22

Duloxetine

Answer 22

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

Question 23

Milnacipran/Levomilnacipran

Answer 23

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

Question 24

Atypical Anti

Answer 24

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

Question 25

Buproprion ## Footnote MOA

Answer 25

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. ## Footnote * A blue tailed skinny cigarrette plane * Skinny Dildo plane

Question 26

Mirtazapine

Answer 26

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 ## Footnote "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.

Question 27

Serotonin Modulators ## Footnote tell me the names and the MOA, the dosing, CI, and SE for all, metabolism

Answer 27

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

Question 28

Nefazodone

Answer 28

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 ## Footnote * nefarious (for liver toxicity) * the bad boy who gets laid, is in shape, and isn't running off to the bathroom

Question 29

Trazodone

Answer 29

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

Question 30

Vilazodone

Answer 30

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

Question 31

Vortioxetine

Answer 31

serotonin modulator dizzy, N/V/D/C fast onset less sexual dysfunction ## Footnote *vortex whirlpool that makes you dizzy and the other symptoms fast rapids so fast onset with a banana

Question 32

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

Answer 32

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

Question 33

Ketamine ## Footnote specific

Answer 33

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

Question 34

MAOI ## Footnote MOA? drug names?

Answer 34

MAOa breaks down **serotonin** and **NE** MAOb works with MAOa to break down **dopamine** Tranylcypromine Phenelzine Isocarboxazid Selegiline ## Footnote a is the one in charge while b is second in command

Question 35

MAOI ## Footnote indications

Answer 35

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

Question 36

MAOI ## Footnote CI , DDI, SE

Answer 36

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)

Question 37

TCAs ## Footnote names, indication, MOA for types

Answer 37

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 ## Footnote secondary : mem * Norepi Drive Pack for notrip, desipram, protrip tertiary mem * mom ADICT (ammi, doxe, imi, clim, tri)

Question 38

TCAs ## Footnote dose, CI, SE

Answer 38

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. ## Footnote 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

Question 39

TeCAs

Answer 39

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