Antidepressants, Mood Stabilizers, and Meds to tx Anxiety Flashcards
Considerations in anxiety tx
Lowest dose possible and increase (Start low go slow), avoid bupropion, maybe add benzos w/ end point in mind
Risk factors for MDE recurrence
- Persistence of subthreshold symptoms
- Severity of episode
- Earlier age of onset
- Presence of additional psychiatric diagnosis
- Presence of chronic medical diagnosis
- Family history of psych disorder
- Persistent sleep disturbance
Withdrawal symptoms of antidepressants
Dizziness, nausea, paresthesias, anxiety, insomnia (prevent by tapering over 2-4wks)
Black box warning on antidepressants
> Suicide risk for children, adolescents, and young adults
= suicide risk for 24yrs+
< suicide risk for 65 yrs +
Antidepressants in pregnancy (and exception to rule!)
All SSRIs are category C (except Paroxetine – D bc risk of cardiac malformations); later use may incrase risk of persistent pulmonary hypertension and use to delivery may result in neonatal w/drawal
SSRIs (6)
- Citalopram
- Escitalopram
- Fluoxetine
- Fluvoxamine
- Paroxetine
- Sertraline
SNRIs (4)
- Desvenlafaxine
- Duloxetine
- Levominalcipran
- Venlafaxine
TCAs (10)
- Amitryptyline
- Clomipramine
- Desipramine
- Doxepin
- Imipramine
- Nortriptyline
- Amoxapine
- Marpotiline
- Protriptyline
- Trimipramine
MAOIs (4)
- Isocarboxasid
- Phenelzine
- Selegiline
- Tranylcypromine
SSRI MOA
Selectively inhibit 5HT reuptake (no other interaxns)
SSRI uses/Metabolism
1st line in depressive and anxiety disorders (QD dosing, metabolized by liver – danger in fluvoxamine for drugs w/ therapeutic indices, fluox/parox w/ opiates)
SSRI w/ long t1/2
Fluoextine
Side effects of SSRIs
GI: NVD (dose dependent), exacerbation of tension headache, some agents activation/insomnia (e.g. fluoxetine – start low dose, take in morning, use sleep med), some agents sedation (paroxetine – give at bedtime), decreased libido/erectile and ejaculatory dysfxn; delayed orgasm or inorgasmia; weight changes (paroxetine)
SNRI MOA
Inhibit reuptake of serotonin and NE (lack of interaxn w/ other receptors)
SNRI uses
Pain, depression etc.
SNRI SEs
NV, sexual dysfxn, activation, addition of NE –> HTN
Bupropion MOA
Weak NDRI (NE and DA reuptake inhibitor)
Uses of bupropion
Smoking cessation, depression (improve sexual fxn); no weight gain
SEs/CIs of bupropion
SE: seizure risk (CI in BN and AN, electrolyte imbalances)
Not good w/ anxiety
Mirtazipine MOA
NE and specific 5HT antidepressant (NOT a RI); antihistiminergic effects
Mirtazipine SEs
Sedation, weight gain (2o to antihistamine)
Vilazadone MOA
SSRI and partial 5HT1A agonist
Vilazadone SEs
More GI effects than SSRI, but less sexual side effects
Trazodone MOA
Weak SSRI, 5HT2r blocker
Trazodone uses
Not usually antidepressant, more often for insomnia
Trazodone SEs
Orthostatic hypotension, priapism
Vortioxetine MOA
SSRI, 5HT1A agonist, 5HT1b partial agonist, other 5HT antagonist
Vortioextine advantage
Advantage for pts w cognitive complaints
TCA MOA
Predominantly NE antidepressants secondary to inhibition of NE RI and some SSRI; also antagonize alpha1-adrenergic receptors, histamine receptors, and muscarinic Ach receptors
NRIs – nortriptyline and desipramine
SRIs – comipramine
TCA uses
Depression (not 1st line), pain syndromes (migraines, neuropathy), enuresis
TCA SEs/DDIs/OD
Cardiac problems – tachycardia, flattened T waves, prolonged QT, depressed ST (baseline EKG)
DDI – avoid similar SE profiles (M, alpha1, H); OD at 5x therapeutic dose (cardiotoxic and seizures)
MAOI MOA
Inhibit breakdown of amine neurotransmitters by inhibiting MAO A (5HT, NE, DA, tyramine) and MAO B (pehnylethylamine, DA, tyramine) – irreversible and nonselective
MAOI Uses
Atypical depression (not first line)
MAO Considerations/SEs
Edema, insomnia, orthostatic hypotension, sexual dysfxn, weight gain
Dietary restriction (tyramine –> hypertensive crisis)
DDIs w/ other 5HT meds –> serotonin syndrome
Hypertensive crisis characteristics and tx
Diastolic BP > 120mmHg, tx w/ phentolamine (alpha antagonist), can be fatal
other characteristics:
- Occipital HA which may radiate forward
- Palpitations
- Neck stiffening
- NV
- Sweating w/ w/o fever
- Dilated pupils/photophobia
- Tachy/bradycardia w/ w/o chest pain
Medication restrictions to prevent hypertensive crisis
Adrenergic stimulation
Decongestants: phenylephrine, ephedrine, pseudoephedrine, phenylpropoanolamine-mine
Stimulants: amphetamines, methylphenidate, modafinil
Appetite suppressants w/ NRI: Sibutramine, phentermine
Antidepressants w/ NRI: TCAs, SNRIs, Bupropion
Serotonin syndrome symptoms
Potentially life threatening rxn from too much 5HT
Can cause:
- Autonomic instability
- Confusion
- Hallucinations
- Hyperthermia
- Hypertonicity
- Myoclonus
- Nausea
- Seizures
- Tremors
- Coma/death
Serotinergic Meds
Antidepressants: SSRIs, SNRIs, TCAs (other tricyclic structures -- cyclobenzaprine, carbamazepine) Triptants Appetite suppressants (sibutramine) Opioids: Destromethorphan, meperidine, tramadol, mehtadone, propoxyphene
Other tx for depressive disorders
Light therapy (esp for seasonal)
Ketamine (but not sustainable and expensive)
ECT (good for resistant to tx or acute suicidality, general anesthesia causes most risk –> induce seizure, effective for 70% of those who don’t respond to meds; CIs: recent MI, space occupying/hemorrhagic cranial lesion, SE: memory problems)
TMS (for tx resistant pts, electrical current depolarizes neurons, 1hr QD x wks, patient awake, headache as SE)
Lithium MOA
Post synaptically at GPCRs – depletion of PIP (indicated for all BPAD phases)
Li pharmacokinetics
95% excreted unchanged by kidney
Li toxicity symptoms/concentrations
> 1.2 mEq/L: Nausea, tremor, diarrhea, ataxia
1.5 mEq/L: Seizure
2.0 mEq/L: Acute renal failure
2.5mEq/L: Coma/death
What increases Li levels?
Nsaids, Calcium channel blockers, ACE inhibitors, Thiazide diuretics, dehydration, decreased kidney fxn, low Na diet
What decreases Li levels?
Pregnancy, high Na diet, theophylline, caffiene, lack of adherence
Li Nuisance SEs (12)
- Acne
- Benign leukocytosis
- Cognitive difficulties
- Edema
- GI distress
- Hair loss
- Incoordination
- Polydypsia, polyuria
- Psoriasis
- Sedation
- Tremor
- Wt gain
Li Medically serious SEs (4)
- Hypothyroidism
- Irreversible kidney disease
- SA node blockade
- Sick sinus syndrome
Li Teratogenicity
Ebsteins anomaly assc w/ 1st trimester use
Li Labs Before Tx
Kidney fxn, CBC, electrolytes, thyroid fxn panel, pregnancy test
Li Labs during Tx
Kidney fxn, CBC, thyroid fxn panel, pregnancy test
Valproic Acid MOA
Increases GABA in brain
Valproic Acid Indications
Acute mania and maintenance
Valproic Acid PKs
Extensively liver metabolized (DDIS), highly protein bound (interaxn w protein bound meds like coumadin, digitalis), onset of effect 5-7d
Valproic Acid Common SEs
- Benign hepatic transaminase elevations
- Benign leukopenia and thrombocytopenia
- GI distress
- Hair loss
- Osteoporosis
- Sedation
- Tremor
- Wt gain
Valproic Acid Serious but rare SEs
- Agranulocytosis
- Hemorrhagic pancreatitis
- Hepatic tox (Hx of liver dysfxn increases risk)
Valproic Acid unique to women SEs
- Polycystic ovarian syndrome
- Neural tube defects (in uterus)
Valproic Acid Labs before Tx
CBC, LFTs, PLTs, pregnancy
Valproic Acid Labs during Tx
CBC, LFTs, PLTs, Val level
Carbmazepine MOA
Inhibits voltage dependent presynaptic Na channels
Carbamazepine Indications
Acute mania and maintenance
Carbamazepine PK
Metabolized by liver (DDIs), induces its own metabolism
Carbamazepine SEs (Common and less frequent)
Common: fatigue, nausea, neurological symptoms (diplopia, blurred vision, ataxis)
Less frequent: Mild leukopenia and thrombocytopenia, mild LFT increase, skin rash
Carbamazepine serious (rare) SEs and teratogenicity
- Agranulocytosis
- Aplastic anemia
- Thrombocytopenia
- Hepatic failure
- Pancreatitis
- SJS (don’t combine w/ lamotrigine)
- Teratogenicity: NTD
Carbamazepine Labs
CBC, PLTs, LFTs, Carb level
Lamotrigine MOA
Inhibits Glu and voltage-gated Na channels
Lamotrigine Indications
Maintenance of BPAD and bipolar depression
What drugs influence Lamotrigine conc?
Depakote INCREASES
Caramazepine DECREASES
Lamotrigine common SEs
- Headache
- INfxn
- Nausea
- Xerostomia
Lamotrigine rare (serious) SEs
- SJS
BPAD Antipsychotic Indications
For acute mania and BPAD depression
Benzodiazepine BPAD Indications
Adjunct for acute mania, agitation, insomnia
Anxiety Tx
1st line – SSRIs
All others efficacious except bupropion
OCD Tx
Serotonergic agent at high dose (SSRI or clomipramine)
Benzodiazepine MOA
Binds benzo receptor –> enhances GABA activity –> more Cl flow
Benzo common properties (6)
- Amenestic
- Anticonvulsant
- Anxiolytic
- Hypnotic
- Muscle relaxation
- Tolerance/dependence
Benzo Rapid onset
Diazepam
Benzo intermediate onset (4)
Alprazolam, Chlordiazepoxide, Clonazepam, Lorazepam
Benzo SEs
- Sedation
- Cognitive probs and falls (elderly)
- Decreased respiration (bad w/ preexisting pulmonary dysfxn)
- Memory problems (anterograde amnesia)
Glucoronidated only benzos (3)
Lorazepam, oxazepam, temazepam
Teratogenic effects of benzos
Cleft palate in 1st trimester
Propanolol psych indications
Social anxiety disorder/social phobia
Propanolol actions in anxiety
Reduces peripheral manifestations (tachycardia, tremor, sweating)
Buspirone MOA
5HT1a agonist
Busipirone Indications
GAD only (not 1st line), qd
Busipirone SEs
- Dizziness most common
- Drowsiness
- Nervousness
- Headache
- GI upset
- Serotonin syndrome
