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NUH Viva Preparations (Pharmacotherapy, Pharmacology) > Antidepressants, Mood stabilizers, Benzodiazepines > Flashcards

Antidepressants, Mood stabilizers, Benzodiazepines Flashcards

1
Q

Identify the symptoms exhibited in a patient suffering from Major Depressive Disorder as defined in the DSM-5

A

5 out of 9 symptoms for 2 weeks:

Interest loss (No pleasure)
Sleep (Insomnia or hypersomnia)
Appetite loss almost daily (Weight loss > 5% within a month)
Depressed Mood (Hopelessness)
Concentration reduced
Activity (Psychomotor agitation or retardation)
Guilt (Worthlessness, self-reproach)
Energy (Fatigue almost every day)
Suicidality (Thoughts of dying, ideation, plan, attempt)

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2
Q

What are the first line treatments for antidepressants?

A
  1. Mirtazapine
  2. SSRIs
  3. SNRIs
  4. Bupropion
  5. Agomelatine
  6. TCAs
  7. RIMA
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3
Q

List all SSRIs available in NUH

A
  1. Fluoxetine (Prozac)
  2. Fluvoxamine (Faverin)
  3. Escitalopram (Lexapro)
  4. Paroxetine
  5. Sertraline (Acoloft)
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4
Q

List all SNRIs available at NUH

A
  1. Venlafaxine
  2. Desvenlafaxine
  3. Duloxetine
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5
Q

List all TCAs available at NUH

A
  1. Amitriptyline
  2. Nortriptyline
  3. Clomipramine
  4. Imipramine
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6
Q

What is considered an adequate trial of antidepressant?

A

4-8 weeks on adequate dose

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7
Q

When would one warrant antidepressant therapy?

A

Moderate severity (PHQ-9 score 10 and above)

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8
Q

What is the course of treatment usually like?

A

Physical symptoms improve in 1-2 weeks (Sleep, appetite)

Mood symptoms improve after 4-8 weeks

Continuation Phase for another 4-9 months

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9
Q

Why is there a delayed onset of effectiveness of antidepressants?

A

Down-regulation of presynaptic autoreceptors is gradual, so the neurotransmitter release is also gradual

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10
Q

What is the typical duration of antidepressant therapy?

A

6 to 12 months

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11
Q

What are some counseling points for antidepressants?

A

Takes a couple of weeks to help with sleep, appetite and months for mood

Alcohol spaced apart 4-6 hours

If feeling that condition is worsening and suicidal (esp ≤ 24 y.o.), contact Dr.

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12
Q

Why is Mirtazapine a first line agent for depression?

A
  1. Side effects: Less GI and sexual dysfunction (Mainly 5HT2,3 selectivity)
  2. DDIs: Fewer CYP interactions
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13
Q

Mirtazapine: Formulation, usual dosing, max dosing?

A

Formulation: ODT 15 mg, 30 mg

Max: 45 mg/day
Initial: 15 mg/day
Usual Range: 15-45 mg/day

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14
Q

Fluoxetine: Formulation, usual dosing, max dosing?

A

Formulation: 10 mg, 20 mg Capsules (Prozac)

Max: 80 mg/day
Initial: 20 mg OM
Usual Range: 20-60 mg/day

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15
Q

Fluvoxamine Maleate: Formulation, usual dosing, max dosing?

A

Formulation: 50 mg Tablet (Faverin)

Max: 80 mg/day
Initial: 20 mg OM
Usual Range: 20-60 mg/day

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16
Q

Escitalopram: Formulation, usual dosing, max dosing?

A

Formulation: 10 mg, 20 mg Tablet (Lexapro)

Max: 20 mg/day
Initial: 5-10 mg/day
Usual Range: 10-20 mg/day

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17
Q

Paroxetine: Formulation, usual dosing, max dosing?

A

Formulation:
- CR Tab: 12.5 mg, 25 mg
- IR Tab: 20 mg

Max: 75 mg/day
Initial: 12.5 mg/day
Usual Range: 12.5-50 mg/day

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18
Q

Sertraline: Formulation, usual dosing, max dosing?

A

Formulation: 50 mg Tablet (Acoloft)

Max: 200 mg/day
Initial: 25-50 mg/day
Usual Range: 25-200 mg/day

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19
Q

Venlafaxine: Formulation, usual dosing, max dosing?

A

Formulation: 75 mg, 150 mg XR Tab

Max: 375 mg/day
Initial: 75 mg/day
Usual Range: 75-225 mg/day

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20
Q

Desvenlafaxine: Formulation, usual dosing, max dosing?

A

Form: 50 mg ER Tab

Max: 100 mg/day
Initial: 50 mg/day
Usual Range: 50 mg/day

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21
Q

Duloxetine: Formulation, usual dosing, max dosing?

A

Form: 30 mg, 60 mg Capsule

Max: 120 mg/day
Initial: 60 mg/day
Usual Range: 30-60 mg/day

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22
Q

Vortioxetine: Drug Class, MOA, Formulation, usual dosing, max dosing?

A

Form:
- 5 mg, 10 mg Tablet
- 20 mg/mL Suspension

Max: 20 mg/day
Initial: 10 mg/day
Usual Range: 10-20 mg/day

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23
Q

Amitriptyline: Formulation, usual dosing, max dosing?

A

Form: 10 mg, 25 mg Tablet

Max: 300 mg/day
Initial: 50-100 mg/day
Usual Range: 30-300 mg/day

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24
Q

Nortriptyline: Formulation, usual dosing, max dosing?

A

Form: 10 mg, 25 mg Cap/Tab

Max: 150 mg/day
Initial: 25 mg/day
Usual Range: 75-100 mg/day

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25
Q

Clomipramine: Formulation, usual dosing, max dosing?

A

Form: 25 mg Tablet

Max: 300 mg/day
Initial: 25 mg/day
Usual Range: 25-250 mg/day

26
Q

Imipramine: Formulation, usual dosing, max dosing?

A

Form: 25 mg Tablet

Max: 300 mg/day
Initial: 75-100 mg/day
Usual Range: 50-200 mg/day

27
Q

Moclobemide: Drug Class, MOA, Formulation, usual dosing, max dosing?

A

Form: 150 mg Tablet

Max: 600 mg/day
Initial: 300 mg/day
Usual Range: 150-600 mg/day

28
Q

Bupropion: Drug Class, MOA, Formulation, usual dosing, max dosing?

A

Form: 150 mg SR Tablet

Max: 300 mg/day
Initial: 150 mg OM x4d, then BD
Usual Range: 150 mg BD

29
Q

Trazodone: Drug Class, MOA, Formulation, usual dosing, max dosing?

A

Form: 50 mg Tablet

Main indication: Insomnia
Max: 600 mg/day
Initial: 75-150 mg/day
Usual Range: 50-300 mg/day

30
Q

Agomelatine: Drug Class, MOA, Formulation, usual dosing, max dosing?

A

Form: 25 mg Tablet

Max: 50 mg/day
Initial: 25 mg/day

31
Q

Lithium Carbonate: Formulation, usual dose, max dosing, TDM range?

A

Form: CR 400 mg Tablet

Max: 1800 mg/day
Initial: 400-800 mg/day

TDM: 0.8 to 1.2 mEq/L

32
Q

What is the washout period for MAO inhibitors?

A

– If switching from Moclobemide to another antidepressant: 24 hour washout.

– If switching from another antidepressant to Moclobemide: Wash-out at least 1 week (or 5 wks if stopping Fluoxetine)

33
Q

Compare the differences in SSRIs and what to look out for

A

Fluoxetine has a long half-life (4-6 days): Do not need to taper gradually for antidepressant discontinuation syndrome

Paroxetine has the most anticholinergic,
sedating, weight gain, T1⁄2 short: Side effects and Withdrawal effects

Escitalopram can cause QTc prolongation if high dose in elderly: Monitor ECG

34
Q

What PD interactions should you look out for antidepressants?

A
  1. Serotonin Syndrome (Triptans, opioids, linezolid, MAOi)
  2. Bleeding risk (NSAIDs, Warfarin, Steroids)
  3. CNS depressant (Alcohol)
  4. Anticholinergics
35
Q

Which antidepressants have to caution about CYP interaction DDIs?

A
  1. Fluvoxamine (CYP1A2, 2C19)
  2. Fluoxetine (CYP2D6)
  3. Paroxetine (CYP2D6)
  4. Bupropion (CYP2D6)
36
Q

Which antidepressants have the least DDIs?

A
  1. Mirtazapine
  2. Escitalopram
  3. Venlafaxine
  4. Desvenlafaxine
  5. Vortioxetine
37
Q

Symptoms of antidepressant discontinuation syndrome

A

FINISH-Symptoms

Flu-like symptoms (Fatigue, headache, aching)

Insomnia (vivid dreams)

Nausea, vomiting

Imbalance (Dizziness, vertigo, lightheadedness)

Sensory disturbance (tingling, electric-like sensation)

Hyperarousal (Anxiety)

38
Q

When does antidepressant discontinuation syndrome typically start and last?

A

Onset: 36 to 72 hours
Duration: 3 to 7 days
Resolves in 1 to 2 weeks without treatment

39
Q

General antidepressant counseling points

A
  1. Takes a couple of weeks to help with sleep, appetite and months for mood
  2. Alcohol spaced apart 4-6 hours
  3. If feeling that condition is worsening and suicidal (esp ≤ 24 y.o.), contact Dr.
40
Q

What are the symptoms of mania?

A

DIG FAST for at least 1 week and functionally impaired

  • Distractibility
    -Irresponsibility (Uninhibited, compulsive)
  • Grandiosity (Inflated self-esteem)
  • Flight of ideas
  • Activity increased (Psychomotor agitation)
  • Sleep < 3 hours
  • Talkativeness
41
Q

Explain bipolar disorder in simple terms

A

Lifelong cyclical mood disorder (recurrent fluctuations)

42
Q

List all mood stabilizers

A

First Line Monotherapies:
(A) Lithium
(B) Antipsychotics:
1. Quetiapine, Risperidone, Olanzapine, Aripiprazole, Haloperidol (Bipolar mania)
2. Olanzapine/Fluoxetine combo (Bipolar depression)

Second Line Monotherapies: Anti-seizure Medications
1. Valproate (Bipolar mania)
2. Lamotrigine (Bipolar depression)

43
Q

Generalized Anxiety Disorders: Why should the dosing regimen for antidepressants be started low and going slow?

Why do you need BZD adjuncts initially?

How long do we use BZDs?

A

Transient jitteriness in the initial 1-2 weeks of antidepressants.

BZDs reduce physical symptoms (e.g. muscle tension) reduced due to fast onset

Aim for short term use (3-4 months)

44
Q

Described the course of the treatment in reducing symptoms of anxiety?

A

Onset: 1-2 months minimally
Full response: 3 months
Duration: 1-2 years minimally, long-term typically
Maintenance of dosing should be at the higher end of the range

45
Q

List of BZDs and categories (Short or long acting)

A

Very Short-acting: Midazolam

Short-acting
1. Lorazepam
2. Alprazolam

Long-acting:
1. Diazepam
2. Clonazepam

46
Q

What are the types of anxiety disorders (most amenable to drug treatment)?

A
  1. Panic disorder: Anticipatory anxiety
  2. SAD: Fear scrutiny
  3. GAD: Excess worry
  4. OCD: Impulsive
  5. PTSD: Re-experiencing trauma
47
Q

What are the main concerns of BZDs?

A
  1. Tolerance (to hypnotic action more than anxiolytic action)
  2. Dependence and withdrawal (need to taper)
  3. Preference for high potency agents for anxiety (clonazepam, lorazepam, alprazolam)
48
Q

Alprazolam formulation and dosing for anxiety

A

Formulations:
- 0.25 mg, 0.5 mg Tab
- 1 mg XR Tab

Usual dose: 0.5 to 4 mg
Max dose: 4 to 10 mg

49
Q

Clonazepam formulation and dosing for anxiety

A

Formulations:
0.1 mg/mL Suspension

Usual dose: 0.5 to 1 mg
Max dose: 1 to 4 mg

50
Q

Lorazepam formulation and dosing

A

Formulations:
- 1 mg Tab
- 4mg/mL Inj

Usual dose: 1 to 3 mg
Max dose: 2 to 8 mg

51
Q

Diazepam formulation and dosing range

A

Formulation:
- 2 mg, 5 mg Tab
- 5 mg Rectal Tube
- 10mg/2mL Inj

Usual dose: 4 to 15 mg
Max dose: 5 to 40 mg

52
Q

What is the principle for dosing benzodiazepines for acute anxiety symptoms?

A

Adjunct. Restrict to the lowest effective dose. PRN for symptomatic relief for 1-2 weeks

53
Q

How do you weigh your options for treatment of insomnia?

A
  1. BZDs: Not monotherapy, adjunct to MDD or anxiety
  2. Z-hypnotics: Relieves insomnia but not anxiety. Apply same cautions as BZD for high abuse potential.
  3. Hydroxyzine, Promethazine: Anticholinergic effect to be cautioned
  4. Melatonin: Preferred for ages > 55 years old
54
Q

Z-hypnotics: List the MOA, drugs, formulation, dosing

A

MOA: Preferential binding to BZD-binding sites with γ and α1 subunits to cause sedation

  1. Zolpidem (Stilnox)
    - CR 6.25 mg, 12.5 mg Tablets
    - Max: 1 tab PRN (12.5 mg) before bedtime with ≥ 7 to 8 hours of planned sleep before waking
  2. Zopiclone (Imovane) 7.5 mg Tablets
    - Max: 1 tab PRN
55
Q

What are some ADRs of Z-hypnotics to counsel?

A

Common ADR:
- Dry mouth, bitter taste: Drink with some water, suck on candy

Rare ADR:
- Unusual sleep-related activities such as walking, eating or cooking
- Unusual excitement, irritability, agitation or over-talkativeness (disinhibition)

56
Q

Lemborexant MOA, formulation, dosing

A

MOA: Orexin OX1 and OX2 receptor antagonist

Dayvigo 5 mg Tablet
- Dose: 1-2 tabs PRN

57
Q

Benefits of lemborexant

A

Lower risk of tolerance and dependence than BZDs and Z-hypnotics

58
Q

Contraindications to Lemborexant

A

Narcolepsy (sleep disorder that makes people very drowsy during the day)

Hepatic impairment

CYP3A inhibitors/inducers

59
Q

Lemborexant ADRs

A

Somnolence (daytime sleepiness), nightmares

NUH Viva Preparations (Pharmacotherapy, Pharmacology) (7 decks)

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