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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
Clomipramine: Formulation, usual dosing, max dosing?
Form: 25 mg Tablet Max: 300 mg/day Initial: 25 mg/day Usual Range: 25-250 mg/day
26
Imipramine: Formulation, usual dosing, max dosing?
Form: 25 mg Tablet Max: 300 mg/day Initial: 75-100 mg/day Usual Range: 50-200 mg/day
27
Moclobemide: Drug Class, MOA, Formulation, usual dosing, max dosing?
Form: 150 mg Tablet Max: 600 mg/day Initial: 300 mg/day Usual Range: 150-600 mg/day
28
Bupropion: Drug Class, MOA, Formulation, usual dosing, max dosing?
Form: 150 mg SR Tablet Max: 300 mg/day Initial: 150 mg OM x4d, then BD Usual Range: 150 mg BD
29
Trazodone: Drug Class, MOA, Formulation, usual dosing, max dosing?
Form: 50 mg Tablet Main indication: Insomnia Max: 600 mg/day Initial: 75-150 mg/day Usual Range: 50-300 mg/day
30
Agomelatine: Drug Class, MOA, Formulation, usual dosing, max dosing?
Form: 25 mg Tablet Max: 50 mg/day Initial: 25 mg/day
31
Lithium Carbonate: Formulation, usual dose, max dosing, TDM range?
Form: CR 400 mg Tablet Max: 1800 mg/day Initial: 400-800 mg/day TDM: 0.8 to 1.2 mEq/L
32
What is the washout period for MAO inhibitors?
– 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
Compare the differences in SSRIs and what to look out for
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
What PD interactions should you look out for antidepressants?
1. Serotonin Syndrome (Triptans, opioids, linezolid, MAOi) 2. Bleeding risk (NSAIDs, Warfarin, Steroids) 3. CNS depressant (Alcohol) 4. Anticholinergics
35
Which antidepressants have to caution about CYP interaction DDIs?
1. Fluvoxamine (CYP1A2, 2C19) 2. Fluoxetine (CYP2D6) 3. Paroxetine (CYP2D6) 4. Bupropion (CYP2D6)
36
Which antidepressants have the least DDIs?
1. Mirtazapine 2. Escitalopram 3. Venlafaxine 4. Desvenlafaxine 5. Vortioxetine
37
Symptoms of antidepressant discontinuation syndrome
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
When does antidepressant discontinuation syndrome typically start and last?
Onset: 36 to 72 hours Duration: 3 to 7 days Resolves in 1 to 2 weeks without treatment
39
General antidepressant counseling points
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
What are the symptoms of mania?
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
Explain bipolar disorder in simple terms
Lifelong cyclical mood disorder (recurrent fluctuations)
42
List all mood stabilizers
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
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?
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
Described the course of the treatment in reducing symptoms of anxiety?
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
List of BZDs and categories (Short or long acting)
Very Short-acting: Midazolam Short-acting 1. Lorazepam 2. Alprazolam Long-acting: 1. Diazepam 2. Clonazepam
46
What are the types of anxiety disorders (most amenable to drug treatment)?
1. Panic disorder: Anticipatory anxiety 2. SAD: Fear scrutiny 3. GAD: Excess worry 4. OCD: Impulsive 5. PTSD: Re-experiencing trauma
47
What are the main concerns of BZDs?
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
Alprazolam formulation and dosing for anxiety
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
Clonazepam formulation and dosing for anxiety
Formulations: 0.1 mg/mL Suspension Usual dose: 0.5 to 1 mg Max dose: 1 to 4 mg
50
Lorazepam formulation and dosing
Formulations: - 1 mg Tab - 4mg/mL Inj Usual dose: 1 to 3 mg Max dose: 2 to 8 mg
51
Diazepam formulation and dosing range
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
What is the principle for dosing benzodiazepines for acute anxiety symptoms?
Adjunct. Restrict to the lowest effective dose. PRN for symptomatic relief for 1-2 weeks
53
How do you weigh your options for treatment of insomnia?
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
Z-hypnotics: List the MOA, drugs, formulation, dosing
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
What are some ADRs of Z-hypnotics to counsel?
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
Lemborexant MOA, formulation, dosing
MOA: Orexin OX1 and OX2 receptor antagonist Dayvigo 5 mg Tablet - Dose: 1-2 tabs PRN
57
Benefits of lemborexant
Lower risk of tolerance and dependence than BZDs and Z-hypnotics
58
Contraindications to Lemborexant
Narcolepsy (sleep disorder that makes people very drowsy during the day) Hepatic impairment CYP3A inhibitors/inducers
59
Lemborexant ADRs
Somnolence (daytime sleepiness), nightmares
60

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

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