Antidepressants: Ott Flashcards
What is Depression?
- SUSTAINED/PERSISTANT feeling of sadness/decreased interest in all or most activities
Who are more likely to have a major depressive episode?
- Women 2-3x more likely than men
What is the Biogenic Amine Hypothesis in Depression?
- A decrease/desensitization in neurotransmitters [Norepinephrine, Dopamine, Serotonin, Acetylcholine, Eprinephrine]
What are some of the risk factors for Depression?
- Guilt, Fatigue, Sleep issues, decrease sex drive, agitation, anxiety, hopelessness
What does SIGECAPS means in depression?
- S: sleep
- I: interest
- G: guilt
- E: energy
- C: concentration
- A: appetite
- P: psychmotor
- S: suicide
What are the risk factors for suicide?
- Plan, Loss, widowed/Unmarried, Increasing Age, Prior Attempts…
What are some of the specifiers for Major Depressive Disorder?
- Psychosis, Catatonia, Peripartum Onset [During Pregnancy], Seasonal Patterns, Distress, Melancholic nature..
What is Substance/Medication Induced depressive disorder?
- Disturbance in mood in the clinical sense
- Symptoms develop after intoxication or withdrawal & involve substance cause symptoms
What are some medications that can cause Substance/Medication Induced Depressive Disorder?
- Beta-Blockers, Hormonal Therarpy, Isotretinoin, CNS Depressants, Interferon-Beta, Levetiracetam, Indomethacin
What is depressive disorder due to another medical condition?
- Period of depressed mood or decreased interest in all, or almost all, activities
What are some of the examples that relate to depressive disorder due to another medical condition?
- Bereavement, Life circumstances, stroke, Parkinson’s dementia, MS, Hypothyroidism, Low vit D, Hypercalcemia, Malignancy, Overactive bladder, Infectious disease…
What are the treatment goals of Depression?
- Eliminate or Reduce acute symptoms
- Minimize adverse drug effects
- Ensure adhernce
- Facilitate return to baseline
- Prevention
What are some of the non-pharmacological therapies for depression?
- Psychotherapy, Mindfulness, Spirituality, Relationship building, Physical activity
What is Electroconvulsive Therapy in Depression?
- Shocks the brain in a specific part to like “reset” it and hopefully decrease brain issues [release monoamines and increases neruonal formation]
- LAST LINE and difficult to get
What are some of the Natural Products used in Depression?
- St. Johns Wart [3A4 Inducer]*
- SAMe, Valerian Root, L-Methylfolate, Omega-3
- *INCREASED risk of serotonin syndrome [Nausea, Dizziness, Headache, Diarrhea, Agitation, Tachycardia, Hallucinations]
What is the way we should treat someone that is new to antidepressants?
- STEP-WISE treatment: Takes about 4-6 weeks
What are the important features that occur during the step-wise treatment for Antidepressants?
- Week 1: Better Appetite*
- Week 2: Better Sleep*
- Week 4: Better Mood
- Week 6: Goal is absence of symptoms
- Months 2-3: Goal is absence of symptoms
- Months 4-6: Goal is Eliminate symptoms
- Month 12-36: Prevent of depression
*Anxiety is INCREASED
What are some other important things to think about for the treatment of depression?
- INCREASED risk of suicidal thinking for ages <24
- PROTECTIVE factor for ages >65
- Medguides are REQUIRED for ALL antidepressants
What are the Selective Serotonin reuptake Inhibitors used?
- Citalopram [Celexa]
- Excitalopram [Lexapro]
- Fluocetine [Prozac]
- Fluvoxamine [Luvox]
- Paroxetine [Paxil]
- Sertialine [Zoloft]
What are the side effects for Citalopram [Celexa]?
- Nausea, Vomiting, Fatigue [take PM], Insomnia [Take AM] = Patient specific dosing
What are some of the clinical pearls for Citalopram [Celexa]?
- Dosed QAM
- High QTc Prolongation risk [Dosed adjustment in elderly]
What is the CYP interaction in Citalopram [Celexa]?
- 2C19, 3A4
What are some of the side effects for Escitalopram [Lexapro]?
- Nausea, Diarrhea, Sexual Dysfunction
What are some of the clinical pearls Escitalopram [Lexapro]?
- Has less QTc Prolongation
What is the CYP interaction of Escitalopram [Lexapro]?
- 2C19
What are the side effects of Fluxoetine [Prozac]?
- Sexual dysfunction, Weight loss, Insomnia, Resting Tremor
What are the clinical pearls of Fluxoetine [Prozac]?
- ACTIVATING
- Suppresses appetite
- QTc Prolongation
- Sarafem is for PMDD
What is the CYP interaction for Fluxoetine [Prozac]?
- 2D6, 2C19
What are the side effects for Fluvoxamine [Luvox]?
- Anorexia, Sexual Dysfunction
What are the clinical pearls Fluvoxamine [Luvox]?
- ONLY really used for OCD
What are the CYP interaction for Fluvoxamine [Luvox]?
- 1A2, 2D6, 2C19, 3A
What are the side effect for Paroxetine [Paxil]?
- Nausea, Vomiting, Diarrhea, Insomnia, Tremor, Sedation, Weight Gain
What are some of the clinical pearls for Paroxetine [Paxil]?
- H1 Blockade & M1 activation =SEDATION
- Most potent SSRI
- Brisdelle is for moderate severe vasomotor symptoms with menopause
- ALWAYS tapered
What are the CYP interactions for Paroxetine [Paxil]?
- 2D6
What are the side effects for Sertaline [Zoloft]?
- Nausea, Vomiting, Diarrhea, Nightmares
What are some of the clinical pearls for Sertaline [Zoloft]?
- QAM for nightmares
- Best tolerated
- PREFERRED for patients with Cardiac Risk
When should you disconitinue a SSRI?
FLUSH
- Flu-like symptoms
- Lightheadedness
- Uneasiness
- Sleep Disturbance
- Headache
What are the Selective Norepinephrine Reuptake Inhibitors?
- Duloxetine [Cymbalta]
- Levomilnacipran [Fetzima]
What are the side effects for Duloxetine [Cymbalta]?
- Liver injury
- CANNOT used in glaucoma
- Sweating
What are some of the clinical pearls for Duloxetine [Cymbalta]?
- Dose >60 NOT beneficial for Depression
- Used for Musculosketetal diagnoses
What are the CYP interactions for Duloxetine [Cymbalta]?
- 2D6, 1A2
What are the side effects for Levomilnacipran [Fetzima]?
- Nausea, Vomiting, Diarrhea
What are some of the clinical pearls for Levomilnaripram [Fetzima]?
- Stronger toward NE than 5HT = Helps sexual dysfunction
- INCREASED seizure risk, urinary retention, NMDA antagonism
What are the CYP interactions for Levomilnacipram [Fetzima]?
- 3A4
What is the one Dopamine Norephinephrine reuptake inhibitor [DNRI]?
- Bupropion [Wellbutrin]
What are the side effects for Bupropion [Wellbutrin]?
- Weight loss, Decrease Seizure therhold, Insomnia
What are some fo the clinical pearls for Bupropion [Wellburtin]?
- CONTRAINDATED: history of serizures, eating disorders, alcohol or sedative withdrawal
- “poor mans cocaine” = abuse
- Contrave: Weight loss
- Zyban: smoking cessation
What is the CYP interactions for Bupropion [Wellburtin]?
- 2D6
What is the dosing for Bupropion [Wellbutrin]?
- Daily: 450 mg IR/XL & 400 mg SR
- Single Dose: 150 mg IR, 200 mg SR, 450 mg XL
What are some of the Serotonin Antagonist Reuptake inhibitors [SARIs] used?
- Trazodone [Desyrel]
- Nefazodone [Serzone]
What are some of the side effects for Trazodone [Desyrel]?
- Praipism [Painful erection], QTc Prolongation, Sedation
What are some of the clinical pearls for Trazodone [Desyrel]?
- Used for sleep
- 300-600mg to get antidepressant activity
What are the CYP interactions for Trazodone [Desyrel]?
- 2D6
What are the side effects for Nefazodone [Serzone]?
- Liver failure
What are some of the clinical pearls for Nefazodone [Serzone]?
- BOXED WARNING: Liver failure
- NO LONGER USED
What is the CYP interaction for Nefazodone [Serzone]?
- 5HT2A, 3A4, 2D6
What are the Multi-modal medication used?
- Mirtazapine [Remeron]
- Valazodone [Viibryd]
- Voritoxetine [Trintellix]
What are the side effects for Vilazodone [Viivryd]?
- NAUSEA
What are some of the clinical pearls for Vilazodone [Viidryd]?
- Less sexual dysfunction
- TAKE WITH FOOD
What are the CYP interactions for Vilazodone [Viivbryd]?
- 3A4
What are the side effects for Mirtazapine [Remeron]?
- QTc Prolongation
- SOMNOLENCE [Sleepy]
- WEIGHT GAIN
What are some of the clinical pearls for Mirtazapine [Remeron]?
- 7.5mg works on H1 = SEDATION
- 15mg works on 5HT = ANTIDEPRESSANT
- > 30mg = INCREASED APPETITE
What are the CYP interactions for Mirtazapine [Remeron]?
- 3A4
What are the side effects for Voritoxetine [Trintellix]?
- Nausea, Vomiting, Diarrhea, Abnormal Dreams
What are some of the clinical pearls for Voritoxetine [Trintellix]?
- Less sexual dysfunction
What are the CYP interactions for Voritoxetine [Trintellix[?
- 2D6
What are some of the Tricyclic - Tertiary Amines used?
- Amitriptyline [Elavil]
- Imipramine [Tofranil] (WEIGHT GAIN)
- Doxepin [Sinequan]
What is important to know for the Tricyclic - Tertiary Amines?
- START with 25mg qhs and INCREASE by 25-50 mg q3-4d until response
- 1G can be fatal
- Taper over 1-2 weeks
What are some of the side effects for the Tricyclic -Tertiary Amines?
- Sedation, weight gain, Orthostatsis, Anticholinergic effects, CARDIAC TOXICITY [Overdose]
What are the Monoamine Oxidase Inhibitors used?
- Phenelzine [Nardil]
- Tranylcypromine [Parnate]
- Isocarboxazid [Marplan]
- Selegiline [Emsam]
What is important to note about the MAO-Is?
- 14 day wash period between serotonin agents
What are some of the side effects for the MAO-Is?
- Hypertensive Crisis [Tyramine restriction], SEROTONIN SYNDROME
What is Serotonin Syndrome?
- MEDICAL EMERGENCY: too much serotonin
- Treat with stopping the agent and supportive care
What are some of the alternative therapies used?
- Esketamine [Spravato]
- Brexanolone [Zulresso]
What are the side effects for Esketamine [Spravato]?
- Increased BP, Sedation, Bad Taste
What are some of the clinical pearls for Esketamine [Spravato]?
- Add on therapy
- Active metabolite for ketamine
- Used for treatment-resistant depression AND acute suicidality
What are the side effects of Brexanolone [Zulresso]?
- Fatigue, Flushing, Sedation
What are some of the clinical pearls for Brexanolone [Zulresso]?
- REMS = EXCESSIVE SEDATION
- 60 hour infusion
- Used for Post-partum depression
What are some of the things that we should do for someone with Treatment resistant depression?
- Increase the dose
- Augment with buspirone
- Augment with lithium
