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M4 PSYCH > Antidepressants (PSYCH DRUGS) > Flashcards

Antidepressants (PSYCH DRUGS) Flashcards

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1
Q

First-line antidepressant

A

SSRI - selective serotonin receptor inhibitor (few SE because selective action on serotonin alone)

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2
Q

SSRI
1. Full name
2. MOA

A

Selective Serotonin Reuptake Inhibitor

  • MOA: block serotonin reuptake by transmitting neurons -> elevated serotonin levels in synaptic space -> prolonged action on receiving neuron
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3
Q

SSRI side effects - common AND uncommon

A

Common
1. Anxiety
2. Insomnia
3. Headache
4. Nausea
5. Diarrhea
6. Sexual dysfunction

Uncommon
1. Antidepressant-induced hypoNa (common in old people, manifestations: lethargy, muscle ache, nausea, more severe- cardiac failure, confusion, seizure)
2. GI bleed/GI ulcer
3. Serotonin syndrome (applies to antidepressants as a class)

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4
Q

SSRI indications

A
  1. Depression with anxiety/obsessional symptoms
  2. Depression in elderly (due to benign SE profile)
  3. Suicidal pt (safe in OD)
  4. (conditions with serotonin deficiency) Panic disorder, social anxiety disorder, PTSD, OCD, bulimia nervosa
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5
Q

SSRI examples AND dose

A

x5
1. Fluoxetine (20 mg OM)
2. Fluvoxamine (50 mg OM to 50 mg BD)
3. Paroxetine (20mg OM)
4. Sertraline (50mg OM)
5. Escitalopram (10mg OM)

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6
Q

SNRI Full name + MOA

A

Serotonin noradrenaline reuptake inhibitor

MOA: dual action - block serotonin and noradrenaline reuptake transporters

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7
Q

SNRI side effects

A

Similar to SSRI PLUS adrenergic SE

  1. Anxiety
  2. Nausea
  3. # Sexual dysfunction
  4. Tachycardia, HTN, mydriasis, diaphoresis
  5. Dry mouth
  6. Constipation
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8
Q

SNRI example and dose

A
  1. Venlafaxine (75mg/day)
  2. Desvenlafaxine (50mg/day)
  3. Duloxetine (60mg/day)
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9
Q

SNRI indications

A
  1. Depression
  2. Generalised anxiety disorder
  3. Pain symptoms in depression
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10
Q

Duloxetine added benefits

A

Effect on pain symptoms in depression eg. Back ache

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11
Q

Which SNRI has Discontinuation symptom?

A

Venlafaxine

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12
Q

TCA MOA

A

MOA: dual action - block both serotonin and noradrenaline transporters PLUS block cholinergic, histamine, alpha-adrenergic receptor, sodium channel ***dirty drug!! broad spectrum

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13
Q

TCA side effect

A
  1. Dry mouth, tachycardia, memory impairment (bad for elderly), acute closed angle glaucoma [muscarinic M1 receptor blockade]
  2. Sedation, weight gain [block histamine receptor]
  3. Postural hypotension [block alpha adrenergic receptor]
  4. Arrythmia ***overdose + wide QRS complex = TCA OD seizure [block Na channel]
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14
Q

TCA efficacy, safety

A

Efficacy: superior to other antidepressants
Safety: highly lethal in OD (VF, seizure 2’ to Na channel blockade)

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15
Q

TCA indication

A
  1. Severe depression (superior to newer agents)
  2. Specific dx (chronic pain, fibromyalgia, migraine, insomnia) - use amitriptyline
  3. Specific dx (OCD) - use clomipramine
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16
Q

Avoid TCA in

A
  1. Elderly
  2. Physically ill
  3. The suicidal (if really need to prescribe, do safety advice - family keep drugs for pt)
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17
Q

TCA examples and dose

A

x4
1. Amitriptyline (25-150mg)
2. Imipramine (25-150mg)
3. Dothiepin (25-150mg)
4. Clomipramine (25-100mg)

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18
Q

Noradrenaline Dopamine Reuptake Inhibitor MOA

A

MOA: block both dopamine and noradrenaline reuptake transporters

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19
Q

Noradrenaline dopamine reuptake inhibitor example AND dose

A

Bupropion 150mg/day

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20
Q

Noradrenaline dopamine reuptake inhibitor/Bupropion Side effects

A
  1. Insomnia, agitation, anxiety (as a result of overstimulation ***rmb that bupropion can be used in ADHD!)
  2. Seizures (due to effects of elevated dopamine levels on seizure threshold)

Has NO effect on sexual dysfunction

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21
Q

Noradrenaline dopamine reuptake inhibitor Indications

A
  1. Depression with anhedonia
  2. Depression with fatigue
  3. Smoking cessation
  4. ADHD (child psych)
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22
Q

Avoid noradrenaline dopamine reuptake inhibitor (bupriopion) in

A
  1. Anxiety disorders
  2. Panic attacks
  3. Seizures
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23
Q

NaSSA full name + MOA

A

Noradrenergic and Specific serotonergic antidepressant **diff from SNRI (block reuptake transporter) VS NaSSA (block receptors)

MOA: x3
1. Block presynaptic alpha 2 receptors of noradrenergic AND serotonergic pathways (which are normally responsible for -ve feedback) -> increases noradrenergic and serotonergic neurotransmission
2. Block postsynaptic serotonin 5HT2 AND 5HT3 receptors
3. block histamine 1 receptor -> sedating effect

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24
Q

Side effects of NaSSA (Mirtazapine)

A
  1. Sedation, weight gain (antihistaminergic effects)

***NO insomnia, nausea, sexual dysfunction (due to selective activity; increased serotonin binds to desired 5HT receptor ie. 5HT1A to exert therapeutic effect

25
Q

NaSSA indications

A
  1. Antidepressant, anxiolytic effect
  2. Depression with anxiety, insomnia, weight loss
  3. Commonly used in elderly
  4. No CYP450 inhibition -> less likely for drug drug interaction
26
Q

NaSSA example AND dose

A

Mirtazapine (30mg/day)

27
Q

Agomelatine MOA

A

Melatonin receptor agonist (active melatonin 1&2 receptors in suprachiasmatic nucleus of hypothalamus -> restore circadian rhythms -> resynchronise disturbed sleep/wake cycle in depressed pt

28
Q

Agomelatine side effects

A
  1. Common: dizziness
  2. Rare: hepatitis

No daytime sedation, sexual dysfunction, weight gain

Safe in overdose

29
Q

Indications for agomelatine

A
  1. Depression with sleep disturbance
  2. Depression with fatigue
30
Q

Agomelatine dose

A

25-50mg/day

31
Q

MOAI full name + MOA

A

Monoamine oxidase inhibitors (MAOI)
MOA: irreversibly inhibit monoamine oxidase -> both serotonergic AND noradrenergic pathways involved

**THIRD LINE (extensive SE profile)

32
Q

MAOI side effect

A
  1. Hypertensive crisis
  2. Serotonin syndrome (interaction with serotonergic drugs)
33
Q

MAOI examples

A

X4
1. Selegiline
2. Isocarboxazid
3. phenelzine
4. Tranylcypromine

34
Q

RIMA full name + MOA

A

Reversible inhibitor of monoamine oxidase A (RIMA)
- MOA: reversibly and selectively inhibit the enzyme MOA

35
Q

RIMA side effect

A
  1. Insomnia

Reduced risk of hypertensive crisis compared to MAOI

36
Q

Multimodal drugs examples AND dose

A
  1. Vortioxetine (10mg/day)
  2. SARI (serotonin antagonist/reuptake inhibitor)
37
Q

Vortioxetine MOA

A
  • multimodal drug
    MOA: x2
    1. Block serotonin receptor
    2. Multiple actions on serotonin receptor -> downstream effect of adrenaline and acetylcholine in specific area of brain (pro-cognitive effect too)
38
Q

Vortioxetine side effect

A

Generally q tolerable
1. Nausea
2. Low sexual dysfunction

No insomnia or weight gain

39
Q

Vortioxetine indication

A

Depression with cognitive dysfunction (rumination, indecision, inattention, poor conc)

40
Q

SARI full name + MOA

A

Serotonin antagonist/reuptake inhibitor
MOA: x4 it is a serotonin modulator
1. Blocks post synaptic serotonin 5HT2A receptors robustly
2. Blocks presynaptic serotonin reuptake transporter weakly
3. Blocks histamine 1 receptor (-> sedating effect)
4. Blocks alpha adrenergic receptors (-> orthostatic hypotension, priapism)

41
Q

SARI side effects

A
  1. Sedation
  2. Orthostatic hypotension and priapism
  3. Cardiac arrhythmias
42
Q

SARI indications

A
  1. Hypnotic for insomnia in depression (lower dose as hypnotic: 25-150mg)
  2. Antidepressant dose higher 150-600ng (but hard to tolerate cause too sedated)
43
Q

Serotonin syndrome symptoms

A
  1. Tremor
  2. Agitation (mental state)
  3. Hyperreflexia, clonus (Neuromuscular hyperactivity)
  4. HTN, tachycardia, diaphoresis, mydriasis (Autonomic hyperactivity)
44
Q

Dangerous complication of combination SSRI use?

A

Serotonin syndrome

45
Q

Strong inhibitors of CYP450 2D6

A

Bupropion, fluoxetine, paroxetine

46
Q

Concern with propranolol (beta blocker) and fluoxetine (SSRI)?

A

Fluoxetine: strong CYP2D6 inhibitor
Beta blocker: major substrate of CYP2D6
Thus beta blocker in body system will increase due to inhibition of metabolism of propranolol

47
Q

Concerns with fluoxetine and phenytoin

A

Fluoxetine: moderate inhibitor CYP2C19
Phenytoin: major substrate of CYP2C19

Although fluoxetine moderate inhibitor, phenytoin has narrow therapeutic index

48
Q

Antidepressant discontinuation symptoms onset and symptoms

A

Onset: 3-5 days of stopping half-life antidepressant
Symptoms: x4
1. Dizziness
2. Headache
3. Insomnia
4. Irritability

49
Q

Antidepressants prone to discontinuation symptoms

A
  1. Fluvoxamine
  2. Paroxetine
50
Q

Why the need to recognise discontinuation symptoms?

A

May mistaken for new physical illness

51
Q

What is the Black box warning?

A

Antidepressant for first few weeks: Increased risk of suicidality (for children and adults up to 24 years of age)

52
Q

Antidepressants that cause MINIMAL sexual dysfunction

A
  1. Mirtazapine
  2. Bupropion
53
Q

SARI examples of drug

A
  1. Trazodone
  2. Nefazodone
54
Q

Key symptom: anxiety
Preferred antidepressant?

A

SSRI or SNRI

Eg. Setraline (SSRI)

55
Q

Key symptom: cognitive difficulties (learning, memory, decision-making)
Preferred antidepressant?

A
  1. Duloxetine
  2. Vortioxetine
56
Q

Key symptom: sleep disturbances eg insomnia
Preferred antidepressant?

A
  1. Mirtazapine
  2. Agomelatine
57
Q

Key symptom: fatigue
Preferred antidepressant?

A

Bupropion

58
Q

Key symptom: pain
Preferred antidepressant?

A

Duloxetine, TCA

59
Q

Key symptom: melancholia (psychomotor retardation, diurnal mood variation)
Preferred antidepressant?

A

TCA

M4 PSYCH (5 decks)

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