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Pharmacology Exam 3 > Anxiety and Depression > Flashcards

Anxiety and Depression Flashcards

1
Q

mood disorders

A

depression (minor, major, dysthimia, SAD), bipolar disorders (associated with depression and mania or hypomania)

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2
Q

antidepresant classes of drugs

A

SSRIs, SNRIs, serotonin reuptake inhibitor/5HT1A receptor partial agonist, mixed reuptake and neuroreceptive antagonists (trycyclics, TCAs), MAOIs, aminoketone, serotonin receptor antagonists, atypical antipsychotics

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3
Q

symptoms of depression - cause

A

reflect changes in brain monomine neurotransmitters - NE, serotonin (5-HT), and dopamine (DA)

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4
Q

anxiety

A

often associated with depression, psychiatric illness. may be acute, transient, situational, or chronic, perstant, psychologic. apprehension, reduced concentration, fatigue, insomnia. somatic (sympathomimetic): tachycardia, palpitations, increased BP, hyperventilation, tremor, sweating, GI

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5
Q

benzodiazepines action and precautions

A

5 main actions: anxiolytic, anterograde amnesia, anticonvulsant, muslce relax, sedation. also hypnosis
Relief of anxiety primarily related to CNS depression (causing sedation and depressing respiratory and vasomotor centers in CNS). Enhance GABA neurotransmission, lenghtening hyperpolarization of impulse, thus slowing down responses to successive impulses - the net effect is to decrease reactivity of brain. Not first line d/t abuse potential.

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6
Q

what type of depression is more likely to be associated with major life events

A

initial depressive episodes

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7
Q

depression etiology theories/hypotheses related to NE, DA, 5-HT

A

biologic amine (insufficient monoamine neurotransmitters or receptors dysfunction, mostly NE but also DA, 5-HT), permissive (low levels serotonin permit depressive state), dysregulation (erratic levels of neurotransmitters, 5-HT*/NE link hypothesis)

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8
Q

SSRI withdrawal syndrome

A

depressive symptoms or mania, FLUSSH (Flu-like with fatigue, myalgia, loose stools, nausea; Lightheaded/dizziness; Uneasiness/restlessness; Sleep and Sensory disturbances, HA). Symtoms stop within 24 hours of restarting. Risk factors: time on drug, potency, half-life.

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9
Q

benzos PK

A

distribution: all highly lipid soluble, 70-98% protein binding. met: extensive hepatic, phase I (3A4, 2C19), and phase II (glucuronidation), active metabolites. excretion: renal

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10
Q

serotonin reuptake inhibitor/5HT1A receptor partial agonist used to treat depression medications available

A

vilazodone (Viibryd)

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11
Q

benzodiazepine indications (category IV drug)

A

for acute and short term use in treatment of panic attacks, GAD, insomnia, ETOH withdrawal. those used for insomnia are: flurazepam/Dalmane, temazepam/Restoril

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12
Q

serotonin norepinephrine reuptake inhibitors SNRIs available

A

venlafaxine (Effexor and Effexor XR), desvenlafaxine (Pristique), duloxetine (Cymbalta, which also treats neuropathic pain), milnacipran (Savella, which also treats fibromyalgia)

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13
Q

serotonin receptor antagonists (reuptake inhibitors) available

A

mirtazapine (Remeron), trazodone, nefazodone. fewer side effects than TCAs. antidepressant/antianxiety: alpha 2 antagonist

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14
Q

SSRIs drug/drug

A

CYP2D6 met: affects tamoxifen, warfarin. SIADH

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15
Q

benzo pharmacodynamics

A

bind to molecular components of GABA A (gamma-aminobutyric acid) receptors in neuronal membranes in CNS. Potentiate GABA-ergic inhibition at all levels of CNS -> decreased firing rate of critical neurons in many regions of brain.

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16
Q

other drugs to treat depression

A

atypical antipsychotic Abilify

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17
Q

SSRIs monitoring concerns

A

assess for depression, SI (Black Box up to age 24). SEs: sex probs, tremor, w/l or gain, CNS. Assess substance use: caution against use of caffeine, alcohol, extacy. Medication inventory: drugs met by P450, St. Johns Wort. Heart: prolonged QT, angina. Prego: newer concerns ?pulm HTN in newborn.

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18
Q

monoamine oxidase inhibitors (MAOIs) available

A

phenelzine (Nardil), isocarboxazid, tranylcypromine. decreases metabolic inactivation of catecholamines. many SEs, drug/drug

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19
Q

aminoketones available (also called NE-DA reuptake inhibitor)

A

buproprion (Wellbutrin, Wellbutrin SR, Wellbutrin XL). weak inhibitor of neuronal uptake of dopamine, NE, serotonin

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20
Q

benzo antagonist

A

flumazenil/Romazicon IV 0.1mg/ml

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21
Q

mixed reuptake and neuroreceptor antagonisis available (trycyclics, TCAs) (nonselective NE-5HT reuptake inhibitors) available

A

amitriptyline (Elavil); nortriptyline, imipramine/Tofranil (the prototype), doxepin, trimipramine, maleate, amoxapine, desipramine, protriptyline HCL, clomipramine

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22
Q

long acting benzos available

A

Klonipin/clonazepam, Libruim/chlordiazepoxide

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23
Q

benzos teaching and monitoring

A

monitor: excessive sedation SEs, escalating use. ed: dont use with ETOH or other CNS depressants (kava-kava), do not increase Rx dose, slowly taper after prolonged use, caution with driving

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24
Q

benzos adverse and precautions

A

excessive sedation, respiratory depression, tolerance/physiologic dependence. Caution elders. Prego C or D.

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25
Q

SSRI indications

A

often first choice for depression. Treatment of anxiety disorders and anxiety-complicating depression. OCD. Little evidence to support use of one in class over other for effectiveness.

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26
Q

intermediate acting benzos available

A

Valium/diazepam

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27
Q

SSRI drugs available

A

Zoloft/sertraline (prototype), Paxil/paroxetine, Celexa/citalopram, Lexapro/escitalopram, Luvox/fluvoxamine, Prozac/fluoxetine, olanzapine-fluoxetine

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28
Q

SSRIs PK and half life

A

distribution: wide Vd, extensive protein binding. met: interference with CYP450 system. Excretion: renal. half lives vary (Prozac longest 4-6 days, Luvox shortest 15-26h)

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29
Q

SSRI actions

A

potently and selectively inhibit serotonin uptake pump on pre-synaptic neuron. Increase concentration of 5HT in synapse by inhibiting re-uptake. Weak effect on NE and dopamine reuptake. “blocks transport mechanism for unbound 5HT, making more available to bind to postsynaptic 5HT receptor)

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30
Q

major SEs of SSRIs

A

nausea, loose stools, sexual dysfunction, weight gain, serotonin syndrome (potentially life-threatening condition resulting from excess serotonin agonist activity)

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31
Q

what increases serotonin syndrome risk /who

A

SSRIs + MAO or St. Johns Wort or antiemetics. Or if given high doses. Especially problematic in elderly.

32
Q

insomnia meds

A

nonbenzo hypnotics (Ambien/zolpidem, Lunesta/eszopicione), serotonin recetpor antagnists (Trazedone, Remeron), Trycyclics (Elavil)

33
Q

benzos available - short acting

A

Ativan/lorazepam, Xanax/alprazolam, Serax/oxazepam

34
Q

serotonin syndrome

A

rigidity, hyperthermia, autonomic instability, myoclonus, tremors, confusion, delerium, coma. increased risk with higher doses and with adding MAOIs, St. Johns Worth

35
Q

anxiety and depression neurobiology

A

result from interaction between CNS, PNS, endocrine systems, genetic and enironmental factors.

36
Q

serotonin receptor antagonists (reuptake inhibitors) action, indications, precautions

A

inhibit reuptake of 5HT and block their subtypes. With long term use, ability to increase serotonin release through desensitization of 5-HT1A receptors. nefazadone and trazadone. usually not first line. drowsy, dizzy, often given at night.

37
Q

structures of brain involved in depression

A

cerebral cortex, frontal, temporal, brain stem, basal nuclei, limbic system, hippocampus, amygdyla, cingulate gyrus

38
Q

goals of treatment for anxiety

A

reducation of symptoms and self management of symptoms, understanding etiology/contributing symptoms, education (coping skills, becoming involved in altering hypothalamus-pituitary axis responses)

39
Q

depression neurobiology

A

theories evolving, changing. include theory of complex dysregulation of brain circuits in different parts of brain; classic monoamine theory (emphasis on deficiency of NE, 5HT, DA)

40
Q

neuroconduction-neurotransmission cascade

A

communication between neurons accomplisehd through action potentials and neuro-chemical events: depolarization, repolarization, resting stage, postsynaptic neuroreceptor binding

41
Q

nonselective NE-5HT reuptake inhibitors considerations

A

not first line, high SEs profile. 1 week rx can cause death in overdose. careful with refill amounts w/new onset of depression, hx of suicide, high risk populations

42
Q

depression goals

A

treat to remission! understand contributing factors. education: neurobiology, counseling/coping skills

43
Q

neurotransmitters involved with depression

A

serotonin 5HT, NE, dopamine DA, gamma-aminobutyric acid GABA, acetylcholine Ach

44
Q

aminoketones (also called NE-DA reuptake inhibitor) uses and precautions

A

used to treat smoking (blocks receptor sites in reward center). increased risk for seizures. not effective to treat anxiety (may exacerbate anxiety, agitation). Has been used as drug of abuse.

45
Q

monoamine oxidase inhibitors (MAOIs) action and precautions

A

block monoamine oxidase (the enzyme that terminates the actions of neurotransmitters) by binding to enzyme and permanently inactivating it. Allows for levels of NE, DA, and 5HT to rise. Synthesis of replacement MAOI takes about 2 weeks. should ONLY be rx by psychiatrist. Sig dietary restrictions, if not followed, can contribute to deadly SEs. many food/drug/drug interactions. not first line. low safety margin.

46
Q

nonselective NE-5HT reuptake inhibitors action

A

previously referred to as trycyclics/TCAs. Inhibit reuptake of NE and 5HT while also blocking serotenergic, alpha adrenergic, histaminic, and muscarinic receptors.

47
Q

NE and 5HT specific agonist action, SEs

A

block 5-HT-2 and -3 receptors, leading to increase in NE, 5HT. Also blocks histamine, causing drowsiness and weight gain. Remeron/mirtazapine

48
Q

non-benzo GABA agonist available

A

Buspar/buspirone

49
Q

neurobiology of anxiety

A

neurotransmitters like GABA, glutamate, NE, 5HT all been associated with CSTC loop and information processing in amygdyla in all of anxiety disorders. Neurobiology leads to more understanding why certain meds that increase GABA and 5HT helpful

50
Q

serotonin norepinephrine reuptake inhibitors SNRIs caution

A

because of addition of NE, are lethal in overdose

51
Q

serotonin norepinephrine reuptake inhibitors SNRIs action

A

increase levels of 5HT and NE by inhibiting their reuptake into cells in brain

52
Q

pharmacodynamics of anxiety and depression drugs

A

all current psychoactive drugs affect the neuroconduction-neurotranmission cascade. classes of drugs used for anxiety and depression: nonselective norepinephrine-serotonin reuptake inhibitors, SSRIs, SNRIs, NE-DA antagonists, serotonin agonist reuptake inhibitor, NE and 5HT specific agonist, MAOI, benzos/GABA-ergics

53
Q

non drug approaches to anx/depr

A

exercise, CBT, exposure therapy, EMDR, ST psychodynamic psychotherapy

54
Q

monitoring with anx/depr

A

once treatment started, assess frequently for response, SEs, safety, SI, adherence. When considering fu frequency, consider severity of illness, co-occuring med conditions, avail support system, progression of symptom change, pts cooperation w/treatmetn. eval is essential component: referral if no change even when adjusing meds, minimal response, need to reassess dx

55
Q

additional risks antidep/anx meds - SI

A

adolescents, young adults, and anyone w/dep or anxiety have increased risk of SI w/drug start and dose adjust (safety plan always in place, s/s to warn pt to report immediately).

56
Q

rational drug selection for anxiety and depression

A

having correct dx (know rel btwn anx/depr), understanding populations (elderly vs child vs teen), understanding neurobiology, look for high risk pops, look for comorbidities (drug/alc, chronic illness, learning disability, ADHD, other pyschiatric disorders)

57
Q

when planning to d/c antidepressant

A

select target time when stressors low. tapered over at least several weeks. relapse risk high in first 2mos after d/c, important to fu during that time

58
Q

pt education anx/dep

A

evaluation must be ongoing. monitor increase in SI/behavior (all those rx antidepresant and parents). understand role of counseling, lifestyle, stress reduction. after d/c, ed on s/s and potential of relapse and need to restart if they occur

59
Q

when to refer anx/dep patient

A

fail adequate trial of 1 antidepressant. suspect bipolar. Someone with sig suicide hx or current suicidal thinking. suspect drugs, alc, PD might be contributing to antidepressant failure

60
Q

antidepressants in prego

A

risk/ben discussion needs to happen with all women of childbearing age. risks of fetal damage like primary pulm HTN, premie, LBW. also evidence of poor neonatal outcomes in moms not treated for depression.

61
Q

TCAs PK, PD, ADRs

A

act on 5HT, NE, histamine, Ach. fairly long 1/2 life 6-18r. strong CYP2D6 met. ADRs: paradoxical diaphoresis, causing anticholinergic effects, ortho hypo, sedation, drowsiness. imipramine: also used for nocturnal enuresis, intractable pain, anxiety disorders.

62
Q

MAOIs side effects

A

ortho hypo, HA, insomnia, diarrhea, hypertensive crisis when used with other antidepressants or sympathomimetic drugs or with foods containing tyramine

63
Q

Zoloft PK and PD

A

all SSRIs have inhibitory effects on presynaptic serotonin reuptake and weak effects on NE and DA neuronal uptake. slow absorption, 26h half life, extensive first pass met. Fluoxetine half life 1-3 days and first metabolite 4-16 days!. Liver met may involve 2C19 and 2D6

64
Q

TCAs pt ed and monitoring

A

doing d/c abruptly. avoid OTCs. must let provider know if having MI, glaucoma. must report any CP. Baseline EKG. Reassess patient after 2-4 weeks starting (suicide, ADRs)

65
Q

monitoring and pt ed for SSRIs

A

never give >4wk first rx. watch electrolytes in elderly. ed: adherence, avoid ETOH, OTC meds that stimulate, insomnia or drowsiness, SI. preg cat C

66
Q

MAOIs PK and PD

A

inactivate enzymes that met NE, 5HT, DA. They prevent breakdown of tyramine found in many foods. Major first pass effect of liver met and most have CYP450 2D6 as substrate. quick onset: 1-2 weeks

67
Q

SNRI uses, PK, PD

A

duloxetine/Cymbalta, venlafaxine/Effexor. MDD, GAD, neuropathic pain, fibromyalgia. NOT approved for kids. considered atypical antidepressants. Inhibit reuptake of 5HT and NE. NOT used in pts with narrow angle glaucoma. PK: food decreases absorption, 8-17h 1/2 life. met in liver by CYP 1A2 and 2D6, forms multiple metabolites. watch with quinolone abx.

68
Q

SNRI pt ed, ADRs, monitoring

A

HA, somnolence, dizzy, insomnia, fatigue, dry mouth, constipation, ortho hypo, may increase BG, urinary retention. ed: adherence, SI, avoid OTCs. Mtr: used with MAJOR depresison, may increase serum transamine levels: watch in pts with liver disease, watch for elite imbalances elderly

69
Q

serotonergic anxiolitics

A

buspirone. reduced first pass affect, has many metabolites, one has noradrenergic effects NOT used with panic attacks. takes up to 2 weeks for onset to occur and up to 6 weeks for max effect

70
Q

barbiturates (cat II-IV)

A

short acting: phenobarbitol (Nembutal, secobarbital/Seconal). intermediate: amobarbital/Amytal, aprobarbital/Alurate, butabarbitol (Mebaral), PHENOBARBITAL/LUMINAL, (1/2 life in children 30-72h, in adults 50-150hr).

71
Q

sedative hypnotics (non-benzos)

A

zolpidem/Ambien, zaleplon/Sonata, eszopiclone/Lunesta

72
Q

sedative hypnotics (benzo)

A

flurazepam/Dalmane, temazepam/Restoril, triazolam/Halcion

73
Q

anxiolytics

A

benzos, serotonergic anxiolytics, barbiturates

74
Q

valproates for mood stabilization

A

add everything here

75
Q

lithium carbonate (Lithobid, Esaklith)

A

unknown MOA. absorbed in GI, no protein binding, NOT met in liver, excreted by kidney. long half life: 15-36h, steady state 5-7d. very narrow therapeutic index (0.6-1.5mEz/L), monitor levels every 10-14d after initiating, then every 2-3mos. ed: maintain adequate salt intake.

Pharmacology Exam 3 (4 decks)

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