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Pharm > Anxiety and Depression > Flashcards

Anxiety and Depression Flashcards

1
Q

The monoamine theory of depression emphasized

A

deficiency of norepinephrine (NE), serotonin (5-HT) and dopamine (DA)

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2
Q

Depressed mood-> processing issues in the

A

amygdala and the prefrontal cortex

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3
Q

Sleep and appetite-> dysfunction in the

A

hypothalamus

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4
Q

Fatigue-> NE and DA dysregulation in the

A

prefrontal cortex and nucleus accumbens

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5
Q

Guilt, suiciality and worhlessness -> dysregulation in the

A

prefrontal cortex and the amygdala

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6
Q

Worry and obsession -> dysfunction of the

A

cortico-striatal-thalamo-cortical (CSTC) loops in the brain

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7
Q

GAD-> dysfunction of the circuits and the

A

amygdala that are persistent may be the cause of persistent worry, whereas a repetitive loop may be involved in OCD.

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8
Q

PTSD

A

The dysfunction of the amygdala in interpretation of traumatic events and the hippocampus in the memory and re-experiencing of these events

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9
Q

Panic attacks and phobias involve the malfunctioning of neurotransmitters that include the

A

monoamines as well as gamma-aminobutyric acid (GABA) and glutamate

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10
Q

There’s no consensus on the best treatment for

A

PTSD

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11
Q

Non Selective Norepinephrine-Serotonin Reuptake Inhibitors used to be called

A

TCAs (tricyclic antidepressants)

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12
Q

TCAs (tricyclic antidepressants) are now called

A

Non Selective Norepinephrine-Serotonin Reuptake Inhibitors

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13
Q

Non Selective Norepinephrine-Serotonin Reuptake Inhibitors (TCAs) work by

A

stopping the reuptake of NE and 5HT while also blocking serotonergic, alpha-adrenergic, histaminic, and muscarinic receptors.
Increases in NE and 5HT binding to postsynaptic receptors

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14
Q

Non Selective Norepinephrine-Serotonin Reuptake Inhibitors (TCAs) have 2 benefits:

A

Efficacious
Low cost
(Nevertheless, the risks outweigh the benefits)

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15
Q

Some problems with Non Selective Norepinephrine-Serotonin Reuptake Inhibitors (TCAs) are

A 
Highly sedating
Weight gain common 
Gynecomastia , decreased libido/ sexual dysfunction
Overdose potential 
Cardiac arrhythmia 
hypotension
seizures
death
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16
Q

Non Selective Norepinephrine-Serotonin Reuptake Inhibitors (TCAs): What time should you take them

A

bed time because they are sedating

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17
Q

Non Selective Norepinephrine-Serotonin Reuptake Inhibitors (TCAs): What quality causes weight gain and sedation

A

histaminergic actions

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18
Q

Non Selective Norepinephrine-Serotonin Reuptake Inhibitors (TCAs): can cause cardiac arrhythmia because they have a

A

direct alpha adrenergic and quinidine like effect on the heart

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19
Q

Non Selective Norepinephrine-Serotonin Reuptake Inhibitors (TCAs): ADRs

A

Adverse effects include urinary hesitancy/retention, lowering seizure threshold, ECG changes

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20
Q

Non Selective Norepinephrine-Serotonin Reuptake Inhibitors (TCAs): Pharmacokinetics: Highly ____ and ___ ___

A

Highly lipophilic and protein bound

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21
Q

Amitriptyline and imipramine (TCAs) have active metabolites which

A

extend their half lives

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22
Q

Non Selective Norepinephrine-Serotonin Reuptake Inhibitors (TCAs): Should they be used during pregnancy

A

unknown

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23
Q

Non Selective Norepinephrine-Serotonin Reuptake Inhibitors (TCAs): Stopping the regimen

A

Abrupt discontinuation -> nausea, headache, vertigo, malaise and nightmares

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24
Q

Non Selective Norepinephrine-Serotonin Reuptake Inhibitors (TCAs): Monitoring: ECG

A

Risk of conduction issues- sinus tachycardia due to NE reuptake inhibition and anticholinergic actions
Prolongation of QRS complex and PR/QT intervals due to slowing of depolarization of the cardiac muscles

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25
Q

Non Selective Norepinephrine-Serotonin Reuptake Inhibitors (TCAs): Monitoring: Suicidal ideations

A

Monitor for sudden “ups” then “downs”

Do not give them more than 1 week worth of medicine

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26
Q

Non Selective Norepinephrine-Serotonin Reuptake Inhibitors (TCAs): Monitor for potential to lower ____ thresholds

A

seizure

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27
Q

Non Selective Norepinephrine-Serotonin Reuptake Inhibitors (TCAs): Monitoring: Elderly

A

Anticholinergic and norepinephrine effects can contribute to confusion, orthostatic hypotension and falls.

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28
Q

Non Selective Norepinephrine-Serotonin Reuptake Inhibitors (TCAs): ____ risks increase with use of SRIs, cannabis, and sympathomimetics

A

Cardiotoxicity

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29
Q

Non Selective Norepinephrine-Serotonin Reuptake Inhibitors (TCAs): Cardiotoxicity risks increase with use of

A

SRIs, cannabis, and sympathomimetics

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30
Q

Non Selective Norepinephrine-Serotonin Reuptake Inhibitors (TCAs): ____ can occur with MAOIs + TCAs

A

Hyperpyrexia

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31
Q

Non Selective Norepinephrine-Serotonin Reuptake Inhibitors (TCAs): Hyperpyrexia can occur with

A

MAOIs + TCAs

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32
Q

Non Selective Norepinephrine-Serotonin Reuptake Inhibitors (TCAs): For OCD, which TCA would you use

A

clomipramine

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33
Q

Non Selective Norepinephrine-Serotonin Reuptake Inhibitors (TCAs): Can be used for Anxiety disorders due to

A

serotonergic and noradrenergic effects

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34
Q

Non Selective Norepinephrine-Serotonin Reuptake Inhibitors (TCAs): For Panic Disorder, which TCA would you use

A

imipramine

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35
Q

Non Selective Norepinephrine-Serotonin Reuptake Inhibitors (TCAs): imipramine is for

A

Panic Disorder

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36
Q

Non Selective Norepinephrine-Serotonin Reuptake Inhibitors (TCAs): clomipramine is used for

A

OCD

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37
Q

Non Selective Norepinephrine-Serotonin Reuptake Inhibitors (TCAs): for Insomnia you would give

A

Doxepin, amitriptyline and trazodone

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38
Q

Non Selective Norepinephrine-Serotonin Reuptake Inhibitors (TCAs): Amitriptyline and imipramine are for

A

Neuropathic pain

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39
Q

Non Selective Norepinephrine-Serotonin Reuptake Inhibitors (TCAs): for Neuropathic pain use

A

Amitriptyline and imipramine are for

40
Q

Non Selective Norepinephrine-Serotonin Reuptake Inhibitors (TCAs): Doxepin, amitriptyline are used for

A

insomnia (and so is trazadone)

41
Q

Non Selective Norepinephrine-Serotonin Reuptake Inhibitors (TCAs): Some random problems they can be used for

A

Enuresis in children > 6 years old

Eating disorder

42
Q

SSRIs: ___ has the longest half life - up to 16 days

A

Fluoxetine

43
Q

SSRIs: __ __ washout period when considering MAOIs

A

2 week (at least 3 with fluoxetine)

44
Q

SSRIs: Monitor in ___ renal and hepatic impairment

A

severe

45
Q

SSRIs: pregnancy

A

Avoid use in the first and last trimesters of pregnancy

Sertraline is safest, paroxetine is NOT safe

46
Q

SSRIs: St. John’s Wort and SAMe may increase risk of

A

serotonin syndrome

47
Q

SSRIs: use in children: for OCD use

A

Fluoxetine
Fluvoxamine
Sertraline

48
Q

SSRIs: use in children: for Major depression use

A

Fluoxetine

Escitalopram

49
Q

Serotonin partial agonist reuptake inhibitor (SPARI) example

A

Vilazodone

50
Q

Vilazodone (Serotonin partial agonist reuptake inhibitor) is used for

A

adult major depressive disorder

51
Q

SSRIs: Sexual dysfunction

A

35% of patient may experience sexual dysfunction -> may decrease dose or change agent in the same class

52
Q

Serotonin syndrome symptoms

A

nausea, diarrhea, chills, sweating, hyperthermia, hypertension, myoclonic jerking, tremor, agitation, ataxia, disorientation, confusion and delirium

53
Q

Serotonin syndrome : Drug causes:

A

tramadol, meperidine, St.John’s wort, dextromethorphan, decongestants

54
Q

SSRIs: Withdrawal symptoms are likely with the agents that have

A

short half lives (paroxetine, sertraline, citalopram, and escitalopram)

55
Q

SSRIs: All of them need to be tapered except for

A

Fluoxetine because it has a long half life

56
Q

SSRIs: Citalopram: Limit of 40mg per day due to

A

QT prolongation

57
Q

SSRIs: Citalopram: Age consideration

A

Age over 60 years at higher risk (if over 60 Maximum dose of 20mg daily and QTc>500 ms)

58
Q

SSRIs: uses

A 
Depression
Anxiety
Panic disorders
OCD (fluvoxamine- only approved use)
Bulimia 
Premenstrual Dysphoric disorder
Post-traumatic Stress disorder
Generalized anxiety disorder
Social phobia
59
Q

SSRIs: Benefits

A

Due to minimal effects on norepinephrine, DA, histamine, or acetylcholine there are few adverse reactions due to the blockade of these receptors
Anxiety, restlessness, drowsiness, constipation, and orthostasis

60
Q

SSRIs: Disadvantages

A

Reduced sexual desire, delayed or absent orgasm, premature ejaculation, and erectile disturbances are most common with SSRIs
Occurs in about a month
Use of sildenafil or tadalafil may be considered

61
Q

Serotonin-norepinephrine reuptake inhibitors (SNRIs): Examples

A

Venlafaxine, duloxetine, desvenlafaxine, levomilnacipran, milnacipran, nefazodone

62
Q

Serotonin-norepinephrine reuptake inhibitors (SNRIs): Mechanism of action

A

Blocks the reuptake mechanism of NE and 5HT, allowing greater availability of these neurotransmitters to bind with receptors in the brain

63
Q

Serotonin-norepinephrine reuptake inhibitors (SNRIs): Metabolism and excretion

A

Metabolized extensively in the liver

64
Q

Serotonin-norepinephrine reuptake inhibitors (SNRIs): Caution

A

Duloxetine may exacerbate narrow-angle glaucoma and can increase serum transaminase levels

65
Q

Serotonin-norepinephrine reuptake inhibitors (SNRIs): Adverse Effects: Venlafaxine and duloxetine

A

Headache, somnolence, dizziness, insomnia, nervousness, nausea, dry mouth, constipation, and abnormal ejaculations
Appetite and weight decreases
May increase BP

66
Q

Serotonin-norepinephrine reuptake inhibitors (SNRIs): Adverse Effects: Milnacipran

A

Nausea, headache, constipation, hot flush, dizziness, hyperhidrosis, palpitations, sexual dysfunction in men

67
Q

Serotonin-norepinephrine reuptake inhibitors (SNRIs): Adverse Effects: Levomilnacipran

A

Nausea, constipation, hyperhidrosis, tachycardia; dose related- erectile dysfunction and urinary hesitancy

68
Q

Serotonin-norepinephrine reuptake inhibitors (SNRIs): Uses: All are approved to treat

A

major depressive disorders and bipolar mood disorders

69
Q

Serotonin-norepinephrine reuptake inhibitors (SNRIs): Uses: Venlafaxine

A

Anxiety disorders - GAD, social phobia, PTSD

May be effective for adults with depression and ADHD

70
Q

Serotonin-norepinephrine reuptake inhibitors (SNRIs): Uses: Duloxetine

A

Neuropathic pain
Overactive bladder
Diabetic neuropathy

71
Q

Serotonin-norepinephrine reuptake inhibitors (SNRIs): Venlafaxine: Withdrawal symptoms

A

Withdrawal symptoms- paresthesias, dizziness, nausea, vomiting

72
Q

Serotonin-norepinephrine reuptake inhibitors (SNRIs): Considerations for Duloxetine

A

Doses greater than 60mg/day not considered to be of greater efficacy
Monitor liver function

73
Q

Serotonin-norepinephrine reuptake inhibitors (SNRIs): Uses: Levomilnacipran

A

Major depressive disorder

74
Q

Serotonin-norepinephrine reuptake inhibitors (SNRIs): Uses: Milnacipran

A

Fibromyalgia only

75
Q

Serotonin-norepinephrine reuptake inhibitors (SNRIs): NOT first choice for patients with:

A

uncontrolled HTN, preexisting sleep disturbance and autonomic instability
Overdose can be lethal

76
Q

Norepinephrine-dopamine reuptake inhibitors (NDRIs): Bupropion: Indications

A

Treatment of major depressive disorder, including seasonal affective disorder, adjunct smoking cessation

77
Q

Norepinephrine-dopamine reuptake inhibitors (NDRIs): Bupropion: Considerations

A

If a second daily dose is required, give second dose not later than 5 hours before bedtime due to its stimulating effects
Seizure risk at high doses- max daily dose 450mg

78
Q

Norepinephrine-dopamine reuptake inhibitors (NDRIs): Bupropion: Adverse effects

A

Dry mouth, sweating, tremors, nervousness

Lower incidence of sexual side effects

79
Q

Norepinephrine-dopamine reuptake inhibitors (NDRIs): Bupropion: Mechanism of action

A

Increases NE and DA by weakly inhibiting their neuronal reuptake

80
Q

Serotonin-agonist reuptake inhibitors (SARIs): Nefazodone and trazodone: Mechanism of action

A

Inhibit the reuptake of 5HT and blocks the postsynaptic 5HT2 receptor

81
Q

Serotonin-agonist reuptake inhibitors (SARIs): Nefazodone and trazodone: Place in therapy

A

Use side effects for treatment of insomnia

82
Q

Serotonin-agonist reuptake inhibitors (SARIs): Nefazodone: Black box warning-

A

hepatotoxicity

83
Q

Serotonin-agonist reuptake inhibitors (SARIs): trazodone:

A

Associated with priapism and anticholinergic side effects

Not first line therapy due to sedation and orthostatic hypotension

84
Q

Norepinephrine- and Serotonin specific agonists (NaSSAs): Mirtazapine: Mechanism of action

A

5HT agonist and reuptake inhibitor that blocks the reuptake of NE
Blocking 5HT2 and 5HT3 specifically results in less sexual, gastrointestinal, and anxiogenic side effects.
The blocking of histamine also results in drowsiness and weight gain
No antimuscarinic side effects of NNSRIs

85
Q

Norepinephrine- and Serotonin specific agonists (NaSSAs): Mirtazapine: Place in therapy

A

Depression in a patient with difficulty sleeping and weight loss

86
Q

Monoamine oxidase inhibitors (MAOIs): examples

A

Phenelzine, tranylcypromine, isocarboxazid, selegiline

87
Q

Monoamine oxidase inhibitors (MAOIs): Monoamine oxidase is an enzyme that contributes to the degradation of the monoamines-

A

DA, 5HT, and NE.

88
Q

Monoamine oxidase inhibitors (MAOIs): Mechanism

A

The MAOIs permanently block onoamine oxidase. It takes about 2 weeks to replace MAO. The catecholamines and 5HT will rise, and so will dietary tyramine and phenylethylamine levels because MAO is needed to metabolize them.

89
Q

Monoamine oxidase inhibitors (MAOIs): Adverse effects-

A

occipital headache radiating frontally, sweating, photophobia, palpitations, stiffness in the neck, nausea or vomiting

90
Q

Benzodiazepines: Short acting agents

A

Oxazepam and triazolam

91
Q

Benzodiazepines: Intermediate acting agents

A

Alprazolam, lorazepam, estazolam, temazepam

92
Q

Benzodiazepines: Long acting agents

A

Diazepam, quazepam, clorazepate, chlordiazepoxide, flurazepam

93
Q

Benzodiazepines: Mechanism of action-

A

decrease reactivity of the brain by enhancing GABA neurotransmission, which lengthens hyperpolarization of the impulse, slowing down responses to successive impulses

94
Q

Benzodiazepines: Place in therapy

A

Anxiolytic, anterograde amnesia, anticonvulsant, muscle relaxation and sedation

95
Q

Benzodiazepines: Advantages

A

Rapid onset of action
Tolerability
Little CV effect

96
Q

Benzodiazepines: Disadvantages

A

Dependence and withdrawal
Risk of overdose, respiratory depression and death
Sedation, impaired motor coordination and cognition
Depressive symptoms worsen
Abrupt discontinuation can lead to seizures and withdrawal symptoms

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