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SHPCPJEN3 > ANXIETY/DepressionSH > Flashcards

ANXIETY/DepressionSH Flashcards

1
Q

Chronic anxiety

A

SSRIs, SNRIs, buspirone, NOT a benzodiazepines

BBs ( propranolol ) somatic sx associated with anxiety, stage fright

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2
Q

Benzodiazepines MOA

A

Enhances inhibitory effect of GABA by increasing neuronal permeability to chloride ions. Shift in chloride ions results in hyper polarization( a less excitable state ).

Alcohol, propofol, non benzo ( zolpidem, zaleplon , phenobarbital ) all work on benzo receptors

Benzo schedule 4

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3
Q

Duration of benzos by group

A

Long acting ( 1/2 life: 24-100 hours )
• diazepam ( has active metabolites )

Intermediate: 12-24 hours
• lorazepam ( no active metabolite

Short - acting: <12 hours

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4
Q

LOT

A

Lorazepam
Oxazepam
Temazepam

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5
Q

Long acting

A

Increased sedation and hangover effects

Chlordiazepoxide ( Librium ) —- PO
•anxiety and alcohol withdrawal
Clonazepam( klonopin ) :—— PO
•panic and seizure disorders
Diazepam ( Valium ) —— IV, IM, oral tabs / soln, rectal gel ( seizures )
• anxiety, seizures, status epilepticus, alcohol withdrawal
Flurazepam ( dalmane) : PO
• insomnia

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6
Q

Diazepam has quick onset and gives a euphoria effect to patients and gives cause for abuse

A

T

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7
Q

Lorazepam

A

IV, IM, oral tabs , oral soln, ( NO RECTAL GEL )

Off label use: chemo associated N/V
Not first line just as add on
First line was ( 5HT inhibitors , add steroid, then add emend : main therapy )

Medium half life

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8
Q

Temazepam ( restoril )

A

Oral for insomnia

Medium half life

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9
Q

Estazolam

A

ProSom

Only for insomnia I

Medium half life

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10
Q

Alprazolam

A

Xanax: only PO

Short half life ( <12 H )

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11
Q

Oxazepam

A

PO only
1/2 life: 8 hours
Short half life ( <12 H )

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12
Q

Triazolam

A

( halcion )
PO tabs

Insomnia use approved only not anxiety

Short half life ( <12 H )
• triazolam shortest half life 1-6 hours

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13
Q

All benzos except LOT are substrates

A

T

Inhbitors can increase them and inducers can decrease them

Really worry about inhibitors bc they can increase benzo ( respiratory depression and death )

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14
Q

Midazolam

A

IV, IM, Oral syrup/ anesthesia

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15
Q

Pregnancy category for benzodiazepines?

Boxed warning for benzo?

A

Pregnancy category D

BBW: can be lethal if combined w/ opioids, alcohol, or other meds that depress CNS, result in respiratory depression and deaths

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16
Q

Benzo withdrawal sx

A

Severe effects on sleep, tremors, muscle aches, poor coordination, mild paranoia, confusion, anxiety, psychosis, and seizures.

Withdrawal after LT tx and rebound anxiety after short term tx.

Patients can have seizures if coming off of it. Benzos work on that gaba receptors and now with no benzo receptor in excitatory state : seizures

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17
Q

Antidote for benzo overdose

A

FLumazenil

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18
Q

Benzo metabolism

A

Hepatic

Inhbitors that will increase benzo:

Inhibitors ( 3A4) :
•Clarithromycin, erythromycin, telithromycin
• Ketoconazole, itraconazole, fluconazole, voriconazole,
• verapamil, diltiazem,
• Ritonavir( strongest 3a4 inhbitors ) , nelfinavir, saquinavir
• HIV PIs
• Grapefruit juice

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19
Q

Buspirone

A

MOA: not completely understood. Does increase serotonin ( we worry about additives and dont give with a MAOI )
Indicated for anxiety only

Does not help with acute anxiety attack.
With or without food.

Cyp3a4 substrate ( avoid grapefruit juice )

SE: dizziness and drowsiness. HA nervousness

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20
Q

Depression

A

Five or more sx present nearly every day for 2 weeks. At least one of the sx is depressed mood or 2 loss of interest or pleasure

SIG E CAPS

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21
Q

Meds for Depression

A

SSRI
SNIR
NDRI
Serotonin modulators
TCAs
MAOIs
Antipsychotics for MDD

OTC meds for depression

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22
Q

SSRIs

A

Citalopram ( celexa )
Escitalopram ( lexapro )
Fluoxetine ( Prozac, sarafem)
Fluvoxamine ( Luvox ) : only approved for OCD
Paroxetine ( Paxil ) pregnancy category D ( all the rest are C )
Sertraline ( Zoloft )

Vortioxetine ( trintellix )
Vilazodone ( Viibryd)
* Not only functions as a SSRI ( SE like SSRI ) but slightly different. It’s a 5HT1 B partial agonist , 5HT3 and 5HT7 antagonists

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23
Q

dx for depression

A

SIG E CAPS

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24
Q

SSRIs MOA

A

MOA: inhibit reputable of serotonin ( 5 HT ) at all 5 HT receptors acting as a serotonin agonist.

• 5-HT1 involved in depression
• 5-HT2 causes sexual dysfunction
•5-HT3 causes GI side effects ( when patients have N/V from chemo we use a 5HT-3 inhibitor ( zofran ) so if we increase 5HT3 it’ll cause GI effects )

25
Q

Serotonin syndrome

A

HTN, NV, diaphoresis, hallucinations, delirium, coma

Watch out for MAOIs : linezolid ( zyvox ) , dextromethorphan, sumatriptan, tramadol, methadone, St. John’s wort

26
Q

SSRIs and bleeding

Side effects:

A

SSRI’s can increase GI bleed similar to nsaids

Fluvoxamine and celexa are associated with less bleeding.

SE: activating/sedating, GI , weight gain, sexual dysfunction, HA, hyponatremia , orthostatic hypotension…

27
Q

HOWS G

A

H- hypotension , HA , hyponatremia,
O - occular (eye), bOne
W- weight gain
S- sexual dysfunction, suicidal thinking, serotonin syndrome

G— GI bleed

28
Q

SSRI drug interactions

A
29
Q

If patient on Prozac ( fluoxetine ) and we want patient to start a medication that is a MAOI how long does the patient have to wait before starting MAOI?

A

5 weeks bc fluoxetine has a long half life.

Also you dont need to wean off fluoxetine bc of the long half life.

Also MAOIs should be d/c 14 days before starting fluoxetine.

30
Q

Tamoxifen has DDI with

A

Fluoxetine ( 2d6 inhibitor ) which can decrease tamoxifen

Paroxetine strongest 2d6 inhibitor
Sertraline moderate to weak 2d6 inhibitor

31
Q

Sarafem

A

recall 28 day cycle on day 14 is when progesterone increases ( mood changes, hunger ) so you start sarafem( fluoxetine ) on day 14 and take for 2 weeks and stop when she has menstruation

32
Q
A
33
Q

Trintellix

A

Vortioxetine
Indications: MDD ( depression )
Increases serotonin ( so similar SE )
But also partial agonist
And 5ht3 antagonist

Dont use MAOIs w/in 21 days of stopping trintellix

One big difference: no significant effect on weight gain

34
Q

SNRIs

A

serotonin norepinephrine reuptake inhibitors

• venlafaxine ( Effexor )
• desvenlafaxine ( pristiq )
•desvenlafaxine ( Khedezla )
•duloxetine ( cymbalta )
•milnacipran ( savella )
•levomilnacipran ( fetzima )

All SNRI need dose adjustment in renal/ hepatic

SE: GI , dizziness , dry mouth , sweatiness, can increase BP ( SSRIs were crusting hypotension , but SNRI cause hypertension )

35
Q

SNRIs SE

A

HOWS G

But increases blood pressure.
And a pseudoanticholinergic effect ( Constipation , dry mouth, urinary retention )

36
Q

Tamoxifen and duloxetine DDi

A

Duloxetine is a 2d6 inhbitors and this is a SNRI

37
Q

Milnacipran

A

Savella
SNRI
Approved for fibromyalgia

SE: similar to other SNRI and SSRI

38
Q

Levomilnacipran

A

Fetzima
Indicated for depression ( not fibromyalgia )

not recommended in ESRD

Never take this medication with alcohol

39
Q

NE & dopamine reuptake inhibitor

A

Bupropion

Wellbutrin SR
XL
Aplenzin ( ER )
Zyban

SE: weight loss , GI

A 2D^ inhibitor

This does not affect serotonin at all so no serotonin side effects ( Sexual dysfunction )

In this class we worry about increasing chance of seizures. Dont want to go above max dosage. Seizure risk is dose related

40
Q

Serotonin modulators

A

Trazodone ( sedating and can cause pripiasm )

Nefazodone

Vilazodone

All are hepatically cleared

41
Q

Nefazodone

A

indication: MDD

SE: hepatotoxicity -BBW , no pripiasm

42
Q

Vilazodone

A

Viibryd

Increases serotonin but no weight gain.

indication: MDD

Taper very slow to decrease GI upset

Dc for 14 days before MAOI

43
Q

Mirtazapine

A

Remeron

Indication: MDD
Used to increase weight gain and for sleep.

SE: sedation, weight gain
And comes in ODT

MOA: alpha 2 adrenergic antagonist, -> increase NE
And serotonin R antagonists

44
Q

TCA’s tertiary amines

A

Tricyclic antidepressants
Problem : major anticholinergic

Tertiary amine ( Higher serotonin reuptake blockage ) ( recall secondary TCA have higher NE effect )

• amitriptyline ( elavil )
Indicated for : depression, off label uses: chronic pain, diabetic neuropathy , migraine prophylaxis , PTSD

•clomipramine ( anafranil ) : OCD

•doxepin ( silenor ) : for insomnia , depression, anxiety
Off label : chonic urticaria ( hives )

•imipramine ( tofranil )
Indicated

45
Q

TCA secondary amines

A

Secondary amines ( higher norepinephrine/ serotonin reuptake blockade ratio )

• amoxapine : depression ( TCAs are not first line but eventually can try a TCA if needed )

• desipramine ( norpramin )

• maprotiline

•nortriptyline ( pamelor )

46
Q

TCAs MOA

A

Both 3° and 2°: NE and serotonin
If 3°: higher serotonin effect and 2° more norepi effect

All effect alpha: all can cause orthostatic hypotension, histamine ( wg and sedation ), all anticholinergic

47
Q

Imipramine indication

A

Night time bed wetting

We can also use DDAVP and anticholinergics

48
Q

you can OD on TCA with arrhythmia but not SSRI

A

T
SSRI will cause serotonin side effects

49
Q

MAOIs
Monoamine oxidase inhibitors

A

Inhibit MAOI-a and MAOI-b

•Isocarboxazid ( marplan )
•phenelzine ( nardil )
• tranylcypromine ( parnate )
- chemical structure similar to amphetamine

Selegiline ( Emsam ) - QD patch
Comes in a patch ( at lower dose ( 6mg ) only effects MAOb and not MAOa) non selective at higher doses.

50
Q

MAOI MOA

A

MOA: inhibit MAO enzyme, causing a decrease in breakdown of dopamine, serotonin and NE in the synapse.

Indications: can be effective in treatment resistant depression.

51
Q
A
52
Q

Antipsychotics approved for MDD

A

Aripiprazole ( abilify ): at lower doses

Olanzapine / fluoxetine ( symbyax)

Quetiapine ( seroquel XR )

Brexipiprazole ( rexulti)

53
Q

Symbyax

A

Olanzapine /fluoxetine

Take qhs at night

54
Q

If metabolic changes are a concern , suggest abilify instead of olanzapine

A

T

55
Q

OTC for depression

A

SAME-e : watch for serotonin syndrome

St. John’s wort
-increases serotonin ( watch for additive )
-inducer
-photosensitivity at higher doses

56
Q

Brexanolone

A

Zulresso

Indication: postpartum depression
IV*****

IV infusion for 2.5 days, ( 60 h )

BBW: excessive sedation and loss of consciousness

57
Q

Esketamine

A

(Spravato ). CIII

MOA: NMDA receptor antagonists

Administered by healthcare provider

Indicated : treatment resistant depression

SE: disassociation feeling of detachment , sedation, vertigo , BP , vomiting and feeling drunk

58
Q

Lithium

A

Bipolar disorder

SHPCPJEN3 (13 decks)

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