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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
Serotonin syndrome
HTN, NV, diaphoresis, hallucinations, delirium, coma Watch out for MAOIs : linezolid ( zyvox ) , dextromethorphan, sumatriptan, tramadol, methadone, St. John’s wort
26
SSRIs and bleeding Side effects:
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
HOWS G
H- hypotension , HA , hyponatremia, O - occular (eye), bOne W- weight gain S- sexual dysfunction, suicidal thinking, serotonin syndrome G— GI bleed
28
SSRI drug interactions
29
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?
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
Tamoxifen has DDI with
Fluoxetine ( 2d6 inhibitor ) which can decrease tamoxifen Paroxetine strongest 2d6 inhibitor Sertraline moderate to weak 2d6 inhibitor
31
Sarafem
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
33
Trintellix
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
SNRIs
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
SNRIs SE
HOWS G But increases blood pressure. And a pseudoanticholinergic effect ( Constipation , dry mouth, urinary retention )
36
Tamoxifen and duloxetine DDi
Duloxetine is a 2d6 inhbitors and this is a SNRI
37
Milnacipran
Savella SNRI Approved for fibromyalgia SE: similar to other SNRI and SSRI
38
Levomilnacipran
Fetzima Indicated for depression ( not fibromyalgia ) not recommended in ESRD Never take this medication with alcohol
39
NE & dopamine reuptake inhibitor
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
Serotonin modulators
Trazodone ( sedating and can cause pripiasm ) Nefazodone Vilazodone All are hepatically cleared
41
Nefazodone
indication: MDD SE: hepatotoxicity -BBW , no pripiasm
42
Vilazodone
Viibryd Increases serotonin but no weight gain. indication: MDD Taper very slow to decrease GI upset Dc for 14 days before MAOI
43
Mirtazapine
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
TCA’s tertiary amines
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
TCA secondary amines
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
TCAs MOA
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
Imipramine indication
Night time bed wetting We can also use DDAVP and anticholinergics
48
you can OD on TCA with arrhythmia but not SSRI
T SSRI will cause serotonin side effects
49
MAOIs Monoamine oxidase inhibitors
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
MAOI MOA
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
52
Antipsychotics approved for MDD
Aripiprazole ( abilify ): at lower doses Olanzapine / fluoxetine ( symbyax) Quetiapine ( seroquel XR ) Brexipiprazole ( rexulti)
53
Symbyax
Olanzapine /fluoxetine Take qhs at night
54
If metabolic changes are a concern , suggest abilify instead of olanzapine
T
55
OTC for depression
SAME-e : watch for serotonin syndrome St. John’s wort -increases serotonin ( watch for additive ) -inducer -photosensitivity at higher doses
56
Brexanolone
Zulresso Indication: postpartum depression IV***** IV infusion for 2.5 days, ( 60 h ) BBW: excessive sedation and loss of consciousness
57
Esketamine
(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
Lithium
Bipolar disorder

SHPCPJEN3 (13 decks)

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