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4. Mood Disorders > CANMAT Guidelines: Depression Part 2 (pharmacology) > Flashcards

CANMAT Guidelines: Depression Part 2 (pharmacology) Flashcards

1
Q

effective dosing range for citalopram

A

20-40mg

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2
Q

effective dosing range for escitalopram

A

10-20mg

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3
Q

effective dosing range for fluoxetine

A

20-60mg

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4
Q

effective dosing range for fluvoxamine

A

100-300mg

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5
Q

effective dosing range for paroxetine

A

20-50mg

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6
Q

effective dosing range for sertraline

A

50-200mg

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7
Q

effective dosing range for venlafaxine

A

75-225mg

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8
Q

effective dosing range for desvenlafaxine

A

50-100mg

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9
Q

effective dosing range for duloxetine

A

60mg

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10
Q

effective dosing range for milnacipran

A

100mg

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11
Q

effective dosing range for buproprion

A

150-300mg

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12
Q

effective dosing range for mirtazapine

A

15-45mg

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13
Q

effective dosing range for mianserin

A

60-120mg

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14
Q

effective dosing range for vortioxetine

A

10-20mg

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15
Q

effective dosing range for agomelatine

A

25-50mg

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16
Q

list 3 factors that predict poorer response to AD therapy

A

increasing age

anxiety

longer episode

*age, sex, race, ethnicity do NOT predict outcomes with a specific AD

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17
Q

have differences in AD effectiveness (between different ADs) been shown for the following subtype:
melancholic

A

no differences reliably noted

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18
Q

have differences in AD effectiveness (between different ADs) been shown for the following subtype:

psychotic depression

A

AD + AP combo is better than either alone for treating psychotic depression

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19
Q

have differences in AD effectiveness (between different ADs) been shown for the following subtype:

atypical

A

no differences reliably noted

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20
Q

have differences in AD effectiveness (between different ADs) been shown for the following subtype:

mixed features

A

lurasidone or ziprasidone monotherapy (over placebo… not comparison to other ADs)

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21
Q

have differences in AD effectiveness (between different ADs) been shown for the following subtype:

anxious

A

no differences reliably shown though consider using AD that has evidence in treatment of anxiety as well

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22
Q

have differences in AD effectiveness (between different ADs) been shown for the following symptom clusters in MDD:

cognitive dysfunction

A

VORTIOXETINE–> largest effect on processing speed, executive control, cognitive control

duloxetine–> largest effect on delayed recall

SSRIs, buproprion, duloxetine, moclobemide–> may improve learning and memory and executive function

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23
Q

have differences in AD effectiveness (between different ADs) been shown for the following symptom clusters in MDD:

sleep disturbance

A

agomelatine

mirtazapine

trazodone

quetiapine

*all but agomelatine have side effects including daytime somnolence and sedation

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24
Q

have differences in AD effectiveness (between different ADs) been shown for the following symptom clusters in MDD:

pain

A

SNRIs, especially DULOXETINE

there are no comparative studies for fatigue or low energy

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25
Q

what are the principles of pharmacotherapy in MDD per the CANMAT guidelines

A
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26
Q

list patient factors to consider when choosing and antidepressant

A

clinical features and dimensions

comorbid conditions

response and side effects of previous ADs

patient preference

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27
Q

list medication factors to consider when choosing an antidepressant

A

comparative efficacy

comparative tolerability

potential drug interactions

simplicity of use

cost and availability

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28
Q

what medication or combo of meds should you choose for someone with MDD and:

anxious distress

A

antidepressant with efficacy in GAD
(no differences between SSRI, SNRI, buproprion)

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29
Q

have differences in AD effectiveness (between different ADs) been shown for the following symptom clusters in MDD:

catatonic features

A

benzodiazepines
–> no ADs have been studied

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30
Q

have differences in AD effectiveness (between different ADs) been shown for the following symptom clusters in MDD:

melancholic features

A

no specific antidepressants have demonstrated superiority–> TCAs and SNRIs have been studied

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31
Q

have differences in AD effectiveness (between different ADs) been shown for the following symptom clusters in MDD:

atypical features

A

no specific antidepressants have demonstrated superiority

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32
Q

have differences in AD effectiveness (between different ADs) been shown for the following symptom clusters in MDD:

with psychotic features

A

AP + AD combo

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33
Q

have differences in AD effectiveness (between different ADs) been shown for the following symptom clusters in MDD:

mixed features

A

lurasidone
ziprasidone

*no comparative studies done

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34
Q

have differences in AD effectiveness (between different ADs) been shown for the following symptom clusters in MDD:

with seasonal pattern

A

no specific ADs have demonstrated superiority–> SSRIs, agomelatine, buproprion, meclobemide have been studied

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35
Q

have differences in AD effectiveness (between different ADs) been shown for the following symptom clusters in MDD:

with cognitive dysfunction

A

level 1 evidence for VORTIOXETINE

also buproprion, duloxetine, SSRIS (level 2) and moclobemide (level 3)

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36
Q

have differences in AD effectiveness (between different ADs) been shown for the following symptom clusters in MDD:

with sleep disturbances

A

level 1 evidence for AGOMELATINE

mirtazapine, quetiapine, trazodone have level 2

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37
Q

have differences in AD effectiveness (between different ADs) been shown for the following symptom clusters in MDD:

with somatic symptoms

A

level 1 evidence for DULOXETINE (PAIN) and BUPROPRION (FATIGUE)

level 2 evidence for other SNRIs (pain), SSRIs (fatigue), and duloxetine (for energy)

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38
Q

which of the following groups/pairs of ADs have shown superiority in efficacy based on meta-analyses:

agolematine and sertraline

A

AGOMELATINE superior over sertaline

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39
Q

which of the following groups/pairs of ADs have shown superiority in efficacy based on meta-analyses:

paroxetine, citalopram, reboxetine

A

CITALOPRAM superior over paroxetine and reboxetine

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40
Q

which of the following groups/pairs of ADs have shown superiority in efficacy based on meta-analyses:

milnacipran and fluoxetine

A

FLUOXETINE superior over milnacipran

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41
Q

which of the following groups/pairs of ADs have shown superiority in efficacy based on meta-analyses:

SSRIS as a class, venlafaxine, mirtazapine

A

MIRTAZAPINE superior over SSRIs as a class and venalfaxine

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42
Q

which of the following groups/pairs of ADs have shown superiority in efficacy based on meta-analyses:

fluoxetine and paroxetine

A

PAROXETINE superior over fluoxetine

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43
Q

which of the following groups/pairs of ADs have shown superiority in efficacy based on meta-analyses:

sertraline and fluoxetine

A

SERTRALINE superior over fluoxetine

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44
Q

which of the following groups/pairs of ADs have shown superiority in efficacy based on meta-analyses:

escitalopram and citalopram

A

ESCITALOPRAM superior over citalopram

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45
Q

which of the following groups/pairs of ADs have shown superiority in efficacy based on meta-analyses:

fluoxetine and venlafaxine

A

VENLAFAXINE superior over fluoxetine

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46
Q

which of the following groups/pairs of ADs have shown superiority in efficacy based on meta-analyses:

escitalopram and duloxetine

A

ESCITALOPRAM over duloxetine

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47
Q

which of the following groups/pairs of ADs have shown superiority in efficacy based on meta-analyses:

fluoxetine and escitalopram

A

ESCITALOPRAM over fluoxetine

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48
Q

what have the differences in response rate generally been between ADs in head to head trials

A

modest–> 5-6%

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49
Q

list the 4 ADs that have level 1 evidence for superior efficacy per the CANMAT guidelines

A

escitalopram

mirtazapine

sertraline

venlafaxine

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50
Q

list the 2 ADs that have level 2 evidence for superior efficacy based on the CANMAT guidelines

A

agomelatine

citalopram

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51
Q

is there any AD that can be cited as demonstrating superior functional improvement?

A

no

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52
Q

which AD seems to have lower rates of sexual side effects

A

buproprion

(also vortioxetine, agomelatine, desvenlafaxine, mirtazapine, vilazodone)

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53
Q

which ADs seem to have higher rates of sexual side effects

A

escitalopram

paroxetine

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54
Q

are there clear differences in tolerability of ADs?

A

no–> based on product monographs

(*Dr. Rhandawa’s lecture I recall indicating that vortioxetine may be better tolerated)

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55
Q

what is the relationship between ADs and suicide risk

A

for SSRIs in adolescents–> DOUBLE the risk of suicide w SSRI use but this was based on OBSERVATIONAL studies (use caution; black box warning… no specific ADs, caution in all)

in adults (above age 25) and the elderly (above age 65), ADs seem to show decreased suicidal ideation + acts/attempts
in adults, risk may be DECREASED by as much as 40% and in elderly may be by as much as 50% with use of SSRIs

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56
Q

which 3 ADs have been most implicated with QTC prolongation

A

citalopram

escitalopram

quetiapine

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57
Q

what is the association between ADs and QTc prolongation/torsades

A

torsades is often idiosyncratic, unclear associations

per systemic review, can occur even at therapeutic dose and torsades can occur even with normal QTc

most cases had additional risk factors –> without additional risk factors, VERY LOW RISK with SSRIs/ADs

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58
Q

with which AD should you monitor LFTs

A

agomelatine–> can icnrease liver enzymes and there is sporadic toxic hepatitis

(uncommon with other ADs)

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59
Q

list 4 other possible adverse consequences of SSRI use

A
  1. increased falls
  2. increased fractures–> highest risk within first 6 weeks of exposure to SSRI
  3. hyponatremia
  4. inhibited platelet aggregation–> increased risk of GI bleeding
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60
Q

what population is particularly as risk of SSRI associated hyponatremia

A

elderly patients with other risk factors

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61
Q

what can increase the risk of GI bleed in patients taking SSRIs

A

NSAIDs–> concomittant NSAID use increases risk of GI bleed by 2x

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62
Q

what is one way to significantly reduce the risk of GI bleed in patients taking SSRIs

A

acid suppressing drugs

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63
Q

list 19 possible side effects of antidepressants

A
  1. nausea
  2. constipation
  3. diarrhea
  4. dry mouth
  5. headaches
  6. dizziness
  7. somnolence
  8. nervousness
  9. anxiety
  10. agitation
  11. insomnia
  12. fatigue
  13. sweating
  14. asthenia
  15. tremor
  16. anorexia
  17. increased appetite
  18. weight gain
  19. male sexual dysfunction
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64
Q

list 3 ADs associated in particular with the following side effect:

nausea

A

fluvoxamine

venlafaxine IR and XR

65
Q

what AD is particularly associated with headaches as a side effect

A

buproprion both SR and XL

(also venlafaxine and fluvoxamine)

66
Q

what are some of the most common side effects of ADs

A

nausea, dry mouth, headaches, sexual dysfunction, insomnia or somnolence

67
Q

which AD is associated with somnolence in particular

A

mirtazapine

68
Q

which ADs in particular might you want to mention side effects of nervousness/agitation

A

fluoxetine

venlafaxine and fluvoxamine to a lesser extent

69
Q

main side effects of the following AD:

escitalopram

A

nausea

sexual dysfunction

70
Q

main side effects of the following AD:

fluvoxamine

A

nausea++

constipation

dry mouth

headaches

dizziness

somnolence

insomnia

71
Q

main side effects of the following AD:

venlafaxine

A

nausea ++

dry mouth

headaches

dizziness

somnolence

nervousness

insomnia

sweating

male sexual dysfunction

72
Q

main side effects of the following AD:

mirtazapine

A

increased appetite

increased weight gain

somnolence++

dry mouth

constipation

73
Q

main side effects of the following AD:

vortioxetine

A

nausea

74
Q

are there differences in efficacy or tolerability between extended and immediate release versions of ADs

A

no–> may consider extended release if there are adherence/compliance issues

75
Q

what level of bioequivalence is required between generic and branded medications in the US and Canada

A

80-125% bioequivalence

76
Q

is there a difference between generic and branded meds?

A

generic are safe and reliable for MOST patients however–> consider the risk/benefit for switching patient who is benefitting from branded med

77
Q

what is the primary metabolic pathway for ADs

A

CYP 450 metabolic pathway in the liver

78
Q

name two ADs that are primarily metabolized via the CYP 1A2 pathway

A

agomelatine

duloxetine

*should not be coadministered with agents that inhibit the CYP1A2 pathway

79
Q

name two non psych medications that are potent inhibitors of the CYP1A2 pathway

A

cimetidine

ciprofloxacin

*note that fluvoxamine is also a potent CYP3A4 inhibitor

80
Q

name an AD that is primarily metabolized by CYP3A4

A

vilazodone

81
Q

name a common non psych medication that is a potent inhibitor of the CYP3A4 pathway

A

ketoconazole

*note that fluvoxamine is also a potent CYP3A4 inhibitor

82
Q

name 3 ADs that are potent CYP pathway inhibitors

A

fluoxetine

paroxetine

fluvoxamine

83
Q

which CYP enzyme foes fluoxetine inhibit

A

CYP2D6

84
Q

which CYP enzyme does paroxetine inhibit

A

CYP 2D6

85
Q

which CYP enzyme does fluvoxamine inhibit

A

CYP 1A2, 2C19, 3A4

86
Q

name 3 ADs that are moderate CYP inhibitors–which CYP enzyme do they inhibit

A

buproprion

duloxetine

sertraline

all inhibit 2D6

*these drug drug interactions are RARELY clinically relevant except at higher doses

87
Q

is there any consistent evidence of P-glycoprotein interactions with antidepressants (or antipsychotics)

A

no

88
Q

why is the P-glycoprotein system important

A

important component of the blood brain barrier and the intestinal barrier and affects efflux of medications (including psychotropic, cardiac and cancer agents)

89
Q

what drug combinations are particular risk for serotonin syndrome

A

when serotonergic or sympathomimetic drugs are combined with MAOIs like moclobemide and selegiline

SS is rare except in overdose but can occur with use of multiple serotonergic agents (i.e SSRIs, SNRIs, tramadol)

90
Q

list 5 antidepressants that have MINIMAL or LOW potential for drug-drug interactions

A

citalopram

desvenlafaxine

escitalopram

mirtazapine

venlafaxine

91
Q

list 7 antidepressants that have MODERATE potential for drug-drug interactions

A

agomelatine

buproprion

duloxetine

levomilacipran

sertraline

vilazodone

vortioxetine

92
Q

list 5 antidepressants that have HIGHER potential for drug-drug interactions

A

fluoxetine

fluvoxamine

paroxetine

selegiline

moclobemide

93
Q

list 1 antipsychotic with MINIMAL or LOW potential for drug drug interactions

A

paliperidone

94
Q

list 3 antipsychotics with MODERATE potential for drug drug interactions

A

aripiprazole

olanzapine

risperidone

95
Q

list 3 antipsychotics with HIGHER potential for drug drug interactions

A

clozapine

lurasidone

quetiapine

96
Q

state whether the following agent has minimal/low, moderate or higher potential for drug drug interactions

if moderate or higher potential, state which part of the CYP system is relevant (i.e which enzyme) and in what way (substrate or inhibitor):

citalopram

A

minimal/low

97
Q

state whether the following agent has minimal/low, moderate or higher potential for drug drug interactions

if moderate or higher potential, state which part of the CYP system is relevant (i.e which enzyme) and in what way (substrate or inhibitor):

aripiprazole

A

moderate

2D6 + 3A4 substrate

98
Q

state whether the following agent has minimal/low, moderate or higher potential for drug drug interactions

if moderate or higher potential, state which part of the CYP system is relevant (i.e which enzyme) and in what way (substrate or inhibitor):

fluoxetine

A

higher potential

2D6 + 2C19 inhibitor

99
Q

state whether the following agent has minimal/low, moderate or higher potential for drug drug interactions

if moderate or higher potential, state which part of the CYP system is relevant (i.e which enzyme) and in what way (substrate or inhibitor):

vortioxetine

A

moderate

2D6 substrate

100
Q

state whether the following agent has minimal/low, moderate or higher potential for drug drug interactions

if moderate or higher potential, state which part of the CYP system is relevant (i.e which enzyme) and in what way (substrate or inhibitor):

desvenlafaxine

A

minimal/low

101
Q

state whether the following agent has minimal/low, moderate or higher potential for drug drug interactions

if moderate or higher potential, state which part of the CYP system is relevant (i.e which enzyme) and in what way (substrate or inhibitor):

duloxetine

A

moderate

2D6 inhibitor

1A2 substrate

102
Q

state whether the following agent has minimal/low, moderate or higher potential for drug drug interactions

if moderate or higher potential, state which part of the CYP system is relevant (i.e which enzyme) and in what way (substrate or inhibitor):

quetiapine

A

higher potential

3A4 substrate

103
Q

state whether the following agent has minimal/low, moderate or higher potential for drug drug interactions

if moderate or higher potential, state which part of the CYP system is relevant (i.e which enzyme) and in what way (substrate or inhibitor):

paroxetine

A

higher potential

2D6 inhibitor

104
Q

state whether the following agent has minimal/low, moderate or higher potential for drug drug interactions

if moderate or higher potential, state which part of the CYP system is relevant (i.e which enzyme) and in what way (substrate or inhibitor):

agomelatine

A

moderate

1A2 substrate

105
Q

state whether the following agent has minimal/low, moderate or higher potential for drug drug interactions

if moderate or higher potential, state which part of the CYP system is relevant (i.e which enzyme) and in what way (substrate or inhibitor):

buproprion

A

moderate

2D6 inhibitor

106
Q

state whether the following agent has minimal/low, moderate or higher potential for drug drug interactions

if moderate or higher potential, state which part of the CYP system is relevant (i.e which enzyme) and in what way (substrate or inhibitor):

mirtazapine

A

minimal/low

107
Q

state whether the following agent has minimal/low, moderate or higher potential for drug drug interactions

if moderate or higher potential, state which part of the CYP system is relevant (i.e which enzyme) and in what way (substrate or inhibitor):

paliperidone

A

minimal/low

108
Q

state whether the following agent has minimal/low, moderate or higher potential for drug drug interactions

if moderate or higher potential, state which part of the CYP system is relevant (i.e which enzyme) and in what way (substrate or inhibitor):

sertraline

A

moderate

2D6 inhibitor

109
Q

state whether the following agent has minimal/low, moderate or higher potential for drug drug interactions

if moderate or higher potential, state which part of the CYP system is relevant (i.e which enzyme) and in what way (substrate or inhibitor):

fluvoxamine

A

higher potential

1A2 + 2C19 + 3A4 inhibitor

110
Q

state whether the following agent has minimal/low, moderate or higher potential for drug drug interactions

if moderate or higher potential, state which part of the CYP system is relevant (i.e which enzyme) and in what way (substrate or inhibitor):

clozapine

A

higher potential

3A4 and 1A2 substrate

111
Q

state whether the following agent has minimal/low, moderate or higher potential for drug drug interactions

if moderate or higher potential, state which part of the CYP system is relevant (i.e which enzyme) and in what way (substrate or inhibitor):

escitalopram

A

minimal/low

112
Q

state whether the following agent has minimal/low, moderate or higher potential for drug drug interactions

if moderate or higher potential, state which part of the CYP system is relevant (i.e which enzyme) and in what way (substrate or inhibitor):

venlafaxine

A

minimal/low

113
Q

state whether the following agent has minimal/low, moderate or higher potential for drug drug interactions

if moderate or higher potential, state which part of the CYP system is relevant (i.e which enzyme) and in what way (substrate or inhibitor):

selegiline

A

higher potential

MAO inhibitor cautions

114
Q

state whether the following agent has minimal/low, moderate or higher potential for drug drug interactions

if moderate or higher potential, state which part of the CYP system is relevant (i.e which enzyme) and in what way (substrate or inhibitor):

lurasidone

A

higher potential

3A4 substrate

115
Q

state whether the following agent has minimal/low, moderate or higher potential for drug drug interactions

if moderate or higher potential, state which part of the CYP system is relevant (i.e which enzyme) and in what way (substrate or inhibitor):

levomilnacipran

A

moderate

3A4 substrate

116
Q

state whether the following agent has minimal/low, moderate or higher potential for drug drug interactions

if moderate or higher potential, state which part of the CYP system is relevant (i.e which enzyme) and in what way (substrate or inhibitor):

olanzapine

A

moderate

1A2 substrate

117
Q

state whether the following agent has minimal/low, moderate or higher potential for drug drug interactions

if moderate or higher potential, state which part of the CYP system is relevant (i.e which enzyme) and in what way (substrate or inhibitor):

risperidone

A

moderate

2D6 + 3A4 substrate

118
Q

state whether the following agent has minimal/low, moderate or higher potential for drug drug interactions

if moderate or higher potential, state which part of the CYP system is relevant (i.e which enzyme) and in what way (substrate or inhibitor):

moclobemide

A

higher potential

MAO inhibitor cautoins

119
Q

is routine pharmacogenetic testing recommended (for CYP enzymes)

A

no because data on utility of these tests is still lacking

may be helpful in certain situations–> i.e inabilty to tolerate minimum dose = ? poor metabolizer?/ repeated failure to respond to high doses may suggest rapid metabolizer

120
Q

is drug level monitoring recommended for 2nd gen ADs?

A

no–> poor correlation between blood levels and clinical response

only useful really to detect nonadherence

121
Q

inhibition of CYP 1A2 would increase serum levels of which psych meds?

A

agomelatine

clozapine

duloxetine

olanzapine

risperidone

122
Q

inhibition of CYP 1A2 would increase serum concentrations of what important non-psych. meds

A

warfarin

theophylline

naproxen

caffeine

123
Q

inhibition of CYP 2C19 would increase serum levels of which non- psych meds?

A

propanolol

warfarin

omeprazole

antiepileptics like phenobarbital

antiarrhythmics

124
Q

inhibition of CYP 2D6 would increase serum levels of which psych meds?

A

TCAs

olanzapine

risperidone

vortioxetine

125
Q

inhibition of CYP 2D6 would increase serum levels of which non psych meds?

A

tramadol

opioids (reduces effect)

beta blockers

tamoxifen (reduces effect)

126
Q

inhibition of CYP 3A4 would increase serum levels of which psych meds?

A

haloperidol

methadone

vilazodone

quetiapine

levomilnacipran

127
Q

inhibition of CYP 3A4 would increase serum levels of which non psych meds?

A

HIV protease inhibitors

statins

antihistamines

antiarrhythmics

immune modulators like tacrolimus

tamoxifen

sildenafil

macrolide antibiotics like erythromycin

128
Q

what is the definition of “early improvement” on an AD trial? why do we care?

A

defined as more than 20-30% reduction from baseline in depression rating scale after 2-4 weeks

correlated with response and remission at 6-12 weeks

*lack of early improvement at 2-4 weeks also predictor of later AD nonresponse/nonremission

129
Q

what should you do if someone does not show early improvement at an AD at 2-4 weeks

A

increase the dose if medication is tolerated

if med not tolerated then should switch to a different AD

130
Q

why should you not stop an AD within 6 months of starting it

A

high risk of relapse/recurrence if stopped within 6 months

131
Q

how long should you continue an AD

A

6-9 months after symptomatic remission

continue for AT LEAST 2 years if has risk factors for recurrence

132
Q

what is a mnemonic to remember antidepressant discontinuation symptoms

A

FINISH

Flu like symptoms
Insomnia
Nausea
Imbalance
Sensory disturbance
Hyperarousal

133
Q

which two ADs are most likely to give people discontinuation syndrome

A

paroxetine

venlafaxine

134
Q

which two ADs are least likely to give people discontinuation syndrome

A

fluoxetine

vortioxetine

(longer half lives)

135
Q

what % of people will develop discontinuation syndrome if stop ADs abruptly

A

40% approx

*recommend slowly tapering dose over several weeks

136
Q

what should you do if someone has a partial response or no response to initial AD

A

ensure treatment OPTIMIZATION

–> reevaluate dx, consider treatment issues
i.e ?subtherapeutic dose, ?inadequate tx duration, ?poor adherence

consider psychotherapy + neurostim approaches

137
Q

was is the definition of partial response to an AD

A

25-49% reduction in symptoms

(no response is less than 25% reduction in symptoms)

138
Q

what is the definition of “treatment resistant depression”

A

inadequate response to two or more antidepressants

does NOT consider adjunctive strategies or partial vs no response

139
Q

is there evidence guiding whether, after inadequate response to AD monotherapy, you should switch within SSRI class vs non-SSRI class?

A

insufficient evidence

140
Q

is there evidence guiding whether, after inadequate response to AD monotherapy, you should switch pursue ongoing AD monotherapy vs atypical antipsychotic augment?

A

low quality evidence for superiority of atypical antipsychotic augment strategy

141
Q

is there evidence guiding whether, after inadequate response to AD monotherapy, there is a particular atypical antipsychotic you should use vs other adjuncts?

A

insufficient evidence

142
Q

is there evidence to support switching AD nonresponders to another antidepressant?

A

yes, there is evidence for good response and remission rates with switching

*HOWEVER–> few studies comparing switch strategy with continuing current AD for longer, and a systematic review suggested that there was no difference in response or remission rates between switch and continuing strategies

143
Q

if you’re switching antidepressants, which one do you pick?

A

guidelines recommend ideally switching to an AD with “superior efficacy”

(though there is some evidence noted in the guidelines that there may be some benefit to switching AD class if does not respond to initial AD)

144
Q

list the 3 FIRST LINE meds for adjunctive therapy in MDD

A

aripiprazole (2-15mg)

risperidone (1-3mg)

quatiapine (150-300mg)

all level 1 evidence

145
Q

list the 7 SECOND LINE meds for adjunctive therapy in MDD

A

level 1 evidence:
brexpiprazole
olanzapine
lithium

level 2 evidence:
buproprion
mirtazapine/mianserin
modafinil
triiodothyronine

146
Q

list the 4 THIRD LINE meds/classes for adjunctive therapy in MDD

A

TCAs (level 2)

other antidepressants
others stimulants
ziprasidone
(all level 3)

147
Q

name an experimental med that could be used adjunctively in tx of MDD

A

ketamine (0.5mg/kg single IV dose)

148
Q

name a med that is NOT recommended as adjunctive treatment for MDD

A

pindolol (level 1 negative evidence)

149
Q

which class of med has the most consistent evidence for efficacy in adjunctive tx of MDD

A

atypical antipsychotics

150
Q

did adverse event rates differ from placebo in RCTs examining modafinil as adjunctive treatment for MDD

A

no they were about the same

*to date, other stimulants seem to have negative studies

151
Q

according to a network meta-analysis of 48 RCTs, which 4 medications were more effective than placebo as adjunctive strategies for MDD treatment

A

aripiprazole

quetiapine

lithium

T3 (triiodothyronine)

*stronger efficacy for aripiprazole and quetiapine

152
Q

should you combine ADs at initiation of treatment

A

no–> increased side effects and not clear benefit for efficacy

wait to see if responds to monotherapy then consider augmentation/switch etc

153
Q

how did T3 compared to lithium as an adjunctive agent for MDD

A

T3 was better tolerated and had lower dropout rates compared to lithium

154
Q

what factors would make you consider switching meds (instead of adding adjunctive treatment) when treating MDD

A

this is the first trial of antidepressant

initial AD was poorly tolerated

no response to initial AD

there is more time available to wait for a response

patient prefers to switch

155
Q

what factors would make you consider adding an adjunctive agent rather than switching agents in the treatment of MDD

A

there have been 2 or more AD trials

initial AD is well tolerated

there has been a partial response to the initial AD

less time is available to wait for a response (i.e more severe or impairing sx)

patient prefers to add on

there are specific/residual symptoms or side effects that can be targeted

156
Q

what systems are being targeted by evolving novel treatments for MDD

A

glutamate system

endocannabinoid system

157
Q

what experimental meds for MDD target the glutamate system

A

ketamine

esketamine

lanicemine

memantine

158
Q

list 5 novel/experiemental treatments for MDD

A

ketamine/esketamine

memantine

targeting endocannabinoid system

adjunctive celecoxib

cariprazine

pramipexole

4. Mood Disorders (17 decks)

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