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Pharm Exam 4 - Class Review > ch 27 > Flashcards

ch 27 Flashcards

1
Q

non-drug therapy for depression

A

psychotherapy (cognitive behavioral or interpersonal)

Electroconvulsive therapy

transcranial magnetic stimulation

aerobic exercise

resistance training

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2
Q

drug classes for mild to moderate depression

A

none, little to no effect

for major depression

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3
Q

timeline of initial response in antidepressants

A

1-3 weeks

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4
Q

timeline of max response to antidepressants

A

12 weeks

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5
Q

what is the min timeline for a drug to be considered a treatment failure

A

at least 1 month

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6
Q

usual first choice drug classes for depression

A

SSRI, SNRI, bupropion (wellbutrin) and mirtazapine

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7
Q

are all side effects harmful or not wanted?

A

no, some cases the side effects of a drug can be beneficial

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8
Q

for a pt with fatigue, what drugs would have a beneficial side effect

A

one that causes CNS stim such as fluoxetine and bupropion

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9
Q

for a pt with insomnia, what drugs would have a beneficial side effect

A

a drug that causes substantial sedation

mirtazapine

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10
Q

for a pt with sexual dysfunction, what drugs would have a beneficial side effect

A

bupropion - enhances libido

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11
Q

for a pt with chronic pain, what drugs would have a beneficial side effect

A

choose duloxetine or a TCA - drugs that can relieve chronic pain

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12
Q

Name your SSRIs

A

Citalopram (Celexa)

Escitalopram (Lexapro)

Fluoxetine (Prozac)

Paroxetine (Paxil)

Sertraline (Zoloft)

Vortioxetine (Trintellix)

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13
Q

Name your SNRIs

A

Desvenlafaxine (Pristiq)

Duloxetine (Cymbalta)

Levomilnacipran (Fetzima)

Venlafaxine (Effexor XR)

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14
Q

Name your TCAs

A

amitriptyline

Desipramine (Norpramin)

Doxepin (Sinequan)

Imipramine (Tofranil)

Maprotiline

Nortriptyline (Pamelor)

Protriptyline (Vivactil)

Trimipramine (Surmontil)

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15
Q

after symptoms are in remission, how long should you continue treatment to prevent relapse

A

4-9 mos

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16
Q

when you prescribe an antidepressant how often should you follow up

A

ideally once weekly for the first 4 weeks
biweekly for the next 4 weeks
1 month later
periodically after

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17
Q

what symptoms should family be aware of for a pt newly prescribed antidepressant

A 
anxiety
agitation
panic attacks
insomnia
irritability
hostility
impulsivity
hypomania
emergence of suicidality
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18
Q

if the initial drug choice for antidepressant fails, what are your choices

A

increase dose

switch to another drug in the same class

switch to another drug in a diff class

add a second drug, such as an atypical antidepressant

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19
Q

Name your MAOIs

A

Isocarboxazid (Marplan)

Phenelzine (Nardil)

Selegiline (Emsam) - transdermal)

Tranylcypromine (Parnate)

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20
Q

Name your atypical antidepressants

A

Amoxapine

Bupropion (Wellbutrin)

Mirtazapine (Remeron)

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21
Q

what drug class is Fluoxetine (Prozac)?

A

SSRI

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22
Q

CNS for Fluoxetine - excitation or depression

A

excitation

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23
Q

can you take fluoxetine with food?

A

yes

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24
Q

fluoxetine approved for

A 
major depression
bipolar disorder
OCD
panic disorder
bulimia nervosa
premenstrual dysphoric disorder
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25
how long does it take for fluoxetine to produce a steady drug plasma level? how long does it take to washout after stopping
4 weeks | 4 weeks
26
most common side effects of Fluoxetine (Prozac)
``` sexual dysfunction nausea headache manifestations of nervousness, insomnia and anxiety weight gain ```
27
ways to manage sexual dysfunction for Fluoxetine (Prozac)
consider reducing the dosage taking "drug holidays" such as d/c medication on fridays and saturdays can help (close mgmt is needed) or add a drug to overcome the problem yohimbine, buspirone (Buspar) Bupropion (Wellbutrin) Nefazodone Mirtazapine (Remeron) or adding sildenafil (Viagra) or trying a different antidepressant
28
explain weight gain in Fluoxetine (Prozac)
lose weight at first secondary to nausea/vomiting with long term treatment, gain weight back some will continue to gain - possibly due to decreased sensitivity of 5HT receptors that regulate appetite
29
serious side effects of Fluoxetine (Prozac)
Serotonin syndrome | Neonatal effects from use in pregnancy
30
when does serotonin syndrome typically occur
2-72 hours after treatment onset
31
s/s of serotonin sydrome
AMS - agitation, confusion, disorientation, anxiety, hallucinations, poor concentration) ``` incoordination myoclonus hyperreflexia excessive sweating tremor fever death ``` resolves spontaneously after d/c drug
32
risk for serotonin syndrome is increased by
concurrent use of MAOIs and other drugs
33
withdrawal syndrome symptoms for SSRI
``` dizziness headache nausea sensory disturbances tremor anxiety dysphoria ```
34
time frame for withdrawal syndrome for SSRI
begins within days to weeks of last dose and persists for 1-3 weeks
35
what are neonatal effects from use of Fluoxetine (Prozac) during pregnancy
neonatal abstinence syndrome (NAS) persistent pulmonary hypertension of the newborn (PPHN)
36
NAS (neonatal abstinence syndrome) is characterized by
``` irritability abnormal crying tremor resp distress seizures ```
37
management for NAS
supportive care and generally abates within a few days
38
PPHN
``` compromises tissue oxygenation sig risk for death for survivors - risk for cognitive delay hearing loss neurologic abnomalities ```
39
treatment for PPHN
vent support Oxygen and nitric oxide to dilate pulmonary blood vessels IV sodium bicarbonate to maintain alkalosis dopamine or dobutamine to increase cardiac output and to maintain pulmonary perfusion
40
when should infants be monitored closely for NAS and PPHN
when exposed to SSRIS late in gestation
41
what two SSRIS may cause septal heart defects
paroxetine | fluoxetine
42
What drug class is contraindicated to take with SSRIs due to increasing the risk for serotonin syndrome
MAOIs
43
How long do you need to wait after stopping an MAOI before starting a SSRI
at least 14 days
44
Im stopping Fluoxetine (Prozac) and starting an MAOI, how long must I wait and why
at least 5 weeks due to risk of serotonin syndrome remember for Fluoxetine (Prozac) it has a longer half life due to the active metabolite
45
what antidepressant drug classes carry the risk for serotonin sydrome
SSRIs SNRIs TCAs
46
Fluoxetine (Prozac) _____ plasma levels of TCAs and Lithium
increase
47
Fluoxetine (Prozac) combined with what can increase risk for gI bleeding
antiplatelet drugs (ASA, NSAIDs, anticoagulants such as warfarin) Fluoxetine (Prozac) is highly protein bound to plasma proteins and can displace other highly bound drugs
48
``` characteristic side effects of "Other SSRIS" Citalopram (Celexa) escitalopram (Lexapro) Fluvoxamine (Luvox CR) Paroxetine (Paxil) Sertraline (Zoloft) ```
``` nausea insomnia weight gain sexual dysfunction hyponatremia GI bleeding NAS PPHN serotonin syndrome ```
49
SSRI especially safe in breastfeeding
Sertraline
50
what is Venlafaxine (Effexor XR) approved for
major depression general anxiety disorder social anxiety disorder panic disorder
51
can you take Venlafaxine (Effexor XR) with food
yes
52
the most common side effect of Venlafaxine (Effexor XR)
``` nausea headache anorexia nervousness sweating somnolence insomnia weight loss secondary to anorexia sustained diastolic hypertension sexual dysfunction mydriasis - increased r/o eye injury or elevated IOP or glaucoma hyponatremia esp when combined with diuretics suicide ```
53
half life for Venlafaxine (Effexor XR)
5 hours for the parent drug and 11 hours for the metabolite as opposed to days with the SSRI
54
combined use of Venlafaxine (Effexor XR) with an MAOI increases r/o
Serotonin Syndrome
55
MAOIs should be withdrawn at least ______ before starting Venlafaxine (Effexor XR)
14 days
56
when switching from Venlafaxine (Effexor XR) to an MAOI, Venlafaxine (Effexor XR) should be discontinued ____ before starting the MAOI
7 days
57
use of Venlafaxine (Effexor XR) late in pregnancy can result in
Neonatal withdrawal syndrome (irritability, abnormal crying, tremor, resp distress, seizures) supportive care
58
withdrawal syndrome for SNRI can be minimized by tapering dosage over
2-4 weeks
59
symptoms of withdrawal syndrome in SNRI
``` anxiety agitation tremors headache vertigo nausea tachycardia tinnitus ```
60
most common adverse effects of TCAs
sedation orthostatic hypotension anticholinergic effects
61
most dangerous adverse effects of TCAs
cardiac toxicity
62
pt education for orthostatic hypotension when taking a TCA
move slowly when assuming an upright posture if you become dizzy or lightheaded - sit or lie down
63
anticholinergic effects of TCAs
``` dry mouth blurred vision photophobia constipation urinary hesitancy tachycardia ```
64
what paradoxical effect is seen in TCAs
diaphoresis despite anticholinergic effects
65
CNS excitation or depression for TCAs
depression causing sedation
66
When do you worry about the cardiac toxicity of TCAs
in overdose | or when you have a preexisting cardiac condition
67
How does TCAs affect the heart
decreasing vagal influence on the heart (secondary to muscarinic blockade) acts directly on the bundle of HIS to slow conduction which increases the risk of dysrhythmias all pt should have a ECG before treatment and periodically after.
68
TCAs and seizures
lower seizure threshold and thereby increase seizure risk
69
The combo of a MAOI with a TCA can lead to
can lead to severe hypertension due to excessive adrenergic stim of the heart and blood vessels can lead to hypertensive crisis
70
drug interaction of TCA with direct acting sympathomimetics such as epinephrine and dopamine
TCAs block uptake of these agent into adrenergic nerve terminals so they prolong the presence of these agents in the synaptic space
71
drug interactions of TCA with indirect acting sympathomimetics (ephedrine and amphetamine)
block uptake of agents and prevent them from reaching their site of action within the nerve terminal
72
drug interactions of TCA with anticholinergic agents
Avoid all other drugs with anticholinergic properties such as antihistamines and certain OTC sleep aids classes antimuscarinic drugs antinicotinic drugs cholinesterase regenerators ``` atropine darifenacin (enablex) dicylomine fesoterodine (Toviaz) ipratropium (Atrovent) scopalomine solifenacin (vesicare) tiotropium (spiriva_ tolerodine (detrol) trospium diphenhydramine (Benadryl) ```
73
3 categories of anticholinergic drugs
muscarinic antagonists ganglionic blocking agents neuromuscular blocking agents
74
2 other terms for anticholinergic
muscarinic antagonists | parasympatholytic
75
examples of anticholinergic
``` atropine scopolamine Atrovent dicyclomine (bentyl) oxybutynin tolterodine ```
76
highly selective m3 anticholinergic for OAB
Darifenacin (enablex)
77
primarily M3 selective anticholinergic for OAB
Oxybutynin | Solifenacin (Vesicare)
78
nonselective anticholinergic for OAB
Fesoterodine (Toviaz) Tolterodine (Detrol) Trospium
79
CNS depressants and TCA
watch for alcohol antihistamines opioids barbiturates depress CNS
80
clinical manifestations of TCA tox
dysrhythmias including ``` tachycardia intraventricular blocks complete AV block v-tach v-fib ``` ``` muscarinic blockade hyperthermia flushing dry mouth dilation of pupils ``` CNS confusion agitation hallucinations seizures coma
81
Treatment for TCA tox
gastric lavage activated charcoal IV sodium bicarb - to control dysrhythmias physostigmine - to combat anticholinergic do NOT treat dysrhythmias with procainamide or quinidine because they will cause cardiac depression
82
which TCA has weaker anticholinergic properties
nortriptyline
83
MAOIs greatest concern is _____ | triggered by _____
hypertensive crisis | eating foods rich in tyramine
84
MAOIs are the drug of choice only for
atypical depression
85
which MAOI is transdermal patch
Selegiline (Emsam)
86
All MAOI in current use are reversible or irreversible
irreversible
87
MAOI causes CNS stim or depression
Stimulation
88
MAOI orthostatic hypotension
reduce bp through actions in CNS | reduction in sympathetic activity that controls vascular tone causes venous pooling which makes bp fall
89
MAOI and bp
avoid foods rich in tyramine because can produce hypertensive crisis
90
Hypertensive crisis is characterized by
``` severe headache tachycardia HTN n/v confusion profuse sweating ``` can lead to stroke and death
91
what other foods besides tyramine when taking MAOI to avoid
caffeine | phenylethylamine
92
foods that contain tyramine
``` short and sweet avocado fermented anything soybean figs banana smoked anything aged anything (cured) liver bologna pepperoni salami beer wine cheese chocolate soup shrimp paste soy sauce fava bean ginseng caffeine ``` Avocado fermented bean curd fermented soybean soybean paste figs bananas fermented meats smoked meats aged meats liver bologna peperroni salami ``` dried or cured fish fermented fish smoked fish aged fish spoiled fish ``` ``` ALL cheeses Yeast extract (foods with yeast) some imported beers chiani wine soups shrimp paste soy sauce ``` ``` other non-tyramine foods with same chocolate fava beans ginseng caffeine ```
93
drug interaction pt education
do not take any over the counter or prescribed med without consulting doctor first
94
drug interaction MAOI and indirect acting sympathomimetic agents (ephedrine and ampheatine)
hypertensive crisis ``` pt need to avoid all sympathomimetic drugs including ephedrine methylphenidate amphetamines cocaine may be present in cold remedies nasal decongestants asthma meds ```
95
MAOI and epi, NE, dopamine
decreases metabolism of epi, NE and dopamine so effects will be more intense and prolonged
96
TCA and MAOI
HTN and HTN crisis
97
MAOI and SSRI
Serotonin syndrome
98
Antihypertensive drugs with MAOI
may result in excessive lowering of BP
99
Transdermal MAOI
risk for hypertensive crisis from dietary tyramine is much lower than with oral dosing does not pass through GI so can achieve therapeutic levels while preserving activity of MAO-A in intestinal wall and liver
100
what two drugs can significantly raise levels of selgiline
Carbamazepine (Tegretol) | Oxcarbazepine (trileptal)
101
most common adverse reaction of Selegiline and how to treat
localized rash - treat with topical glucocorticoids
102
Bupropion (Wellbutrin) effects begin in
1-3 weeks
103
Bupropion (Wellbutrin indicated for
Major depressive disorder prevention of seasonal affective disorder (SAD) marketed as Zyban to aid is smoking cessation
104
most common adverse effects Bupropion (Wellbutrin)
``` agitation headache dry mouth constipation weight loss GI upset dizziness tremor insomnia blurred vision tachycardia psychotic symptoms - hallucinations and delusions ```
105
Bupropion (Wellbutrin and sexual dysfunction
does not carry this adverse effect
106
Bupropion (Wellbutrin and seizures
can cause seizures can be reduced by avoiding doses above 450mg/day rapid dose titration pt with risk factors such as head trauma, preexisting seizure disorder, CNS tumor, use of other drugs that lower seizure threshold anorexia nervosa or bulimia (also increases risk) Drugs that inhibit CYP2B6 (sertraline, fluoxetine, paroxetine)
107
Bupropion (Wellbutrin) with sertraline, fluoxetine, paroxetine
can elevate bupropion levels which increases risk for seizures
108
Mirtazapine (Remeron) benefits appear to result from
increased release of 5HT and NE
109
side effects of Mirtazapine (Remeron)
``` Somnolence - most prominent Weight gain increased appetite elevated cholesterol minimal sexual dysfunction reversible agranulocytosis potentially mild anticholinergic effects ```
110
Mirtazapine somnolence can be exacerbated by
alcohol benzodiazepines other CNS depressents
111
Do not combine Mirtazapine with
MAOIs
112
symptoms of Peripartum depression
``` tearfulness sadness nervousness irritability anxiety difficulty eating difficulty sleeping ``` cry for no reason self esteem and self confidence may decline usually transient and gone by day 10 but if goes past its more serious
113
According to the DSM-5 (diagnostic and statistical manual of mental disorders, fifth edition), for a depressive episode to qualify as having peripartum onset, symptoms must begin within
4 weeks of delivery however most clinicians count it up to 3 months after
114
risk factors for peripartum depression
history of premenstrual dysphoric disorder major stress r/t family, work, residence
115
what plasma levels need to be checked in peripartum depression
thyroid levels - levels of thyroid hormone often decline after delivery, causing symptoms that mimic depression
116
what screening tool for Peripartum depresion
Edinburgh postnatal depression scale
117
non drug help with peripartum depression
reduce isolation - go out for a short time each day ensure adequate rest - do what's really needed and letting the rest go spend time alone with partner support group
118
which antidepressant can be taking safely while breastfeeding
sertraline
119
first choice drug class peripartum depression
SSRI
120
for a diagnosis of major depression to be made
symptoms must be present most of the day, nearly every day for at least 2 weeks ``` symptoms insomnia or hypersomnia anorexia weight loss or weight gain mental slowing loss of concentration feelings of guilt, worthlessness, helplessness thoughts of death and suicide ```

Pharm Exam 4 - Class Review (14 decks)

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