ch 27 Flashcards
non-drug therapy for depression
psychotherapy (cognitive behavioral or interpersonal)
Electroconvulsive therapy
transcranial magnetic stimulation
aerobic exercise
resistance training
drug classes for mild to moderate depression
none, little to no effect
for major depression
timeline of initial response in antidepressants
1-3 weeks
timeline of max response to antidepressants
12 weeks
what is the min timeline for a drug to be considered a treatment failure
at least 1 month
usual first choice drug classes for depression
SSRI, SNRI, bupropion (wellbutrin) and mirtazapine
are all side effects harmful or not wanted?
no, some cases the side effects of a drug can be beneficial
for a pt with fatigue, what drugs would have a beneficial side effect
one that causes CNS stim such as fluoxetine and bupropion
for a pt with insomnia, what drugs would have a beneficial side effect
a drug that causes substantial sedation
mirtazapine
for a pt with sexual dysfunction, what drugs would have a beneficial side effect
bupropion - enhances libido
for a pt with chronic pain, what drugs would have a beneficial side effect
choose duloxetine or a TCA - drugs that can relieve chronic pain
Name your SSRIs
Citalopram (Celexa)
Escitalopram (Lexapro)
Fluoxetine (Prozac)
Paroxetine (Paxil)
Sertraline (Zoloft)
Vortioxetine (Trintellix)
Name your SNRIs
Desvenlafaxine (Pristiq)
Duloxetine (Cymbalta)
Levomilnacipran (Fetzima)
Venlafaxine (Effexor XR)
Name your TCAs
amitriptyline
Desipramine (Norpramin)
Doxepin (Sinequan)
Imipramine (Tofranil)
Maprotiline
Nortriptyline (Pamelor)
Protriptyline (Vivactil)
Trimipramine (Surmontil)
after symptoms are in remission, how long should you continue treatment to prevent relapse
4-9 mos
when you prescribe an antidepressant how often should you follow up
ideally once weekly for the first 4 weeks
biweekly for the next 4 weeks
1 month later
periodically after
what symptoms should family be aware of for a pt newly prescribed antidepressant
anxiety agitation panic attacks insomnia irritability hostility impulsivity hypomania emergence of suicidality
if the initial drug choice for antidepressant fails, what are your choices
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
Name your MAOIs
Isocarboxazid (Marplan)
Phenelzine (Nardil)
Selegiline (Emsam) - transdermal)
Tranylcypromine (Parnate)
Name your atypical antidepressants
Amoxapine
Bupropion (Wellbutrin)
Mirtazapine (Remeron)
what drug class is Fluoxetine (Prozac)?
SSRI
CNS for Fluoxetine - excitation or depression
excitation
can you take fluoxetine with food?
yes
fluoxetine approved for
major depression bipolar disorder OCD panic disorder bulimia nervosa premenstrual dysphoric disorder
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
most common side effects of Fluoxetine (Prozac)
sexual dysfunction nausea headache manifestations of nervousness, insomnia and anxiety weight gain
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
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
serious side effects of Fluoxetine (Prozac)
Serotonin syndrome
Neonatal effects from use in pregnancy
when does serotonin syndrome typically occur
2-72 hours after treatment onset
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
risk for serotonin syndrome is increased by
concurrent use of MAOIs and other drugs
withdrawal syndrome symptoms for SSRI
dizziness headache nausea sensory disturbances tremor anxiety dysphoria
time frame for withdrawal syndrome for SSRI
begins within days to weeks of last dose and persists for 1-3 weeks
what are neonatal effects from use of Fluoxetine (Prozac) during pregnancy
neonatal abstinence syndrome (NAS)
persistent pulmonary hypertension of the newborn (PPHN)
NAS (neonatal abstinence syndrome) is characterized by
irritability abnormal crying tremor resp distress seizures
management for NAS
supportive care and generally abates within a few days
PPHN
compromises tissue oxygenation sig risk for death for survivors - risk for cognitive delay hearing loss neurologic abnomalities
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
when should infants be monitored closely for NAS and PPHN
when exposed to SSRIS late in gestation
what two SSRIS may cause septal heart defects
paroxetine
fluoxetine
What drug class is contraindicated to take with SSRIs due to increasing the risk for serotonin syndrome
MAOIs
How long do you need to wait after stopping an MAOI before starting a SSRI
at least 14 days
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
what antidepressant drug classes carry the risk for serotonin sydrome
SSRIs
SNRIs
TCAs
Fluoxetine (Prozac) _____ plasma levels of TCAs and Lithium
increase
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
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
SSRI especially safe in breastfeeding
Sertraline
what is Venlafaxine (Effexor XR) approved for
major depression
general anxiety disorder
social anxiety disorder
panic disorder
can you take Venlafaxine (Effexor XR) with food
yes
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
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
combined use of Venlafaxine (Effexor XR) with an MAOI increases r/o
Serotonin Syndrome
MAOIs should be withdrawn at least ______ before starting Venlafaxine (Effexor XR)
14 days
when switching from Venlafaxine (Effexor XR) to an MAOI, Venlafaxine (Effexor XR) should be discontinued ____ before starting the MAOI
7 days
use of Venlafaxine (Effexor XR) late in pregnancy can result in
Neonatal withdrawal syndrome
(irritability, abnormal crying, tremor, resp distress, seizures)
supportive care
withdrawal syndrome for SNRI can be minimized by tapering dosage over
2-4 weeks
symptoms of withdrawal syndrome in SNRI
anxiety agitation tremors headache vertigo nausea tachycardia tinnitus
most common adverse effects of TCAs
sedation
orthostatic hypotension
anticholinergic effects
most dangerous adverse effects of TCAs
cardiac toxicity
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
anticholinergic effects of TCAs
dry mouth blurred vision photophobia constipation urinary hesitancy tachycardia
what paradoxical effect is seen in TCAs
diaphoresis despite anticholinergic effects
CNS excitation or depression for TCAs
depression causing sedation
When do you worry about the cardiac toxicity of TCAs
in overdose
or when you have a preexisting cardiac condition
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.
TCAs and seizures
lower seizure threshold and thereby increase seizure risk
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
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
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
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)
3 categories of anticholinergic drugs
muscarinic antagonists
ganglionic blocking agents
neuromuscular blocking agents
2 other terms for anticholinergic
muscarinic antagonists
parasympatholytic
examples of anticholinergic
atropine scopolamine Atrovent dicyclomine (bentyl) oxybutynin tolterodine
highly selective m3 anticholinergic for OAB
Darifenacin (enablex)
primarily M3 selective anticholinergic for OAB
Oxybutynin
Solifenacin (Vesicare)
nonselective anticholinergic for OAB
Fesoterodine (Toviaz)
Tolterodine (Detrol)
Trospium
CNS depressants and TCA
watch for alcohol
antihistamines
opioids
barbiturates
depress CNS
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
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
which TCA has weaker anticholinergic properties
nortriptyline
MAOIs greatest concern is _____
triggered by _____
hypertensive crisis
eating foods rich in tyramine
MAOIs are the drug of choice only for
atypical depression
which MAOI is transdermal patch
Selegiline (Emsam)
All MAOI in current use are reversible or irreversible
irreversible
MAOI causes CNS stim or depression
Stimulation
MAOI orthostatic hypotension
reduce bp through actions in CNS
reduction in sympathetic activity that controls vascular tone causes venous pooling which makes bp fall
MAOI and bp
avoid foods rich in tyramine because can produce hypertensive crisis
Hypertensive crisis is characterized by
severe headache tachycardia HTN n/v confusion profuse sweating
can lead to stroke and death
what other foods besides tyramine when taking MAOI to avoid
caffeine
phenylethylamine
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
drug interaction pt education
do not take any over the counter or prescribed med without consulting doctor first
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
MAOI and epi, NE, dopamine
decreases metabolism of epi, NE and dopamine so effects will be more intense and prolonged
TCA and MAOI
HTN and HTN crisis
MAOI and SSRI
Serotonin syndrome
Antihypertensive drugs with MAOI
may result in excessive lowering of BP
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
what two drugs can significantly raise levels of selgiline
Carbamazepine (Tegretol)
Oxcarbazepine (trileptal)
most common adverse reaction of Selegiline and how to treat
localized rash - treat with topical glucocorticoids
Bupropion (Wellbutrin) effects begin in
1-3 weeks
Bupropion (Wellbutrin indicated for
Major depressive disorder
prevention of seasonal affective disorder (SAD)
marketed as Zyban to aid is smoking cessation
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
Bupropion (Wellbutrin and sexual dysfunction
does not carry this adverse effect
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)
Bupropion (Wellbutrin) with sertraline, fluoxetine, paroxetine
can elevate bupropion levels which increases risk for seizures
Mirtazapine (Remeron) benefits appear to result from
increased release of 5HT and NE
side effects of Mirtazapine (Remeron)
Somnolence - most prominent Weight gain increased appetite elevated cholesterol minimal sexual dysfunction reversible agranulocytosis potentially mild anticholinergic effects
Mirtazapine somnolence can be exacerbated by
alcohol
benzodiazepines
other CNS depressents
Do not combine Mirtazapine with
MAOIs
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
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
risk factors for peripartum depression
history of premenstrual dysphoric disorder
major stress r/t family, work, residence
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
what screening tool for Peripartum depresion
Edinburgh postnatal depression scale
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
which antidepressant can be taking safely while breastfeeding
sertraline
first choice drug class peripartum depression
SSRI
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
