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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
Q

how long does it take for fluoxetine to produce a steady drug plasma level?

how long does it take to washout after stopping

A

4 weeks

4 weeks

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26
Q

most common side effects of Fluoxetine (Prozac)

A 
sexual dysfunction
nausea
headache
manifestations of nervousness, insomnia and anxiety
weight gain
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27
Q

ways to manage sexual dysfunction for Fluoxetine (Prozac)

A

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

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28
Q

explain weight gain in Fluoxetine (Prozac)

A

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

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29
Q

serious side effects of Fluoxetine (Prozac)

A

Serotonin syndrome

Neonatal effects from use in pregnancy

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30
Q

when does serotonin syndrome typically occur

A

2-72 hours after treatment onset

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31
Q

s/s of serotonin sydrome

A

AMS - agitation, confusion, disorientation, anxiety, hallucinations, poor concentration)

incoordination
myoclonus
hyperreflexia
excessive sweating
tremor
fever
death

resolves spontaneously after d/c drug

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32
Q

risk for serotonin syndrome is increased by

A

concurrent use of MAOIs and other drugs

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33
Q

withdrawal syndrome symptoms for SSRI

A 
dizziness
headache
nausea
sensory disturbances
tremor
anxiety
dysphoria
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34
Q

time frame for withdrawal syndrome for SSRI

A

begins within days to weeks of last dose and persists for 1-3 weeks

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35
Q

what are neonatal effects from use of Fluoxetine (Prozac) during pregnancy

A

neonatal abstinence syndrome (NAS)

persistent pulmonary hypertension of the newborn (PPHN)

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36
Q

NAS (neonatal abstinence syndrome) is characterized by

A 
irritability
abnormal crying
tremor
resp distress
seizures
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37
Q

management for NAS

A

supportive care and generally abates within a few days

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38
Q

PPHN

A 
compromises tissue oxygenation
sig risk for death
for survivors - risk for
cognitive delay 
hearing loss
neurologic abnomalities
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39
Q

treatment for PPHN

A

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

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40
Q

when should infants be monitored closely for NAS and PPHN

A

when exposed to SSRIS late in gestation

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41
Q

what two SSRIS may cause septal heart defects

A

paroxetine

fluoxetine

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42
Q

What drug class is contraindicated to take with SSRIs due to increasing the risk for serotonin syndrome

A

MAOIs

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43
Q

How long do you need to wait after stopping an MAOI before starting a SSRI

A

at least 14 days

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44
Q

Im stopping Fluoxetine (Prozac) and starting an MAOI, how long must I wait and why

A

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

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45
Q

what antidepressant drug classes carry the risk for serotonin sydrome

A

SSRIs
SNRIs
TCAs

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46
Q

Fluoxetine (Prozac) _____ plasma levels of TCAs and Lithium

A

increase

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47
Q

Fluoxetine (Prozac) combined with what can increase risk for gI bleeding

A

antiplatelet drugs (ASA, NSAIDs, anticoagulants such as warfarin)

Fluoxetine (Prozac) is highly protein bound to plasma proteins and can displace other highly bound drugs

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48
Q 
characteristic side effects of "Other SSRIS"
Citalopram (Celexa)
escitalopram (Lexapro)
Fluvoxamine (Luvox CR)
Paroxetine (Paxil)
Sertraline (Zoloft)
A 
nausea
insomnia
weight gain
sexual dysfunction
hyponatremia
GI bleeding
NAS 
PPHN
serotonin syndrome
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49
Q

SSRI especially safe in breastfeeding

A

Sertraline

50
Q

what is Venlafaxine (Effexor XR) approved for

A

major depression
general anxiety disorder
social anxiety disorder
panic disorder

51
Q

can you take Venlafaxine (Effexor XR) with food

A

yes

52
Q

the most common side effect of Venlafaxine (Effexor XR)

A 
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
Q

half life for Venlafaxine (Effexor XR)

A

5 hours for the parent drug and 11 hours for the metabolite as opposed to days with the SSRI

54
Q

combined use of Venlafaxine (Effexor XR) with an MAOI increases r/o

A

Serotonin Syndrome

55
Q

MAOIs should be withdrawn at least ______ before starting Venlafaxine (Effexor XR)

A

14 days

56
Q

when switching from Venlafaxine (Effexor XR) to an MAOI, Venlafaxine (Effexor XR) should be discontinued ____ before starting the MAOI

A

7 days

57
Q

use of Venlafaxine (Effexor XR) late in pregnancy can result in

A

Neonatal withdrawal syndrome

(irritability, abnormal crying, tremor, resp distress, seizures)

supportive care

58
Q

withdrawal syndrome for SNRI can be minimized by tapering dosage over

A

2-4 weeks

59
Q

symptoms of withdrawal syndrome in SNRI

A 
anxiety
agitation
tremors
headache
vertigo
nausea
tachycardia
tinnitus
60
Q

most common adverse effects of TCAs

A

sedation
orthostatic hypotension
anticholinergic effects

61
Q

most dangerous adverse effects of TCAs

A

cardiac toxicity

62
Q

pt education for orthostatic hypotension when taking a TCA

A

move slowly when assuming an upright posture

if you become dizzy or lightheaded - sit or lie down

63
Q

anticholinergic effects of TCAs

A 
dry mouth
blurred vision
photophobia
constipation
urinary hesitancy
tachycardia
64
Q

what paradoxical effect is seen in TCAs

A

diaphoresis despite anticholinergic effects

65
Q

CNS excitation or depression for TCAs

A

depression causing sedation

66
Q

When do you worry about the cardiac toxicity of TCAs

A

in overdose

or when you have a preexisting cardiac condition

67
Q

How does TCAs affect the heart

A

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
Q

TCAs and seizures

A

lower seizure threshold and thereby increase seizure risk

69
Q

The combo of a MAOI with a TCA can lead to

A

can lead to severe hypertension due to excessive adrenergic stim of the heart and blood vessels

can lead to hypertensive crisis

70
Q

drug interaction of TCA with direct acting sympathomimetics such as epinephrine and dopamine

A

TCAs block uptake of these agent into adrenergic nerve terminals so they prolong the presence of these agents in the synaptic space

71
Q

drug interactions of TCA with indirect acting sympathomimetics (ephedrine and amphetamine)

A

block uptake of agents and prevent them from reaching their site of action within the nerve terminal

72
Q

drug interactions of TCA with anticholinergic agents

A

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
Q

3 categories of anticholinergic drugs

A

muscarinic antagonists
ganglionic blocking agents
neuromuscular blocking agents

74
Q

2 other terms for anticholinergic

A

muscarinic antagonists

parasympatholytic

75
Q

examples of anticholinergic

A 
atropine
scopolamine
Atrovent
dicyclomine (bentyl)
oxybutynin
tolterodine
76
Q

highly selective m3 anticholinergic for OAB

A

Darifenacin (enablex)

77
Q

primarily M3 selective anticholinergic for OAB

A

Oxybutynin

Solifenacin (Vesicare)

78
Q

nonselective anticholinergic for OAB

A

Fesoterodine (Toviaz)
Tolterodine (Detrol)
Trospium

79
Q

CNS depressants and TCA

A

watch for alcohol
antihistamines
opioids
barbiturates

depress CNS

80
Q

clinical manifestations of TCA tox

A

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
Q

Treatment for TCA tox

A

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
Q

which TCA has weaker anticholinergic properties

A

nortriptyline

83
Q

MAOIs greatest concern is _____

triggered by _____

A

hypertensive crisis

eating foods rich in tyramine

84
Q

MAOIs are the drug of choice only for

A

atypical depression

85
Q

which MAOI is transdermal patch

A

Selegiline (Emsam)

86
Q

All MAOI in current use are reversible or irreversible

A

irreversible

87
Q

MAOI causes CNS stim or depression

A

Stimulation

88
Q

MAOI orthostatic hypotension

A

reduce bp through actions in CNS

reduction in sympathetic activity that controls vascular tone causes venous pooling which makes bp fall

89
Q

MAOI and bp

A

avoid foods rich in tyramine because can produce hypertensive crisis

90
Q

Hypertensive crisis is characterized by

A 
severe headache
tachycardia
HTN
n/v
confusion
profuse sweating

can lead to stroke and death

91
Q

what other foods besides tyramine when taking MAOI to avoid

A

caffeine

phenylethylamine

92
Q

foods that contain tyramine

A 
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
Q

drug interaction pt education

A

do not take any over the counter or prescribed med without consulting doctor first

94
Q

drug interaction MAOI and indirect acting sympathomimetic agents (ephedrine and ampheatine)

A

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
Q

MAOI and epi, NE, dopamine

A

decreases metabolism of epi, NE and dopamine so effects will be more intense and prolonged

96
Q

TCA and MAOI

A

HTN and HTN crisis

97
Q

MAOI and SSRI

A

Serotonin syndrome

98
Q

Antihypertensive drugs with MAOI

A

may result in excessive lowering of BP

99
Q

Transdermal MAOI

A

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
Q

what two drugs can significantly raise levels of selgiline

A

Carbamazepine (Tegretol)

Oxcarbazepine (trileptal)

101
Q

most common adverse reaction of Selegiline and how to treat

A

localized rash - treat with topical glucocorticoids

102
Q

Bupropion (Wellbutrin) effects begin in

A

1-3 weeks

103
Q

Bupropion (Wellbutrin indicated for

A

Major depressive disorder
prevention of seasonal affective disorder (SAD)
marketed as Zyban to aid is smoking cessation

104
Q

most common adverse effects Bupropion (Wellbutrin)

A 
agitation
headache
dry mouth
constipation
weight loss
GI upset
dizziness
tremor
insomnia
blurred vision
tachycardia
psychotic symptoms - hallucinations and delusions
105
Q

Bupropion (Wellbutrin and sexual dysfunction

A

does not carry this adverse effect

106
Q

Bupropion (Wellbutrin and seizures

A

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
Q

Bupropion (Wellbutrin) with sertraline, fluoxetine, paroxetine

A

can elevate bupropion levels which increases risk for seizures

108
Q

Mirtazapine (Remeron) benefits appear to result from

A

increased release of 5HT and NE

109
Q

side effects of Mirtazapine (Remeron)

A 
Somnolence - most prominent
Weight gain
increased appetite
elevated cholesterol
minimal sexual dysfunction
reversible agranulocytosis potentially
mild anticholinergic effects
110
Q

Mirtazapine somnolence can be exacerbated by

A

alcohol
benzodiazepines
other CNS depressents

111
Q

Do not combine Mirtazapine with

A

MAOIs

112
Q

symptoms of Peripartum depression

A 
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
Q

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

A

4 weeks of delivery

however most clinicians count it up to 3 months after

114
Q

risk factors for peripartum depression

A

history of premenstrual dysphoric disorder

major stress r/t family, work, residence

115
Q

what plasma levels need to be checked in peripartum depression

A

thyroid levels - levels of thyroid hormone often decline after delivery, causing symptoms that mimic depression

116
Q

what screening tool for Peripartum depresion

A

Edinburgh postnatal depression scale

117
Q

non drug help with peripartum depression

A

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
Q

which antidepressant can be taking safely while breastfeeding

A

sertraline

119
Q

first choice drug class peripartum depression

A

SSRI

120
Q

for a diagnosis of major depression to be made

A

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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