CNS Flashcards
Which MAOI’s is hepatotoxicity most likely?
Phenelzine
Isocarboxazid
Which MAOI more likely to cause hypertensive crisis?
Tranylcypramine
Which MAOI has no wash-out period?
Moclobemide
What to look out for with MAOI’s?
- Throbbing headache - D/C
- Indicates hypertensive crisis
- Increased risk with:
Pseudoephedrine
Adrenaline/Noradrenaline
Levodopa
TCA’s (esp clomipramine)
S/E of MAOI’s
- Hepatotoxicity
- Hypertensive crisis
- Postural hypotension / hypertensive responses - D/C if palpitations or frequent headaches
Which SSRI safe in MI / Unstable angina
Sertraline
Which SSRI licensed in children?
Fluoxetine
Which SSRI has an increased risk of withdrawal reactions?
Paroxetine
SSRI’s causing QT interval prolongation?
Citalopram
Escitalopram
Antidepressant withdrawal?
- Withdrawal effects may occur within 5 days of cessation
- Higher risk if >8wks treatment
- Taper over 4 few weeks (6 months if long term maintenance treatment)
- Abrupt withdrawal may cause FLU-LIKE symptoms
ADR’s of SSRI’s
G - GI disturbance
A - Appetite / weight disturbance
S - Serotonin syndrome
H - Hypersensitivity reactions - stop if RASH occurs
- ⬇️ seizure threshold : C/I in uncontrolled epilepsy
- ⬆️ bleeding risk (NSAIDS, anticoags)
- QT interval prolongation
- Movement disorders
How long do SSRI’s take to work?
- 2 to 4 weeks
- 4 weeks of treatment before deeming ineffective
- If partial response continue for further 2-4 weeks
How often should SSRI treatment be reviewed?
Every 1-2 weeks at start of treatment
How long should SSRI’s be continued following remission?
- 6 months
- Elderly & GAD = 12 months
- Recurrent depression = 2 years
Drug management of depression?
1st line: SSRI
2nd line:
- Increase dose
- Switch to different SSRI or Mirtazepine
- Other options: Lofepramine, Moclobomide, Reboxetine
3rd line:
- Addition of another antidepressant of different class
- Use of augmenting agent (lithium/aripiprazole/quetiapine etc)
Washout periods?
SSRI’s, TCA’s, MAOI’s
SSRI = 1 week (sertaline = 2wks fluoxetine = 5 wks) TCA = 1-2 weeks (clomipramine/imipramine = 3wks) MAOI's = 2 weeks (moclobemide = no wash out period)
Sedating TCA’s
Amitriptylline Clomipramine Dosulepin Doxepin Trimipramine
Less-sedating TCA’s
Imipramine
Lofepramine
Nortriptylline
What TCA has the most antimuscarinic effects?
Imipramine
TCA most dangerous in overdose?
Dosulepin - specialist use
Effects of TCA’s
Accronym: TCAS
T - more TOXIC in overdose
C - Cardiac S/E - QT prolongation, arrhythmias, heart block
A - Antimuscarinic effects
S - Seizures
TCA contraindications
- Arrhythmias
- Heart block
- Manic phase of bipolar
- Immediate recovery after MI
Focal seizures
1st line: Carbamazepine or Lamotrigine
2nd line:
- Oxcarbazepine
- Sodium Val
- Levetiracetam
Tonic-clonic
1st line: Sodium Val (except in pre-menopausal females)
2nd line: Lamotrigine (may exacerbate myoclonic seizures)
Can also consider Carbamazepine or Oxcarbazepine
Absence
1st line: Ethosuximide or Sodium Val
2nd line: Lamotrigine
If monotherapy ineffective can combine any 2 of the above
Myoclonic
1st line: Sodium Val
2nd line: Levetiracetam or Topirimate (worse S/E)
Atonic and Tonic
1st line: Sodium Val
2nd line: Lamotrigine (adjunct)
