CNS 4 Flashcards
What are the 3 classes of Antidepressants
Tricyclic and related Antidepressants ( Inc 5HT and N)
SSRIs( increase 5HT)
Monoamine oxidase inhibitors ( increase 5HT, NA abd DA)
SNRI( venfalaxine and duloxetine)
Egs of Tricyclic Antidepressants
Amitriptyline and nortriptyline( neuropathic pain )
Clomipramine
Dosulepin
Imipramine ( most antimuscuranic side effects)
Lofepramie ( Liver toxic)
List examples of tetracycline Antidepressants
Manserin and trazodone
Egs of SSRI
Citalopram
Fluoxetine
Sertraline
Paroxetine
An SSRI that is licensed for children is called?
Fluoxetine
An SSRI with a high withdrawal effect is called
Paroxetine
An SSRI safe in Unstable Angina and MI is called
Sertraline
List examples of MAOIs
Irreversible and reversible
List examples of Irreversible MAOI
Phenelzine
Isocarboxid
Tranylcypromine( htn crisis risk)
List examples of reversible MAOI
RIMA( no washing out period)
Eg Moclobamide- licensed for social anxiety disorder
What type of depression are Antidepressants effective for?
Moderate to severe depression
Which Antidepressants class is first line and why?
SSRIs
Better tolerated and safer in OD
Less sedating
Fewer antismuscarinic and cardiotoxic effects
Sertraline is safe in pt with Unstable Angina or recently had MI
Facts about TCA
Similar efficacy to SSRIs but more side effects
Toxicity in OD
More sedating
More Antimuscarinic and cardiotoxic side effect
Facts about MAOI
Dangerous interaction with some foods and drugs
Reserve for use by specialists
Facts about St John’s wort
It is an inducer
Used to tx mild depression
Increase conc of another drug a pt is taken
Do not Prescribe or recommend for depression
It pt stops taking St John’s wort, the concentration of interacting drugs may increase, leading to toxicity
Management of depression
Review pt every 1-2wks at start of tx
They take atleast wks to work
Continue tx for atleast 4wks ( 6wks for elderly) before switching due to lack of efficacy)
What’s the duration of tx depression if no efficacy efficacy after 1-2wks
Incase of Partial response, continue for further 2-4weeks( elderly pts may take longer to respond)
What’s the duration for tx pt with a hx of recurrent depression
2 years
State the duration of tx depression after remission
Atleast 6months
12 months in elderly
12months for generalised Anxiety disorder because higher risk of relapse
All Antidepressants cause hyponatremia . True or false?
True
Occurs more with SSRIs in elderly esp
What are the signs of hyponatremia( salt loss)
Stupor / coma
Anorexia
Lethargy
Tendon reflexes reduced
Limp muscle weakness
Orthostatic hypotension
Seizures/ headache
Stomach cramps
Antidepressants are linked with suicidal thoughts and behaviour. True or false?
True
What pts group are at risk of suicidal thoughts?
Children, young adults and individuals
What is serotonin syndrome?
High levels of serotonin esp when SSRIS /SNRis plus drugs that raises serotonin are given together esp MAOi- do not mix
What are the symptoms of Serotonin syndrome
Neuromuscular hyperactivity( tremor, clonus, rigidity, hyper reflexia)
Autonomic dysfunction ( Tachycardia, BP, hyperthermia, diarrhoea, sweating)
Altered mental State( confusion, coma, agitation)
Withdraw medication if symptoms occur
Tx failure with Antidepressants
Increase dose or switch to different SSRIs or Mirtazapine if initial response to SSRIS fail
Or second line choice eg Fluoxetine, roboxetine or moclobemide
Venlafaxine reserved for more severe cases
MAoi requires specialist
Third line
Add another Antidepressants class or lithium or Antisychotics
Examples of sedating TCA’s
Give to anxious pt
Amitriptyline
Clomipramine
Dosulepin( toxic in OD)
Trazodone
Trimipramine
Doxepin
Examples of less sedating TCA’s
Imipramine ( most antimuscarinic side effects
Lofepramine
Nortripyline
For withdrawn and apathetic patients
NIL
Contraindications of TCA’s
Manic phase in bipolar
Arrhythmia
Heart block
Immediate recovery period after M.I
Mainly CV related
TCA cautions
CV disease
Diabetes
Chronic constipation
Epilepsy
History of bipolar and psychosis
Hyperthyroidism ( risk of Arrhythmia)
Glaucoma, urinary retention
Elderly pts more susceptible to side effects cus can cause hypotension
Common side effects of TCA
TCA
T- more toxic in OD than SSRIS
C- Cardiac side effects, QT prolongation, heart block, HTN, Arrhythmia)
A- Antimuscarinic side effects
S- seizures
Common side effects of TCA
QT interval elongation
Drowsiness, Anticholinergic syndrome
What are Antimuscarinic side effects
Can’t see
Can’t pee
Can’t shit
Can’t spit
Anorexia
Blurry vision
Constipation/ Confusion
Dry mouth
Static urine
ABCDS
Signs of TCA OD
Dry mouth
Coma
Hypotension ( Amitriptyline)
Hypothermia
Convulsions
Arrhythmia
Dilated pupil
Urinary retention
Cardiac conduction defect
Respiratory failure
TCAs have varying Antimuscarinic and cardio toxic effects in OD. True or false
True
Facts about Lofepramine as a TCA
Less side effects, Less dangerous in OD but associated with hepatoxicity
Is Lofepramine safe in severe liver impairment?
Avoid
A TCA that has more Antimuscarinic side effects than the rest is ….
Imipramine
A TCA that is effective but dangerous in OD and not recommended in tx of depression is…
Amitriptyline/ dosulepin
Why are TCA’s given once daily at night?
Due to long half life
TCAs can aggravate conditions especially in mania. T/f
True
Stop if pts enter manic phase
Common TCAs interaction
Lithium ( increase risk of toxicity…see photo on fav.
Examples of
irreversible MAOI s
Isocarboxazid( cause hypatoxicity)
Phenelzine( hepatoxicity)
Tranylcypromine( greater stimulant action than above more likely to cause htn crisis
List examples of reversible MAOI( RIMA)
Moclobemide- reserved for 2nd line
Important points to note about MAOIs
Massive hypertensive crisis eg massive headache
Avoid tyramine( triggers htn crisis) -Stroke and MI
Interacts with OTc meds
Increase suicide risk
Don’t give with pseudoephredine
Do not mix with other Antidepressants cause Serotonin syndrome
State the withdrawal symptoms associated with MAOIs
Agitation, irritability, ataxia, movement disorders, Insomnia, drowsiness, vivid dreams, hallucinations, slowed speech, delusion
Risk of symptoms increased if stopped suddenly after regular administration 8wks or more
Side effects of MAOIs
Risk of postural hypertension mainly in elderly and hypertensive responses( severe increase in BP that may cause a stroke)
Withdraw if palpitation or frequent headches occur
Wash out period for Antidepressants
See fav photos
List drugs that can cause hypertensive crisis when given with MAOI
Sympathomimetics such as
Ephedrine and pseudoephridine eg cold and flu remedies
TCA( imipramine and clomipramine)
Dopaminergic drugs such as Levodopa and MAO-B
Food that interacts with MAOI
Food that contains tyramine cus tyramine triggers nerve cell to release noradrenaline which increase NP which cause throbbing headache
Which food contains tyramine
Mature cheese
Pickled herring
Broad bean pods
Bovril, Oxon, Marmite
Fermented soya bean extract
Pt and carer advise for pt on MAOI
Eat only fresh food and avoid stale food or going off food esp meat, poultry, fish or offal.
Game should be avoided
Avoid alcoholic drink or dealcholized drinks
Drowsiness may affect skilled task
Danger of food and drug interaction last for 2weeks after MAOI is stopped
Facts about RIMA
Moclobemide- major depressed and social anxiety
Reversible inhibition of monoamine oxidase A- second line tx
Interaction with RIMA
Less tyramine effects than irreversible MAOI but avoid large amounts in tyramine rich food
Less risk of drug interaction but still avoid Sympathomimetic
Don’t give with other Antidepressants
Examples of SSRI
Sertraline (safe in Angina and MI)
Citalopram ( QT prolongation)
Escitalopram( qt prolongation)
Fluoxetine ( can be given to children)
Fluvoxamine
Paroxetine ( higher withdrawal)
Which Antidepressants has increased harmful outcomes in children and adolescent such as self harm, aggression and suicide risk?
SSRIs
Which Antidepressants is licensed for children and at what age?
8-17
Unlicensed- 5-7
Fluoxetine
Contraindications of SSRI
Poorly controlled epilepsy ( discontinue if convulsion occurs)
Manic phase
Cautions for SSRIs
See fav photos
What is the MHRA/ CSM advice for SSRIs or SNRis
Small risk of post partum haemorrhage when used the month before delivery
Increased risk of bleeding
Risk more significant in patients with other risk factors for bleeding disorders
Anticoagulant medication in women at high risk of thrombotic events should not be stopped but prescriber should be aware of this
Facts about SSRIS
Less sedating and fewer Antimuscarinic effects than TCA
Hypontraemia
Anxiety, Arrhythmia, confusion, drowsiness, constipation, QT interval prolongation, dry mouth, skin reactions, nausea, Palpitation
Important SSRIS interaction
See fav photos
