Depression Flashcards
Class:
Indications:
MOA:
Dosage forms:
Dosing:
Max dose:
Contraindications:
Warnings:
Side Effects:
Monitoring:
Pearls/Notes:
Drug-Drug/Food interactions:
The causes of depression are poorly understood, but involve some combination of genetic, biologic, and environmental factors. Neurotransmitters believed to be involved with depression include: __________________________
serotonin (5-HT)
norepinephrine (NE)
epinephrine (Epi)
dopamine (DA)
glutamate
acetylcholine (ACh)
________ may be the most important neurotransmitter (NT) involved with feelings of well-being.
(5-HT) serotonin
Diagnosis and treatment of depression is difficult since it is not possible to measure brain chemical imbalances. Diagnosis relies on symptom assessment according to the __________
(DSM-5) Diagnostic and Statistical Manual of Mental Disorders, 5th edition
The _______1_______ is the most widely used depression assessment scale. It is designed to be used in a medical office. The patient rates their symptoms of depression on a numerical scale, and the total score indicates whether or not depression is present.
This is used ________2___
- Hamilton Depression Rating Scale (HDRS or Ham-D)
- after someone is diagnosed with depression. It measures the effectiveness with depression treatment.
Generally, a score of less than 7 indicates the absence of depression.
7-17 = mild depression
18-24 = moderate depression
25 and higher = severe depression
Depression Diagnosis: DSM-5 Criteria
- At least ________ of the following symptoms present during the same two week period (must include Depressed Mood OR Diminished interest/pleasure)
*Remember M SIG E CAPS
- At least 5 of the following symptoms present during the same two-week period (must include Depressed Mood OR Diminished Interest/Pleasure)
Mood- depressed*
Sleep- Increased/decreased
Interest/Pleasure - diminished*
Guilt or feelings of worthlessness
Energy - decreased
Concentration - decreased
Appetite - Increased/decreased
Psychomotor agitation or retardation
Suicidal ideation
It is necessary to rule out ________1________ prior to initiating antidepressant therapy to avoid _____2______ or causing rapid-cycling (cycling rapidly between bipolar depression and mania).
Screening forms to assess mood and identify symptoms include questions such as:
(cycling rapidly between bipolar depression and mania).
1) bipolar disorder
2) inducing mania
I get into moods where I feel very “speeded up” or irritable.
When depression and anxiety occur together, ______________ should NOT be used alone; they can worsen and/ or mask depression and can be problematic in patients with concurrent substance use disorders.
benzodiazepines (BZDs)
Key Drugs that Cause or Worsen Depression:
-
-
-
-
Cardiovascular medications: Beta-blockers (especially Propranolol)
ADHD medications: atomoxetine (Strattera)
Analgesics: Indomethacin
Antiretrovirals (NNRTIs):
Efavirenz (in Atripla)
Rilpivirine (in Complera, Odefsey)
Hormones:
Hormonal contraceptives
Anabolic steroids
Other:
benzodiazepines
systemic steroids
interferons
varenicline
ethanol
Natural Products: that may be helpful for treating depression, but there is less evidence of efficacy than with standard treatments.
-
-
St. John’s wort
SAMe (S-adenosyl-L-methionine)
valerian
5-HTP (5-hydroxytryptophan)
Which natural products can increase the risk for Serotonin Syndrome and SHOULD NOT be used with other serotonergic agents?
St. John’s wort
SAMe (S-adenosyl-L-methionine)
5-HTP (5-hydroxytryptophan)
“St. Johns wort is a broad spectrum CYP450 enzyme inducer with many significant drug interactions, and it can cause PHOTOTOXICITY.”
“Valerian can cause sedation.”
Drug Treatment for Depression:
Treatment for depression can require one or more trials of medication.
If a drug does not work after a suitable trial of at least ______________, treatment should be reassessed. If there is no response then ___________
A thorough patient History is CRITICAL. (Should Help Guide Therapy)
What worked in the past?
What did NOT work?
Any relatives that have depression? What medications have been successful for them?
4-8 weeks
increase dose, switch drug or add on a drug
The effectiveness of the different antidepressant classes is generally comparable.
*The Initial Choice of medication should be based on: _____1________
*For most patients an _______2__________ is preferred OR with “specific concurrent conditions” ________3______ OR ___________4_____
1 - the side effect profile, safety concerns, and patient-specific factors.
2- SSRI or SNRI
3- mirtazapine
4- bupropion
What other specific patient factors “comorbid conditions” need to be considered when deciding patient therapy
- insomnia
- overweight/obese
- neuropathy
Is feeling sad the same as being depressed? _________
The loss of a loved one, losing a job, or ending of a relationship are difficult experiences for a person to endure.
It is normal for feelings of sadness or grief to develop in response to such situations. Those that are experiencing loss, often describe themselves as feeling depressed.
NO, being sad is NOT the same as being depressed.
In Grief, painful feelings come in waves, often with positive memories of the deceased and one’s self-esteem is usually maintained.
However, in Major Depression, Mood and/or Interest are decreased for about 2 weeks, symptoms are Persistent, and feelings of worthlessness and self-loathing are common.
once persistent symptoms impact quality of life this can lead to depression.
A diagnosis of depression is also called ____________
Major depressive disorder or Unipolar depression
- it is when someone has recurrent episodes of depression
Depression is multifactorial. Groups of people that experienced substance abuse or trauma (physical or sexual assault) are at a higher risk of depression.
Drug treatment for depression often involves increasing ____________
serotonin (5-HT) neurotransmitter
Bipolar Disorder:
-
-
Mood
Energy
Clarity of thinking
Bipolar Disorder:
Can be represented by 2 polar opposite ends.
On one end there would be ____1___
On the other end there would be ____2____
1- Mania “extremely elevated mood/energy”
2- Depressive episodes, where the individual will report with symptoms similar to depressive symptoms when making a diagnosis and assessment
Antidepressants can induce mania (high energy, extreme mood). Antidepressants can also cause rapid-cycling between depression and mania. So, it is important to rule out bipolar disorder before initiating an antidepressant for depression.
Antidepressants can be used in bipolar disorder but often with a mood stabilizer like lithium.
Do NOT use _____________ alone for depression
benzodiazepines
- they do not have a role in depression management
- they do not treat underlying problem
- can mask the symptoms of depression
Boxed Warnings for benzodiazepines include:
-
-
Abuse, misuse, and addiction
physical dependance
withdrawal symptom’s
sedation, respiratory depression and death
C-IV, so should not be used in someone with active or Hx of substance abuse. **Remember substance is an environmental factor that can contribute to depression
Treatment Overview: (Treatment Options for Depression)
After an individual is diagnosed with depression the goal is to ______________. But what type of initial treatment is best to resolve those symptoms?
-
-
resolve the symptoms of depression.
Psychotherapy
Natural Products
Pharmacotherapy
Initial Treatment for Mild symptoms can include:
Psychotherapy “cognitive behavioral therapy” or medication or combination of both
Initial treatment for Moderate -Severe symptoms can include:
Psychotherapy + medication, combination has shown to be more effective than either alone.
St, Johns wort induces the enzymes that affect OCPs
Oral Contraceptive Pills, so these medications will be metabolized at a faster rate. Leading to less serum drug levels and making them less effective.
Same can be said with transplant medications.
Depression is often overlooked and untreated in pregnant women. This is a serious problem because untreated depression in pregnancy can cause __________
negative outcomes such as premature birth, low birth weight, or postnatal complications,
Managing depression in someone that is planning to become pregnant:
If patient is already on an antidepressant, then tapering off medication is an appropriate choice for some people. Only appropriate if the female does not experience any setbacks in depression control while off medication. Antidepressant should be slowly tapered off 1-2 months. best would be done in someone with mild depression and who is symptom free for at least 6 months.
Before and During Pregnancy:
- Taper off medications, IF possible
- Psychotherapy preferred for Mild depression
- If medications are needed ______1_____ are preferred with the exception of ________2______ due to _______3______
1) SSRIs
2) paroxetine
3) potential cardiac effects
” DO NOT USE paroxetine in pregnant patients” - increased teratogenic effects
Although SSRIs are preferred in pregnant women for the treatment of depression, there is a warning regarding their use during pregnancy which is ________________________.
the potential risk of persistent pulmonary hypertension of the newborn (PPHN)
this is when pulmonary vascular resistance of the new born remains elevated after birth and results in severe hypoxemia.
Postpartum Depression is sometimes mislabeled as the _________
“baby blues”
the baby blues are normal and are a temporary feeling that occurs after delivery. Patients can be more emotional and may have changes in sleep, increased stressed, caused by hormone fluctuations. Should go away with a couple weeks.
In contrast, Postpartum Depression is serious and while it can look like the baby blues at first, these symptoms persist and are more severe. Such as _______________
___3______ can help with the emotional and physical symptoms.
Drug safety when breastfeeding is essential. ___________4_______ are generally preferred, with the exception of ______5____
- suicidal thoughts
- inability to care for the newborn
3) breastfeeding
4) SSRIs or tricyclics
5) doxepin (Silenor, Zonalon), per ACOG recommendations, doxepin can worsen depression and suicidal thoughts and should be avoided.
_______________, is a C-IV drug FDA-approved for postpartum depression.
Brexanolone (Zulresso), It is given as a continuous IV infusion over 60 hours.
All Antidepressants carry a BOXED Warning for:
Suicidal Thoughts and Behaviors
-antidepressants increased the risk of suicidal thoughts and behavior in pediatric and young adult patients in short term studies. Closely monitor all antidepressant-treated patients for clinical worsening, and for emergence of suicidal thoughts and behaviors.
“book text” - possible increase in suicidal thoughts or actions in some children, teenagers, or young adults within the first few months of treatment or when the dose is changed.
Due to safety concerns (drug-drug and drug-food interactions) the use of oral Non-selective monoamine oxidase inhibitors (MAO inhibitors) is ____________ to patients unresponsive to other treatments.
restricted
Since many antidepressants increase serotonin levels, Serotonin Syndrome can occur with the administration of ___________________1__________
The risk is most severe when an ________2______ is administered with another serotonergic medication. _______3___ increase the risk.
1) one or more serotonergic medications
(SSRIs, SNRIs, mirtazapine, trazodone, opioids, tramadol, lithium, buspirone, triptans, dextromethorphan and St. John’s wort)
2) MAO inhibitor
3) Higher doses
-
-
-
-
-
-
-
- Agitation
- Dizziness
- Hallucinations
- Diarrhea
- Severe nausea
- Muscle rigidity
- Headache
- Tachycardia
If an antidepressant is being discontinued, it should generally be tapered over __________________ to avoid withdrawal.
Withdrawal symptoms include: ______
several weeks
anxiety, agitation, insomnia, dizziness, and flu-like symptoms
___________ and _________ carry a higher risk of withdrawal symptoms and must be tapered upon discontinuation.
- An exception to this rule is _____________, which self-tapers because of its long half life.
paroxetine & venlafaxine
fluoxetine
____________ are required for ALL antidepressants.
MedGuides
With antidepressants: Patients must be counseled on the __________ AND _________
Lag effect with these medications
AND
Suicide Prevention
Counseling with Antidepressants:
-
- All Antidepressant medications must be used daily and will take time to work
- All Antidepressants can take 1-2 weeks to feel a benefit from this drug and 6-8 weeks to feel the full effect on mood
- All Antidepressants can cause suicidal ideation
(Physical symptoms such as low energy improve within 1-2 weeks, but psychological symptoms, such as low mood, may take a month or longer.)
- Physicians and pharmacists must educate patients, family and caregivers about the risk of suicidality and screen for suicide risk
- If a patient reports suicidal ideation, refer the patient to the emergency department, the suicide hotline or elsewhere for help. If someone has a plan to attempt suicide, it is more likely that the threat is immediate.
What are the Contraindications with SSRIs?
DO NOT USE with MAO inhibitors, linezolid (Zyvox), IV methylene blue or pimozide (1st generation atypical antipsychotic), pimozide toxicity can occur
What are the Warnings with SSRIs?
-***QT prolongation
” An abnormal prolonged QT interval is > 440 ms (milliseconds)
BUT > 500 ms is worrisome for torsades de pointes” “twisting of the peaks”, a life-threatening heart rhythm disturbance.
The Risk of QT prolongation is greatest with
Higher doses of Citalopram & Higher doses of Escitalopram. This is a dose-dependent adverse effect.
If someone is a CYP2C19 poor metabolizer OR on 2C19 inhibitors along with citalopram or escitalopram this will also put the patient at risk for QT prolongation.
- ***(SIADH) Syndrome of Inappropriate Antidiuretic Hormone: is when the body makes too much antidiuretic hormone (ADH). ADH helps the kidneys control the amount of water your body loses through the urine. So in SIADH the body retains too much water. Since there is much more water in the blood, many different things are diluted like (Na) sodium.
/hyponatremia,
***fall risk (Beer’s criteria: use caution in elderly, avoid if history of falls/fractures or use of CNS depressants)
***Additive Bleeding risk, when used with anticoagulants/antiplatelets/NSAIDs/select natural products “Ginko/Garlic/Ginger/Ginseng/Glucosamine/Fish Oils”/thrombolytics)
What are the side effects with SSRIs?
*** Sexual Side effects, such as low libido and functional problems (erectile dysfunction)
*** “they are CNS depressants” so CNS effects:
- somnolence, insomnia, dizziness, headache, weakness, tremor
Nausea, Dry mouth
Which SSRIs should be taken in the morning?
fluoxetine, most activating
Which SSRIs should be taken in the evening?
paroxetine, fluvoxamine, are very sedating agents.
Which SSRI is not FDA indicated for depression but for (OCD) Obsessive Compulsive Disorder?
fluvoxamine
If a lab report shows low sodium, check to see if the patient is on an ____________. Can contribute to lab abnormality.
SSRI
What is the normal range for Na?
normal range: (135-145 mEq/L)
Which SSRI does not need to be tapered due too it’s long half life?
fluoxetine
If we want to switch a patient from fluoxetine 20mg daily to fluoxetine delayed release 90mg once every week, How would we do so?
Start 7 days after the last daily dose.
Which fluoxetine product is indicated for (PMDD) premenstrual dysphoric disorder?
*Sarafem(fluoxetine)
Which fluoxetine product is indicated for treatment resistant depression?
(Symbyax)- fluoxetine + olanzapine
initial: 6mg/25mg every day at bedtime
what is the conversion between IR paroxetine and CR paroxetine?
10mg IR = 12.5mg CR
Which SSRI is preferred in patients who have cardiac risk?
sertraline
What are the SSRI combined mechanism drugs?
(Viibryd) vilazodone
(Trintellix) vortioxetine
Celexa
Class:
Indications:
MOA:
Dosage forms:
Dosing:
Max dose:
Contraindications:
Warnings:
Side Effects:
Monitoring:
Pearls/Notes:
Drug-Drug/Food interactions:
citalopram
Class: Antidepressant-Selective Serotonin Reuptake Inhibitor (SSRI)
Indications: depression
MOA: drug increases (5-HT) serotonin levels by inhibiting its reuptake and keeping it in the neuronal synapse “synaptic cleft”, keeping serotonin neurotransmitters present for a longer duration. They weakly affect NE and DA.
Dosage forms:
Dosing: 20-40 mg/day
*Max dose: 40mg /day
Max dose for elderly (>60 years): 20mg/ day
Contraindications:
-**Do NOT Use with MAO inhibitors, linezolid (Zyvox), IV methylene blue or pimozide= (1st generation atypical antipsychotic)
Warnings:
-* QT prolongation
- *(SIADH) Syndrome of Inappropriate Antidiuretic Hormone: is when the body makes too much antidiuretic hormone (ADH). ADH helps the kidneys control the amount of water your body loses through the urine. So in SIADH the body retains too much water. Since there is much more water in the blood, many different things are diluted like (Na) sodium.
/hyponatremia,
*fall risk (Beer’s criteria: use caution in elderly, avoid if history of falls/fractures or use of CNS depressants)
- liver disease, also puts those at risk for QT prolongation
- *Bleeding (additive risk when used with anticoagulants/antiplatelets/NSAIDs/select natural products “Ginko/Garlic/Ginger/Ginseng/Glucosamine/Fish Oils”/thrombolytics)
Side Effects:
- * Sexual Side effects: decreased libido, ejaculation difficulties, anorgasmia, erectile dysfunction
- *Somnolence, insomnia, nausea, dry mouth, diaphoresis “sweating” (dose-related) weakness, tremor, dizziness, headache
Monitoring:
Pearls/Notes:
- All SSRIs approved for depression and a variety of anxiety disorders, EXCEPT fluvoxamine which is only approved for OCD
-All are available in solution EXCEPT fluvoxamine
-Sertraline preferred in patients with cardiac risk*
Drug-Drug/Food interactions:
Lexapro
Class:
Indications:
MOA:
Dosage forms:
Dosing:
Max dose:
Contraindications:
Warnings:
Side Effects:
Monitoring:
Pearls/Notes:
Drug-Drug/Food interactions:
escitalopram
Class: Antidepressant-Selective Serotonin Reuptake Inhibitor (SSRI)
Indications: depression
MOA: drug increases (5-HT) serotonin levels by inhibiting its reuptake in the neuronal synapse, keeping serotonin neurotransmitters present for longer duration. They weakly affect NE and DA.
Dosage forms:
Dosing: 10-20mg / day
*Max dose: 20mg/day
Max dose for elderly (>60 years): 10mg/ day
Contraindications:
-**Do NOT Use with MAO inhibitors, linezolid (Zyvox), IV methylene blue or pimozide= (1st generation atypical antipsychotic)
Warnings:
-* QT prolongation
- *(SIADH) Syndrome of Inappropriate Antidiuretic Hormone/hyponatremia, fall risk (Beer’s criteria: use caution in elderly, avoid if history of falls/fractures or use of CNS depressants)
- *Bleeding (additive risk when used with anticoagulants/antiplatelets/NSAIDs/select natural products “Ginko/Garlic/Ginger/Ginseng/Glucosamine/Fish Oils”/thrombolytics)
Side Effects:
- * Sexual Side effects: decreased libido, ejaculation difficulties, anorgasmia, erectile dysfunction
- *Somnolence, insomnia, nausea, dry mouth, diaphoresis “sweating” (dose-related) weakness, tremor, dizziness, headache
Monitoring:
Pearls/Notes:
- All SSRIs approved for depression and a variety of anxiety disorders, EXCEPT fluvoxamine which is only approved for OCD
-All are available in solution EXCEPT fluvoxamine
-Sertraline preferred in patients with cardiac risk*
Drug-Drug/Food interactions:
Prozac
Class:
Indications:
MOA:
Dosage forms:
Dosing:
Max dose:
Contraindications:
Warnings:
Side Effects:
Monitoring:
Pearls/Notes:
Drug-Drug/Food interactions:
fluoxetine
Class: Antidepressant-Selective Serotonin Reuptake Inhibitor (SSRI)
Indications: depression
MOA: drug increases (5-HT) serotonin levels by inhibiting its reuptake in the neuronal synapse, keeping serotonin neurotransmitters present for longer duration. They weakly affect NE and DA.
Dosage forms:
Dosing: 10-60mg
*Max dose: 80mg/day, 90mg/week (delayed-release)
Contraindications:
-**Do NOT Use with MAO inhibitors, linezolid (Zyvox), IV methylene blue or pimozide= (1st generation atypical antipsychotic)
Warnings:
-* QT prolongation
- *(SIADH) Syndrome of Inappropriate Antidiuretic Hormone/hyponatremia, fall risk (Beer’s criteria: use caution in elderly, avoid if history of falls/fractures or use of CNS depressants)
- *Bleeding (additive risk when used with anticoagulants/antiplatelets/NSAIDs/select natural products “Ginko/Garlic/Ginger/Ginseng/Glucosamine/Fish Oils”/thrombolytics)
Side Effects:
- * Sexual Side effects: decreased libido, ejaculation difficulties, anorgasmia, erectile dysfunction
- *Somnolence, insomnia, nausea, dry mouth, diaphoresis “sweating” (dose-related) weakness, tremor, dizziness, headache
Monitoring:
Pearls/Notes:
- All SSRIs approved for depression and a variety of anxiety disorders, EXCEPT fluvoxamine which is only approved for OCD
-All are available in solution EXCEPT fluvoxamine
-Sertraline preferred in patients with cardiac risk*
Drug-Drug/Food interactions:
Paxil
Class:
Indications:
MOA:
Dosage forms:
Dosing:
Max dose:
Contraindications:
Warnings:
Side Effects:
Monitoring:
Pearls/Notes:
Drug-Drug/Food interactions:
paroxetine hydrochloride
Class: Antidepressant-Selective Serotonin Reuptake Inhibitor (SSRI)
Indications: depression
MOA: drug increases (5-HT) serotonin levels by inhibiting its reuptake in the neuronal synapse, keeping serotonin neurotransmitters present for longer duration. They weakly affect NE and DA.
Dosage forms:
Dosing:
IR: 10-60mg/day
CR: 12.5-62.5mg/day
*Max dose:
Contraindications:
-*Pregnancy
-Do NOT Use with MAO inhibitors, linezolid (Zyvox), IV methylene blue or pimozide= (1st generation atypical antipsychotic)
Warnings:
-* QT prolongation
- *(SIADH) Syndrome of Inappropriate Antidiuretic Hormone/hyponatremia, fall risk (Beer’s criteria: use caution in elderly, avoid if history of falls/fractures or use of CNS depressants)
- *Bleeding (additive risk when used with anticoagulants/antiplatelets/NSAIDs/select natural products “Ginko/Garlic/Ginger/Ginseng/Glucosamine/Fish Oils”/thrombolytics)
Side Effects:
- * Sexual Side effects: decreased libido, ejaculation difficulties, anorgasmia, erectile dysfunction
- *Somnolence, insomnia, nausea, dry mouth, diaphoresis “sweating” (dose-related) weakness, tremor, dizziness, headache
Monitoring:
Pearls/Notes:
- All SSRIs approved for depression and a variety of anxiety disorders, EXCEPT fluvoxamine which is only approved for OCD
-All are available in solution EXCEPT fluvoxamine
-Sertraline preferred in patients with cardiac risk*
Drug-Drug/Food interactions:
Pexeva
Class:
Indications:
MOA:
Dosage forms:
Dosing:
Max dose:
Contraindications:
Warnings:
Side Effects:
Monitoring:
Pearls/Notes:
Drug-Drug/Food interactions:
paroxetine mesylate
Class: Antidepressant-Selective Serotonin Reuptake Inhibitor (SSRI)
Indications: depression
MOA: drug increases (5-HT) serotonin levels by inhibiting its reuptake in the neuronal synapse, keeping serotonin neurotransmitters present for longer duration. They weakly affect NE and DA.
Dosage forms:
Dosing:
*Max dose:
Contraindications:
-*Pregnancy
-Do NOT Use with MAO inhibitors, linezolid (Zyvox), IV methylene blue or pimozide= (1st generation atypical antipsychotic)
Warnings:
-* QT prolongation
- *(SIADH) Syndrome of Inappropriate Antidiuretic Hormone/hyponatremia, fall risk (Beer’s criteria: use caution in elderly, avoid if history of falls/fractures or use of CNS depressants)
- *Bleeding (additive risk when used with anticoagulants/antiplatelets/NSAIDs/select natural products “Ginko/Garlic/Ginger/Ginseng/Glucosamine/Fish Oils”/thrombolytics)
Side Effects:
- * Sexual Side effects: decreased libido, ejaculation difficulties, anorgasmia, erectile dysfunction
- *Somnolence, insomnia, nausea, dry mouth, diaphoresis “sweating” (dose-related) weakness, tremor, dizziness, headache
Monitoring:
Pearls/Notes:
- All SSRIs approved for depression and a variety of anxiety disorders, EXCEPT fluvoxamine which is only approved for OCD
-All are available in solution EXCEPT fluvoxamine
-Sertraline preferred in patients with cardiac risk*
Drug-Drug/Food interactions:
Brisdelle
Class:
Indications:
MOA:
Dosage forms:
Dosing:
Max dose:
Contraindications:
Warnings:
Side Effects:
Monitoring:
Pearls/Notes:
Drug-Drug/Food interactions:
paroxetine
Class: Antidepressant-Selective Serotonin Reuptake Inhibitor (SSRI)
Indications: menopausal vasomotor symptoms
MOA: drug increases (5-HT) serotonin levels by inhibiting its reuptake in the neuronal synapse, keeping serotonin neurotransmitters present for longer duration. They weakly affect NE and DA.
Dosage forms:
Dosing: 7.5mg everyday at bedtime
*Max dose:
Contraindications:
-*Pregnancy
-Do NOT Use with MAO inhibitors, linezolid (Zyvox), IV methylene blue or pimozide= (1st generation atypical antipsychotic)
Warnings:
-* QT prolongation
- *(SIADH) Syndrome of Inappropriate Antidiuretic Hormone/hyponatremia, fall risk (Beer’s criteria: use caution in elderly, avoid if history of falls/fractures or use of CNS depressants)
- *Bleeding (additive risk when used with anticoagulants/antiplatelets/NSAIDs/select natural products “Ginko/Garlic/Ginger/Ginseng/Glucosamine/Fish Oils”/thrombolytics)
Side Effects:
- * Sexual Side effects: decreased libido, ejaculation difficulties, anorgasmia, erectile dysfunction
- *Somnolence, insomnia, nausea, dry mouth, diaphoresis “sweating” (dose-related) weakness, tremor, dizziness, headache
Monitoring:
Pearls/Notes:
- All SSRIs approved for depression and a variety of anxiety disorders, EXCEPT fluvoxamine which is only approved for OCD
-All are available in solution EXCEPT fluvoxamine
-Sertraline preferred in patients with cardiac risk*
Drug-Drug/Food interactions:
Zoloft
Class:
Indications:
MOA:
Dosage forms:
Dosing:
Max dose:
Contraindications:
Warnings:
Side Effects:
Monitoring:
Pearls/Notes:
Drug-Drug/Food interactions:
sertraline
Class: Antidepressant-Selective Serotonin Reuptake Inhibitor (SSRI)
Indications: depression, (PMDD) premenstrual dysphoric disorder
MOA: drug increases (5-HT) serotonin levels by inhibiting its reuptake in the neuronal synapse, keeping serotonin neurotransmitters present for longer duration. They weakly affect NE and DA.
Dosage forms:
Dosing: 50-200mg/day
For PMDD: 50-150mg daily or 50-150mg daily starting 14 days prior to menstruation through 1st full day of bleeding
*Max dose:
Contraindications:
-**Do NOT Use with MAO inhibitors, linezolid (Zyvox), IV methylene blue or pimozide= (1st generation atypical antipsychotic)
Warnings:
-* QT prolongation
- *(SIADH) Syndrome of Inappropriate Antidiuretic Hormone/hyponatremia, fall risk (Beer’s criteria: use caution in elderly, avoid if history of falls/fractures or use of CNS depressants)
- *Bleeding (additive risk when used with anticoagulants/antiplatelets/NSAIDs/select natural products “Ginko/Garlic/Ginger/Ginseng/Glucosamine/Fish Oils”/thrombolytics)
Side Effects:
- * Sexual Side effects: decreased libido, ejaculation difficulties, anorgasmia, erectile dysfunction
- *Somnolence, insomnia, nausea, dry mouth, diaphoresis “sweating” (dose-related) weakness, tremor, dizziness, headache
Monitoring:
Pearls/Notes:
- All SSRIs approved for depression and a variety of anxiety disorders, EXCEPT fluvoxamine which is only approved for OCD
-All are available in solution EXCEPT fluvoxamine
-Sertraline preferred in patients with cardiac risk*
Drug-Drug/Food interactions:
Luvox
Class:
Indications:
MOA:
Dosage forms:
Dosing:
Max dose:
Contraindications:
Warnings:
Side Effects:
Monitoring:
Pearls/Notes:
Drug-Drug/Food interactions:
fluvoxamine
Class: Antidepressant-Selective Serotonin Reuptake Inhibitor (SSRI)
Indications: depression
MOA: drug increases (5-HT) serotonin levels by inhibiting its reuptake in the neuronal synapse, keeping serotonin neurotransmitters present for longer duration. They weakly affect NE and DA.
Dosage forms:
Dosing: 50-300mg/day (doses > 100mg should be divided BID)
*Max dose:
Contraindications:
-**Do NOT Use with MAO inhibitors, linezolid (Zyvox), IV methylene blue or pimozide= (1st generation atypical antipsychotic)
Warnings:
-* QT prolongation
- *(SIADH) Syndrome of Inappropriate Antidiuretic Hormone/hyponatremia, fall risk (Beer’s criteria: use caution in elderly, avoid if history of falls/fractures or use of CNS depressants)
- *Bleeding (additive risk when used with anticoagulants/antiplatelets/NSAIDs/select natural products “Ginko/Garlic/Ginger/Ginseng/Glucosamine/Fish Oils”/thrombolytics)
Side Effects:
- * Sexual Side effects: decreased libido, ejaculation difficulties, anorgasmia, erectile dysfunction
- *Somnolence, insomnia, nausea, dry mouth, diaphoresis “sweating” (dose-related) weakness, tremor, dizziness, headache
Monitoring:
Pearls/Notes:
- All SSRIs approved for depression and a variety of anxiety disorders, EXCEPT fluvoxamine which is only approved for OCD
-All are available in solution EXCEPT fluvoxamine
-Sertraline preferred in patients with cardiac risk*
Drug-Drug/Food interactions:
Unique mechanism with Viibryd-
benefit with mechanism-
generic name-
SSRI + 5-HT1A partial agonist “which is similar to buspirone’s MOA”
- appear to have fewer sexual side effects
vilazodone
Unique mechanism with Trintellix
benefit of mechanism-
generic name-
SSRI + 5-HT1A partial agonist + 5-HT3 antagonist
- appear to have fewer sexual side effects
vortioxetine
Viibryd
Class:
Indications:
MOA:
Dosage forms:
Dosing:
Max dose:
Contraindications:
Warnings:
Side Effects:
Monitoring:
Pearls/Notes:
Drug-Drug/Food interactions:
vilazodone
Class:
Indications:
MOA:
Dosage forms:
Dosing:
Max dose:
Contraindications:
Warnings:
Side Effects:
Monitoring:
Pearls/Notes:
- Must be taken with food for optimal absorption and in order too produce adequate systemic concentrations in order to result in a desired effect
Drug-Drug/Food interactions:
Trintellix
Class:
Indications:
MOA:
Dosage forms:
Dosing:
Max dose:
Contraindications:
Warnings:
Side Effects:
Monitoring:
Pearls/Notes:
Drug-Drug/Food interactions:
vortioxetine
What are the side effects of SNRIs different from those in SSRIs?
- -* Effects due to increased NE:
increased blood pressure (especially at higher doses), *increased heart rate, *dilated pupils, *dry mouth, *excessive sweating, *constipation
– Can affect urethral resistance; caution using SNRIs in patients prone to obstructive urinary disorders
All SNRIs have risk for increased blood pressure, especially at higher doses, but the SNRI with the greatest risk is ___________
venlafaxine when doses > 150mg/day
venlafaxine has additive risk for QT prolongation with other QT prolonging agents.
Which SNRI(s) can leave a ghost tablet in the stool?
Pristiq
Which SNRI(s) is also indicated for peripheral neuropathy (pain), fibromyalgia, and chronic musculoskeletal pain?
Cymbalta
Which SNRI(s) is also indicated for generalized anxiety disorder (GAD)?
venlafaxine & duloxetine
Main Drug interactions involving SSRIs and SNRIs:
MAO inhibitors with SSRIs or SNRIs
*Allow a 2-week wash out between MAO inhibitors and SSRIs & SNRIs
(unless fluoxetine, allow a 5-week washout if going from fluoxetine to MAO inhibitor)
Serotonin Syndrome
Hypertensive Crisis
Which SNRI is preferred if to be used in combination with tamoxifen (Soltamox)?
venlafaxine
tamoxifen requires conversion to its active form by CYP2D6. Decreased effectiveness occurs with fluoxetine and paroxetine.
Which SSRIs and SNRIs are CYP2D6 inhibitors?
what other antidepressant are CYP2D6 inhibitors?
fluoxetine STRONG
paroxetine STRONG
fluvoxamine
duloxetine MODERATE
——————————————————————
bupropion STRONG
Effexor XR
Class:
Indications:
MOA:
Dosage forms:
Dosing:
Max dose:
Contraindications:
Warnings:
Side Effects:
Monitoring:
Pearls/Notes:
Drug-Drug/Food interactions:
venlafaxine
Class: antidepressant- Serotonin and Norepinephrine Reuptake Inhibitor (SNRI)
Indications: depression, generalized anxiety disorder, panic disorder, social anxiety disorder
MOA: drug increases (5-HT) serotonin levels and norepinephrine levels by inhibiting its reuptake in the presynaptic neuron blocking the corresponding receptors. This keeps serotonin and norepinephrine neurotransmitters in the synaptic cleft for longer duration.
Dosage forms:
Dosing: 37.5-375
Max dose:
(IR) - 375mg/day MAX
(ER) - 225mg/day MAX
(different generics check Orange Book)
Contraindications:
**SNRIs and MAO inhibitors can potentially cause a lethal drug interaction: Hypertensive Crisis
** Do Not initiate in a patient receiving linezolid (Zyvox) or IV methylene blue
Warnings:
- *(SIADH) Syndrome of Inappropriate Antidiuretic Hormone: is when the body makes too much antidiuretic hormone (ADH). ADH helps the kidneys control the amount of water your body loses through the urine. So in SIADH the body retains too much water. Since there is much more water in the blood, many different things are diluted like (Na) sodium.
/hyponatremia,
*fall risk (Beer’s criteria: use caution in elderly, avoid if history of falls/fractures or use of CNS depressants)
- *Bleeding (additive risk when used with anticoagulants/antiplatelets/NSAIDs/select natural products “Ginko/Garlic/Ginger/Ginseng/Glucosamine/Fish Oils”/thrombolytics)
Side Effects:
- Sexual Side effects: decreased libido, ejaculation difficulties, anorgasmia, erectile dysfunction
- *Somnolence, insomnia, nausea, dry mouth, diaphoresis “sweating” (dose-related) weakness, tremor, dizziness, headache
-* Effects due to increased NE:
increased blood pressure (especially at higher doses), increased heart rate, dilated pupils, dry mouth, excessive sweating, constipation
Monitoring:
Pearls/Notes:
Drug-Drug/Food interactions:
Cymbalta
Class:
Indications:
MOA:
Dosage forms:
Dosing:
Max dose:
Contraindications:
Warnings:
Side Effects:
Monitoring:
Pearls/Notes:
Drug-Drug/Food interactions:
duloxetine
Class: antidepressant- Serotonin and Norepinephrine Reuptake Inhibitor (SNRI)
Indications: depression, peripheral neuropathy (pain), fibromyalgia, (GAD) generalized anxiety disorder, chronic musculoskeletal pain
MOA: drug increases (5-HT) serotonin levels and norepinephrine levels by inhibiting its reuptake in the presynaptic neuron blocking the corresponding receptors. This keeps serotonin and norepinephrine neurotransmitters in the synaptic cleft for longer duration.
Dosage forms:
Dosing: 40-60mg/day (or 20-30mg BID)
Max dose: 120mg/day; doses > 60mg/day not more effective
Contraindications:
**SNRIs and MAO inhibitors can potentially cause a lethal drug interaction: Hypertensive Crisis
** Do Not initiate in a patient receiving linezolid (Zyvox) or IV methylene blue
Warnings:
- *(SIADH) Syndrome of Inappropriate Antidiuretic Hormone: is when the body makes too much antidiuretic hormone (ADH). ADH helps the kidneys control the amount of water your body loses through the urine. So in SIADH the body retains too much water. Since there is much more water in the blood, many different things are diluted like (Na) sodium.
/hyponatremia,
*fall risk (Beer’s criteria: use caution in elderly, avoid if history of falls/fractures or use of CNS depressants)
- *Bleeding (additive risk when used with anticoagulants/antiplatelets/NSAIDs/select natural products “Ginko/Garlic/Ginger/Ginseng/Glucosamine/Fish Oils”/thrombolytics)
Side Effects:
- Sexual Side effects: decreased libido, ejaculation difficulties, anorgasmia, erectile dysfunction
- *Somnolence, insomnia, nausea, dry mouth, diaphoresis “sweating” (dose-related) weakness, tremor, dizziness, headache
-* Effects due to increased NE:
increased blood pressure (especially at higher doses), increased heart rate, dilated pupils, dry mouth, excessive sweating, constipation
Monitoring:
Pearls/Notes:
*DO NOT USE duloxetine with CrCl < 30mL/min
Drug-Drug/Food interactions:
Pristiq
Class:
Indications:
MOA:
Dosage forms:
Dosing:
Max dose:
Contraindications:
Warnings:
Side Effects:
Monitoring:
Pearls/Notes:
Drug-Drug/Food interactions:
desvenlafaxine
Class: antidepressant- Serotonin and Norepinephrine Reuptake Inhibitor (SNRI)
Indications: depression
MOA: drug increases (5-HT) serotonin levels and norepinephrine levels by inhibiting its reuptake in the presynaptic neuron blocking the corresponding receptors. This keeps serotonin and norepinephrine neurotransmitters in the synaptic cleft for longer duration.
Dosage forms:
Dosing:50mg/day (can increase to 400mg/day but no benefit > 50mg)
Max dose:
Contraindications:
**SNRIs and MAO inhibitors can potentially cause a lethal drug interaction: Hypertensive Crisis
** Do Not initiate in a patient receiving linezolid (Zyvox) or IV methylene blue
Warnings:
- *(SIADH) Syndrome of Inappropriate Antidiuretic Hormone: is when the body makes too much antidiuretic hormone (ADH). ADH helps the kidneys control the amount of water your body loses through the urine. So in SIADH the body retains too much water. Since there is much more water in the blood, many different things are diluted like (Na) sodium.
/hyponatremia,
*fall risk (Beer’s criteria: use caution in elderly, avoid if history of falls/fractures or use of CNS depressants)
- *Bleeding (additive risk when used with anticoagulants/antiplatelets/NSAIDs/select natural products “Ginko/Garlic/Ginger/Ginseng/Glucosamine/Fish Oils”/thrombolytics)
Side Effects:
- Sexual Side effects: decreased libido, ejaculation difficulties, anorgasmia, erectile dysfunction
- *Somnolence, insomnia, nausea, dry mouth, diaphoresis “sweating” (dose-related) weakness, tremor, dizziness, headache
-* Effects due to increased NE:
increased blood pressure (especially at higher doses), increased heart rate, dilated pupils, dry mouth, excessive sweating, constipation
Monitoring:
Pearls/Notes:
Drug-Drug/Food interactions:
Counseling with SNRIs:
Fetzima
Class:
Indications:
MOA:
Dosage forms:
Dosing:
Max dose:
Contraindications:
Warnings:
Side Effects:
Monitoring:
Pearls/Notes:
Drug-Drug/Food interactions:
levomilnacipran
Class: antidepressant- Serotonin and Norepinephrine Reuptake Inhibitor (SNRI)
Indications: depression
MOA: drug increases (5-HT) serotonin levels and norepinephrine levels by inhibiting its reuptake in the presynaptic neuron blocking the corresponding receptors. This keeps serotonin and norepinephrine neurotransmitters in the synaptic cleft for longer duration.
Dosage forms:
Dosing: Start 20mg/day for 2 days, then increase to 40mg/day; can titrate by 40mg/day no sooner than every 2 days.
DO NOT open, chew or crush capsules, DO NOT take with alcohol
Max dose: 120mg/day
Contraindications:
**SNRIs and MAO inhibitors can potentially cause a lethal drug interaction: Hypertensive Crisis
** Do Not initiate in a patient receiving linezolid (Zyvox) or IV methylene blue
Warnings:
- *(SIADH) Syndrome of Inappropriate Antidiuretic Hormone: is when the body makes too much antidiuretic hormone (ADH). ADH helps the kidneys control the amount of water your body loses through the urine. So in SIADH the body retains too much water. Since there is much more water in the blood, many different things are diluted like (Na) sodium.
/hyponatremia,
*fall risk (Beer’s criteria: use caution in elderly, avoid if history of falls/fractures or use of CNS depressants)
- *Bleeding (additive risk when used with anticoagulants/antiplatelets/NSAIDs/select natural products “Ginko/Garlic/Ginger/Ginseng/Glucosamine/Fish Oils”/thrombolytics)
Side Effects:
- Sexual Side effects: decreased libido, ejaculation difficulties, anorgasmia, erectile dysfunction
- *Somnolence, insomnia, nausea, dry mouth, diaphoresis “sweating” (dose-related) weakness, tremor, dizziness, headache
-* Effects due to increased NE:
increased blood pressure (especially at higher doses), increased heart rate, dilated pupils, dry mouth, excessive sweating, constipation
Monitoring:
Pearls/Notes:
*DO NOT USE levomilnacipran with CrCl < 15mL/min
Drug-Drug/Food interactions:
How to remember brand names of Tricyclics?
E
A
T
Pie
N
Spaghetti
what are the corresponding generics and what type of tricyclics are each?
(Elavil)————————-amitriptyline—————————tertiary
(Anafranil)——————-clomipramine————————–tertiary
(Tofranil)———————imipramine—————————–tertiary
(Pamelor)——————–nortriptyline—————————-secondary
(Norpramin)—————-desipramine—————————-secondary
(Silenor)- for insomnia–doxepin———————————-tertiary
What is the mechanism of action of tricyclic antidepressants?
Which neurotransmitters are involved?
-primarily inhibit (NE) norepinephrine and (5-HT) serotonin, SOOOOOO sounds like an SNRI, but also BLOCK
(ACh) acetylcholine AND histamine receptors
- NE, 5-HT, ACh, Histamine
which group of tricyclic antidepressants are relatively selective for NE?
Secondary amines
which group of tricyclic antidepressants can be slightly more effective?
Tertiary amines
If a patient is on an MAO inhibitor and we want to switch them to a TCA, then what is required?
2-week washout period
Elavil* E
Class:
Indications:
MOA:
Dosage forms:
Dosing:
Max dose:
Contraindications:
Warnings:
Side Effects:
Monitoring:
Pearls/Notes:
Drug-Drug/Food interactions:
amitriptyline
Class: tricyclic antidepressant (TCA)
Indications: depression
MOA: drug increases (5-HT) serotonin levels and norepinephrine levels by inhibiting its reuptake in the presynaptic neuron blocking the corresponding receptors. This keeps serotonin and norepinephrine neurotransmitters in the synaptic cleft for a longer duration. Drug also blocks (ACh) acetylcholine and histamine receptors, allowing for those to build up, which contributes to side effect profiles.
Dosage forms:
Dosing:
Depression: 100-300mg/day every day at bedtime (HS)* or in divided doses
Neuropathic pain/migraine prophylaxis: 10-150mg QDHS
Max dose:
Contraindications:
-**Do NOT Use with MAO inhibitors, linezolid (Zyvox), IV methylene blue;
Side Effects:
Cardiotoxicity
*QT prolongation with overdose (monitor for suicidal ideation, as overdose can quickly cause fatal arrhythmias); obtain baseline ECG if cardiac risk factors or age > 50 years old
*Orthostasis (low blood pressure that happens when standing up from sitting down or lying down), tachycardia
Anticholinergic SE-due to blocking ACh receptors and Histamine
*Dry mouth, blurred vision, urinary retention, constipation (must taper off to avoid cholinergic rebound)
Vivid dreams, *weight gain (varies by agent and patient), sedation, sweating, myoclonus (muscle twitching- a symptom of drug toxicity)
Beers Criteria (Use caution in elderly): *risk of falls (avoid if history of falls/fractures or use of CNS depressants)
Monitoring:
Pearls/Notes:
*Tertiary amines have increased anticholinergic properties, and more likely to cause sedation and weight gain.
Drug-Drug/Food interactions:
Anafranil A
Class:
Indications:
MOA:
Dosage forms:
Dosing:
Max dose:
Contraindications:
Warnings:
Side Effects:
Monitoring:
Pearls/Notes:
Drug-Drug/Food interactions:
clomipramine
Class: tricyclic antidepressant (TCA)
Indications: depression
MOA: drug increases (5-HT) serotonin levels and norepinephrine levels by inhibiting its reuptake in the presynaptic neuron blocking the corresponding receptors. This keeps serotonin and norepinephrine neurotransmitters in the synaptic cleft for a longer duration. Drug also blocks (ACh) acetylcholine and histamine receptors, allowing for those to build up, which contributes to side effect profiles.
Dosage forms:
Dosing:
Max dose:
Contraindications:
-**Do NOT Use with MAO inhibitors, linezolid (Zyvox), IV methylene blue;
Side Effects:
Cardiotoxicity
*QT prolongation with overdose (monitor for suicidal ideation, as overdose can quickly cause fatal arrhythmias); obtain baseline ECG if cardiac risk factors or age > 50 years old
*Orthostasis (low blood pressure that happens when standing up from sitting down or lying down), tachycardia
Anticholinergic SE-due to blocking ACh receptors and Histamine
*Dry mouth, blurred vision, urinary retention, constipation (must taper off to avoid cholinergic rebound)
Vivid dreams, *weight gain (varies by agent and patient), sedation, sweating, myoclonus (muscle twitching- a symptom of drug toxicity)
Beers Criteria (Use caution in elderly): *risk of falls (avoid if history of falls/fractures or use of CNS depressants)
Monitoring:
Pearls/Notes:
*Tertiary amines have increased anticholinergic properties, and more likely to cause sedation and weight gain.
Drug-Drug/Food interactions:
Tofranil T
Class:
Indications:
MOA:
Dosage forms:
Dosing:
Max dose:
Contraindications:
Warnings:
Side Effects:
Monitoring:
Pearls/Notes:
Drug-Drug/Food interactions:
imipramine
Class: tricyclic antidepressant (TCA)
Indications: depression
MOA: drug increases (5-HT) serotonin levels and norepinephrine levels by inhibiting its reuptake in the presynaptic neuron blocking the corresponding receptors. This keeps serotonin and norepinephrine neurotransmitters in the synaptic cleft for a longer duration. Drug also blocks (ACh) acetylcholine and histamine receptors, allowing for those to build up, which contributes to side effect profiles.
Dosage forms:
Dosing:
Max dose:
Contraindications:
-**Do NOT Use with MAO inhibitors, linezolid (Zyvox), IV methylene blue;
Side Effects:
Cardiotoxicity
*QT prolongation with overdose (monitor for suicidal ideation, as overdose can quickly cause fatal arrhythmias); obtain baseline ECG if cardiac risk factors or age > 50 years old
*Orthostasis (low blood pressure that happens when standing up from sitting down or lying down), tachycardia
Anticholinergic SE-due to blocking ACh receptors and Histamine
*Dry mouth, blurred vision, urinary retention, constipation (must taper off to avoid cholinergic rebound)
Vivid dreams, *weight gain (varies by agent and patient), sedation, sweating, myoclonus (muscle twitching- a symptom of drug toxicity)
Beers Criteria (Use caution in elderly): *risk of falls (avoid if history of falls/fractures or use of CNS depressants)
Monitoring:
Pearls/Notes:
*Tertiary amines have increased anticholinergic properties, and more likely to cause sedation and weight gain.
Drug-Drug/Food interactions:
Silenor S
Class:
Indications:
MOA:
Dosage forms:
Dosing:
Max dose:
Contraindications:
Warnings:
Side Effects:
Monitoring:
Pearls/Notes:
Drug-Drug/Food interactions:
doxepin
Class: tricyclic antidepressant (TCA)
Indications: depression
MOA: drug increases (5-HT) serotonin levels and norepinephrine levels by inhibiting its reuptake in the presynaptic neuron blocking the corresponding receptors. This keeps serotonin and norepinephrine neurotransmitters in the synaptic cleft for a longer duration. Drug also blocks (ACh) acetylcholine and histamine receptors, allowing for those to build up, which contributes to side effect profiles.
Dosage forms:
Dosing:
Depression: 100-300mg/day
Max dose:
Contraindications:
-**Do NOT Use with MAO inhibitors, linezolid (Zyvox), IV methylene blue;
Side Effects:
Cardiotoxicity
*QT prolongation with overdose (monitor for suicidal ideation, as overdose can quickly cause fatal arrhythmias); obtain baseline ECG if cardiac risk factors or age > 50 years old
*Orthostasis (low blood pressure that happens when standing up from sitting down or lying down), tachycardia
Anticholinergic SE-due to blocking ACh receptors and Histamine
*Dry mouth, blurred vision, urinary retention, constipation (must taper off to avoid cholinergic rebound)
Vivid dreams, *weight gain (varies by agent and patient), sedation, sweating, myoclonus (muscle twitching- a symptom of drug toxicity)
Beers Criteria (Use caution in elderly): *risk of falls (avoid if history of falls/fractures or use of CNS depressants)
Monitoring:
Pearls/Notes:
*Tertiary amines have increased anticholinergic properties, and more likely to cause sedation and weight gain.
*Brand name Silenor is indicated for insomnia. All generic doxepin for depression
Drug-Drug/Food interactions:
Zonalon
Class:
Indications:
MOA:
Dosage forms:
Dosing:
Max dose:
Contraindications:
Warnings:
Side Effects:
Monitoring:
Pearls/Notes:
Drug-Drug/Food interactions:
doxepin
trimipramine
Pamelor
Class:
Indications:
MOA:
Dosage forms:
Dosing:
Max dose:
Contraindications:
Warnings:
Side Effects:
Monitoring:
Pearls/Notes:
Drug-Drug/Food interactions:
nortriptyline
Class: tricyclic antidepressant (TCA)
Indications: depression
MOA: drug increases (5-HT) serotonin levels and norepinephrine levels by inhibiting its reuptake in the presynaptic neuron blocking the corresponding receptors. This keeps serotonin and norepinephrine neurotransmitters in the synaptic cleft for a longer duration. Drug also blocks (ACh) acetylcholine and histamine receptors, allowing for those to build up, which contributes to side effect profiles.
Dosage forms:
Dosing:
Depression: 25mg TID-QID
Max dose:
Contraindications:
-**Do NOT Use with MAO inhibitors, linezolid (Zyvox), IV methylene blue;
Side Effects:
Cardiotoxicity
*QT prolongation with overdose (monitor for suicidal ideation, as overdose can quickly cause fatal arrhythmias); obtain baseline ECG if cardiac risk factors or age > 50 years old
*Orthostasis (low blood pressure that happens when standing up from sitting down or lying down), tachycardia
Anticholinergic SE-due to blocking ACh receptors and Histamine
*Dry mouth, blurred vision, urinary retention, constipation (must taper off to avoid cholinergic rebound)
Vivid dreams, *weight gain (varies by agent and patient), sedation, sweating, myoclonus (muscle twitching- a symptom of drug toxicity)
Beers Criteria (Use caution in elderly): *risk of falls (avoid if history of falls/fractures or use of CNS depressants)
Monitoring:
Pearls/Notes:
*Tertiary amines have increased anticholinergic properties, and more likely to cause sedation and weight gain.
Drug-Drug/Food interactions:
Norpramin
Class:
Indications:
MOA:
Dosage forms:
Dosing:
Max dose:
Contraindications:
Warnings:
Side Effects:
Monitoring:
Pearls/Notes:
Drug-Drug/Food interactions:
desipramine
Class: tricyclic antidepressant (TCA)
Indications: depression
MOA: drug increases (5-HT) serotonin levels and norepinephrine levels by inhibiting its reuptake in the presynaptic neuron blocking the corresponding receptors. This keeps serotonin and norepinephrine neurotransmitters in the synaptic cleft for a longer duration. Drug also blocks (ACh) acetylcholine and histamine receptors, allowing for those to build up, which contributes to side effect profiles.
Dosage forms:
Dosing:
Max dose:
Contraindications:
-**Do NOT Use with MAO inhibitors, linezolid (Zyvox), IV methylene blue;
Side Effects:
Cardiotoxicity
*QT prolongation with overdose (monitor for suicidal ideation, as overdose can quickly cause fatal arrhythmias); obtain baseline ECG if cardiac risk factors or age > 50 years old
*Orthostasis (low blood pressure that happens when standing up from sitting down or lying down), tachycardia
Anticholinergic SE-due to blocking ACh receptors and Histamine
*Dry mouth, blurred vision, urinary retention, constipation (must taper off to avoid cholinergic rebound)
Vivid dreams, *weight gain (varies by agent and patient), sedation, sweating, myoclonus (muscle twitching- a symptom of drug toxicity)
Beers Criteria (Use caution in elderly): *risk of falls (avoid if history of falls/fractures or use of CNS depressants)
Monitoring:
Pearls/Notes:
*Tertiary amines have increased anticholinergic properties, and more likely to cause sedation and weight gain.
Drug-Drug/Food interactions:
Counseling with TCAs:
What is the mechanism of action of bupropion?
Which neurotransmitters are involved?
why can this benefit the patient compared to other antidepressants?
(DA) dopamine AND (NE) norepinephrine reuptake inhibitor
drug increases (DA) dopamine levels and norepinephrine (NE) levels by inhibiting its reuptake in the presynaptic neuron blocking the corresponding receptors.
Has NO EFFECT ON (5-HT) serotonin
So no sexual side effects, if patients are experiencing with other agents, this is a good option too switch too.
Wellbutrin XL
Class:
Indications:
MOA:
Dosage forms:
Dosing:
Max dose:
Contraindications:
Warnings:
Side Effects:
Monitoring:
Pearls/Notes:
Drug-Drug/Food interactions:
bupropion
Class: antidepressant—-(DA) dopamine AND (NE) norepinephrine reuptake inhibitor
Indications: depression, seasonal affective disorder
MOA: drug increases (DA) dopamine levels and norepinephrine (NE) levels by inhibiting its reuptake in the presynaptic neuron blocking the corresponding receptors.
Dosage forms:
Dosing: 150-450mg daily
IR: is TID
XL: is daily
Max dose: Do NOT exceed 450mg/day (IR and XL products)
(up to 522mg/day with Aplenzin)
due to seizure risk
Contraindications:
- *Seizure disorder (bupropion can lower seizure threshold)
- * Hx of anorexia/bulimia (higher incidence of seizures)
- Increased Seizures risk in those who undergo abrupt discontinuation of alcohol or sedatives “benzodiazepines.”
- * DO NOT USE with MAO inhibitors, linezolid (Zyvox), IV methylene blue or other forms of bupropion
Warnings:
neuropsychiatric adverse events possible when used for smoking cessation (can include mood changes, hallucinations, paranoia, aggression, anxiety)
Side Effects:
-* Dry mouth, CNS stimulation (insomnia, restlessness), tremors/ *seizures (dose-related), *weight loss, headache/migraine, nausea/vomiting, constipation and possible blood pressure changes (more hypertension than hypotension)
Monitoring:
Pearls/Notes:
Has NO EFFECT ON (5-HT) serotonin
So, NO sexual side effects, if patients are experiencing with other agents, this is a good option too switch too.
Do NOT USE multiple formulations of bupropion.
Increased risk of Hypertensive Crisis with MAO inhibitors. Allow a 14-day washout when converting to an MAO inhibitor.
Drug-Drug/Food interactions:
Aplenzin
Class:
Indications:
MOA:
Dosage forms:
Dosing:
Max dose:
Contraindications:
Warnings:
Side Effects:
Monitoring:
Pearls/Notes:
Drug-Drug/Food interactions:
bupropion
Class:
Indications: depression, seasonal affective disorder
MOA:
Dosage forms:
Dosing:
Max dose:
Contraindications:
Warnings:
Side Effects:
Monitoring:
Pearls/Notes:
Drug-Drug/Food interactions:
Wellbutrin SR
Class:
Indications:
MOA:
Dosage forms:
Dosing:
Max dose:
Contraindications:
Warnings:
Side Effects:
Monitoring:
Pearls/Notes:
Drug-Drug/Food interactions:
bupropion
Class:
Indications:
MOA:
Dosage forms:
Dosing: Wellbutrin SR is BID
Max dose: 200mg/dose (400mg/day when used for depression) (300mg/day when used for smoking cessation)
Contraindications:
Warnings:
Side Effects:
Monitoring:
Pearls/Notes:
Drug-Drug/Food interactions:
Contrave
Class:
Indications:
MOA:
Dosage forms:
Dosing:
Max dose:
Contraindications:
Warnings:
Side Effects:
Monitoring:
Pearls/Notes:
Drug-Drug/Food interactions:
bupropion + naltrexone
Class:
Indications: weight management
MOA:
Dosage forms:
Dosing:
Max dose:
Contraindications:
Warnings:
Side Effects:
Monitoring:
Pearls/Notes:
Drug-Drug/Food interactions:
What is the “TIP” for knowing the non-selective MAO-inhibitors?
Tranylcypromine (Parnate)
Isocarboxazid (Marplan)
Phenelzine (Nardil)
What is the MOA of monoamine oxidase inhibitors?
How many isoforms of MAO are there?
drug inhibits the enzyme monoamine oxidase located in the presynaptic neurons, which is responsible for the breakdown of many catecholamines 5-HT, NE, Epi, and DA. By inhibiting these MAO enzymes, these neurotransmitters are more readily available.
monoamine oxidase-A and monoamine oxidase-B
MAO-A: affinity for serotonin, NE, EPi, DA
MAO-B: affinity for dopamine
Parnate
Class:
Indications:
MOA:
Dosage forms:
Dosing:
Max dose:
Contraindications:
Warnings:
Side Effects:
Monitoring:
Pearls/Notes:
Drug-Drug/Food interactions:
tranylCYPromine
Class: antidepressant - - monoamine oxidase inhibitor- NON-selective
Indications: depression
MOA: drug inhibits the enzyme monoamine oxidase located in the presynaptic neurons, which is responsible for the breakdown of many catecholamines 5-HT, NE, Epi, and DA. By inhibiting these MAO enzymes, these neurotransmitters are more readily available.
Dosage forms:
Dosing:
Max dose:
Contraindications:
- History of cardiovascular disease, cerebrovascular defect, headache, hepatic disease, pheochromocytoma
Warnings:
- Not commonly used but watch for *drug-drug AND drug-food interactions- if missed could be fatal!
- Hypertensive Crisis OR Serotonin Syndrome can occur when taken with TCAs, SSRIs, SNRIs, many other drugs and tyramine rich foods
Side Effects:
Anticholinergic effects (taper upon discontinuation to avoid cholinergic rebound)
Orthostasis
Sedation (EXCEPT tranylcypromine causes stimulation)
sexual dysfunction, weight gain, headache, insomnia
Monitoring:
Pearls/Notes:
Drug-Drug/Food interactions:
“Products that increase serotonin.” can cause Serotonin Syndrome
-TCA’s
-SSRIs
-SNRIs
- bupropion
- amphetamine/stimulants
- linezolid
- methylene blue
- lithium
-St. Johns wort
- Tramadol
- opioids
“Products that increase epinephrine and norepinephrine.”
-tyramine-rich food: “increases NE” (Aged, fermented, pickled, or smoked foods- aged cheese, cured, smoked or processed meats, soy sauce, beer) are contraindicated with MAO inhibitors since it can cause Hypertensive Crisis
Marplan
Class:
Indications:
MOA:
Dosage forms:
Dosing:
Max dose:
Contraindications:
Warnings:
Side Effects:
Monitoring:
Pearls/Notes:
Drug-Drug/Food interactions:
isocarboxazid
Class: antidepressant - - monoamine oxidase inhibitor- NON-selective
Indications: depression
MOA: drug inhibits the enzyme monoamine oxidase located in the presynaptic neurons, which is responsible for the breakdown of many catecholamines 5-HT, NE, Epi, and DA. By inhibiting these MAO enzymes, these neurotransmitters are more readily available.
Dosage forms:
Dosing:
Max dose:
Contraindications:
- History of cardiovascular disease, cerebrovascular defect, headache, hepatic disease, pheochromocytoma
Warnings:
- Not commonly used but watch for *drug-drug AND drug-food interactions- if missed could be fatal!
- Hypertensive Crisis OR Serotonin Syndrome can occur when taken with TCAs, SSRIs, SNRIs, many other drugs and tyramine rich foods
Side Effects:
Anticholinergic effects (taper upon discontinuation to avoid cholinergic rebound)
Orthostasis
Sedation (EXCEPT tranylcypromine causes stimulation)
sexual dysfunction, weight gain, headache, insomnia
Monitoring:
Pearls/Notes:
Drug-Drug/Food interactions:
“Products that increase serotonin.” can cause Serotonin Syndrome
-TCA’s
-SSRIs
-SNRIs
- bupropion
- amphetamine/stimulants
- linezolid
- methylene blue
- lithium
-St. Johns wort
- Tramadol
- opioids
“Products that increase epinephrine and norepinephrine.”
-tyramine-rich food: “increases NE” (Aged, fermented, pickled, or smoked foods- aged cheese, cured, smoked or processed meats, soy sauce, beer) are contraindicated with MAO inhibitors since it can cause Hypertensive Crisis
Nardil
Class:
Indications:
MOA:
Dosage forms:
Dosing:
Max dose:
Contraindications:
Warnings:
Side Effects:
Monitoring:
Pearls/Notes:
Drug-Drug/Food interactions:
phenelzine
Class: antidepressant - - monoamine oxidase inhibitor– NON-selective
Indications: depression
MOA: drug inhibits the enzyme monoamine oxidase located in the presynaptic neurons, which is responsible for the breakdown of many catecholamines 5-HT, NE, Epi, and DA. By inhibiting these MAO enzymes, these neurotransmitters are more readily available.
Dosage forms:
Dosing:
Max dose:
Contraindications:
- History of cardiovascular disease, cerebrovascular defect, headache, hepatic disease, pheochromocytoma
Warnings:
- Not commonly used but watch for *drug-drug AND drug-food interactions- if missed could be fatal!
- Hypertensive Crisis OR Serotonin Syndrome can occur when taken with TCAs, SSRIs, SNRIs, many other drugs and tyramine rich foods
Side Effects:
Anticholinergic effects (taper upon discontinuation to avoid cholinergic rebound)
Orthostasis
Sedation (EXCEPT tranylcypromine causes stimulation)
sexual dysfunction, weight gain, headache, insomnia
Monitoring:
Pearls/Notes:
Drug-Drug/Food interactions:
“Products that increase serotonin.” can cause Serotonin Syndrome
-TCA’s
-SSRIs
-SNRIs
- bupropion
- amphetamine/stimulants
- linezolid
- methylene blue
- lithium
-St. Johns wort
- Tramadol
- opioids
“Products that increase epinephrine and norepinephrine.”
-tyramine-rich food: “increases NE” (Aged, fermented, pickled, or smoked foods- aged cheese, cured, smoked or processed meats, soy sauce, beer) are contraindicated with MAO inhibitors since it can cause Hypertensive Crisis
Emsam
Class:
Indications:
MOA:
Dosage forms:
Dosing:
Max dose:
Contraindications:
Warnings:
Side Effects:
Monitoring:
Pearls/Notes:
Drug-Drug/Food interactions:
selegiline
Class: antidepressant - - monoamine oxidase inhibitor- MAO-B selective
Indications: depression
MOA: drug inhibits the enzyme monoamine oxidase located in the presynaptic neurons, which is responsible for the breakdown of many catecholamines 5-HT, NE, Epi, and DA. By inhibiting these MAO enzymes, these neurotransmitters are more readily available.
Dosage forms:
Dosing:
Max dose:
Contraindications:
- History of cardiovascular disease, cerebrovascular defect, headache, hepatic disease, pheochromocytoma
Warnings:
- Not commonly used but watch for *drug-drug AND drug-food interactions- if missed could be fatal!
- Hypertensive Crisis OR Serotonin Syndrome can occur when taken with TCAs, SSRIs, SNRIs, many other drugs and tyramine rich foods
Side Effects:
Anticholinergic effects (taper upon discontinuation to avoid cholinergic rebound)
Orthostasis
Sedation (EXCEPT tranylcypromine causes stimulation)
sexual dysfunction, weight gain, headache, insomnia
Monitoring:
Pearls/Notes:
Drug-Drug/Food interactions:
“Products that increase serotonin.” can cause Serotonin Syndrome
-TCA’s
-SSRIs
-SNRIs
- bupropion
- amphetamine/stimulants
- linezolid
- methylene blue
- lithium
-St. Johns wort
- Tramadol
- opioids
“Products that increase epinephrine and norepinephrine.”
-tyramine-rich food: “increases NE” (Aged, fermented, pickled, or smoked foods- aged cheese, cured, smoked or processed meats, soy sauce, beer) are contraindicated with MAO inhibitors since it can cause Hypertensive Crisis
Zelapar
Class:
Indications:
MOA:
Dosage forms:
Dosing:
Max dose:
Contraindications:
Warnings:
Side Effects:
Monitoring:
Pearls/Notes:
Drug-Drug/Food interactions:
selegiline
Class: antidepressant - - monoamine oxidase inhibitor- MAO-B Selective
Indications: Parkinson Disease
MOA: drug inhibits the enzyme monoamine oxidase located in the presynaptic neurons, which is responsible for the breakdown of many catecholamines 5-HT, NE, Epi, and DA. By inhibiting these MAO enzymes, these neurotransmitters are more readily available.
Dosage forms: ODT
Dosing:
Max dose:
Contraindications:
Warnings:
- Not commonly used but watch for *drug-drug AND drug-food interactions- if missed could be fatal!
- Hypertensive Crisis OR Serotonin Syndrome can occur when taken with TCAs, SSRIs, SNRIs, many other drugs and tyramine rich foods
Side Effects:
Anticholinergic effects (taper upon discontinuation to avoid cholinergic rebound)
Orthostasis
Sedation (EXCEPT tranylcypromine causes stimulation)
sexual dysfunction, weight gain, headache, insomnia
Monitoring:
Pearls/Notes:
Drug-Drug/Food interactions:
“Products that increase serotonin.” can cause Serotonin Syndrome
-TCA’s
-SSRIs
-SNRIs
- bupropion
- amphetamine/stimulants
- linezolid
- methylene blue
- lithium
-St. Johns wort
- Tramadol
- opioids
“Products that increase epinephrine and norepinephrine.”
-tyramine-rich food: “increases NE” (Aged, fermented, pickled, or smoked foods- aged cheese, cured, smoked or processed meats, soy sauce, beer) are contraindicated with MAO inhibitors since it can cause Hypertensive Crisis
Counseling with MAO inhibitors:
Remeron
Class:
Indications:
MOA:
Dosage forms:
Dosing:
Max dose:
Contraindications:
Warnings:
Side Effects:
Monitoring:
Pearls/Notes:
Drug-Drug/Food interactions:
mirtazapine
Class: Tetracyclic antidepressant
Indications:
MOA: drug has central presynaptic alpha-2 adrenergic antagonist effects, which results in increased release of (NE) norepinephrine AND (5-HT) serotonin
Dosage forms: tablet, ODT = (Remeron SolTab)
Dosing:
Max dose:
Contraindications:
DO NOT USE with MAO inhibitors, linezolid, or IV methylene blue, again due too increased risk of Serotonin Syndrome.
Warnings:
anticholinergic effects, additive QT prolongation (watch for other QT prolonging agents), blood dyscrasias, CNS depression
Side Effects:
*sedation, increase appetite, weight gain, dry mouth, dizziness,
Monitoring:
Pearls/Notes:
Drug-Drug/Food interactions:
Desyrel*
Class:
Indications:
MOA:
Dosage forms:
Dosing:
Max dose:
Contraindications:
Warnings:
Side Effects:
Monitoring:
Pearls/Notes:
Drug-Drug/Food interactions:
trazodone
Class:
Indications:
MOA: drug inhibits 5-HT reuptake, blocks Histamine-1 and alpha-1 adrenergic receptors
Dosage forms: tablet
Dosing: QDHS
Max dose:
Contraindications:
DO NOT USE with MAO inhibitors, linezolid, or IV methylene blue
Warnings:
Side Effects:
sedation
orthostasis (risk in elderly for falls)
priapism (painful erection longer than 4 hours, seek medical attention- medical emergency)
Monitoring:
Pearls/Notes:
- rarely used as an antidepressant due too sedation; used primarily off-label for sleep
- the ER formulation maybe less sedating
Drug-Drug/Food interactions:
Serzone*
Class:
Indications:
MOA:
Dosage forms:
Dosing:
Max dose:
Contraindications:
Warnings:
Side Effects:
Monitoring:
Pearls/Notes:
Drug-Drug/Food interactions:
nefazodone
Class:
Indications:
MOA: drug inhibits reuptake of (5-HT) serotonin and (NE) norepinephrine, it also blocks 5-HT2 and alpha-1 adrenergic receptors
Dosage forms:
Dosing:
Max dose:
Boxed warning:
*Hepatotoxicity - - rarely used due too this
Contraindications:
Warnings:
Side Effects:
Monitoring:
Pearls/Notes:
Drug-Drug/Food interactions:
Selecting the best antidepressant:
Which antidepressant is preferred for a patient with Cardiac/QT risk?
- having a QT interval greater than 440 ms is prolonged and something to consider.
- *Sertraline is preferred
- Avoid high doses of citalopram and escitalopram
Selecting the best antidepressant:
Which antidepressant is preferred for a patient that smokes or can be used for smoking cessation?
Bupropion SR is FDA-approved for smoking cessation
Bupropion SR is indicated for ___________
Both smoking cessation AND depression
MAX dose for smoking cessation = 300mg/day
MAX dose for depression =
Selecting the best antidepressant:
Which antidepressant is preferred for a patient with peripheral neuropathy or pain AND depression?
duloxetine
Selecting the best antidepressant:
Which antidepressant is NOT preferred for a patient with a seizure disorder or at risk for seizures (bulimia/anorexia, recent alcohol or sedative withdrawal?)
bupropion
Selecting the best antidepressant:
Which antidepressant is NOT preferred in a pregnant patient?
Which antidepressants are preferred in a pregnant patient if needed?
paroxetine
with mild-moderate depression: psychotherapy is first line
Severe depression: certain SSRIs are first line (citalopram, escitalopram, fluoxetine, sertraline)
Although if an antidepressant is needed in a patient who is pregnant, SSRIs are preferred with ____1_______ being an exception. What is the general warning regarding the use of this class of agents? ____2_____
1) paroxetine (DO NOT USE in pregnant patients) - studies have found an association with congenital cardiovascular malformations
2) general warning with the potential risk of persistent pulmonary hypertension in the newborn
Selecting the best antidepressant:
Which antidepressants are more sedating and should NOT be taken early in the day?
paroxetine
mirtazapine
trazadone
Selecting the best antidepressant:
Which antidepressants are more activating and should be taken in the morning and NOT later in the day?
fluoxetine
bupropion
Selecting the best antidepressant:
Which antidepressant is preferred for a patient with insomnia?
the more sedating agents
- paroxetine
- mirtazapine
- trazodone
When taking SSRIs and SNRIs, there is increased bleeding risk when taking these agents with _________________
anticoagulants, antiplatelets, NSAIDs, and some natural products (gingko, garlic, ginger, ginseng, glucosamine, fish oils)
Selecting the best antidepressant:
Which antidepressants are High risk for sexual dysfunction?
Which are Low risk for sexual dysfunction? Which
High Risk: SSRIs and SNRIs
Low risk: bupropion and mirtazapine
Treatment-Resistant Depression: is depression that ____________
does not fully respond to 2 full treatment trials.
- a trial is 4-8 weeks at a therapeutic dose
The (APA) American Psychiatric Association guidelines state that a patient should receive a ______________ trial of medication at a therapeutic dose before concluding that a drug is not working.
If the patient is not improving (making progress toward the treatment goal of remission) or has incomplete response, the following should be considered: ________
4-8 weeks
- change to a new antidepressant
- increase the antidepressant dose
- use a combination of antidepressants with different mechanisms of action
- augment with buspirone or a low dose of an atypical antipsychotic
- augmentation with lithium, thyroid hormone (T3), or in some cases, electroconvulsive therapy (ECT)
Atypical antipsychotics approved for augmentation in treatment resistant depression include:
-
-
- aripiprazole (Abilify)
- brexpiprazole (Rexulti)
- olanzapine + fluoxetine (Symbyax)
- quetiapine ER (Seroquel XR)
- esketamine (Spravato)
Atypical antipsychotics carry a BOXED warning stating: ___
Elderly individuals with dementia-related psychosis treated with antipsychotics are at increased risk of death!
Abilify
Class:
Indications:
MOA:
Dosage forms:
Dosing:
Max dose:
Contraindications:
Warnings:
Side Effects:
Monitoring:
Pearls/Notes:
Drug-Drug/Food interactions:
aripiprazole
Class: antipsychotic
Indications: treatment resistant depression,
MOA:
Dosage forms:
Dosing:
Max dose:
*Boxed Warning: Elderly individuals with dementia-related psychosis treated with antipsychotics are at increased risk of death
Contraindications:
Warnings:
Side Effects: *Anxiety, *Insomnia, *Akathisia (restlessness with anxiety and inability to remain still; (Tx with benzodiazepines or propranolol)
Monitoring:
Pearls/Notes:
- NOT Approved for dementia related psychosis
- metabolic issue:
Drug-Drug/Food interactions:
Abilify Maintena
Class:
Indications:
MOA:
Dosage forms:
Dosing:
Max dose:
Contraindications:
Warnings:
Side Effects:
Monitoring:
Pearls/Notes:
Drug-Drug/Food interactions:
aripiprazole
Class: antipsychotic
Indications: treatment resistant depression,
MOA:
Dosage forms: injection
Dosing:
Max dose:
*Boxed Warning: Elderly individuals with dementia-related psychosis treated with antipsychotics are at increased risk of death
Contraindications:
Warnings:
Side Effects: *Anxiety, *Insomnia, *Akathisia (restlessness with anxiety and inability to remain still; (Tx with benzodiazepines or propranolol)
Monitoring:
Pearls/Notes:
- NOT Approved for dementia related psychosis
- metabolic issue:
Drug-Drug/Food interactions:
akathisia:
is a state of constant movement with an inability to stay still
Abilify MyCite
Class:
Indications:
MOA:
Dosage forms:
Dosing:
Max dose:
Contraindications:
Warnings:
Side Effects:
Monitoring:
Pearls/Notes:
Drug-Drug/Food interactions:
aripiprazole
Class: antipsychotic
Indications: treatment resistant depression,
MOA:
Dosage forms:
Dosing:
Max dose:
*Boxed Warning: Elderly individuals with dementia-related psychosis treated with antipsychotics are at increased risk of death
Contraindications:
Warnings:
Side Effects: *Anxiety, *Insomnia, *Akathisia (restlessness with anxiety and inability to remain still; (Tx with benzodiazepines or propranolol)
Monitoring:
Pearls/Notes:
- NOT Approved for dementia related psychosis
- metabolic issue:
Drug-Drug/Food interactions:
Symbyax
Class:
Indications:
MOA:
Dosage forms:
Dosing:
Max dose:
Contraindications:
Warnings:
Side Effects:
Monitoring:
Pearls/Notes:
Drug-Drug/Food interactions:
olanzapine + fluoxetine
Class: antipsychotic
Indications: treatment resistant depression,
MOA:
Dosage forms:
Dosing:
Max dose:
*Boxed Warning: Elderly individuals with dementia-related psychosis treated with antipsychotics are at increased risk of death
Contraindications:
DO NOT USE with MAO inhibitors, linezolid (Zyvox), IV methylene blue, DUE TOO THE RISK of Serotonin Syndrome
Warnings:
Side Effects:
*sedation, *weight gain, *increase in lipids, *increase in glucose
Monitoring:
Pearls/Notes:
- NOT Approved for dementia related psychosis
- metabolic issue:
Drug-Drug/Food interactions:
Seroquel
Class:
Indications:
MOA:
Dosage forms:
Dosing:
Max dose:
Contraindications:
Warnings:
Side Effects:
Monitoring:
Pearls/Notes:
Drug-Drug/Food interactions:
quetiapine
Class: antipsychotic
Indications: treatment resistant depression,
MOA:
Dosage forms:
Dosing:
Max dose:
*Boxed Warning: Elderly individuals with dementia-related psychosis treated with antipsychotics are at increased risk of death
Contraindications:
Warnings:
Side Effects:
*sedation, *weight gain, *increase in lipids, *increase in glucose, *orthostasis, EPS (lower risk)
Monitoring:
Pearls/Notes:
- NOT Approved for dementia related psychosis
- metabolic issue:
Drug-Drug/Food interactions:
(EPS) Extrapyramidal Side Effects: include-
Dystonias:
Akathisia:
Parkinsonism:
Tardive Dyskinesias:
Dyskinesias:
Seroquel XR
Class:
Indications:
MOA:
Dosage forms:
Dosing:
Max dose:
Contraindications:
Warnings:
Side Effects:
Monitoring:
Pearls/Notes:
Drug-Drug/Food interactions:
quetiapine ER
Class: antipsychotic
Indications: treatment resistant depression,
MOA:
Dosage forms:
Dosing:
Max dose:
*Boxed Warning: Elderly individuals with dementia-related psychosis treated with antipsychotics are at increased risk of death
Contraindications:
Warnings:
Side Effects:
Monitoring:
Pearls/Notes:
- NOT Approved for dementia related psychosis
- metabolic issue:
Drug-Drug/Food interactions:
Rexulti
Class:
Indications:
MOA:
Dosage forms:
Dosing:
Max dose:
Contraindications:
Warnings:
Side Effects:
Monitoring:
Pearls/Notes:
Drug-Drug/Food interactions:
brexpiprazole
Class: antipsychotic
Indications: treatment resistant depression,
MOA:
Dosage forms:
Dosing:
Max dose:
*Boxed Warning: Elderly individuals with dementia-related psychosis treated with antipsychotics are at increased risk of death
Contraindications:
Warnings:
Side Effects:
Monitoring:
Pearls/Notes:
- NOT Approved for dementia related psychosis
- metabolic issue:
Drug-Drug/Food interactions:
Lithobid
Class:
Indications:
MOA:
Dosage forms:
Dosing:
Max dose:
Contraindications:
Warnings:
Side Effects:
Monitoring:
Pearls/Notes:
Drug-Drug/Food interactions:
lithium
All Antidepressants require an ________________ when dispensed.
MedGuide
Spravato
Class:
Indications:
MOA:
Dosage forms:
Dosing:
Max dose:
Contraindications:
Warnings:
Side Effects:
Monitoring:
Pearls/Notes:
Drug-Drug/Food interactions:
esketamine C-III (risk of abuse and misuse)
Class: NMDA receptor antagonist
Indications: reserved for patients having treatment resistant depression, and depression with suicidality.
MOA:
Dosage forms: nasal spray
Dosing: start 56mg intranasally twice weekly, can increase to 84mg twice weekly if tolerated.
Max dose:
Contraindications:
Warnings:
Side Effects:
Monitoring:
*- Must be administered under the supervision of a health care provider; monitor for adverse effects for at least 2 hours following administration (due to risk of blood pressure spikes and hallucinations)
Pearls/Notes:
- Due to risks, only available through a restricted distribution system under the Spravato REMS Program.
- Must be administered with another antidepressant
Drug-Drug/Food interactions:
