Depression Flashcards by Jimmy Hayden

Why should benzos not be used alone in depression?

leaves depression itself untreated
can cause and/or mask depression
puts patient at risk for physiological dependence and withdrawal symptoms if it wears off

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Natural products for depression

St John's Wort (CYP inducer)
or SAMe (s-adenosyl-l-methionine)

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List the MAO-I’s

phenelzine, tranylcypromine, isocarboxazid, selegeline (patch)

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Why do we limit use of MAO-I’s

High risk of serotonin syndrome

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Which antidepressant self-tapers due to its long half life?

Fluoxetine

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Antidepressants with high risk of withdrawal and require a taper

Paroxetine, venlafaxine

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Drugs that can cause or worsen depression

ADHD meds
Analgesics (indomethacin, methadone)
Antiretrovirals (efavirenz, rilpivirine)
CV drugs (BB’s esp propranolol, clonidine, methyldopa, procainamide, reserpine)
Hormones (contraceptives, steroids)
Systemic steroids, cyclosporine, ethandol, irotretinoin, interferons, varinicline (Chantix)

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Adequate trial for antidepressant

6-8 weeks for full effect

May take 1-2 weeks to feel any benefit

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Initial choice in pregnancy

Usually SSRI’s EXCEPT paroxetine (contraindicated in Brisdelle, new formulation for menopause)
Followed by TCA’s

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Fluoxetine class, brand, dose, combo drug

SSRI
Prozac
10-60 mg/day, or 90 mg weekly
Combined with olanzapine (Symbyax) for resistant depression

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Paroxetine class, brand, dose

SSRI
Paxil
10-60 mg/day or comes as CR 12.5-62.5 mg/day
10 mg IR = 12.5 mg CR

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Sertraline class, brand, dose

SSRI
Zoloft
50-200 mg/day

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Citalopram class, brand, dose

SSRI
Celexa
20-40 mg/day
MAX 40 mg/day bc of QT prolong
MAX 20 mg/day in elderly bc of QT prolong

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Escitalopram class, brand, dose

SSRI
Lexapro
10 mg/day max 20 mg/day

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SSRI’s used in PMDD

Fluoxetine, sertraline

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Vilazodone class, brand, dose

Viibryd
Combot SSRI and 5-HT1a partial agonist
10 mg x 7 days then 20 mg daily TAKE W FOOD

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Vortioxetine class, brand, dose

Trintellix

10 mg/day, can increase 20 mg/day or down to 5 mg/day

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SSRI’s boxed warnings, contraindications, regular warnings, side effects

Boxed: inc risk of suicidal thoughts or behavior
Contraindicaed with MAO-I’s or linezolid
May cause QT prolongation (esp citalopram)
May cause sexual side effects (dec libido, ED), somnolence, insomnia, nausea, dry mouth, diaphoresis (dose-related), weakness, tremor, dizziness, headache (but may help w migraines if taken continuously) (ALL of this shit was underlined)
Fluoxetine can cause activation - take in AM
Can cause SIADH, hyponatremia

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Why don’t we use fluvoxamine a lot?

SSRI w a lot of drug interactions

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SSRI w weekly dosing, how to switch

Fluxetine
90 mg/weekly (usually 10-60 mg/daily)
Start 7 days after last daily dose

Benefit of vilazodone over other SSRI’s

Less sexual side effects

Washout period for MAO-I’s

14 days except fluoxetine its 5 weeks

Fluoxetine drug interactions

2D6 and 2C19 inhibitor

Paroxetine drug interactions

2D6 inhibitor

Tamoxifen drug interaction w SSRI's

Decreased effectiveness with fluoxetine, paroxetine, and sertraline (also with duloxetine and bupropion)

Venlafaxine class, brand, dose

SNRI Effexor 37.5-375 mg/day

Duloxetine class, brand, dose

SNRI Cymbalta 40-60 mg/day up to 120 mg/day (but doses > 60 mg/day may not be more effective)

Desvenlafaxine class, brand, dose

SNRI Pristiq, Khedezla 50 mg/day, no benefit higher than this but up to 100 mg/day

SNRI warnings

Increased BP, greatest w venlafaxine > 150 mg/day (but all SNRI's have risk) Same risk of suicidal ideation and whatnot especially in young adults/children Venlafaxine QT prolongation

SNRI to MAO-I switch

Washout period of 5-14 days (duloxetine) or 7 days (venlafaxine, desvenlafaxine, levomilnacipan)

Amitriptyline class, brand, dose

TCA Elavil 100-300 mg qHS for depression, lower doses for neuropathic pain/migraine ppx (10-50 mg HS)

Doxepin class, dose

TCA | 100-300 mg/day

Nortriptyline class, brand, dose

TCA Pamelor 25 mg TID to QID

Warnings w TCAs

Anticholinergic (dry mouth, blurred vision, urinary retention, constipation) Also can cause orthostasis, QT prolongation w overdose

Isocarboxazid class, brand, dose

MAO-I Marplan 20 mg/day in divided doses

Phenelzine class, brand, dose

MAO-I Nardil 15 mg TID, max 60-90 mg/day

Tranylcypromine class, brand, dose

MAO-I Parnate 30 mg/day divided doses

Selegiline class, brand, dose

MAO-I (B selective) Emsam = transdermal 6 mg patch/day up to 9-12 mg/day

Warnings w selegiline

Avoidhigh tyramine foods, discontinue 10 days before elective surgery requiring general anesthesia No dietary concerns w 6 mg patch, just 9 or 12 mg!

Warnings w MAO-I's

Fatal drug interactions can occur, although these drugs aren't commonly used

Emsam patch counseling

``` Silegiline Change once daily Apply to upper chest, back (below neck, above the waist), upper thigh, or outer surface of the upper arm Do not use the same site 2 days in a row Wash hands with soap after patch ```

Buproprion class, brand, dose, warnings, counseling

Dopamine and norepinephrine reuptake inhibitor 300-450 mg daily Wellbutrin SR = 200 mg BID Wellbutrin XL = once daily (seasonal affective disorder) Warnings = inc seizure risk Side effects = dry mouth, insomnia, tremors/seizures (dose-related) Note no 5-HT activity so sexual dysfuction is rare

Mirtazepine class, brand, dose, side effects

``` Remeron TCA sorta Very sedating so take at night 15-45 mg qHS Increased appetite and weight gain as well ```

Trazodone class, brand, dose, side effects

Inhibits 5-HT reuptake, blocks H1 and alpha1 adrenergic receptors Dose 150-300 mg/day divided doses (Sleep dose is 50-100 mg HS) Sedating, can cause sexual dysfunction and priapism

Drugs associated with weight gain, weight loss

``` Mirtazepine = weight gain Bupropion = weight loss ```

Drugs to avoid in cardiac issues | Which is preferred?

``` Avoid = citalopram, escitalopram Pref'd = sertraline ```

Avoid in patients w seizure risk

Bupropion, do not exceed 450 mg/day

Drug that causes priapism

Trazodone

Define treatment resistant depression, what are adjunctive therapy options

Depression that does not fully respond to two full treatment trials Can add aripiprazole (Abilify) or quetiapine (Seroquel) Symbyax is also a combo olanzapine/fluoxetine and is an option