Depression/Anxiety Flashcards
classification of drugs used in depression
- MAOIs
- TCAs
- SSRIs
- SNRIs (serotonin and norepi reuptake inhibitors)
- NaSSA (noradrenergic & specific serotonergic antidepressants)
- 5HT2 blockers that are also reuptake inhibitors
- NDRIs (norepi and dopamine reuptake inhibitors)
- multimodal antidepressants
- mood stabilizers
(1-8 are specific classes of antidepressants; in order of introduction to market)
name the MAOIs
- phenelzine (Nardil)
- tranylcypromine (Parnate)
- isocarboxazid (Marplan)
- selegiline (Deprenyl, Eldepryl)
- Emsam patch which is mostly used for Parkinson disease and depression
Info about MAOIs
MOA: inhibit enzyme MAO so NE/5HT not degraded; adrenergic, serotonergic
AEs: orthostatic hypotension, insomnia, sexual dysfunction, dietary issues (tyramine can cause hypertensive crisis);
Drug-drug: numerous/severe; 1. stimulants (cocaine, diet pills, nasal decongestants)
- narcotic analgesics (meperidine, Demerol)
- SSRIs/TCAs - wait min 2 weeks when switching from/to these med, otherwise causes serotonin syndrome - leads to fatal hypertensive crisis + GI problems
Other: first AD, only for non-responsive patients
Food rich in tyramine
cheese especially aged (philly cream cheese and cottage cheese exceptions), chicken/beef liver, yeast preparations (baker’s yeast ok), fava/broad beans, herring, beer, sherry, red wine, ale, liquers, canned figs, proteins extracts, bologna, salami, pepperoni, Spam
(excessive use to avoid, yogurt, sour cream, ripe acovados/guac, choco, caffeine, white wine, liquors)
name the TCAs
- amitriptyline (Elavil)
- nortriptyline (Pamelor)
- protriptyline (Vivactil)
- imipramine (Tofranil)
- clomipramine (Anafranil)
- desipramine (Norpramin)
- trimipramine (Surmontil)
- amoxapine (Asendin)
- doxepin (Sinequan)
- maprotiline (Ludiomil)
Info on TCAs
MOA: increases 5HT/NE in brain; adrenergic/serotonergic
AEs: antihistamine aes of weight gain/drowsiness, anticholinergic of can’t see (worsened glaucoma)/spit/pee/shit, drowsiness; confusion, orthostatic hypotension
- > amoxapine: TD
- > aprotline/clomipramine: seizures
- > really bad for geriatric patients
overdose: especially toxic to children, cardiac effects
usefulness: off-label pain management, older ADs mainly for non-responsive patients
Name the SSRIs
- paroxetine (Paxil/CR, Pexeva)
- sertraline (Zoloft)
- fluoxetine (Prozac, Sarafem)
- fluvoxamine (Luvox)
- citalopram (Celexa)
- escitalopram (Lexapro) - related S-enantiomer drug
Info on SSRIs
most commonly used AD class today b/c of improved safety
MOA: block 5HT reuptake in synapse (purely serotonergic)
Usefulness: all label indicated for MDD
off-label: pruritus, smoking cessation, chronic pain, menopausal vasomotor instability/hotflushes, premature ejaculation
ANXIETY SYNDROMES
1. paroxetine: GAD, panic disorder, OCD, social anxiety disorder, PTSD
2. sertraline: panic, OCD, social anxiety, PTSD
3. escitalopram: GAD, OCD
4. fluoxetine: panic, OCD
5. fluvoxamine: social anxiety, OCD
AEs: panicogenic (may cause panic attacks though used to treat panic disorders, called paradoxical reaction), sexual dysfunction, nausea/diarrhea due to 5HT effect in GI tract, risk of bleeding due to platelet effects, headache, bruxism, hyponatremia, discontinuation syndrome, serotonin syndrome with serotonergic drugs, some teratogenic - pulmonary disease in infants born to mothers on SSRIs
drug-drug: sometimes results in cardiac problems (long QT syndrome), sometimes reduced effectiveness of other drugs, never use within two weeks of MAOI, with lithium may enhance serotonergic effects
Name the SNRIs
- venlafaxine (Effexor-XR/immediate release)
- desvenlafaxine (Pristiq), the active component of venlafaxine
- duloxetine (Cymbalta)
- levomilnacipran (Fetzima)
Info of SNRIs
MOA: increases 5HT and NE in brain (adrenergic/serotonergic), at higher doses may increase dopamine in brain
AEs: since serotonergix, all AEs of SSRIs
venlafaxine - HTN
duloxetine - hepatitis, jaundice
Usefulness
label and off-label: 1. MDD and relapse prevention
2. GAD, PTSD, social anxiety, panic
3. fibromyalgia, diabetic peripheral neuropathy (DPN)
note: milnacipran (Savella) is also an SNRI used to treated fibromyalgia ONLY, thus it’s not listed in depression meds
drug-drug: duloxetine interacts with quinolone antibiotics
so summary of specifics: diastolic HTN, hyponatremia (low blood sodium), hepatitis/jaundice with duloxetine
Name the NaSSA drugs
- mirtazapine (Remeron and Remeron SolTab dissolving tablet)
Info on NaSSA drugs
really here for mirtazapine
MOA: raises levels of NE/5HT by receptor blockade in brain
AEs: antihistamine properties of weight gain, sedation, drowsiness, and dizziness (anticholinergic of dry mouth); risk of elevated cholesterol/triglycerides; risk of neutropenia (agranulocytosis)
drug-drug: with MAOIs; portentiates alcohol, benzos, CNS sedatives, and some anti-HTNs
Name the 5HT2 blockers that are also reuptake inhibitors
- trazadone (Desyrel)
2. nefazodone (Serzone)
infor on 5HT2 blockers that are also reuptake inhibitors
MOA: serotonergic effects from blockade of 5HT2 receptor
Usefulness: MDD (depression), reduces anxiety, sedation to treat insomnia
AEs: priapism, seizures, drowsiness, leucopenia, elevated LFTs (liver function tests)
nefazodone (Serzone): black box of liver failure
drug-drugs: other sedatives; MAOIs
special:
trazodone: prob safest AD if patient takes an overdose, often used at bedtime for insomnia, add-on to SSRIs often to reverse ED and libido loss
are all 5HT2 blockers antidepressants?
no, though others have similar sedation effects
- antihistamine: cyproheptadine (Periactin) used in migraine prophylaxis in children and used to for anorexia in children/adolescents
- migraine prophylaxis drug: methysergide (potential for severe toxicity)
- atypical antipsychotics: risperidone (Risperdal); olanzapine (Zyprexa)
