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PR - CNS > DEPRESSION: SSRIs > Flashcards

DEPRESSION: SSRIs Flashcards

1
Q

Why are SSRIs first line in depression?

A

Better tolerated and safer in overdose

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2
Q

MoA

A

Selectively inhibit the reuptake of 5-HT from the synaptic cleft

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3
Q

Commonly used SSRIs

A

Sertraline
Fluoxetine
Fluoxetine
citalopram
escitalopram
fluvoxamine

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4
Q

Side effects - SSRIs

A
  • GI
  • Hyponatraemia
  • QT prolongation
  • Suicidal tendencies
  • Seizures
  • SS
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5
Q

Interactions - increased risk of hyponatraemia

A

Diuretics - loop/thiazides
Desmopressin
Carbamazepine
NSAIDs

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6
Q

initial dose of sertraline in depression, OCD and panic disorder/PTSD/social anxiety disorder

A

depression and OCD: 50mg
panic disorder, PTSD, social anxiety disorder: 25mg

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7
Q

max dose sertraline per day

A

200mg

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8
Q

Which SSRI is safe in stable angina + MI

A

Sertraline

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9
Q

is chest pain a common symptom of sertraline

A

Yes

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10
Q

Which antidepressant in licensed for children?

A

Under 17
Fluoxetine

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11
Q

Which SSRIs cause QT prolongation

A

Citalopram
Escitalopram

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12
Q

Which SSRI has higher risk of withdrawal reactions?

A

Paroxetine

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13
Q

Other SSRIs

A

Escitalopram
Fluvoxamine
Paroxetine

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14
Q

Benefit of SSRIs over TCAs

A

o less cardiotoxic
o less sedating
o less antimuscarinic than TCAs
o SSRis safer in unstable angina and myocardial infarction and in overdose

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15
Q

T or F - symptoms of sexual dysfunction will stop on treatment discontinuation

A

false. they can persist even after treatment has stopped

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16
Q

SSRIs interactions

A

o CYP enzyme inhibitors (Avoid grapefruit, increases plasma conc)
o CYP enzyme inducers e.g. St John’s Wart (reducers effectiveness)
o Drugs that cause QT prolongation
o Drugs increasing risk of bleed
o Hyponatraemia (carbamazepine and diuretics)
o Serotonin syndrome

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17
Q

SSRIs in pregnancy

A

Risk vs benefits
Use lowest effective dose
Small increased risk of persistent pulmonary hypertension in newborns with use beyond 20 weeks
Use in later stages = neonatal withdrawal symptoms
Small increased risk of PP haemorrhage when used in month before delivery

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18
Q

Using SSRIs in later stages of pregnancy may result in neonatal withdrawal symptoms. What do we monitor?

A

Associated CNS, motor, respiratory, and GI symptoms

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19
Q

You know that a patient is due to give birth in a couple of weeks. You see that she has just had an rx for sertraline 50mg OD come in. You know there was recent MHRA safety info published about the use of SSRIs in the month before delivery having a possible increased risk of PP haemorrhage. What do you do?
- contact prescriber and tell them this is contraindicated
- dispense it

A

dispense it. there MIGHT be a small increased risk of PP haemorrhage when used in month before delivery. but specialist sources indicate SSRIs may be suitable for use in pregnancy, but risks and benefits of use may be considered, and lowest effective dose to be used

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20
Q

SSRIs in BF

A
  • sertraline and paroxetine preferred
  • however all can be used with caution
  • risks with switching SSRIs so may be more clinically appropriate to continue treatment with SSRI that has been effective, or restart with one that has previously been effective
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21
Q

What should you monitor the infant for when BF?

A

Monitor infant for drowsiness, poor feeding, adequate weight gain, GI disturbances, irritability, restlessness

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22
Q

Although all SSRIs can be used in BF women with caution, the following two are preferred based on passage into milk, half-life, published evidence of safety

A

paroxetine
sertraline

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23
Q

use of sertraline in BF

A

can be used (preferred in BF, along with paroxetine)
long half life increase risk of accumulation in infant
monitor infant for drowsiness, poor feeding, irritability, GI disturbance, restlessness, adequate weight gain

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24
Q

important safety info for all SSRIs - small increased risk of PP haemorrhage when used in month before delivery

A

increased bleeding risk due to effect on platelet function
using in last month before delivery may increase risk of PP haemorrhage
consider benefits and risks of AD during pregnancy, and risks of untreated depression in pregnancy

25
Q

Overdose

A

N + V
Agitation
Tremor
Nystagmus
Drowsiness
Sinus tachycardia
Convulsion

26
Q

Interactions - increased plasma concentrations

A

Grapefruit juice (enzyme inhibitor)

27
Q

Interactions - increased risk of bleeding

A

NSAIDs/Aspirin (GI bleeding)
Anticoagulant
Antiplatelets e.g. warfarin

28
Q

Interactions - increased risk of QT prolongations

A

Erythromycin (macrolides)
TCAs
Sotalol
Amiodarone
Chloroquine
Mefloquine
Lithium
Quinine
Antipyschotics

29
Q

Interactions - increased risk of QT prolongation due to hypokalaemia

A

These cause hypokalaemia, which in turn can lead to QT prolongation increases risk of torsade de pointes
- Theophylline
- Beta 2 agonists
- Loop/thiazide diuretics
- Corticosteroids

30
Q

Interactions - increased risk of serotonergic effects/serotonin syndrome

A

St. Johns wort (serotonergic antidepressant)
Amfetamines
Sumatriptan (5-HT1a agonist)
Selegiline (MAO-B inhibitor)
Tramadol (opioid that also inhibits reuptake of 5-HT + NA)
TCAs/MAOIs (serotonergic drugs)
Ondansetron (5-HT3 antagonists)

31
Q

Under 18s

A

Citalopram, escitalopram, paroxetine, sertraline, mirtazapine + venlafaxine are NOT recommended in under 18s.

ONLY fluoxetine effective in children + adolescents.

Monitor carefully for suicidal behaviour, self-harm or hostility esp @ the start.

32
Q

Cautions

A

Epilepsy (poorly controlled/if seizures develop = discontinue)
Cardiac disease
Diabetes
Susceptibility to angle-closure glaucoma
History of mania
Bleeding disorders

33
Q

Overdose (poisoning)

A

N + V
Agitation
Tremor
Nystagmus
Drowsiness
Sinus tachycardia

34
Q

Treatment cessation

A

GI disturbances
Headache
Anxiety
Electric shock sensation in head, neck + spine
Tinnitus
Sleep disturbances
Fatigue
Flu-like symptoms
Sweating

Palpitations + visual disturbances (less common)

35
Q

withdrawal effects may occur within the following timeframe of stopping treatment with AD
usually mild and self limiting but sometimes severe

A

within 5 days

36
Q

risk of withdrawal symptoms is increased if AD stopped suddenly after regular administration for ….. weeks or more

A

8 weeks or more

37
Q

how to withdraw sertraline

A

withdraw dose gradually over about 4 weeks or longer if withdrawal symptoms occur
6 months in pt who have been on long term maintenance

38
Q

labels for sertraline

A

do not drink grapefruit juice (increases amount of sertraline in body, it is a inhibitor!)

39
Q

this electrolyte imbalance has been associated with all types of AD, but more freq with SSRIs

A

hyponatraemia

40
Q

is vortioxetine an SSRI

A

no but inhibits the re-uptake of serotonin (5-HT) and is an antagonist at 5-HT3 and an agonist at 5-HT1A receptors

41
Q

when to consider hyponatramia

A

Drowsiness
Confusion
Convulsions

42
Q

pt has drowsiness, confusion and convulsions. what is this

A

consider hyponatraemia

43
Q

main interactions with sertraline - increasing bleeding risk, sedation, hyponatramia

A

bleeding: aspirin, NSAIDs, dalteparin, heparin, DOACs, warfarin, other ADs

hyponatraemia: desmopressin, TCAs, diuretics, antipsychotics, NSAIDs

44
Q

max dose citalopram in elderly (drops vs tabs)

A

20mg tabs
16mg drops

45
Q

3 contraindications for citalopram (2 of them are for all SSRIs)

A

all SSRIs: poorly controlled epilepsy, do not use if enters manic phase
other: QT interval prolongation

46
Q

interactions citalopram - hypokalaemia

A

hypokalaemia potentially increases risk of TDP: aminophylline, theophylline, amphotericin B, CCs, thiazides, diuretics (NOT K sparing SEAT),

47
Q

interactions citalopram - QT interval and

A

QT: amiodarone, dronedarone, antipsychotics, apomorphine, clomipramine, erythromycin, fluconazole, hydroxyzine, methadone

48
Q

how to withdraw citalopram

A

The dose should preferably be reduced gradually over about 4 weeks, or longer if withdrawal symptoms emerge (6 months in patients who have been on long-term maintenance treatment).

49
Q

max dose escitalopram in elderly

A

10mg

50
Q

3 contraindications for escitalopram

A

all SSRIs: poorly controlled epilepsy, pt enters manic phase
escital: qt interval prolongation

51
Q

max dose paroxetine in elderly

A

40mg

52
Q

this SSRI can be given for menopausal symptoms, particularly hot flushes, in women with breast cancer (except those taking tamoxifen) at a dose of 10mg OD - UNLICENSED

A

paroxetine

53
Q

withdrawing paroxetine

A

higher risk of withdrawal reations
dose should preferably be reduced gradually over about 4 weeks, or longer if withdrawal symptoms emerge (6 months in patients who have been on long-term maintenance treatment)

54
Q

this SSRI can be used for menopausal symptoms, particularly hot flushes, in women with breast cancer (except those taking tamoxifen) at a dose of 20mg OD. UNLICENSED

A

fluoxetine

55
Q

This OTC supplement commonly used increases the risk of bleeding. Therefore they interact with other drugs including SSRIs

A

omega 3

56
Q

can you use vortioxetine in BF

A

avoid

57
Q

can you use vortioxetine in pregnancy

A

Avoid unless benefit outweighs risk—toxicity in animal studies.

If used during the later stages of pregnancy, there is a risk of neonatal withdrawal symptoms and persistent pulmonary hypertension in the newborn.

58
Q

can vortioxetine be stopped abruptly

A

Manufacturer advises treatment can be stopped abruptly, without need for gradual dose reduction.

PR - CNS (61 decks)

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