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Exam 3: Depresso Flashcards

1
Q

Serotonin syndrome definition

A
  • mental status changes
  • autonomic instabiltiiy
    - diaphoresis
    - hypersalivation
  • neuromuscular aboramlity
  • GI symptoms
  • hyperrefleia, clonus
  • dilated pupils
  • hyperactive bowel sounds
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2
Q

Serotonin syndrome cause

A

conmittant use of serotonergic drugs

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3
Q

Neuroleptic malignant syndrome definition

A

da agents more likely to cause this (vs. serotonin agents)
- lead pipe rigidity in all muscle gorups
- hyporeflexia
- normal pupils
- normal or decreased bowel sounds

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4
Q

Neuroleptic malignant syndrome causes

A

Dopamine D2 receptor antagonism

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5
Q

Types of depressive disorders

A

Major depressive disorder (MDD)
Adjustment disorder w/ depressed mood
Seasonal affective disorder (SAD)
Substance-induced mood disorder

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6
Q

New depressive disorders in DSM 5

A

PMDD (different from PMS)
Bereavement if >2 months

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7
Q

MDD risk factors

A

Comorbidities (61% psych, 60% medical)
Family history
Age (bimodal: 12-16/elderly)
Medical (hypothyroidism)
Untreated pain

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8
Q

MDD etiology

A

unknown/complicated
probably due to altered neurotransmitters
- anatomical changes on imaging
- receptor change = delay onset of antidepressant

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9
Q

Biological markers of MDD

A

neuroendocrine abnormality
hypersecretion of cortisol - chronic stress
Depletion of BDNP
decreased neurogenesis
Substance P released during stress

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10
Q

Presentation of MDD

A

Initial sx: days-weeks
- anxiety sx appear first (if u have them)
Can last 4 months if untreated
MDD may remit, partially 35%, or never 15%
Repeat. episodes are common
RULE OUT MEDICAL DISORDERS
- get TSH, CBC, electrolytes

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11
Q

Emotional sx of MDD

A

cont. diminished capacity to experience pleasure in activities used to be enjoyed
Life stressors trigger depression
Anxiety sx present in 90% of people
if psychosis, tx with APS/hospitalize

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12
Q

Physical sx MDD

A

Psychomotor: slowed physical movement, speech, agitation, pacing, purposelessness

More common in elderly = chronic fatigue, pain, sleep disorders (early wake, daytime sleepy), appetite changes

watch for residual symptoms: if untreated, can be disabling (partial remission)

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13
Q

Medical causes of depression (6)

A
  1. hypothyroidism
  2. anemia
  3. HIV/AIDs/STDs
  4. Autoimmune disease
  5. CV disease
  6. Neuro disorder: EPILEPSY, Huntington’s, Parkinson’s, Alzheimers, post-stroke
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14
Q

Medications that can Induce Depression

A

CV: BB, CCB
Hormone: OC, steroids
AED: topiramate, levetiracetam
Opioids
Stimulants

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15
Q

Suicide risk features

A

Male
single/living alone
describes feelings of hopelessness/suicide
substance misuse
unusual behavior: missed work, giving away personal items
Initial therapy: increased energy to act on (suicide) plans

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16
Q

Black Box Warning on AD

A
  1. risk in children/teens with depression
  2. increased suicidality (thoughts/behaviors) in 18-24 y/o, ESPECIALLY AT EARLY STAGE OF TREATMENT
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17
Q

Counseling AD

A
  1. have patient/family monitor closely at start of treatment
  2. possible ADR: agitation, irritation, anxiety
  3. Deal with subject of suicide directly
  4. get help immediately
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18
Q

SSRI drugs

A

citalopram
escitalopram
fluoxetine
fluvoxamine
paroxetine
sertraline

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19
Q

SNRI drugs

A
  1. desvenlafaxine
  2. duloxetine
  3. levominacipran
  4. venlafaxine
  5. milnacipran
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20
Q

Serotonin modulator agents

A

nefazodone
trazodone
vilazodone (viibryd)
vortioxetine (trintellex)

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21
Q

TCA agents

A

-tyline
* amitripltyline
* nortriptyline
* protriptyline

amoxapine
doxepin

-amine
* clomipramine
* desipramine
* trimipramine

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22
Q

MAOI agents

A

Phenelzine
tranylcypromine
selegeline
rasagiline

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23
Q

Misc AD agents

A
  • brexanolone
  • bupropion
  • buspirone
  • esketamine
  • mirtazapine
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24
Q

Auvelity (dxm/bupropion) indication

A

the only PO NMDA receptor antagonist
for MDD

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25
Q

DXM

A

Noncompetitve NMDA receptor antag
Sigma-1 receptor Agonist
rapid/extensive cyp2D6 metabolism
post 5HT2A stimulation, some 5HT reuptake inhibition

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26
Q

Bupropion

A

FDA approved for depression/smoking
CYP2D6 inhibitor (inhibit DXM metabolism)
Weak inhibitor of NE and DA reuptake
Does NOT inhibit MAO or 5HT reuptake

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27
Q

DXM/Bupropion Contraindications

A
  • Seziure disorder (bupropion)
  • Current/hx bulimia or anorexia nervousa abrupt d/c etoh, benzo, barbituates, AED
  • Concurrent use w/in 15 days of d/c maoi
  • Elevated BP and HTN (DxM)
  • Activation of mania/hypomania
  • Angle closure galucoma
  • Dizziness
  • Embryo-fetal toxicity
  • Serotonin syndrome
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28
Q

Most common ADRs of DXM/Bupropionv (auvelity)

A
  1. dizzy
  2. headache
  3. diarrhea
  4. somnolence
  5. dry mouth
  6. hyperhidrosis
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29
Q

Aripiprazole (abilifty) Indications? (4)

A
  1. schizophrenia
  2. Bipolar disorder
  3. MDD augmentation
  4. Sx of autism/tourette’s
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30
Q

brexpiprazole (Rexulti) indicagtions

A
  1. Schizophrenia
  2. MDD
  3. dementia induced agitation
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31
Q

olanzapine (Zyprexa) indications

A
  1. Schizophrenia
  2. MDD
  3. Bipolar
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32
Q

olanzapine (Zyprexa) indications

A
  1. Schizophrenia
  2. Bipolar disorder
  3. MDD when used with fluoxetine
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33
Q

quetiapine (Seroquel) indications

A
  1. Schizophrenia
  2. Bipolar disorder
  3. MDD
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34
Q

desvenlafaxine indications

A

MDD

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35
Q

Duloxetine indications

A
  1. MDD
  2. GAD
  3. pain
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36
Q

levomilnacipran indications

A

MDD

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37
Q

citalopram indications

A

MDD

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38
Q

escitalopram indnications

A
  1. MDD
  2. GAD
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39
Q

fluoxetine indications

A
  1. MDD
  2. OCD
  3. Panic
  4. PMDD
  5. bulimia nervosa
  6. BPD
40
Q

fluvoxamine indications

41
Q

paroxetine indications

A
  1. MDD
  2. GAD
  3. OCD
  4. panic
  5. PTSD
  6. PMDD
  7. SAD
42
Q

setraline indications

A
  1. MDD
  2. OCD
  3. panic
  4. PTSD
  5. PMDD
  6. SAD
43
Q

First line treatments for depression

A
  • SSRI, SNRI
  • Bupropion
  • Mirtazapine
  • Vortioxetine (Trintellix)
44
Q

AD effect expectations after 1 week

A

decreased anxiety
improved sleep
improved appetite

45
Q

AD effect expectations after 1-3 weeks

A

Increased activity, sex drive, self care, memory
thinking/movements becoem normal
Sleeping/eating become normal

46
Q

AD effect expectations after 2-3 weeks

A

Relief of depressed mood
thoughts of suicide subside a little

47
Q

How to tell the difference between Serotonin Syndrome and NMS?

A

NMS will show elevated CPK

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49
Q

Antidepressants that DO NOT cause anxiety NOR agitation as ADR

A
  • Escitalopram
    __
  • Levomilnacipran
    __
  • Befazodone
  • Trazodone
  • Vilaxodone
  • Vortioxetine
    __
  • Buspirone
  • Mirtazapine
50
Q

Antidepressants that DO NOT cause anxiety but CAN cause agitation as ADR

A
  • Fluoxetine
  • Desvenlafaxine
51
Q

Antidepressants that can CAUSE agitation/anxiety as ADR

A
  • Bupropion
    __
  • Duloxetine
  • Venlafaxine
    __
  • Citalopram
  • Fluvoxamine
  • Paroxetine
  • Sertraline
52
Q

When should you avoid using paroxetine?

A

pregnancy
elderly
bone fracture risk

53
Q

AD to avoid in QTc prolongation?

A

Citalopram (FDA)
Escitalopram maybe

54
Q

Fluoxetine DDIs

A

2D6 inhibition (TCA)
3A4 inhibition (Carbamazepine)

55
Q

Sertraline contraindicated in

A

Hepatic failure

56
Q

DDI that can cause serotonin syndrome

A

Triptans
tramadol or fentanly
nausea products (zofran, reglan)
BUSPIRONE
Linezolid
Ritonavir
Drugs that impair 5HT metabolism

57
Q

Venlafaxine ADR/DDI

A

2D6
Causes abnormal bump in BP
give with food
preferred over desvenlafaxine

58
Q

SNRI general traits

A

More energy boosting
variable indications
same bleed risk and activation to mania as SSRI

59
Q

Desvenlafaxine FDA indication

60
Q

Duloxetine FDA indication

A
  • MDD
  • GAD
  • Fibromyalgia
  • Musculoskeletal pain
  • neuropathic pain
61
Q

Venlafaxine FDA indication

A
  1. MDD
  2. GAD
  3. panic disorder
  4. social phobia
62
Q

Levomilnacipran FDA indication

63
Q

TCA warning

A

over dose can be fatal
Highly anticholinergic
higher doses for inpatient/hospitalized

64
Q

TCAs indicated for depression

A

Amitriptyline
amoxapine
desipramine
Doxepin
Imipramine
Notrtyptiline
Maprotiline

65
Q

TCA with additional indicatins

A

Clomipramine - OCD only
Doxepin - also for insomnia

66
Q

MAOI washout for fluoxetine

A

5 weeks d/t long half life

67
Q

MAOI washout for vortioxetine

68
Q

MAOI washout for most AD

69
Q

MAOI use for AD

A

last resort drug
has many fussy requirements

70
Q

Tyramine foods

A

cheese, dairy
wine, beer
herring, sardine, anchovy
processsed meat
MSG
fermented foods
Dried fruits
Soy sauce
chocolate
coffee
ripe avocado

71
Q

5HT modulators

A

Nefazodone
Trazodone
Vilazodone
Vortioxetine

72
Q

Nefazodone (serzone) BBW

A

associated with severe hepatic failure

73
Q

Trazodone (Desyrel) caution

A

more anticholinergic
more bleed risk
shouldn’t be used as sedation, but often is
risk of pripaism –> damage –> ED

74
Q

Bupropion m ADR/risk

A

seizures
eating disorders AUD (Bulimia, purging = electrolyte abnormal- seizures)
HTN
Insomnia
Activation
Anxiety

75
Q

Mirtazapine pearls

A

Very sedating
Weight gain common
(good for thin, insomniac)
ODT
FYI: “inverse relationship with dose and sedation”

76
Q

Spravato (esketamine) nasal spray indication

A

For ADULTS in COMBO with other ORAL AD
MUST HAVE FAILED 2 other AD

77
Q

Spravato (esketamine) nasal spray MOA

A

NMDA receptor antagonist

78
Q

Spravato (esketamine) nasal spray C/I

A

Hx of aneurysmal vascular disease, intracerebral hemorhage

79
Q

Spravato (esketamine) nasal spray ADR

A
  • HTN
  • cognitive impairment
  • impaired ability to drive/operate
  • embryo/fetal tox
80
Q

Spravato (esketamine) nasal spray BBW

A

Sedation
dissociation
abuse/misuse
suicidal thoughts/behaviors

REMS PROGRAM - must be taken in front of hcp and monitor 2hrs post administration

81
Q

Brexanolone (zulresso) formulation

A

IV infusion only, takes 60 hours
stay at clinic 2.5 days
NOT ORAL

82
Q

Brexanolone (zulresso) ADR

A

Hypoxia - get pulse Ox
Excessive sedation - every 2 hr monitor

83
Q

Brexanolone (zulresso) indication

A

post partum depression

not C/I in preg but also not recommended

84
Q

Brexanolone (zulresso) MOA

A

allosteric modulation GABA A

85
Q

If patient has seizures you should avoid

86
Q

If patient has substance abuse you should avoid

87
Q

If patient has Cardiac complications you should avoid

88
Q

If patient has Gi bleed or anticoag you should avoid

89
Q

Elderly patient AD choices

A
  1. SSRI initial best
  2. Bupropion, venlafaxine
  3. mirazapine: sleep, anxiety, apetite stimulation (watch cholesterol)

AVOID TCAs
avoid paroxetine - very anticholinergic

90
Q

Augmentation agents for AD

A

Lithium - first line for depressive episodes that fail monotherapy

SGAs: adjunct to AD

91
Q

Which second gen antipsychotics are used as augmentation agents for depression??

A

aripiprazole
brexpiprazole
quetiapine
olanzapine+fluoxetine
monitor metabo

92
Q

Controversial natural products

A

omega3
folate, lmethylfolate
s-adensoyl methione
St. johns wort

93
Q

What can trigger Serotonin syndrome?

A

when on ≥3 serotonergic meds

94
Q

What to counsel for serotonin syndrome?

A
  1. GI sx, mms, autonomic instability, NM abnormal
    VERY RARE
    CAN BE FATAL
  2. avoid concomitatnt use of 5HT drugs/metabolism impair
95
Q

Treatment for resistant depression

A

no universal guidelines

  • switch drug MOA
  • augment with APS
  • 2+ fail try esketamine spray in addition

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