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Neurologic & Psych > EXAM 4 Pharmacotherapy of Depression Dr. Thomason > Flashcards

EXAM 4 Pharmacotherapy of Depression Dr. Thomason Flashcards

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1
Q

How is depression with hallucination or delusion treated?

A

antidepressants + antipsychotics

hallucination: things that aren’t there (see, hear, feel)
delusion: false beliefs (ex: wife has an affair)

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2
Q

What are other diseases that come with depression?
CNS

A

-Alzheimer
-Parkinson’s disease
-CVA (cerebrovascular accident, stroke)
-HIV dementia
-Multiple sclerosis

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3
Q

What are other diseases that come with depression?
Cardiovascular

A

-Cerebral ateriosclerosis
-CHF
-MI

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4
Q

What are other diseases that come with depression?
Endocrine

A

Addison’s disease
Diabetes
Hypothyroidism (treated with Levothyroxine)

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5
Q

What are other diseases that come with depression?
Womens Health

A

-Perimenopause
-Postpartum
-PMDD (around the time of the menstrual cycle)

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6
Q

What are other diseases that come with depression?
Other

A

-Chronic fatigue syndrome, chronic pain syndrome
-fibromyalgia
-IBS
-Malignancies
-Rheumatic arthritis
-headaches
-lupus

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7
Q

Cardiovascular meds causing depression

A

-ß-blockers !!! (most common, especially propranolol since causes BBB)
-Reserpine !!! (NAPLEX question)
-Clonidine
-Methyldopa
-Procainamide

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8
Q

CNS agents causing depression

A

-Barbiturates
-Benzos
-Chloral hydrate
-Ethanol
-Phenytoin

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9
Q

Hormonal agents causing depression

A

-Anabolic steroids
-Corticosteroids
-Estrogen? (data says probably not)
-Progestin
-Tamoxifen

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10
Q

Other meds causing depression

A

-Indomethacin
-Interferon
-Isotretinoin (retinoid, for severe acne)
-Mefloquine

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11
Q

What is an entry tool to screen for depression?

A

-questionnaire PHQ-2 (2 questions)

if they affirm either of the questions -> give them the PHQ-9

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12
Q

When is a patient considered to have depression?

A

5 or more symptoms for 2 weeks -> must have depressed mood or anhedonia (inability to feel pleasure)

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13
Q

What are the symptoms of depression

A

-depressed mood
-loss of interest or pleasure (anhedonia)
-weight change
-sleep disturbance
-psychomotor agitation or retardation
-fatigue
-feelings of worthlessness or guilt
-decreased concentration
-recurrent thoughts of death, suicidal ideation or attempt

older patients have more somatic symptoms (ex: back pain)

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14
Q

What happens if a patient is treated with antidepressants but actually has bipolar disorder?

A

it can cause them to have a manic episode (feel very happy or irritable and angry)

-they need a mood stabilizer
-always rule out bipolar disorder before starting an antidepressant (ex: with the rapid mood screen tool)

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15
Q

What is a grief reaction?

A

depression after someone passed away: symptoms must persist for 2 months to be considered depression

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16
Q

What is the Gold standard for assessing depression?

A

Hamilton Rating Scale for Depression (Ham-D): often used in clinical trials, but they are very long and not the best for practice

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17
Q

What are the risk factors of suicide?

A

-detailed plan
-living alone
-unemployed
-physical illness
-15-24y or older than 65
-hx of substance abuse
-family hx or suicide !!!

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18
Q

What are the symptoms of suicide?

A

D Sig E Caps

-Depression

-Sleep
-Interest (loss of interest, including libido)
-Guilt

-Energy

-Concentration
-Appetite
-Psychomotor (agitationon or retardation)
-Suicide

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19
Q

Which drug should be avoided in patients who are at risk for suicide?

A

antidepressants with a narrow therapeutic index

-TCA
-MAO inhibitor

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20
Q

Which drug should be avoided in patients having depression and anxiety?

A

Bupropion (NET/DAT reuptake inhibitor)
-> activating effect -> more anxiety

-also other antidepressant can cause it
-reduce the dose of antidepressants

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21
Q

What is the most common side effect of SSRIs?

A

-GI: nausea, diarrhea (fluoxetine, sertraline, and citalopram are worst - Paroxetine cause constipation (anticholinergic) avoid in patients over 65
-headache
->transient, they go away

take it with food in the first week

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22
Q

What is a long-term side effect of SSRIs?

A

-sexual dysfunction
-weight gain

-increased bleeding (antiplatelet effects)
-sometimes Hyponatremia (check the Na levels)

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23
Q

Which antidepressants don’t cause sexual dysfunction?

A

-buproprion
-Mirtazepine
-Duloxetine (low)
-Vilazodone

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24
Q

Which SSRI can cause weight loss?

A

Fluoxetine

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25
Q

One difference between Fluoxetine and Paroxetine?

A

Fluoxetine has a long halflife: patients who forget to take it will still have sufficient levels and no discontinuation symptoms

Paroxetine has a short half-life - have to taper
Venlafaxine also has discontinuation symptoms

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26
Q

Common side effects of Paroxetine

A

anticholinergic:
-sedating
-constipation
-sedation (take it at night)
-sexual dysfunction (it slows things down so much)

-extrapyramidal side effects (Parkinson-like: stiffness, tremor)
-akathisia (cant stay still)
-weight gain (most of all SSRIs)

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27
Q

When would Duloxetine be the preferred choice?

A

fibromyalgia (with chronic pain) and depression

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28
Q

Is Duloxetine activating or does it make patients tired?

A

activating -> SNRI (mixed serotonin and NE)
NE is activating
->take it in the morning, once a day
(also Fluoxetine)

-some patients get tired on it (take it in the evening)

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29
Q

Which antidepressants are activating and should be given in the morning?

A

sertraline
fluoxetine
duloxetine

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30
Q

What is special about Mirtazepine dosing?

A

the lower the dose, the greater the antihistamine effect

-7.5 mg and 15 mg causes sleepiness
-from 30 mg we see more of the anxiolytic and antidepressant effect

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31
Q

When might Mirtazepine be a good choice?

A

Patients with depression, insomnia, and weight loss

side effects:
-somnolence (may cause a hangover the next day though)
-weight gain

32
Q

Common side effects of SNRIs?

A

sweating (especially in women)

-Duloxetine
-Venlafaxine

33
Q

Which antidepressant is preferred in pregnant women?

A

sertraline
citalopram
escitalopram

34
Q

Which antidepressant should not be used in pregnant women?

A

paroxetine

can cause malformation

35
Q

Which antidepressants are big CYP2D6 inhibitors?

!!!

A

fluoxetine, paroxetine

others are:
-sertraline
-bupropion

36
Q

Which antidepressants are CYP3A4 inhibitors?

A

-citalopram
-fluoxetine

37
Q

What is the BBW for citalopram?

A

Qtc prolongation

max dose of 40 mg
in practice they don’t go over 20 mg

38
Q

What is the role of TCAs in therapy?

A

not really used in depression due to the side effects
-used for migraine prophylaxis, neuropathic and chronic pain

-may be used in melancholic depression (with atypical features)

39
Q

What are the contraindications of TCAs?

NAPLEX

A

it is anticholinergic, so avoid it in

-BPH
-arrhythmias (prevent the slowing of the heart -> tachycardia -> can be fatal)
-narrow-angle glaucoma
-dementia
-it lowers seizure threshold

40
Q

What are the MAO inhibitors and what is their role?

A

1st gen
-Tranylcypromine
-Phenelzine

2nd gen:
-selegiline

-last line antidepressant

41
Q

Why are selegiline and Phenelzine dosed in the morning and at noon?

A

because it produces amphetamine metabolites and would keep patients awake when taken at bedtime

42
Q

What are the drug interactions of MAO inhibitors?

A

-hypertensive crisis (accumulation of tyramine and NE reverse transport -> hypertensive crisis)

-interaction with amphetamine precursor:
Phenylpropanolamine, pseudoephedrine

-DDI with Meperdine (a synthetic opioid)
-serotonin syndrome when used with serotonergic

43
Q

A patient switches from an SSRI to an MAO-i. What should be taken care of?

NAPLEX, EXAM QUESTION

A

washout period of 14 days to prevent serotonin syndrome

-5 weeks for Fluoxetine due to its long half-life

44
Q

What are symptoms of hypertensice crisis?

A

-worst headache of their life
-BP up to 220/130
-flushing
-palpitations
-diaphoresis
-N/V

45
Q

Which foods contain tyramine?

A

-aged cheese
-smoked, aged, or pickled meat or fish
-Sauerkraut
-yeast extracts
-fava beans

moderate:
-beer
-red wine
-avocados
-meat extracts

46
Q

What is a common formulation for selegiline?

A

transdermal patch
-at higher doses, it inhibits both MOA-A and MOA-B irreversibly

-both need to be inhibited to see the antidepressant effect

-can’t use it with other antidepressants, some opioids, st. John wort, amphetamines

-cautious with dietary restrictions (aged meats, tyramine)

47
Q

What are the serotonin syndrome symptoms?

A

seen when used 3 or more serotonergic drugs

TRIAD of symptoms: mental autonomic, neurological

-confusion
-agitation
-insomnia
-fever
-diaphoresis (excessive sweating)
-myoclonus
-tremor
-hyperreflexia

severe but rare: cardiovascular collapse, coma, death

48
Q

How is Serotonin syndrome treated?

A

-remove causing agents
-giving fluid
-managing the blood pressure
-control hyperthermia
-if needed: control agitations with benzo

with 5-HT2A antagonists
-Cyproheptadine (antihistamine)
-sublingual olanzapine

49
Q

What is the starting dose of Duloxetine?
SNRI

A

30 mg

maintenance: 30-90 mg

50
Q

What is the starting dose of Desvenlafaxine?
SNRI

A

(metabolite of Venlafaxine)
50 mg

then 50-100 mg (there is no evidence that 100 mg has benefits)

51
Q

What is the starting dose of Venlafaxine?
SNRI

A

37.5 - 75 mg

75-225 mg (the higher the dose, the more difficult to taper off, discontinue syndrome)

52
Q

Which SNRI causes elevation of blood pressure?

A

Venlafaxine

avoid if BP is uncontrolled -> go with Duloxetine

53
Q

Side effects of Trazodone

A

-sedation
-Orthostasis
-priapism (prolonged erection, rare)

54
Q

Side effects of Bupropion

A

-nausea
-tremor
-seizure (dose-related, max dose 450 mg in divided doses)

55
Q

Side effects of Mirtazapine

A

-somnolence
-weight gain

-dry mouth
-constipation

-rare: agranulocytosis, LFT elevation

56
Q

How is bupropion/DXM (Auvelity)

A

-bupropion 45mg/DXM 105mg

start: one tablet in the morning for 3 days

then: one in the morning -> space 8h -> 2nd dose

max dose: not more than 2 tablets a day

-swallow as a whole (not crushed or chewed)

57
Q

When not using Gepirone

A

-Qtc > 450 msec !!!
-congenital long Qtc syndrome !!!

-strong CYP3A4 inhibitors
-liver impaired (cause accumulation)
-MAOI in 14 days

58
Q

Which meds are used for post-partum depression

A

-Zuranalone: take it with food in the eveneing (makes sleepy, food improves absorption)

-Brexanalone: continuous infusion (inpatient)
BBW: excessive sedation, may pass out
->not often seen bc very expensive and people need to stay inpatient

59
Q

How to manage sexual dysfunction in anti-depression therapy

A

-healthy lifestyle: exercise, lose weight, smoking cessation, substance use disorder (marijuana, meph causes sexual dysfunction)

-change to bupropion, mirtazapine, nefazodone (not often used due to hepatotoxicity)

-add bupropion 150 mg in the morning (make sure she doesn’t have a seizure disorder or eating disorder), mirtazapine or sildenafil

-it might go away, or they get tolerant
-may drop the dose, but depression may come back

60
Q

What to watch out for when adding bupropion for sexual dysfunction?

A

-(make sure she doesn’t have a seizure disorder or eating disorder

throwing up would cause electrolyte drop and lower the seizure threshold

-watch out that it doesn’t make anxiety worse

61
Q

What happens if TCAs are discontinued abruptly?

A

Cholinergic rebound (opposite of anticholinergic side effects)
-diarrhea, dizziness, insomnia, restless

taper by 25-50 mg per week

62
Q

What happens if SSRIs and venlafaxine are discontinued abruptly?

A

-flu-like symptoms
-brain zaps
-headache
-dizziness
-can’t concentrate
-anxiety, insomnia

takes longer with velnafaxine

63
Q

What is the drug of choice when starting depression therapy?

A

SSRI

switch to another SSRI or non-SSRI if there is no response or adverse effects that are not tolerable

64
Q

How long should patients stay on the maintenance dose?

A

at least 6-12 months

12-36 months

65
Q

Which drug is commonly used for augmentation?

A

Lithium: 600-900 mg, quick response

Triiodothyronine T3: 25-50 mcg
->may lead to hyperthyroidism
long-term risk for osteoporosis, arrhythmias

check TFT at baseline and 3 months; check DMX for post-menopausal patients

66
Q

What are common antipsychotics that are used as adjunctive drugs?

A

-Ariprazole

-brexpriprazole

-Olanzapine

-Quietapine

67
Q

Which drug is a Folate supplement?

A

Rx: Deplin

low folate levels correlate with depression
L-methylfolate is a cofactor for 5-HT, DA and NE

68
Q

Which drugs are approved for depression treatment in children?

A

Fluoxetine
Escitalopram (12-17y)

69
Q

Which drugs are approved for enuresis (bed-wetting) treatment in children?

A

Imipramine

70
Q

Which drugs are approved for OCD (obsessive-compulsive disorder) in children?

A

-Clomipramine (older than 12)
-Fluvoxamine, Fluoxetine, sertraline (children)

71
Q

What are the symptoms/signs of sudden suicide attempts in children on antidepressants?

A

agitation and restlessness

regular follow-up is essential (active outreach)

72
Q

Which antidepressants are most studied in pregnant women?

A

-Fluoxetine (but when the mom breastfeeds it can agitate (and colic) the child - so not the best choice)
-citalopram
-escitalopram

avoid paroxetine!

if they are not on an antidepressant cognitive behavioral therapy is appropriate

73
Q

Drug of choice for patients who breast-feed?

A

sertraline

74
Q

When is electric convulsive therapy (ECT) used in pregnant patients?

A

when they are psychotic or suicidal

75
Q

What is the drug of choice in elderly patients?

A

SSRIs
-avoid paroxetine

Neurologic & Psych (37 decks)

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