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Therapeutics > Exam 5 lecture 2 > Flashcards

Exam 5 lecture 2 Flashcards

1
Q

Risk of recurrence of depression based on number of episodes

A

1 episode- 50-60%
2 episodes- 70%
3 episodes- 90%

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2
Q

What are factors that increase or decreases chances of remission

A

Risk becomes lower over time as duration of remission increases

Persistent mild symptoms during remission is a predictor of recurrence

Function deteriorates during episode and oes back to normal upon remission

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3
Q

DSM 5 Diagnostic criteria for depression

A

SIGE CAPS

S- sleep (insomnia/hypersomnia)
I- Interest decreased (anhedonia)
G- Guilt/worthlessness
E-ENergy loss/fatigue
C-concentration difficulties
A- Appetite change (increase or decrease)
p-Psychomotor agitation/retardation
s- suicidal ideation

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4
Q

Self administered rating scales for depression

A

PHQ-9
MDQ

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5
Q

goals of tx of depression

A

reduce or eliminate signs and symptoms of depression

restore occupational and psychosocial functioning to baseline

Reduce the risk of elapse and recurrence

reduce the risk of harmful consequences

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6
Q

Phases of treatment of depression

A

Acute- 6-12 weeks or remission (induce remission)

continuation- 4-9 months (prevent relapse)

Maintenance- indefinite treatment if > 3 major depressive disorders (prevent recurrence)

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7
Q

What is a boxed warning in ALL antidepressants

A

Boxed warning for suicidality in all antidepressants aged <24

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8
Q

pharmacologic classes of antidepressants

A

SSRIs
SNRIs
TCAs
MAOIs

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9
Q

What are the SSRIs

A

Citalopram
Escitalopram
Fluoxetine
Fluvoxamine
Paroxetine
Sertraline

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10
Q

What are things we must remember about citalopram (side effects and metabolizers)

A

QTC prolongation
Substrate of 2C19and 3A4

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11
Q

Things to remember about fluoxetine ( half life, metabolizer)

A

Long half life (96-144 hrs)
2D6 inhibitor, 3A4 inhibitor

you dont have to taper

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12
Q

fluvoxamine metabolizer

A

1A2 and 2C19 inhibitor

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13
Q

Things to know about paroxetine

A

Must taper due to anticholinergic side effects
weight gain, sedation
Septal wall defect risk to the fetus
inhibitor of 2D6 and 2B6

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14
Q

Sertraline clinical pearls

A

More GI upset than other antidepressants

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15
Q

SNRIs adverse effects and key points

A

Useful in pain syndrome, muscoskeletal pain, fibromyalgia, neuropathic pain

Side effects- BP elevation and nausea

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16
Q

Monitoring for duloxetine

A

Obtain LFTs at baseline and when symptomatic or every 6 months

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17
Q

notable side effects of paroxetine? Fluoxetine? and SSRIs in general

A

weight gain (paroxetine)
Weight loss (Fluoxetine)
Generally- increased bleeding risk, hyponatremia, sexual dysfunction

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18
Q

What to know about desvenlafaxine? CYP metabolism?

A

Active metabolite of venlafaxine. Dose limiting side effect- Nausea

No major CYP interactions

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19
Q

What to know about duloxetine? CYP metabolism?

A

causes nausea

FDA warning for hepatotoxicity

inhibitor of 2D6

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20
Q

What to know about levomilnacipran (Metabolism)

A

Must adjust in renal impairement or strong 3A4 inhibitor

3A4 substrate

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21
Q

Things to know about venlafaxine ( metabolism)

A

Must be >150 mg/day to have NE effects

2D6 inhibitor at higher doses

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22
Q

TCAs MOA

A

Primarily affect serotonin and norepinephrine, but also affects dopamine

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23
Q

What TCA is important for exam? What is it used for?

A

Amitriptyline- pain and headache

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24
Q

TCA adverse effect

A

CNS sedation, reduced seizure threshold, confusion

anticholinergic, blurred vision, urinary retention, constipation

Cardiovascular, orthostatic hypotension, tachycardia

Weight gain sexual dysfunction

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25
Q

Key point to know about TCA

A

Narrow therapeutic index- fatal in OD as low as 1000 mg (4-10 tabs) due to cardiac arrhythmias or seizures

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26
Q

What is an important thing to know before switching antidepressant to MAO inhibitors

A

Must have 2 week washout period before switching antidepressants (5 week washout period if switching from fluoxetine)

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27
Q

What is required to do when on MAO I drug? cautions?

A

all require tyramine diet except for selegiline

caution due to hypotensive crisis and serotonin syndrome

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28
Q

tyramine diet is not required with what MAOI

A

Selegiline patch

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29
Q

Bupropion MOA? side effects?

A

Dopamine and norepinephrine reuptake inhibitor

Stimulated insomnia and appetite suppression

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30
Q

Metabolism of Bupropion

A

2D6 inhibitor

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31
Q

Contraindication of bupropion

A

Contraindiacted in active seizure and eating disorders

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32
Q

Can bupropion be used with SSRIs

A

Yes

33
Q

Mirtazapine dosing?

A

Sedation and increased appetite occurs with doses <15 mg/day (yess less than)

34
Q

Warning of mirtazapine? Can they be combined with SSRIs?

A

Warning- agranulocytosis, increased cholesterol

can be used in combination with SSRI/SNRI

35
Q

MOA of trazodone? Doses?

A

selectively inhibits neuronal reuptake of serotonin and acts as antagonist

dosing- higher doses needed for depression

36
Q

side effects of trazodone

A

Orthostatic hypotension
Risk of priapism- medical emergency

37
Q

Vilazodone MOA

A

Primarily SSRI, may have some 5HT1a agonism which may provide anxiolytic effects

38
Q

can we combine vilazodone with SSRIs?

A

no

39
Q

Metabolism of vilazodone? How to take it?

A

3A4

bioavailability increases with food (significat nausea)

40
Q

Vortioxetine MOA? Can we use with SSRIs

A

SSRI + 5HT1A agonist + 5HT3 antagonist

do not combine with SSRIs/SNRIs

41
Q

Adverse effects and metabolism of vortioxetine

A

Substrate 2D6, Nausea and less sexual function

42
Q

Which SSRIs have withdrawal syndrome? Which ones should always be tapered

A

Common with ALL antidepressants EXCEPT fluoxamine

Antidepressants with anticholinergic activity should be tapered no matter what, NOT life threatening but extremely uncomfortable

43
Q

What are the most common augmentation agents for depression

A

Antipsychotics
Lithium
Lamotrigine (anticonvulsants)

44
Q

What are some FDA approved augmentation agents

A

Aripiprazole
Brexipiprazole
Cariprazine
Quetiapine

45
Q

What are antidepressants used for specific factors?

A

Post-partum depression- Brexanolone, zuranolone

Treatment resistant depression- Esketamine nasal spray

46
Q

Overall counseling points for antidepressants

A

Abrupt discontinuation can lead to antidepressant withdrawal syndrome

possible increase in suicidal thinking during the first few weeks of therapy

47
Q

What is the mood pole experienced most by people with bipolar

A

Depression

48
Q

common comorbidities with bipolar disorder

A

Alcohol and substance use is common (50-60%)

anxiety disorders are common comorbidities and can significantly impact remission of mood episodes if left untreated or inadequately treated

49
Q

difference between bipolar 1 and bipolar 2

A

Bipolar 1 is > or =1 manic episodes

Bipolar 2- hypomanic episodes

both have depression but seems more common in 2

50
Q

1st line therapy of bipolar disorder

A

Lithium or valproic acid
Atypical antipsychotics can also be used in combination with Lithium and valproic acid

51
Q

How effective is lithium for bipolar treatment? what is associated with it? How to convert lithium therapy?

A

Effective and safe

associated with decrease in suicidality

use 1:1 conversion

52
Q

Serum levels considered to be toxic?

A

above 1.2 is toxic
toxicity mild to severe- >1,5 and >3.0

53
Q

Toxicity associated with Li

A

GI, ataxia, coarse hand tremor, altered mental status, seizure, lethargy, confusion, agitation

54
Q

side effects of Li

A

Fine hand tremor, hypothyroidism, polyuria, polydipsia, acne, dry mouth, weight gain

55
Q

When to use and avoid Li in pregnancy

A

Avoid in 1st trimester. Use in caution in 2nd and 3rd trimester

56
Q

Labs to monitor on Li

A

SCr, BUM, urine specific gravity, Na, K, Ca, ECG, thyroid function, CBC, weight, pregnancy test

57
Q

Drug interaction of Li on decreased renal clearence

A

ACEi, ARBs, THiazides, NSAIDs

58
Q

Drug interaction with increased Li renal clearence

A

Caffeine, osmotic diuretic, loop diuretic

59
Q

What is the use of valproate? What are the available dosage forms and what is the difference between them? conversion? Which one is high risk for GI ulceration

A

common 1st line for bipolar

Extended release (ER) dosage form- 10-15% less bioavailable that delayed release (DR)

1:1 cpnversion- expect lower serum concentration with ER

Valproic acid syrup and capsule sprinkle form- higher risk for GI ulcerations

60
Q

What serum levels of valproate associated with most efficacy? When to obtain this level after first dose?

A

Serum levels- 80-125 mcg/ml associated with the most efficacy in mania. Obtain level atleast 96 hours after 1st dose or dose increase

61
Q

Valproate in pregnancy

A

NEVER, PCOS occurs in up to 50% of women

62
Q

Side effects of valproic acid

A

GI- anorexia, N/V/D, dyspepsia, ulceration

increased appetite- weight gain

Thrombocytopenia, platelet dysfunction

Teratogenic- Neural tube defects enduring negative effects on IQ of offspring

hyperammonemia

63
Q

Valproate monitoring

A

Baseline- pregnancy test, LFT, CBC

serum concentration

serum ammonia- if suspect hyperammonemia, routine ammonia monitoring is not necessary

64
Q

Drug interactions present with valproate

A

Significant concerns with combination use with lamotrigine-increased lamotrigine serum concentrations increase risk of stevens johnsosn syndrome

65
Q

What are the two antipsychotics used in mood stabilizing

A

Carbamazepine and oxcarbamezapine

66
Q

Carbamazepine side effects?

A

thrombocytopenia/hematologic effects

67
Q

Oxcarbamazepine metabolism, side effects

A

CYP450 inducer

associated with hyponatremia

68
Q

anticonvulsant drugs

A

lamotrigine
topiramate

69
Q

when is lamotrigine 1st line treatment

A

depressive symptoms of bipolar disorder

70
Q

Is lamotrigine useful for acute treatment for manic episodes?

A

NOT useful

71
Q

Topiramate side effects

A

May cause weight loss
heat intolerance/hypohidrosis
metabolis acidosis and kidney stones

possible teratogen

72
Q

Can antipsychotics be used as monotherapy for bipolar disorder

A

Yes, they can also be used in conjunction with other mood stabilizers (usually valproate or lithium)

73
Q

Monitoring parameters for antipsychotics in bipolar

A

Metabbolic syndorme and movement side effects

74
Q

What are some treatment considerations of mood disorders

A

Mood stabilizer tx is long term and is cnsidered to be maintenance treatment to reduce time to subsequent mood episodes

suicide attempt risk is high in both poles of bipolar disorder- monitor closely, use lithium cautiously

75
Q

Can we use lithium + valproate?

A

yes

we can use valproate +antipsychotic

we can use all 3 + antidepressant

Never use two atypical antipsychotics

76
Q

What drugs are known or possible teratogens in bipolar tx

A

Li, Valproate, carbamazepine, topiramate

77
Q

1st line tx for bipolar pregnant women

A

Atypicl antipsychotics

78
Q

What type of drugs do we prefer to use when handling bipolar disorder

A

prefer to use mood stabilizers that target depressive pol

(lamotrigine, lithium, lurasidone, quetiapine)

79
Q
A

Therapeutics (38 decks)

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