FR Review 8 - Antidepressants, Anxiety, Antipsych, ADD/ADHD

Question 1

What is the GI related AE of MAOIs and how is it mitigated?

Answer 1

MAO in the colon metabolizes vasoactive substances that we eat (tyramine) before they enter the bloodstream. MAOIs allow absorption of these vasoactive chemicals. Patient must adhere to a special diet or suffer risk of hypertensive emergency and urgency.

Question 2

T/F: MAOIs are considered first line therapy for depression.

Answer 2

False –> patients on an MAOI have issues

Question 3

Why are TCAs still kept on the market?

Answer 3

Off label uses - insomnia (Anti-Ach sedation), neuropathic pain, enuresis (bed wetting), migraines.

Question 4

What is the primary AE associated with SSRIs?

Answer 4

Sexual dysfunction

Question 5

What is the mechanism of bupropion?

Answer 5

It is a weak inhibitor of dopamine reuptake with no effect on norepinephrine or serotonin

Question 6

What is the major advantage of prescribing bupropion?

Answer 6

No effect on sexual function

Question 7

What is the common off-label use of bupropion?

Answer 7

Smoking cessation and other addiction disorders

Question 8

What is the major AE associated with bupropion?

Answer 8

Decreases seizure threshold –> cannot use in PMH of seizure or in eating disorders (hyponatremia decreases seizure threshold)

Question 9

What is the most common use of trazodone?

Answer 9

Insomnia –> the drug is highly sedating

Question 10

What kind of drug is duloxetine and what are its primary uses other than as an antidepressant?

Answer 10

SNRI –> peripheral neuropathy, fibromyalgia, and urinary incontinence

Question 11

What is the hallmark sign of lithium toxicity?

Answer 11

Coarse tremor

Question 12

What lab must be monitored in patients taking lithium?

Answer 12

TSH

Question 13

State the clinical uses of BZDs.

Answer 13

Anxiety, agitation, antiemetic (especially in chemo), insomnia, seizures, anesthetic induction, alcohol withdrawal, muscle relaxation

Question 14

Describe the AEs associated with BZDs and state one that can sometimes be beneficial.

Answer 14

Drowsiness, confusion, sluggishness, retrograde amnesia. Retrograde amnesia is beneficial in anesthesia.

Question 15

Which two BZDs used for anxiety have the shortest duration of action (quick on and quick off)?

Answer 15

Lorazepam and Oxazepam –> these drugs are the final metabolites of other BZDs

Question 16

What is the dose limiting AE of BZDs?

Answer 16

Respiratory depression

Question 17

For what patients are the short-acting BZDs preferred?

Answer 17

Elderly and liver failure –> BZDs are lipophilic, short acting agents less toxic to liver

Question 18

Where are you likely to find agitated patients that would benefit from BZDs?

Answer 18

ICUs and nursing homes

Question 19

What is the primary use of Alprazolam?

Answer 19

Panic attacks

Question 20

Describe the mechanism of action of buspirone?

Answer 20

Not a BZD –> serotonin antagonist. It is unknown exactly how it decreases anxiety.

Question 21

What is the advantage of buspirone and what patients most benefit from its use?

Answer 21

No sedative effects –> can be used by bus drivers and other workers that operate machinery

Question 22

Compare buspirone to BZDs regarding their efficacy as an anxiolytic.

Answer 22

They are as effective as BZDs but they take 3 weeks to have effect. Buspirone cannot be used acutely.

Question 23

Describe the general treatment ladder in attempting to manage insomnia.

Answer 23

Improve sleep hygiene
OTC meds: diphenhydramine or melatonin
Prescription meds: non-controlled, then controlled

Question 24

What is meant by a drug being a “non-benzo benzo” and what three drugs are in this classification?

Answer 24

These drugs bind and stimulate BZD receptors but, structurally, they are not BZDs.
Zolpidem, Zaleplon, Eszopiclone

Question 25

Differentiate positive and negative symptoms of schizophrenia.

Answer 25

Positive (I'm positive the person has schizophrenia): delusions, paranoia, hallucinations Negative (historically difficult to resolve with treatment): apathy, withdrawal, blunt affect

Question 26

Which class of anti-psychotics are better at treating negative symptoms of schizophrenia?

Answer 26

Newer, 2nd generation medications

Question 27

Describe neuroleptic malignant syndrome (NMS).

Answer 27

Rare, life-threatening syndrome characterized by hyperpyrexia, cogwheel rigidity, rhabdo s/p rigidity.

Question 28

What are four treatment options for NMS.

Answer 28

D/C the anti-psychotic Bicarb and fluids for rhabdo if present Dantrolene (direct acting skeletal muscle relaxant) Bromocriptine (DA agonist)

Question 29

What is the most common use of haloperidol?

Answer 29

Agitation in Alzheimer's, psychosis, or ICU patients

Question 30

What is a precaution associated with haloperidol?

Answer 30

Decreases seizure threshold

Question 31

T/F: The dose limiting AE of haloperidol is respiratory depression.

Answer 31

False --> haloperidol does not cause respiratory depression

Question 32

What are the disadvantages of atypical anti-psychotics?

Answer 32

Weight gain, even more than typical anti-psychotics Acceleration of development of DM Hyperlipidemia --> increase cardiovascular morbidity and mortality in patients older than 65 Cost

Question 33

What are the effects of quetiapine at various doses?

Answer 33

Low dose: hypnotic (great for insomnia) Medium dose: antidepressant High dose: anti-psychotic

Question 34

T/F: Clozapine is commonly used. State why or why not.

Answer 34

False: Used last line because it has 5 black box warnings

Question 35

What are the primary advantages and disadvantages of risperidone?

Answer 35

Adv: less weight gain Disadv: significant hyperprolactinemia (must monitor prolactin level)

Question 36

What S/S result from hyperprolactinemia?

Answer 36

Galactorrhea, sexual dysfunction, bone density changes

Question 37

Describe the mechanism by which stimulant medications are beneficial in ADD/ADHD.

Answer 37

The problem in ADD/ADHD is the brain cannot organize the multitude of sensory information that is coming in. Stimulants activate the parts of the brain responsible for organizing sensory input.

Question 38

What control schedule is methylphenidate and what is unique about this?

Answer 38

C-2 --> one of the only non-opioid drugs in C-2

Question 39

What is the only non-stimulant option for treatment of ADD/ADHD discussed in class?

Answer 39

Atomoxetine

Question 40

When is atomoxetine used in the management of ADD/ADHD?

Answer 40

Second-line --> not as effective as the stimulant medications

Question 41

What are the precautions associated with use of atomoxetine?

Answer 41

Risk of SI | Weight loss --> less so than the stimulants