general psych Flashcards
major depressive disorder:Diagnosed based on ____, _____ and ______ , change in level of function and interest in patient activities.
on DSM-V, severity & duration of symptoms
what does “SIGECAPS” stand for? (kinda weeds)
clinical features of depression: Sleep disturbances Interest in usual activities is decreased Guilt Energy level changes Concentration impairment Appetite decreased (most common) or increased Psychomotor impairment Suicide (thoughts, ideation, attempt)
three types of therapy options for major depressive disorder. which take longest to be effective? which are best to prevent relapse?
- pyschotherapy - longer for effect, prevents relapse
- pharmacotherapy - shorter for effect, incr. risk relapse
- electroconvulsive therapy
*best combine pyscho and pharm.
7 general classes of drugs for major depressive disorder
- Tricyclic Antidepressants (TCAs)
- MAOIs
- SSRIs
- SSNRI
- Norepinephrine Dopamine Reuptake Inhibitor (NDRI)
- Serotonin Modulators
- Tetracyclic
how does the MOA of TCAs, SSRI, SNRI and alpha block work?
in general, they all block the reuptake of Serotonin or norepi into presynaptic, keeping it in synaptic cleft longer
what are the 5 TCA drugs. which are secondary and which are tertiary?
Imipramine - Desipramine - Amitriptyline - Nortriptyline - Clomipramine
what are the tertiary and secondary TCA drugs, what does this mean?
tertiary: imipramine, amitripyline
secondary: desipramine, nortriptyline
* tertiary converted to secondary when metabolized
what is the one TCA that has a specific indication for OCD?
clomipramine
are TCAs used much for depression?
no, the higher dose needed for depression txt has too many ADRs, more likely used in low doses for other things. (i.e. chronic pain, incontinence)
PKs of TCAs (maybe weeds)
Extensive first pass metabolism, active metabolites
Highly protein bound, lipophilic, and long half-lives
tertiary TCAs are more effective on which receptor? what about secondary?
tertiary (imipramine, amitriptyline) : Serotonin reuptake
secondary (desipramine, nortriptyline) : norepi reuptake
what are the most significant ADRs with imipramine? what are the receptor?
orthostatic hypotension (alpha) cardio tox (Na+ channel on purkinje fibers )
what are the most significant ADRs with amitriptyline? what are the receptors?
anticholinergic (muscarinic)
sedation (histamine)
which TCA has the lowest chance of anticholinergic and sedation?
desipramine
which TCA has the lowest chance of orthostatic hypotension?
norptriptyline
what are the “3 Cs” of TCAs?
convulsions, coma, cardiotox
what is the antidote to an overdose of TCA?
cardiotox major concern- replace Na+ with SODIUM BICARB
*(increase the amount of Na+ that can get through even with blocked channels- cause we’re flooding the channel)
what is the MOA or MAOIs?
block the monoamine oxidase enzyme which normally breaks down serotonin, NE, and dopamine = more of these NTs in the synaptic cleft.
selective vs nonselective MAOIs (maybe weeds)
MAO-A: preferably metabolizes serotonin
MAO-B: preferably metabolizes dopamine
selective- targets MAO- A or MAO- B
nonselective- targets A and B
nardel & parnate: nonselective
selegiline: selective- B (why its good to txt parkinson’s too)
what are the 3 MAOI drugs?
Phenelzine (Nardel)
Tranlcypromine (Parnate)
Selegeline (Eldepryl)
what 2 things do we use MAOIs for?
- reserve for severe depression
- Parkinson’s disease (selegeline)
what are the 4 potential ADRs of MAOI drugs?
- hypotension
- insomnia
- drug- drug: HTN crisis
- drug-drug: serotonin syndrome
how can MAOI cause HTN crisis?
tyramine- comes from food- (fermented food, wine and cheese)
increase in tyramine and SSRIs (increase in serotonin) - will cause increase serotonin, NE and can lead to HTN crisis
txt for HTN crisis from MAOI?
nitrates and CCBs (to vasodilate)
txt for serotonin syndrome from MAOI?
txt supportive (cooling blanket)
- benzo or anti-convulsants
- nifedipine (for HTN)
given an MAOI and pt has muscle rigidity, agitation, increased temp. what is this?
serotonin syndrome!
if someone is on an MAOI and you want to put them on an SSRI, TCA, miperidine, dextomorphine, levodopa… what MUST you do first? why?
2 week washout period (to avoid serotonin syndrome)
SSRI MOA short-term vs longterm
short term- more available in cleft - take advantage of inhib effect of 5HT1
long-term- feedback to 5HT1 - continually till it down-regulates, then it will cause more serotonin released into cleft
overall: takes time to get full effect of agent
what are the 6 SSRI agents?
Fluoxetine (Prozac) Sertraline (Zoloft) Paroxetine (Paxil) Citalopram (Celexa) Escitalopram (Lexapro) Fluvoxamine (Luvox) -
which SSRI is reserved for OCD b/c of significant hepatotox ADR?
fluvoxamine (luvox)
what is the SSRI with the longest half life, what does this mean?
fluvoxamine (luvox) - 75hr 1/2 life. once-a-week pill
what is the metabolism of SSRIs?
Hepatic metabolism
CYP2D6 inhibition – fluoxetine (prozac) , paroxetine (paxil)
CYP3A4 inhibition – fluvoxamine (weakly)
which SSRIs are more stimulating? which are more sedating? which have no effect on sleep?
fluoxetine (prozac) and sertraline (zoloft) - more stimulating
paroxetine (paxil) and fluvoxamine - more sedating
if you dont wanna effect sleep at all- “loprams” (celexa, lexapro)
7 uses for SSRIs ?
Major Depression Anxiety disorders Panic disorder OCD PTSD Eating disorder Perimenopausal vasomotor symptoms
what are the 3 most significant ADRs of SSRIs?
- Weight gain (5-10 lbs)
- Anxiety, initially - can be from 7-10 days. usually stabilize after this time period
- serotonin syndrome
4 other ADRs of SSRIs
GI upset
Insomnia
Drowsiness
Sexual dysfunction: Decreased libido, anorgasmia
are SNRIs more of less selective than TCAs?
more- which means less ADRs
5 SNRI drugs
Duloxetine (Cymbalta) Venlafaxine (Effexor) Desvenlafaxine (Pristiq) Milnacipran (Savella)* Levomilnacipran (Fetzima)
which two SNRIs are reserved for fibromyalgia?
“-ciprans”
which SNRIs have renal elimination ?
“-ciprans”
hepative clearance of SNRIs- cymbalta, effexor and pristiq
cymbalta and effexor - phase 1 - cyp450
pristiq- phase 2 - glucuronidation
Venlafaxine (effexor) metabolism produces active metabolite ________
desvenlafaxine (pristiq)
4 uses for SNRIs
Major depression
Chronic pain disorders (diabetic neuropathy)
Fibromyalgia - duloxetine
Perimenopausal symptoms - venlafaxine for vasomotor symptoms
which SNRI would you use for perimenopausal symptoms?
venlafaxine (effexor) for vasomotor symptoms
which hepatic phase is better for elderly?
2- so give them pristiq
3 ADRs of SNRIs
Anticholinergic side effects: Anti-SLUDGEM
Sedation
Hypertension
CYP2D6 inhibition- which SNRI?
cymbalta
SNRIs, at low doses target what? at high doses? which causes PSNS effects?
low doses- more of an effect on SE, higher doses more effect on NE (where ADRs come from)
-target of NE - PSNS effects
general MOA or serotonin receptor modulators
they hit multiple receptors
what are the “serotonin receptor modulator” drugs?
“-zodones” and vortioxetine
MOA of trazadone?
Postsynaptic 5-HT2A antagonist
α1 receptor antagonist
H1 receptor antagonist
ADR of trazadone?
ADR - priapism (longterm erection)- from alpha blockade
is trazadone stimulating or sedating?
sedating
what are the serotonin modulators used for?
Major Depression
Sedation/hypnosis (trazodone)
4 ADRs of serotonin receptor modulators?
Orthostatic hypotension (trazodone, nefazodone) Sedation (trazodone) Priapism (trazodone) Liver toxicity (nefazodone)
drug/drug with serotonin modulators (kinda weeds)
CYP2D6 substrate (Vortioxetine) CYP3A4 inhibitor (nefazodone) CYP3A4 substrate (vilazodone)
*“substrate” - no effect on other drugs
A 56 year old truck driver is on a disability for a back injury he sustained while making a delivery 3 months ago. He has been on several opioid drugs but continues to complain of “nagging back pain.” The pain specialist he sees decides to try treating him with an antidepressant approved for the management of chronic pain. Which of the following would be an effective option.
Duloxetine - helps with neuropathy
what does wellbutrin target?
target NE and dopamine transporters (NDRI)
what are the 2 uses for wellbutrin?
Major depression
Smoking cessation
what is the major ADR with wellbutrin? how can we avoid this?
increased risk of seizure- avoid by titrating the dose
wellbutrin is a stimulating agent and therefore can cause what other 3 ADRs?
Nervousness, HA, insomnia
what are the 2 benefits of using wellbutrin for major depression over other agents?
Rarely produces cardiovascular effects or sexual dysfunction