lecture 59 Flashcards
ott (resident) - pharmacotherapy of depression
what are the risk of recurrence after each episode?
1 –> 50-60%
2 –> 70%
3 –> 90%
what is pathology associated with depression?
stroke
chronic pain syndrome –> fibromyalgia, low back pain/chronic pelvic pain, bone or disease related pain
MS
hypo/hyperthyroidism
traumatic brain injury
what are the criteria for diagnosis?
at least one of the symptoms must be depressed mood or loss of interest or pleasure in doing things
what are the symptoms of depression diagnosis?
SIGE CAPS
Sleep
Interest decrease
Guilt/worthlessness
Energy loss/fatigue
Concentration difficulties
Appetite change
Psychomotor agitation/retardation
Suicidal ideation
what rating scales are used for depression?
PHQ-9
MDQ
what is the PHQ-9?
patient health questionnaire
developed for the primary care setting
what is MDQ?
mood disorder questionnaire
can be used to rule out bipolar disorder
what are the CP of citalopram (celexa)?
dose-dependent QTc prolongation
substrate of 2c19 and 3A4
what are the CP of fluoxetine (prozac)?
long half life (96-144 hours)
activating potential
2D6 inhibitor, 3A4 inhibitor (norfluoxetine)
what are the CP of fluvoxamine (luvox)?
inhibitor 1A2, 2C19
what are the CP of paroxetine (paxil)?
must taper due to anticholinergic effects
weight gain, sedation
septal wall defect risk to the fetus
inhibitor 2D6, 2B6
what are the CP of sertraline (zoloft)?
more GI upset than other antidepressants
what are the key AE of SSRIs?
weight gain (paroxetine)
weight loss (fluoxetine)
increased bleeding risk (platelet inhibition)
hyponatremia especially in elderly
sexual dysfunction
what drugs are SSRIs?
citalopram
escitalopram
fluoxetine
fluvoxamine
paroxetine
sertraline
what drugs are SNRIs?
desvenlafaxine
duloxetine
levomilnacipran
milnacipran
venlafaxine
what are the CPs of desvenlafaxine (pristiq)?
active metabolite of venlafaxine
dose-limiting SE of nausea
no major CYP interactions
what are the CP of duloxetine (cymbalta)?
nausea
FDA warning for hepatotoxicity
inhibitor 2D6
what are the CP of levomilnacipran (fetzima)?
must adjust in renal impairment or strong 3A4 inhibitors
substrate 3A4
what are the CP of venlafaxine (effexor)?
must be over 150 mg/day to have NE effects
2D6 inhibitor at higher doses
what are the key AE of SNRIs?
BP elevation
nausea
besides depression, what can SNRIs be useful in?
pain syndrome, musculoskeletal pain, fibromyalgia, and neuropathic pain
how should monitoring of duloxetine be?
obtain LFTs at baseline and when symptomatic or every 6 months
what drugs are TCAs?
amitriptyline (elavil) which is tertiary amine
other pramines, triptyline, doxepin
when are TCAs most commonly used?
mostly for neuropathic pain syndrome
what are the SE of TCAs?
limit higher doses
CNS – sedation, reduced seizure threshold, confusion
anticholinergic – blurred vision, urinary retention, constipation
cardiovascular – orthostatic hypotension, tachycardia
other – weight gain, sexual dysfunction
why do TCAs have a narrow therapeutic index?
fatal in overdose as low as 1000 mg (around 4-10 tablets) due to cardiac arrhythmias or seizures
when would MAOi be used?
during a hypertensive crisis
make sure they are following a tyramine diet (smoked, aged, pickled meats or fish)
what is the moa of bupropion (wellbutrin)?
dopamine and NE reuptake inhibitor
stimulating drug (so insomnia and appetite suppression)
what are the CP of bupropion?
2D6 inhibitor
CI in active seizure disorder and eating disorders
can be used in combination with SSRI/SNRIs
has XL dosing
what is the CP of mirtazapine (remeron)?
sedation and increased appetite occur with doses under 15 mg/day
warnings of agranulocytosis and increased cholesterol
can be used in combo with SSRIs/SNRIs
what is the CPs of trazodone (desyrel)?
higher doses needed for depression
SE – orthostatic hypotension, risk of priapism (medical emergency)
interactions with 3A4 and 2D6
what are the CP of vilazodone (viibryd)?
take with food (due to significant nausea and increased absorption with food)
substrate 3A4
what is the MOA of vilazodone (viibryd)?
primarily SSRi, may have some 5HT1a agonism which may provide anxiolytic effets
do not use in combination with SSRIs/SNRIs
what is the moa of vortioxetine (trintellix)?
SSRI + 5HT1a agonist + 5HT3 antagonist
do not use in combination with SSRI/SNRIs
what are the CP of vortioxetine (trintellix)?
possibly less sexual dysfunction
substrate 2D6
nausea
what agents may initiate serotonin syndrome (medical emergency)?
lithium
serotonergic antidepressants
buspirone
linezolid
amphetamines
dextromethorphan
serotonin agonists
st. john’s wort
tramadol
fentanyl, cocaine, LSD
what is antidepressant withdrawal syndrome?
common with all antidepressants except fluoxetine
antidepressants with anticholinergic activity should be tapered no matter what
NOT life-threatening
what are the FDA-approved augmentation agents?
aripiprazole (abilify)
brexpiprazole (rexulti)
cariprazine (vraylar)
quetiapine (seroquel)
what antidepressants are used to treat post-partum depression?
brexanolone
zuranolone
what antidepressants are used for treatment-resistant depression?
NMDA receptor antagonist (esketamine)
what are the key CP of antidepressants?
abrupt d/c can lead to antidepressant withdrawal syndrome
possible increase in suicidal thinking during the first few weeks of therapy
what are the non-pharm treatments of depression?
electroconvulsive therapy (ECT)
psychotherapy
