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AC- CNS lectures > Major depressive disorder 1.1.1 > Flashcards

Major depressive disorder 1.1.1 Flashcards

1
Q

What are some of the emotional symptoms of major depressive disorder?

A
  • Misery
  • Apathy
  • Pessimism
  • Low self esteem
  • Feelings of guilt or inadequacy
  • Suicidal thoughts
    • Indecisiveness
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2
Q

What are some biological symptoms is major depressive disorder?

A

Disturbances in

  • appetite
  • energy
  • sleep
  • ibido
  • psychomotor function
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3
Q

How would you explain reuptake?

A
  • reuptake allows for the recycling “reabsorbing” of neurontransmitters
  • it regulates the level of neurontransmitters in the synapse
  • so it controls how long a signal from neurontransmitter release lasts
  • by BLOCKING reuptake, more 5HT & NA is available to pass messages between cells
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4
Q

What are SIX examples of TCAs?

AINCDD

A
  • Tricyclic antidepressants

Amitriptyline
Imipramine
Nortriptyline
Clomipramine
Dosulepin (Dothiepin)
Doxepin

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5
Q

What is the MOA of TCAs? Are they reversible?

How long does it take to reach therapeutic effect?

A
  • they inhibit the 5HT & NA reuptake transporters into the presynaptic terminal
  • so you get an increase in synaptic levels of NA & 5HT
  • Reversible
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6
Q

Why does it take 2-4 weeks for TCAs to reach therapeutic effect?

A
  • due to adaptive receptor changes
  • leads to downregulation of receptors
  • get inhibitory presynaptic a2-adrenoceptors
  • get inhibitory presynaptic 5HT1A autoreceptors
  • get postsynaptic B-adrenoceptors
  • get postsynaptic 5HT2A receptos
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7
Q

Do TCAs have long or short half lives?

A
  • long half lives
  • ~18-70 hours
    *
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8
Q

Which TCAs block NA uptake more than 5HT uptake?

Secondary or tertiary amines?

A
  • Nortriptyline
  • Desipramine

Secondary amines

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9
Q

Which TCAs block 5HT more than the secondary amines?

A
  • Amitriptyline
  • Clomipramine
  • Imipramine
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10
Q

What are some of the adverse effects of TCAs?

A

Antagonism of muscarinic receptors

  • dry mouth, blurred vision, constipation, urinary retention, cognitive impairment, delirium

Antagonism of a1- adrenoreceptors

  • postural hypotension, sedation, sexual dysfunction

Antagonism of H1 receptors

  • sedation, weight gain
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11
Q

What are the symptoms of TCA withdrawal syndrome?

CRASH

A

NOTE: TCAs must be withdrawn slowly to avoid withdrawal syndrome

Cholinergic rebound

Runny nose

Abdominal pain, D

Sleep & sensory disturbances

Hypersalivation

  • these last no longer than 2 weeks
  • more common in amitriptyline, doxepin
  • similar withdrawal syndromes with SSRIs, venlafaxine
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12
Q

Why does overdose occur in TCAs? What happens?

A
  • TCAs have a low TI & a low therapeutic window
  • it can be life threatening
  • causing respiratory depression, seizures & cardia toxicity followed by COMA
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13
Q

What are some associated drug interactions for TCAs?

A

MAOIs

  • severy hypertension

DIRECT ACTING SYMPATHOMIMETICS

  • NA, adrenaline
  • increase sympathetic activity, accumulation of NA

INDIRECT ACTING SYMPATHOMIMETICS

  • ephedrine, amphetamine
  • reduce the effects of indirect- acting agents

ANTICHOLINERGICS

  • TCA has antocholinergic activity hence will intensify anticholinergic effects

CNS DEPRESSANTS

  • sedation of TCAs exacerbated by agents such as alcohol, antihistamine, opiods, barbiturates, benzos
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14
Q

What are SIX examples of SSRIs?

CEFFPS

A
  • Selective serotonin reuptake inhibitors

Citalopram
Escitalopram
Fluoxetine
Fluvoxamine
Paroxetine
Sertraline

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15
Q

Explain the MOA of SSRIs? How are they different to TCAs?

A
  • selectively inhibit presynaptic 5HT reuptake transporters
  • more commonly prescribed, have a higher TI, as effective BUT much safer, better tolerated than TCAs & don’t cause significant cardiotoxicity
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16
Q

What are some SSRI withdrawl syndrome symptoms?

FLUSH

A

Flu like

Light headness

Uneasiness

Sleep & sensory disturbances

Headache

  • withdrawal symptoms not dangerous
  • last no longer than 2 weeks
  • more common with paroxetine (short acting)
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17
Q

What are some adverse effects for SSRIs?

A
  • n, d, anorexia
  • insomnia, anxiety, irritability, restlessness, tremor, headache, fatigue, drowsiness, dry mouth
  • decreased libido, delayed orgasm
  • weight gain, fever, sweating, palpitations
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18
Q

What are some noteable SSRI drug interactions?

A

MAOIs- serotonin syndrome

Warfarin- avoid as it may cause bleeding, fluoxetine is highly plasma bound

TCAs & lithium- fluoxetine can increase plasma levels of TCAs & lithium, giving rise to toxicity

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19
Q

What is serotonin syndrome? What are some symptoms of SS?

A
  • it a toxic state when theres excess 5HT in the brain
  • mental confusion, hypomania, agitation, headache, coma, fever, HTN, tachycardia, N, D, muscle twitching, tremor

>avoid SSRI w MAOI or RIMA

>avoid drugs that elevate 5HT levels

>avoid opiod analgesics that also ingibit 5HT reuptake; tramadol, pethidine, dextromethorphan

20
Q

What drugs should be avoided to prevent serotoninsyndrome when a patient is on an SSRI?

A
  • avoid SSRI w MAOI or RIMA
  • avoid drugs that elevate 5HT levels
  • avoid opiod analgesics that also ingibit 5HT reuptake; tramadol, pethidine, dextromethorphan
21
Q

What are THREE examples of SNRIs?

VDD

A
  • Serotonin & noradrenaline reuptake inhibitors

Venlafaxine
Desvenlafaxine
Duloxetine

22
Q

WHat is the MOA of SNRIs?

A
  • they reversibly inhibit 5HT & NA transporters
  • lower doses selectively inhibit 5HT reupatke
23
Q

Why are SNRIs safe than TCAs?

A
  • venlafaxine (SNRI), lacks affinity for muscarinic, a1, h1 receptors & it doesn’t impair cardiac conduction significantly
24
Q

What are some adverse effects associated with SNRIs?

A
  • similar to SSRIs
  • N, V, anorexia, headache, sweating, rash, anxiety, dose related increase in diastolic BP, orthostatic hypotension, tremor
25
Q

What is the half life of venlafaxine?

A
  • about 5 hours
  • slow release allows for daily dosing
26
Q

What are some noteable drug interactions associated with SNRIs?

A
  • TCAs, MAOIs, SSRIs, selegiline, mianserin, moclobemide- possible serotonin syndrome combination contraindicated
  • lithium- neurotoxicity or serotonin syndrome
  • fentanyl, pethidine, tramadol-possible serotonin syndrome
27
Q

What are TWO examples of MAOIs?

A
  • Monoamine oxidase inhibitors

Phenelzine
Tranylcypromine

28
Q

What is the MOA of MAOIs? Is it irreverible?

A
  • Irreversible
  • inhibition of MAOA & MAOB resulting in a decrease in the intraneuronal breakdown of NA & 5-HT
  • ​MAOA selectively inactivates 5-HT & NA
  • ​MAOB selectively inactivates DA
  • ​In liver, MAOA inactivates dietary tyramine
29
Q

What are the adverse effects of MAOIs?

A
  • similar to TCAs
  • can produce anxiety, agitation, hypomania & even mania
  • postural hypotension
  • patients should be informed of signs of hypotension, dizziness, light headedness
  • sedation, cardiotoxicity
  • in OD- hyperthermia, convulsions; can be life threatning
30
Q

What foods should be avoided when taking a MAOI? And why? How long does it take to recover?

A
  • cheese, pickles, wine, avocadoes
  • foods rich in tyramine
  • CHEESE/ TYRAMINE RXN
  • tyramine can increase BP by displacing NA from sympathetic nerve terminals
  • ingestion of tyramine by patients on MAOIs can result in hypertensive crisis
  • Can take up to 2 weeks to recover
31
Q

What are some other antidepressants?

A
  • Agomelatine
  • Mirtazapine
  • Moclobemide
  • Reboxitine
  • Mianserin
  • Vortioxetine
32
Q

What are the drug interactions associated with MAOIs?

A

IN DIRECT ACTING SYMPATHOMIMETICS

  • Ephedrine, amphetamine- hypertensive crisis

ANTIDEPRESSANTS

  • TCAs- hypertensive crisis
  • SSRIs- serotonin syndrome

ANTIHYPERTENSIVE AGENTS

  • excess lowering of BP

MEPERIDINE (DEMEROL)

  • can cause hyperpyrexia
33
Q

What class of drug is reboxatine?

A
  • NRI
  • noradrenaline reuptake inhibitor
34
Q

What is the MOA of raboxetine?

When is raboxetine used?

A
  • it selectively inhibits NA transporters
  • it doesn’t the reuptake of 5HT & DA?
  • Can be used in major depression
35
Q

What class of drug is moclobemide?

A
  • reversible MAO-A inhibitor
36
Q

What is the MOA of moclobemide?

A
  • its selectively inhibits MAOa
  • resulting in a decrease in the intraneuronal breakdown of NA & 5HT
37
Q

What is moclobemide used for?

A
  • fatigued depressed patients
  • can be used if sexual dysfunction produced by a SSRI becomes a problem
38
Q

What are some side effects of moclebomide?

A
  • safer than MAOs
  • nausea, dizziness, agitation, insomnia, headache
39
Q

What class of drug is mirtazapine?

A
  • NaSSA
  • Noradrenaline- serotonin specific antidepressan
40
Q

When is mirtazapine used?

A
  • Used in depressed patients requiring sedation
  • or as an alternative to a SSRI if insomnia or sexual dysfunction is problematic
41
Q

What is the MOA of mirtazapine?

A
  • mirtazapine antagonises presynaptic a2- adrenergic autoreceptors, 5HT2A, 5HT2C, 5HT3, H1 receptors
  • antagonism of inhibitory presynaptic a2- adrenoceptors on NA & 5-HT nerve terminals cause an immediate increase in synaptic levels of 5-HT & NA (major therapeutic effect)
42
Q

What are the common side effects of mirtazapine?

A
  • weight gain, excessive drowsiness
  • dizziness, dry mouth, constipation
43
Q

What is a precaution/ important note for mirtazapine?

A
  • it shouldn’t be combined with CNS depressants such as alcohol & benzodiazepines
  • an anti depressant with a depressant makes depression harder to treat
44
Q

For agomelatine

a) What is the MOA?
b) What is the indication?
c) What are the precautions?
d) What are some common adverse effects?

A

a) Its a melatonin receptor agonist, serotonin 5HT2C antagonist
b) Major depression
c) Potent CYP1A2 inhibitors, hepatic impairment
d) Abdominal pain, dizziness, up aminotransferase

45
Q

For vortioxetine?

a) What is the MOA?
b) What is the indication?
c) Common adverse effects?
d) What are some pre cautions?

A

a) it enhances CNS serotonergic activity, inhibits serotonin reuptake
b) Major depression
c) N/D are dose dependent. Similar to other antidepressants.
d) co administration with CYP2D6 inhibitors & CYP3A4 inducers

46
Q

What are some drug interactions associated wth vortioxetine?

A

A) Co-administration with serotonergic medications - triptans, other antidepressants, and tramadol; serotonin toxicity

B) Anticoagulants (eg, warfarin), aspirin, or NSAIDs (eg, ibuprofen, intranasal ketorolac); risk of bleeding

C) Diuretics (eg, furosemide, hydrochlorothiazide); Risk of low blood sodium levels

D)Carbamazepine, phenytoin, or rifampicin; Decreased effectiveness

AC- CNS lectures (28 decks)

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