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Therapeutics 2 > Major Depressive Disorders > Flashcards

Major Depressive Disorders Flashcards

1
Q

What antidepressants are first generation agents?

A

-tricyclic antidepressants (TCAs)
-monoamine oxidase inhibitors (MAOIs)

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2
Q

What antidepressants are second generation agents?

A

-selective serotonin reuptake inhibitors (SSRIs)
-serotonin norepinephrine reuptake inhibitors (SNRIs)

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3
Q

What is the mechanism of action of SSRIs?

A

inhibit presynaptic serotonin reuptake = increased serotonin in the synaptic cleft= more serotonin available (may also increase norepinephrine and dopamine at higher doses)

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4
Q

What is the general dosing of SSRIs?

A

once daily at bedtime or morning

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5
Q

What is the place in therapy of SSRIs?

A

first line due to equivalent efficacy and better tolerability than 1st gen agents

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6
Q

What is the dosing of Fluoxetine?

A

-initial= 10mg/day
-maintenance= 20-40mg
-max dose= 80mg/day

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7
Q

What is the t1/2 of Fluoxetine?

A

up to 6 days with chronic use

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8
Q

What is the dosing of Paroxetine?

A

-immediate release= 10mg initially, max dose 50mg/day
-controlled release= 25mg/day, increased by 12.5mg weekly, max dose 62.5mg/day

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9
Q

What may occur with missed doses of Paroxetine?

A

increased withdrawal effects due to shorter t1/2

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10
Q

What are the significant side effects of Paroxetine?

A

-anticholinergic effects
-weight gain
-sexual dysfunction
-sedation
-tremor

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11
Q

What is the dosing of Sertraline?

A

-initial= 12.5-25 mg/day
-maintenance= 100 mg/day
-max= 200 mg/day

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12
Q

What are the significant side effects of Sertraline?

A

GI side effects initially

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13
Q

What is the contraindications of Sertraline?

A

severe liver impairment

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14
Q

What is the dosing of Citalopram?

A

-initial= 10mg daily
-maintenance= 20mg daily
-max= 40mg daily

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15
Q

What are the risks associated with Citalopram?

A

doses > 40 mg/day not recommended due to prolonged QTc/torsades risk

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16
Q

What is the dosing of Escitalopram?

A

-initial= 10mg daily
-max= 20mg daily

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17
Q

What are the pros of Escitalopram?

A

minimal drug/CYP interactions compared to SSRIs

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18
Q

What is the dosing of Fluvoxamine?

A

-initial= 50mg at bedtime
-increase by 50mg weekly, max dose= 300mg/day
->100mg daily should be dosed BID

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19
Q

What are the significant side effects of Fluvoxamine?

A

sedation

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20
Q

What is the indication of Fluvoxamine?

A

obsessive compulsive disorder (off label for depression)

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21
Q

What are the additional benefits of SNRIs besides MDD?

A

-pain syndromes
-vasomotor symptoms of menopause

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22
Q

What is the dosing of Venlafaxine?

A

extended release preferred
-initial= 37.5-75mg daily
-increase by 37.5-75mg weekly
-usual dose range 75-225mg/day

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23
Q

What is the neurotransmitter activity of Venlafaxine?

A
  • <150mg/day= primary serotonin
  • > 150mg/day= norepinephrine and serotonin
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24
Q

What are the cautions of Venlafaxine?

A

-hypertension (dose related, OK if HTN is controlled)
-increased withdrawal effects in abrupt continuation (IR>ER)
-dose reduction in renal impairment

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25
Q

What is the dosing of Duloxetine?

A

-initial= 20mg/day
-usual dose= 20-60mg/ day, may BID
-max= 120mg/day

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26
Q

What are the concerns with Duloxetine?

A

-avoid in renal (CrCl < 30mL/min) and hepatic dysfunction
-slightly more anticholinergic than venlafaxine
-indicated for use in various pain syndromes
-contraindicated in closed angle glaucoma

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27
Q

What is the MOA of Bupropion?

A

dopamine and norepinephrine uptake inhibitor

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28
Q

What are the indications of Bupropion?

A

-vegetative symptoms/melancholic depression
-hypersomnia
-inattention
-sexual dysfunction or weight gain due to SSRIs

29
Q

When would you avoid using Bupropion?

A

very activating
-avoid dosing after 2PM
-avoid in uncontrolled anxiety

30
Q

What are the contraindications of Bupropion?

A

history of seizure!
-use caution with concomitant use with drugs that lower seizure threshold and in pt that are withdrawing from benzos and alcohol
eating disorders!
-electrolyte abnormalities may lead to seizures

31
Q

What are the side effects of Mirtazapine?

A

dose related side effects!
-lower doses= sedation and weight gain
-higher doses= more activating, less sedation and weight gain

32
Q

What may be the uses of Mirtazapine?

A

-pt with insomnia
-malnourished pt

33
Q

What is the use of Trazodone?

A

not effective in depression, lower doses used for insomnia

34
Q

What are the disadvantages of Vortioxetine?

A

-withdrawal symptoms possible over 15 mg/day
-sexual dysfunction
-CYP2D6 substrate (dose adjustment needed)

35
Q

What is the advantage of Vilazodone?

A

less sexual dysfunction due to less potent serotonin reuptake

36
Q

What is the caution associated with Nefazodone?

A

hepatotoxicity

37
Q

What is the risk of using Gepirone?

A

QTc prolongation and must decrease dose in hepatic impairment

38
Q

What is the MOA of Tricyclic Antidepressants (TCAs)?

A

block serotonin and norepinephrine reuptake

39
Q

What is the use of Tricyclic Antidepressants (TCAs)?

A

adjunct or last line therapy, may be useful in patients with concomitant conditions, such as: pain (neuropathies or migraines), nocturnal enuresis, or OCD

40
Q

What are the side effects of Tricyclic Antidepressants (TCA)?

A

-antihistamine= sedation and weight gain
-antimuscarinic= anticholinergic SE
-alpha 1 agonist= hypotension and dizziness
-voltage gated Na+ channel blocker= antiarrhythmic

41
Q

In what patient populations should Tricyclic Antidepressants (TCAs) be avoided?

A

-actively suicidal pt or history of suicide attempt
-elderly
-significant cardiac comorbidity

42
Q

What may occur with Tricyclic Antidepressant (TCA) toxicity?

A

LD50= 35mg/kg
heart block, seizures, or sudden cardiac death

43
Q

What is the use of Monoamine Oxidase Inhibitors (MAOI)?

A

rarely used due to SE, drug interactions, and dietary restrictions

44
Q

What are the drug interactions of Monoamine Oxidase Inhibitors (MAOI)?

A

-sympathomimetics (stimulants, phenylephrine)
-other serotonin agents REQUIRED 14 day washout

45
Q

What are the adverse effects of Monoamine Oxidase Inhibitors (MAOIs)?

A

-orthostatic hypotension
-sedation
-weight gain
-anticholinergic SE
-sexual dysfunction

46
Q

What are the dietary restrictions when using Monoamine Oxidase Inhibitors (MAOI)?

A

foods high in tyramine
-smoked/aged meats
-aged cheeses
-anything fermented

47
Q

What antidepressant class is the worst offender of QT prolongation?

A

TCAs

48
Q

What are the highest risk antidepressants for QT prolongation?

A

-citalopram at doses > 40mg/day
-escitalopram is a high risk SSRI
-venlafaxine is highest risk SNRI

49
Q

Which antidepressants are considered safe for QT prolongation?

A

-sertraline
-bupropion

50
Q

What is the correlation between antidepressant and NSAID use?

A

do not use NSAIDs for pain but acetaminophen because of increased bleed risk

51
Q

What is the management protocol for Serotonin Syndrome?

A

-discontinue offending agents
-supportive care for mild case (most cases): rehydration, benzos for agitation/sedation, cooling, antihypertensives
-in severe cases: serotonin antagonists

52
Q

What are the symptoms of Antidepressant Withdrawal?

A

VIVID
-Vivid dreams
-Insomnia
-Vomiting
-Irritability
-Dizziness
-others: brain zaps, body aches, fever, worsening mood

53
Q

What is the use of Lithium in major depressive disorder?

A

adjunct agent with quick therapeutic response (48-72h) that can be used to treat acute suicide ideation

54
Q

What are the cautions of Lithium?

A

-tolerability= tremors, dermatologic SE, sedation
-renal impairment

55
Q

What are the atypical antipsychotics used in major depressive disorder?

A

do not use as monotherapy
aripiprazole, brexpiprazole, quetiapine, and cariprazine (FDA approved)

56
Q

How is treatment resistant depression defined?

A

failure of 2+ adequate trials of antidepressant therapy

57
Q

What are the treatment options of treatment resistant depression?

A

-electroconvulsive therapy (ECT)
-transcranial magnetic stimulation (TMS)
-Esketamine

58
Q

What is the MOA od Esketamine?

A

NMDA receptor antagonist= increased glutamate release

59
Q

What are the Black Box Warning of Esketamine?

A

REM program
-sedation
-dissociation
-abuse and misuse
-suicidal behavior

60
Q

What are the antidepressants preferred in pregnancy?

A

sertraline, fluoxetine, escitalopram

61
Q

What antidepressants are preferred in lactation?

A

sertraline and paroxetine

62
Q

What antidepressants should not be used in pregnancy?

A

paroxetine

63
Q

What antidepressant should not be used in lactation?

A

fluoxetine

64
Q

What is the risk of using antidepressants in pregnancy?

A

poor neonatal adaptation syndrome due to newborn withdrawal, symptoms= irritability, difficulty feeding, sleep disturbances

65
Q

What is the use of Brexanolone?

A

post partum depression but is 60h infusion and REM program

66
Q

What is the use of Zuranolone?

A

post partum depression

67
Q

What antidepressants may be used in children/adolescents?

A

fluoxetine (8+ years old) or escitalopram (12+ years old)

68
Q

What are first line therapy antidepressants for geriatric pts?

A

SSRIs (avoid MAOIs and TCAs)

Therapeutics 2 (13 decks)

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