MCP CNS Meds: Part 1 Flashcards
1
Q
How do CNS drugs work?
A
They alter or modulate the CNS via binding to receptors and/or affecting neurotransmitter levels
2
Q
Symptoms of Depression
A
- S: sleep
- Insomnia or hypersomnia
- I: Interest
- Depressed mood, loss of interest of pleasure
- G: Guilt
- Feelings of worthlessness
- E: Energy
- Fatigue
- C: Concentration
- Diminished ability to think or make decisions
- A: Appetite
- Weight change
- P: Psychomotor
- Psychomotor retardation or agitation
- S: Suicidality
- Precoccupation with death, hoplesness
- Plus depressed mood
- To be diagnosed, a person will have 5/9 of these and 1 will be depressed mood
3
Q
Lifestyle and Non-Pharmacologic Treatment for Depression
A
- Exercise
- Avoid Stressors
- Cognitive Behavioral Therapy (CBT)
- Light Therapy (SAD)
- All of these therapies are often used in addition to pharmacologic therapy
4
Q
General Onset for Anti-Depressants
A
- Onset: 2-6 weeks
- Physical Effects (1-2 wks): increases energy and regulation of appetite
- Psychological Effects (2-6 wks): Improved mood
5
Q
General Administration for Antidepressants
A
- Should NOT d/c drug abruptly; need to taper down (or up)
- Therapy generally must continue for at least 6-9 months after sx improvement
- Best to avoid combining alcohol with anti-depressants
- Pt may feel more depressed or anxious, can enhance SEs potential for DDIs (MAOIs, other sedatives)
- May be okay to have occasional drink, depending on individual patient’s situation
6
Q
General Side Effects for Anti-Depressants
A
- People have very different rxns
- Sexual side effects should be condsidered
- Monitoring Suidical Risk for all antidepressants
7
Q
General DDI for Anti-Depressants
A
- Not to be used with MAOI: 14 day without period required
8
Q
Black Box Warning on all Anti-Depressants
A
- Increased risk of suicidal thinking in children, adolescants, and young adults (18-24 yo) with MDD and other psychiatric disorders
- Depression and certain other pschiatric disorders are themselves associated with increases in risk of suicide
9
Q
Monitoring Parameters for all Anti-Depressants
A
- Appropriately monitor patients of all ages who are started on antidepressant therapy and closely observe for clinical worsening, suicidality, or unusal changes in behavior
- Advise families and caregivers of the need for close observation and comunication with prescriber
10
Q
The risk of suicide is increased when
A
- Treatment is initiated
- Dose is increased or decreased
- Some paitents will take action once their energy level has increased in response to therapy, but before further improvement in mood has occured
11
Q
MedGuide Take Away Points on Depression
A
- Depression or other serious mental illnesses are the most important causes of suicide
- Watch for new or sudden changes in mood, behavior, actions, thoughts, or feelings, especially if severe
- Keep in contact with HC provider even between appt
- Rely on close friends and loved ones
- National Suicide prevention lifeline
12
Q
SSRIs MOA
A
- Blocks pre-synaptic reuptake of serotonin
- Increases concentration of serotonin in the synapse
13
Q
SSRIs: Primary Indication, Administration, SE, Important Tidbit
A
- Primary Indications
- MDD
- Various Anxiety Disorders
- Administration
- Same time each day (AM or PM determined whether makes sleepy/awake)
- w or w/o food (via pt response)
- Side Effects
- Nausea, loss of appetit, weight gain, somnolence or insomnia, sexual dysfunction, slight potential for QT prolongation
- Important: Can cause serotonin syndrome
14
Q
Serotonin Syndrome
A
- Life-Threatening condition associated with increased serotenergic activity in teh CNS
- Symptoms:
- high body temp, fast heart beat, agitiation or restlessness, confusion, loss of coordination, D/N/V
- Occurs most often when more than one medication that affects serotonin are taken togethers
- increased release of serotonin
- or the amount of time that serotonin stays in the brain is prolonged
- MAOIs carry the greatest risk, and symptoms can persist for several days
15
Q
SSRI drugs
A
- Citalopram (Celexa)
- Escitalopram (Lexapro)
- Fluoxetine (Prozac)
- Paroxetine (Paxil)
- Sertraline (Zoloft)
16
Q
Citalopram
A
- Celexa
- Consits of two stereoisomers
- Dosage limits due to QT prolongation
17
Q
Escitalopram
A
- Lexapro
- S-enantiomer of citalopram
18
Q
Fluoxetine
A
- Prozac
- Most stimulation agent of SSRIs (Take in AM)
- Appetite suppression common SE
- Longs 1/2 life (careful in elderly)
19
Q
Paroxetine
A
- Paxil
- Potentially assoc. w/ more sexual SE and weight gain than other SSRIs
20
Q
Sertraline
A
- Zoloft
- Initial doses (25-50mg/day)
- Usally must be increased for full therapeutic effects (goal: 100-200 mg/day)
21
Q
Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs): MOA
A
- MOA: Blocks serotonin and NE reuptake and is a weak inhibitor of dopamine
22
Q
SNRIs Drugs
A
- Venlafaxine (Effexor)
- Duloxetine (Cymbalta)
23
Q
SNRI: Primary indication, Administration, Imporatant Tidbit
A
- Primary Indication
- MDD
- Various Anxiety Disorders
- Duloxetine
- Nerve Pain
- Administration
- Same time each day
- Venalfaxine: XR may be swallowed whole or sprinkled on applesauce
- Important: Can Cause Serotonin Syndrome
24
Q
SNRI: SE
A
- GI complaints, insomnia, headache, some sexual dysfunction, increased risk of bleeding (particularly with aspirin or NSAIDs)
- Venlafaxine:
- Take with food
- Hypertension: escpecially with higher doses
- Duloxetine
- incerased risk of hepatotoxicity
25
TriCyclic Anti-Depressants: MOA
* MOA: Increases the synaptic concentration of seotonin and/or norepinephrine by inhibitor of their reuptake by the nerve terminal
26
TCA Drugs
* Amitriptyline (Elavil)
* Nortriptyline (Pamelor)
* nortriptyline is the active metabolite of amitriptyline
27
TCA: indications, onset, administration, important tidbit
* Indications:
* Primary: nerve pain, sleep
* Secondary: depression, anxiety
* Onset: up to 4 wks
* Administration
* Best is taken at night
* Important: Can Causes Serotonin Syndrome
28
TCA: SE and Monitoring
* **SE:**
* Sedation
* Anti-Cholingergic effects
* Weight Gain
* Orthostatic Hypotension
* Less prominent with nortriptyline
* Severe: AV conduction changes
* Monitoring:
* 30 day supply enough to fatally overdose
* Overdose can lead to the 3 C's
* Coma
* Convulsions
* Cardiotoxicity
29
MAOI MOA (Monoamine Oxidase Inhibitors)
* Irrevesible blocking monoamine oxidase, the enzyme responsible for the oxidative deamination of neurotramsitters such as serotonin, norepinephrine, and dopamine
30
MAOI Fun Facts: History, Restrictions, Use
* The first class of antidepressants used clincally
* No longer first line anti-depressants
* Many SE (hypotensive effects)
* Dietary Restrictions: cheese or tyramine reaction
* MAOs is blocked in intestinal tract (where tyramine is normally broken down) allowing tyramine to build up in the systemic circulation and cause HTN crisis
* Ex of food with tyramine: aged meats/cheeses, improperly stored food, beer and wine
* DDI's: potential for serotinin syndrome
* Useful for "Atypical" Dpression as well as treatment-resistant depressed patients
31
MAOI Drugs (FYI)
* Tranylcypromine (Parnate)
* Phenelzine (Nardil)
* Selegiline (Eldepryl or Emsam-patch)
32
Bupropion
* Wellbutrin
* MOA:
* Dual DA/NE reuptake inhibitor with NO serotonin activity
* SE
* Insomina, dry mouth, seizures (with high doses)
* C/I in paitents with hx of seizures, bulimia and anorexia
* Admin
* w or w/o food, Lacks 5HT activity therefore no sex dysf, weight gain, excessive sedation. Avoid EtOH
33
Mirtazipine: MOA, SE, Admin
* Remeron
* MOA:
* Antagonizes alpha-2 receptors centrally which increases release of 5HT and NE
* SE
* increased appetite leading to weight gain
* dry mouth
* constipation
* drowsiness
* Admin/Notes
* At bedtime
* Potential for less sexual SE than SSRIs
34
Trazodone: MOA, SE, Admin
* Desyrel
* MOA:
* Probably a serotonin reuptake inhibitor
* SE
* Drowsiness
* Dizziness
* Headache
* Anti-cholingeric (high doses)
* Rare-priapism
* Admin/notes
* At bedtime
* Commonly used as a non-habit forming sleep aid. Take with food
35
Anxiety: What is it, Nonpharmacologic/Pharm Treatments
* Generalized Anxiety Disorder (GAD)
* Excessive worry and tension
* hard for patient to control
* Interferes with day to day activities
* Symptoms on most days (for at least 6 months)
* Non-Pharmacological Treatments
* CBT
* Relaxation Techniques
* Pharmacological Treatments
* SSRIs and SNRIs first line
36
Benzodiazepines: MOA
* Binds to a separate site on the GABA receptor
* Causes increased effectiveness of GABA
* Less excitable neuronal state (less anxiety, more sedation)
37
Benzodiazepines: Primary Indications, Onset, Admin
* Primary Indications:
* Anti-anxiety
* Anti-convulsant
* Hypnotic
* Onset: 1 hour
* Administration:
* before anxiety promoting activity (flight, dentist, etc)
* If used long term, do not abruptly D/C, withdrawl effects likely
38
Benzodiazepines: SE, Monitoring
* SE
* drowsiness, memory impairment, coordination problems, dizziness, CNS depressive effects
* Monitoring:
* Alcohol and other CNS depresseants intensifies effects and may lead to respiratory depression
* Caution with falls in elderly
* All are schedule (C-IV) drugs-may be habit forming
39
Alprazolam
* Xanax
* Half-life: Short (~11 hours)
* Onset: 1 hour
* Max: 10mg/day
* Short half-life increase abuse potential and increases likelihood for withdrawl sx
40
Clonazepam
* Klonopin
* Half Life: Long (~19-50 hours)
* Onset: 20-60 min
* Max 20mg/day
* Once daily dosing at bedtime sometimes used
41
Diazepam
* Valium
* Half-Life: Long (20-50 hours-active metabolite: 50-100 hours)
* Used with caution in elderly: long half-life
42
Lorazepam
* Ativan
* Half-Life: 13 hours
43
Buspirone: MOA
* Not well understood. Though to not interact with the GABA receptor, but instead act as an agonist for a serotonin receptor
44
Buspirone: Pros and Cons
* Buspar
* Not scheduled
* Cons:
* Less clinical utility
* Not for seizure or sedation...only for anxiety
* Pros:
* Less sedating
* Higher threshold of interaction with other CNS depressants and EtOH
* Good Option for the following patients:
* Unable to tolerate BZDs
* Patients with a history of drug or alcohol abuse
* elderly
45
Buspirone: Onset, Admin
* Onset: a week or more
* Admin:
* Generally dosed twice daily
* Avoid taking concurrently with grapefruit juice
* Do not d/c abruptly
46
Busprione: SE, monitoring
* SE:
* drowsiness, dizziness, lightheadedness, nervousneses, excitement
* Monitoring:
* Alcohol and other CNS depressant intensifies effects and may lead to respiratory despression (lesser extent than BZDs)
47
Insomina
* Difficulty falling asleep
* Difficulty staying asleep
* Sleep that is not restorative
* Poor sleep, difficulty function during the daytime
48
Sleep Hygiene
* Avoid naps
* Avoid stimulants such as caffeine
* Exercise. But vigourous exercise should be done in the morning
* Stay away from large meals at bedtime
* Ensure adequate exposure to natural light
* Bedtime routine
* Don't bring problems to bed
* Associate bed with sleep
* Pleasant and relaxing sleep environmen t
49
Temazepam
* Restoril
* Specifically for sleep
* Half life: 10-12 hours
* Take just before going to sleep
* Only use for very short term duration (7-10d)
* Additional SE to watch out for with sedative-hypnotic Benzos in complex behavior, such as sleep driving
50
Non-Benzo Sedative Hypnotics: Drugs and MOA
* Zolpidem (Ambien, Ambien CR)
* Eszopiclone (Lunesta)
* MOA:
* may bind to a different site on the GABA receptor, eliciting only sedation effects
51
Non-Benzo Sedative Hypnotics: Onset, Admin, Dosing
* Onset: ~30 min
* Admin:
* Take just before going to sleep or once having trouble falling asleep
* Use only when needed and for short-term duration
* Don't take unless you can dedication 8 hours to sleeping
* Dosing: Watch for differential dosing for males and females
52
Non-Benzo Sedative Hypnotics: SE, Monitoring
* SE:
* Droswinss
* CNS dpressive effects
* Complex behavior (sleep driving)
* Monitoring:
* Alcohol and other CNS depressants intensify effects
* EtOH should be avoided
* Do no d/c abruptly
* All are scheduled C-IV drugs and may be habit forming
* Elderly patients most suseptible to SE
