Medications Flashcards
What impact on depressive symptoms can you expect after one week?
Week 1: improvements in terminal insomnia, appetite disturbances, and anxiety
What improvements in depressive symptoms can you expect after 2 weeks of medication therapy?
Week2: improvements in fatigue, poor motivation, somatic complaints, agitation/retardation
Upon initiating medication therapy what improvements in depressive symptoms can you expect after week 3?
Week3: improvements in dysphoric mood, subjective depressive feelings, and suicidal thoughts
What is the first line antidepressant?
Fluoxetine (Prozac) : only antidepressant approved for 8 +
12 years 10-40 mg/daily
For MDD OCD or bulimia
Sertraline (Zoloft)
FDA approved for OCD 6+ minimal data for efficacy in depression
What is the usual dosing for sertraline (Zoloft)?
12 years 25-200 mg/day
For MDD, OCD, or PTSD, GAD
Paroxetine ( Paxil )
One study showed increased suicide attempts. Do not use in children or older adults
Citralopram (celexa)
Lower risk of drug reactions but not prove clearly effective
May use this or lexapro in older adults
Fluvoxamine (Effexor)
fDA approved for 8+ with OCD Not studied in depression
Potent inhibitor of p450 1A2 and 3A4
Venlafaxine (Luvox)
Few trial used in those who fail fluoxetine or sertraline
Usual dosing for citalopram (celexa)?
12 yr 20-60 mg/ day
First line only if fluoxetine drug interactions must be avoided
What is the usual dose for bupropion?
12yr 100-400 mg a day ER
Co morbid ADHD, substance abuse or smoking cessation
When do patients initially starting medication need to be evaluated?
2-2 1/2 weeks to monitor for suicidal thoughts
What are the side effects of SSRIs?
Nausea Nervousness Insomnia Sexual dysfunction HA Weight gain
What are the side effects of TCAs?
Dry mouth Blurred vision Dizziness Constipation Weight gain Postural hypotension Cardiac effects
What are the FDA monitoring guidelines for acute therapy follow up the first 8 to 12 weeks?
Face-to-face contact weekly for four weeks contact every other week for the next four weeks another contact after 12 weeks then as clinically indicated beyond 12 weeks risk of suicide is greatest in the first two weeks with no increased risk after 12 weeks
What is defined as acute therapy?
The first 8 to 12 weeks
What is considered continuation therapy?
6 to 12 months following abatement of acute symptoms the goal is to prevent relapse therapies should continue for 6 to 12 months after symptom-free you made then taper down
When would you consider maintenance therapy?
Maintenance therapy occurs over a long period of time to prevent relapse consider if three or more episodes of major depression or two episodes of major depression and one or more of the following positive family history of bipolar or depressive disorder, history of recurrence within 1 year of previous successful treatment, those episodes were severe life-threatening in the past three years, onset before age 20
When would you consider referral?
Consider referral if the patient prefers it if there is concurrence psychoses incomplete response to therapy actively suicidal psychiatric hospitalization complex psychiatric diagnoses pregnancy occurs or is being planned
How do you switch an SSRI to an SSRI?
Generally done by direct substitution but some experts recommend a cross taper. Give new dose based on whether the dose of the discontinued SSRI is low medium or high. Switching an be done without a washout period for most SSRIs. WHEN SWITCHING FROM PROZAC TO ANOTHER SSRI SOME EXPERTS RECOMMEND A 4 to 7 DAY WASHOUT AND BEGIN REPLACEMENT SSRI LOW DUE TO FLUOXETINES LONG HALF LIFE.
Switching SSRI to/from Venalfaxine (Effexor)?
Usually a direct switch from SSRI to Venalfaxine does not cause discontinuation effects or adverse effects. SSRI THAT INHIBIT THE CYTOCHROME P-450 or 2D6 SUCH AS PAXIL AND PROZAC MIGHT DECREASE METABOLISM OF VENALFAXINE INCREASING RISK OF ADVERSE EFFECTS
How do you taper paroxetine and Venalfaxine ?
Very slowly since they seem to have higher risk of discontinuation syndrome reduce the dose by one quarter every 4 to 6 weeks
When would switch a patient from an SSRI to Wellbutrin?
They switch may help with sexual dysfunction and when an adequate response to SSRI. Patients with comorbid anxiety unresponsive to Bupropion trend may benefit from change to SSRI. To avoid discontinuation symptoms these two must be cross tapered
How do you switch from an SSRI to nefazodone (serzone)?
Concurrent administration of SSRIs and the facet down have been associated with serotonin syndrome a direct switch may not prevent discontinuation symptoms since the drugs are mechanistically different. The best approach maybe to taper the first drug and allow a brief washout period Before beginning the new drug
How do you switch and SSRI to mitazapine (remeron)?
Remeron and SSRIs work by different mechanisms drug interactions among these drugs are unlikely. Cross tapering will prevent discontinuation symptoms
How do you switch from an SSRI to a TCA
The potential for drug interactions between SSRIs and TCAs is high so I direct switch is unwise. Crusty bring with lower doses the TCA when drug interactions are likely should reduce the risk of discontinuation of effects and adverse effects
How do you switch Effexor to/from bupropion, nefazodone or mitazapine?
Because these drugs are mechanistically difference and drug interactions are not likely to be a concern, cross tapering is recommended.
Bupropion to/from nefazodone or mirtazapine?
These drugs all at a different mechanisms. Drug interactions are unlikely cross tapering is a reasonable approach one making the switch
How do you switch them in a MAOI to/from another antidepressant?
Although newer, safer in his presence have regulated MAOIs to the end of the treatment decision tree, they may be effective for atypical unipolar depression in anergic bipolar depression and other agents have failed. Switching that involves MAOIs require particular care. For patients taking in an MAOI and switching to another antidepressant including an MAOI allow at least a 14 day wash out. When switching from another in the present to him in a lie some clinicians follow 5/2 lives of this could discontinue drug including its active metabolites to pass before starting the new drug. HOWEVER WITH EXCEPTION OF PROZAC, SSRI PRODUCT LABELING AND THE AMERICAN PSYCHIATRIC ASSOCIATION DEPRESSION GUIDELINES RECOMMEND AT LEAST A TWO WEEK WASHOUT when switching from an antidepressant without a long half-life to an MAOI
What meds for PTSD?
Sertraline, paroxetine, fluoxetine and possibly short term benzodiazepines lorazepam or diazepam all of these drugs are off label for PTSD they are used placed on known side effects
What are the first line therapy is for OCD
First-line treatment is CBT clinical treatments include SSRIs for initial first treatment by Patsel is the most common flexor prefer panic GAD an SP Buspar ineffective.
What are the treatment remission criteria for PTSD
No or minimal PTSD symptoms objective goal treatment outcome PTSD scale tops eight score less than or equal to five or six subjective goal no or minimal Anxiety HAM-a
What is the first line drug class for major depression?
SSRIs are the mainstay due to side effect profile. They are cleaner than TCAs and do not have active metabolites and work faster. Expect results in 3-4 days
