medications Flashcards
Classes used for treatment of depression.
Tricyclic - act on 5HT, DA, NA, M. AE dry everything and slows things down
MAO I - 5HT, DA, NA - Cheese effect - HTN crisis
SSRI - 5 HT. Discontinuation syndrome
SNRI - good as adjunct for chronic pain, decreased motivation as it works on 5HT, NA.
DNRI - DA, NA - smoking cessation
NRI - Na more for ADHD
NaSSA - ?
What are the different SSRIs and when are they used
Fluoxetine (prozac) first one invented. Safe in children
Sertraline (Zoloft) - in pregnancy, breast feeding, cardiac but decrease sexual function
Escitalopram - First line and good for polypharmacy and liver and renal problems. Good in mixed depressive and anxiety
Fluvoxamine - bad on liver as it inhibits enzymes that increase levels of other drugs and are very sedative
Paroxetine - Bad for liver and short fail life.
Discontinuation syndrome
Flu like symptoms Insomnia Nausea Imbalance - postures Sensory disturbances Hyperarousal Delirium Can occur in drugs with short half lives Rarely occurs in drugs with long half lives.
Side effect of antidepressant
Bleeding especially GIT - due to PLTs
Hyponatraemia (TCA, SSRI, SNRI, MAOIs
Psychomotor impairment and sedation - need to warm patient
Serotonin Toxicity - Triad of neuromuscular excitation (hyperreflexia, clonus, ocular clonus, myoclonus, shivering, Tremor, hypertonia or rigidity), Autonomic effects (hyperthermia, diaphoresis, flushing, mydriasis, tachycardia), and central nervous system (agitation, anxiety, confusion)
Medications that are SNRI and what they are good for
Good for adjunct to chronic pain, decrease motivation
Venlafaxine
Desvenlafaxine
Duloxetine
Medications that are DNRI and what they are used for
Bupropion - smoking cessation
NMS
40% fatality
Cause - due to treatment with a drug that interfere with the Dopamine transmission.
Drugs that cause it - Antipsychotic, antiemetic, antidepressant and lithium. Or after cessation of dopamine agonist.
Symptoms
F - Fever
A - Autonomic instilliblity
L - Leucocytosis
T - Tremor
E - Elevated transaminase and Creatine Kinase
R - Rigidity
Lab findings - Increase WCC, increase CPK, increase liver enzymes, plasma myoglobin, and myoglobinuria.
Tx - Stop meds, Clear CKmm with lots of fluid, IV Dantraline, Orally bromocriptine, Hydration and cooling, Monitoring CPK levels.
Supportive care
ECT
DVT prophylaxis
Antidepressants by length of half life
Short half life - Paroxetine, venlafaxine, desvenlafaxine
Long half life - Fluoxetine,
The different side effect profile of the antidepressant drugs
SSRI
Fluoxetine - Insomnia (2), Agitation (1), Sedation/insomnia(take in morning) (2), GI distress (2), Sexual dysfunction (3), Orthostatic hypotension and dizziness (2), Wt gain (1),
Citalopram - Less orthostatic hypotension/dizziness, QT lengthening.
Escitalopram - No agitation, less orthostatic hypotension and dizziness, less sedation, less sexual dysfunction, no wt gain.
Fluvoxamine - More GI distress, less orthostatic hypotension and dizziness.
Paroextine - HTN, more wt gain.
Sertraline - more GI distress.
SNRI
Desvenlafaxine - Agitation (1), GI distress(3), Insomnia (2), HTN (1), Orthostatic hypotension/dizziness (2), Sedation (2), Sexual dysfunction (1), wt gain (?)
Duloxetine - less GI distress, no HTN, much more sexual dysfunction, wt gain
Venlafaxine - Same.
QT lengthening - all of the especially in combination with antipsychotics. most potent is citalopram
Serotonine syndrome
Can be a medical emergency
Caused by serotonergic agents or drug interaction.
eg SSRI plus MAOI, L tryptophan or lithium
Symptoms in order
1 GI - Vomiting and diarrhoea
2 restlessness
3 extreme agitation, hyperreflexia, autonomic instability with possible rapid fluctuation in vital signs
4 myoclonus, seizure, hyperthermia, uncontrollable shivering, and rigidity.
5 Delirium, coma, status epilepticus, cardiovascular collapse and death.
S- shivering
H - Hyperreflexia
I - increase temp
V- vomiting and vital instability
E - Encephalopathy - agitation and coma
R - Restlessness, increase tone.
Treatment - stop drugs, supportive care - cyproheptadine (antihistamine),cooling blankets, chlorpromazine (sedation), benzodiazepine, mechanical ventilation and parlaying agents.
What do antipsychotic drugs involve
diminish positive symptoms such as hallucination, delusion, and thought disorders.
Decrease symptoms of excitement including hostility.
prevent relapse
Which drugs to used with acute psychotic symptoms
amisulpride, clozapine, olanzapine, risperidone
Prolactin sparing antipsychotic
Clozapine, quetiapine, Olanzapine
Difference between NMS, Serotonin syndrome
Identical features - Hypertension - Tachycardia - Tachypnoea - Hyperthermia - Hypersalivation - Diaphoresis - Coma Neuroleptic Malignant syndrome - Dopamine antagonists - Onset 1-3 days - Pallor - stupor, alert - Lead pipe rigidity in all muscles groups - Hyporeflexia - Normal pupils - Normal or decrease BS Serotonin syndrome - serotonergic agents - Onset less 12hrs - Flushing - agitation - Increase tone but not lead pipe - Hyperreflexia - Clonus - Dilated pupils - Hyperactive BS.
Initating SSRI
Start low and go slow
Start by taking 1/2 dose for 3 day then full dose
R/V 2-4 wk if no improvement
Don’t use with benso or alcohol.
