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Pharmacology Test #6 > Mood Disorder Pharmacology > Flashcards

Mood Disorder Pharmacology Flashcards

1
Q

Criteria for major depressive disorders

A
  1. Depressed mood for 2+ weeks
  2. Anhedonia
  3. Anxiety
  4. Disrupted sleep/appetite
  5. Cognitive deficits
  6. Loss of self-worth
  7. Suicidal thoughts
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2
Q

Co-morbid medical/psychiatric conditions with major depressive disorders

A

CAD, diabetes, stroke, chronic pain, drug abuse

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3
Q

Monoamine hypothesis

A

MDD caused by a deficiency in cortical/limbic 5HT, NE, DA

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4
Q

Two theories of depression that are non-mutually exclusive

A

the monoamine hypothesis and the neurotrophic hypothesis

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5
Q

Evidence for the monoamine hypothesis

A
  1. Reserprine (monoamine depleter) causes depression
  2. Dietary changes: patients treated with AD relapse when tryptophan is withdrawn from diet
  3. Genetics: SNPs in SERT associated with MDD
  4. 5HT, NE receptors are decreased in MDD patients
  5. 5HT/NE/DA agents work
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6
Q

Neurotrophic hypothesis

A

MDD is caused by loss of neurotrophic support and ADs restore neurogenesis and lost synaptic connectivity

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7
Q

Brain-derived neurotropic factor (BDNF) and neurons in a normal state

A

cell receives input from monoamine and BDNF stimulation, which supports neurotrophy and synaptic connectivity

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8
Q

BDNF and neurons in a depressed state

A

in part due to interference via glucocorticoids, BDNF is reduced and results in hypotrophy and loss of connectivity

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9
Q

BDNF and neurons in a treated state

A

monoamines result in increased CREB expression and results in resumption of normal BDNF secretion, re-gained connectivity

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10
Q

BDNF is critical for

A

neurotrophic support and required for the action of ADs

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11
Q

Evidence for the neurotrophic hypothesis:

A
  1. BDNF changes in MDD: stress/pain reduces BDNF, causing structural changes in hippocampus similar to that seen in MDD
  2. BDNF has AD properties: direct infusion of BDNF in rodent has AD effect
  3. ADs cause increased BDNF/neurogenesis
  4. Human MDD and BDNF: MDD associated with drop in BDNF
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12
Q

Why do antidepressants exhibit a delayed onset of several weeks compared to when their biochemical effects are thought to occur?

A

Time for monoamines to changes synthesis of BDNF, time for restored synaptic connectivity, and time for changes to occur such as up-or down-resgulation in signal transduction machinery

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13
Q

Antidepressant drug classes:

A
  1. SSRIs
  2. SNRIs (Serotonin-NE Reuptake Inhibitors)
  3. 5-HT2 Antagonists
  4. Tetracyclic/Unicyclic antidepressants
  5. MAOIs
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14
Q

SSRIs

A
  1. Fluoxetine (Proxac)
  2. Paroxetine (Paxil)
  3. Fluvoxamine (Luvox)
  4. Sertraline (Zoloft)
  5. Citalopram (Celexa)
  6. Escitalopram (Lexapro)
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15
Q

Which SSRIs inhibit P450s?

A
  1. Fluoxetine (Proxac)
  2. Paroxetine (Paxil)
  3. Fluvoxamine (Luvox)
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16
Q

What are SSRIs selective for?

A

more selective for SERT over NET

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17
Q

First choice for treatment of MDD due to safety and efficacy considerations

A

SSRIs

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18
Q

SSRIs Indications

A

MDD; Anxiety disorders; Premenopausal Dysphoric disorder; Eating disorders (bulimia only)

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19
Q

GAD

A

generalized, free-floating anxiety/undue worry

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20
Q

OCD

A

chronic anxiety-provoking thoughts (obsessions) and temporary anxiolytic actions (compulsions) taken to alleviate the anxiogenic thoughts

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21
Q

PTSD

A

anxious thoughts, hypervigilance from a traumatic event

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22
Q

Adverse effects of SSRIs

A
  1. Sexual dysfunciton
  2. Weight gain/loss
  3. Serotonin syndrome
  4. Adolescent suicide
  5. Withdrawal sndrome
  6. Effects on newborns
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23
Q

SSRI withdrawal

A

dizziness, paresthesias

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24
Q

Effects on newborns when mothers are on SSRIs

A

persistent pulmonary HTN (serious, fatal sometimes); withdrawal signs in infants; congenital malformations

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25
Newer SNRIs
1. Duloxetine (Cymbalta) 2. Venlafaxine (Effexor) 3. Desvenlafaxine (Pristiq)
26
Two classes of SNRIs
the older TCAs and a newer group of pure re-uptake inhibitors that hit NET with high affinity
27
Tricyclic Antidepressants (TCA)
1. Amitriptyline (many receptors hit) 2. Nortriptyline (secondary amine) 3. Imipramine (anticholinergic) 4. Desipramine (metabolite of imipramine) 5. Clomipramine
28
Clinical use of TCAs
Used only in refractory MDD (not responsive to SSRIs)
29
Indications of SNRIs
Refractory MDD; anxiety disorders; pain (diabetic neuropathy, fibromyalgia); enuresis (bed wetting); insomnia
30
Adverse effects of SNRIs (most apply to the TCAs)
1. Cardiotoxicity 2. Sexual dysfunction 3. Weight loss 4. Serotonin syndrome (TCA and MAOI co-admin) 5. Suicidal thoughts 6. Withdrawal syndrome 7. Sedation
31
Cardiotoxicity from SNRIs
derives from the ability to block voltage gated sodium channels in the heart, plus the anticholinergic properties as well; high BP, ventricular arrhythmias
32
5HT2 Antagonist
Trazodone
33
Patients on trazodone should avoid
grapefruit juice as it blocks CYP3A4, the same CYP that metabolizes trazodone
34
Bupropion
unicyclic antidepressant; DA and NE reuptake inhibitor; no 5HT systemo activity; nAchR antagonist activity
35
Adverse effects of Buproprion
few sexual side effects, some insomnia, anorexia, agitation, seizures
36
Use of Buproprion
AD, mood enhancer, smoking cessation
37
Mirtazapine
tetracyclic antidepressant; mixed antagonist or inverse agonist activity at 5HT, alphaAR, histamine, mACh, DA, NET, DAT, and SERT; stimulates release of NE and 5HT yet blocks 5HT receptors
38
Adverse effects of Mirtazapine
few sexual, sedative (histamine), low cardio risk
39
Use of Mirtazapine
refractory MDD, other mood disorders
40
Monoamine Oxidase Inhibitors
1. Selegiline (MAO-b, irreversible) 2. Tranylcypromine (non-selective, irreversible) 3. Phenelzine (non-selective, irreversible)
41
MAO Type A
found in monoamine-expressing neurins in the CNS
42
MAO Type B
found in DA neurons and in cells that need to break down phylethylamine and other trace amines
43
When would you use MAOIs
used in cases of refractory MDD
44
Adverse effects of MAOIs
orthostatic hypotension, sexual dysfunction, and CNS stimulant-like properties
45
TCA overdose
mainly a cardiovascular event, such as arrhythmia and BP changes, but also includes CNS activation, anticholinergic effects and seizures
46
TCA overdose treatment
usually directed toward the cardiovascular symptoms
47
MAOI overdose
characterized by a hyperadrenergic state, including psychosis, confusion, fever and seizures
48
MAOI overdose treatment
cardiac monitoring, HCO3
49
5HT syndrome
A poisoning due to overstimulation of 5HT receptors - not an idiosyncratic drug reaction; likely in central gray nuclei/medulla in brain stem, likely 5HT2A
50
Severe side effects of 5HT syndrome
delirium, coma, hypertension, tachycardia, diaphoreses, clonus, hyperreflexia, tremor, akathisia (agitation, restlessness)
51
How do you prevent serotonin syndrome?
stop other ADs 2-4 weeks prior to starting MAOI (fluoxetine in particular); stop MAOI at least 2 weeks prior to starting/switching to SSRI (or other 5HT agent)
52
What is the Tyramine Effect
MAOI prevents tyramine breakdown in the gut; tyramine builds up in the serum and acts as a peripheral only catecholamine releasing agent; noradrenergic effects are enhanced
53
What is a bad combination with non-selective MAOIs
Tyramine-rick foods (meat, cheese, dairy, many others)
54
Result of the Tyramine Effect
malignant hypertension, stroke, MIs
55
Prevention of the Tyramine Effect
low-tyramine diet, use MAO-B inhibitor, use reversible MAOIs, avoid other sympathomimetics (pseudoephedrine, phenylpropanolamine) combined with MAOIs
56
Herbal Antidepressants
St. John's Wort (Hypericum perforatum plant)
57
MOA of St. John's Wort
monoamine reuptake block though some uncertainty exists
58
Defining feature of bipolar disorder
Mania
59
Symptoms of mania
hyperactivity, impulsive, disinhibition, aggression, less sleep, psychosis, cognitive impairment
60
Bipolar I
extreme manic episodes; depressive episodes; recurring; rapid cycling (>4 per year); more severe
61
Bipolar II
hypomanic episodes; depressive episodes often dominant; some functionality during hypomania; less severe
62
Drug classes for Bipolar Disorder
Lithium carbonate Atypical antipsychotics Antiepileptics Benzodiazepines
63
First-choice drug for bipolar
Lithium carbonate
64
Atypical antipsychotics
Aripiprazole, olanzapine, paliperidone, quetiapine, risperidone, ziprasidone, (clozapine)
65
Antiepileptics
Carbamazepine, valproate, (levetiracetam, primidone, zonisamide)
66
MOA for lithium
largely unknown and highly speculative; may be inositol depletion which may alter signaling systems or change plasticity; may be from inhibition of GSK-3
67
What must you monitor with lithium
1. plasma lithium levels 2. Diuretic usage 3. Sodium in diet should be consistent 4. Exercise
68
Why must you follow diuretic usage with lithium
diuretics can reduce the clearance of lithium, which would require the dose of lithium to be lowered
69
Hallmark feature of lithium side effects
tremor which can be treated with a beta blocker
70
Side effects of lithium
tremor, low thyroid fxn, edema, arrhythmias
71
Lithium overdose
cognitive disturbances, GI issues, ataxia, nystagmus, slurred speech, muscle spasms
72
What has replaced lithium in chronic treatment of bipolar
anticonvulsants
73
What are antipsychotics/benzodiazepines used for
severe mania
74
1st line maintenance therapy for bipolar disorder
Lithium (plus benzo in severe); Lamotrigine; Risperidone
75
2nd line maintenance therapy for bipolar disorder
aripiprazole, quetiapine, olanzapine; and valproate
76
Other options for maintenance therapy for bipolar disorder
carbamazepine, combination therapy

Pharmacology Test #6 (12 decks)

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