Mood disorders- PHARM- Exam 2 Flashcards by Johannah Crumpton

_____ Naturally occurs in the body; may raise dopamine levels
Can be used as an adjunctive option for mild to moderate.

S-Adenosylmethionine (SAMe)

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S-Adenosylmethionine (SAMe) may trigger ____

manic episodes

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____ Natural precursor to serotonin. What are the SE?

5-Hydroxytryptophan (5-HTP)

GI upset, serotonin syndrome, eosinophilic myalgia syndrome

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_____ works better if combined with antidepressant, may increase risk of bleeding

Omega-3 Fatty Acids

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_____ increases serotonin, and possibly norepinephrine and dopamine levels

St. Johns Wort

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What are the SE of St. John’s Wort? Why do prescribers tend to dislike it?

GI upset, serotonin syndrome, photosensitivity

LOTS of drug-drug interactions

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_____ may help with depression but risk of GI upset, mania, bleeding; can be fatal at high doses

Saffron

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____ Improved mood in pts being treated for memory loss; may increase sensitivity to serotonin, may increase risk of bleeding

Ginkgo biloba

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**What are the prescribing guidelines for oral antidepressants?

-Start low and go slow : titrate dose over 7-10 days

-trial of at least 4 weeks (usually 4-6 weeks)

-Rx should be continued for 6+ months after s/s improvement

-Gradual down titration is recommended when discontinuing antidepressants

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**When can pts start to see an improvement once starting oral antidepressants?

Patients may see improvement as early as week 1, but it generally takes 4-6 weeks to see a response

May consider treatment modification if <25% improvement in baseline s/s after 4-6 weeks

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What are the 3 classes of antidepressants that fall under the first generation?

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What are the 5 classes of antidepressants that fall under the second generation?

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______ selectively decreases the action of 5-HT reuptake pump, leading to increased serotonin levels in the synapse

SSRI

often takes several weeks to see the benefit

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What are the drugs that fall into the SSRI category?

Sertraline (Zoloft)
Citalopram (Celexa)
Escitalopram (Lexapro)
Fluoxetine (Prozac)
Paroxetine (Paxil)
Fluvoxamine (Luvox)

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When are SSRIs usually dosed? What is the 1/2 life?

Typically QAM (½ life approx. 24 hrs.)

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SSRIs are metabolized in the ____

liver

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**If your pt is on a SSRI and want to change to MAOI, how long do you need to wait?

2 weeks

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**If your patient is on Fluoxetine and you want to start an MAOI, how long do you need to wait?

5 weeks

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What are some common SE of SSRIs? What are the two major ones?

nausea, diarrhea, anorexia

insomnia or hypersomnia

headache, dizziness

↓libido, anorgasmia, ED

anxiety, ↑ risk of suicide**

prolonged QT, weight gain, bleeding, orthostatic hypotension, serotonin syndrome**

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When does Serotonin syndrome typically occur?

within 24 hours (often within 6 hours) of starting/changing a medication or overdosing

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What are some s/s of serotonin syndrome?

Diarrhea, increased bowel sounds, agitation, hyperreflexia, dry mucous membranes, autonomic instability, hyperthermia, HTN, tremor, clonus, seizure, death

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True/False: If you are concerned about serotonin syndrome you can order a 5-HT level test

FALSE, 5-HT levels do not correspond

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What is the treatment for serotonin syndrome?

Supportive care
D/C serotonergic medications
Sedation with benzodiazepines
Normalize vitals and hydration status

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_____ is more likely to cause GI upset than others in the class, esp. diarrhea

Sertraline (Zoloft)

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_____ has a slightly higher chance of insomnia so should be dosed in the morning

Sertraline (Zoloft)

_____ is most associated with prolonged QT and palpitations and has minimal SE profile otherwise

Citalopram (Celexa) Escitalopram (Lexapro)

SSRI ____ has the least inhibition of hepatic cytochrome enzymes

Citalopram (Celexa) Escitalopram (Lexapro)

_____ is a good choice for alcoholics

Citalopram (Celexa) Escitalopram (Lexapro)

_____ is a bad choice for patients with heart problems

Citalopram (Celexa) Escitalopram (Lexapro)

_____ has the shortest 1/2 life and frequently causes somnolence and should be taken at bedtime SSRI

Fluvoxamine (Luvox)

SSRI _____ and ____ are a potent inhibitor of 2 cytochrome systems, potential for DDIs

Fluvoxamine (Luvox) Paroxetine (Paxil)

____ longest half-life of any in the class (up to 3 days)

Fluoxetine (Prozac)

_____ was the first SSRI on the market

Fluoxetine (Prozac)

_____ has a slightly higher risk of insomnia SE and can increase anxiety

Fluoxetine (Prozac)

Which two drugs should not be written with Tamoxifen?

Fluoxetine (Prozac) and Paroxetine (Paxil)

SSRI _____ causes anticholinergic SE, unlike others in the class

Paroxetine (Paxil)

_____ slightly higher risk of orthostatic hypotension, weight gain, & sexual dysfunction than other SSRIs

Paroxetine (Paxil)

_____ are used for tx of other disorders, including anxiety disorders, fibromyalgia, neuropathy, menopausal s/s

SNRIs

_____ blocks reuptake of 5-HT and norepinephrine (NE), increasing their levels in the synapse

SNRIs

Which two SNRI has a greater effect on the NE?

Savella and Fetzima

Which SNRIs have a greater effect on 5-HT?

Venlafaxine (Effexor) Desvenlafaxine (Pristiq) Duloxetine (Cymbalta)

What are the 5 SNRIs?

Venlafaxine (Effexor) Desvenlafaxine (Pristiq) Duloxetine (Cymbalta) Milnacipran (Savella) Levomilnacipran (Fetzima)

____ are cleared through the kidneys and liver

SNRIs

What are the CI to SNRIs?

-use within 2 weeks of an MAOI -Caution if using with other serotonergic drugs -Caution if angle closure glaucoma

(SSRIs/SNRIs) are more associated with weight gain

SSRIs

What are some common SE of SNRIs?

N/V/D, constipation, dry mouth insomnia or hypersomnia HA, dizziness anorgasmia, ED *may be less than SSRIs* anxiety, ↑ risk of suicide** diaphoresis, hypertension, serotonin syndrome

The sexual dysfunction side effects are more severe with SSRIs or SNRIs?

SSRIs

_____ has a higher risk of SE than other SNRIs More N/V than SSRIs as a class

Venlafaxine (Effexor)

_____ is the SNRI most associated with an elevated BP

Venlafaxine (Effexor)

____ is the synthetic form of the major metabolite of venlafaxine Less risk of HTN, general SE than venlafaxine

Desvenlafaxine (Pristiq)

____ is the only SNRI with hepatic cytochrome inhibition → most likely to have DDIs

Duloxetine (Cymbalta)

____ least associated with elevated BP and has an indication for chronic pain relief

Duloxetine (Cymbalta)

_____ or ____ is the most likely SNRIs to have pseudo-anticholinergic SE Urinary retention, constipation, dry mouth, etc.

Milnacipran (Savella) Levomilnacipran (Fetzima)

_____ is marketed as more for pain relief than for depression

Savella

What drug class is often used as second-line therapy if pts fail SSRIs; may be first-line in special cases

Atypical Antidepressants

What two drugs are considered atypical antidepressants?

Bupropion (Wellbutrin; Zyban) Mirtazapine (Remeron)

_____ acts as a dopamine-norepinephrine reuptake inhibitor

Bupropion

____ MOA also antagonizes nicotinic receptors, and is sometimes used to help people quit smoking

Bupropion (Wellbutrin; Zyban)

_____ antagonizes alpha-2 adrenergic receptors and 5-HT2 and 5-HT3 receptors, which causes increased release of serotonin and norepinephrine

Mirtazapine (Remeron)

What are the SE of Bupropion (Wellbutrin)? What is the major one?

Dry mouth, insomnia, nausea, risk of suicidal thoughts/ideation **increased risk of seizures Not associated with weight gain or sexual dysfunction

Atypical _____ does have hepatic cytochrome enzyme inhibition, so can cause DDIs

Bupropion (Wellbutrin)

What are the CI of Bupropion (Wellbutrin)? What are the two major ones?

seizure disorder **high seizure risk **anorexia or bulimia hx use within 2 weeks of an MAOI

What are the SE of Mirtazapine (Remeron)?

Dry mouth, *drowsiness, sedation, increased appetite, *weight gain, sexual dysfunction, risk of suicidal thoughts/ideation

_____ has more risk of weight gain than SSRIs, SNRIs and may have less sexual dysfunction than SSRIs

Mirtazapine (Remeron)

____ has a lower risk of orthostatic hypotension than other antidepressants

Mirtazapine (Remeron)

____ is helpful in patients with depressive symptoms who also are suffering from insomnia

Mirtazapine (Remeron)

____ are often used as second-line therapy for patients who cannot tolerate SSRIs; may be first-line therapy

Serotonin Modulators

_____ and ____ all block reuptake of 5-HT, also antagonize 5-HT receptors, causing increased release of serotonin

Nefazodone and trazodone

____ and _____ all block reuptake of 5-HT, also partial agonist of 5-HT receptors, mimicking serotonergic effects

Vilazodone and vortioxetine

What are the 4 serotonin modulators?

Nefazodone (Serzone) Trazodone (Desyrel) Vilazodone (Viibryd) Vortioxetine (Brintellix/Trintellix)

______ causes liver toxicity and not available anymore

Nefazodone (Serzone)

What are the SE of serotonin modulators?

Headache, diarrhea, nausea are common Increased suicide risk Serotonin syndrome risk

_____ hepatic cytochrome enzyme inhibition - most DDI risk among 5HT modulators

Nefazodone (Serzone)

What is the BBW for Nefazodone (Serzone)?

hepatotoxicity CI in patients with hx of liver disease, and elevated liver enzymes

What are the SE of Nefazodone (Serzone)?

headache, agitation, dizziness, drowsiness or insomnia, xerostomia, hypotension Not associated with sexual side effects Less GI upset and weight gain than SSRIs

What are the SE of Trazodone?

sedation, nausea, dry mouth, fatigue, constipation, sexual dysfunction

What are the rare SE of Trazodone?

priapism, cardiac arrhythmias

Does Trazodone have (more/less) sexual dysfunction that SSRIs and SNRIs

less sexual side effects

What are the SE of Vilazodone (Viibryd)?

headache, diarrhea, nausea, sexual dysfunction

Vilazodone (Viibryd) and Vortioxetine (Trintellix) may have a (faster/slower) onset and (more/less) sexual dysfuntion than SSRI and SNRIs

faster onset less sexual dysfunction

What are the SE of Vortioxetine (Trintellix)?

dizziness, N/V/D/C, sexual dysfunction

Ketamine/Esketamine is newly approved to treat severe, refractory depression without ____

psychosis

(Ketamine/Esketamine) is usually given in IV formulation (Ketamine/Esketamine) is given in a nasal spray

Ketamine Esketamine

Ketamine/Esketamine may have _____ in the long term setting and can cause _____ effects

neurotoxicity psychotomimetic

_____ opioid and AMPA (glutamate) agonist, NMDA antagonist

Ketamine/Esketamine

May see fewer psychotomimetic effects with (Ketamine/Esketamine)

Esketamine

_____ contraindications are aneurysmal disease or AV malformation; hx of ICH; inability to tolerate increase in BP

Ketamine/Esketamine

____ breaks down serotonin and norepinephrine

MAOa

_____ works with MAOa to break down dopamine

MOAb

**_____ have extensive side effects, DDIs, and dietary restrictions. Usually only for treatment-resistant or atypical depression

MOAIs

_____ used at low doses for Parkinson’s

Selegiline

What are the drugs in the MAOIs?

Tranylcypromine (Parnate) Phenelzine (Nardil) Isocarboxazid (Marplan) Selegiline (Eldepryl); available orally or transdermal

_____ CIs are cardiovascular disease; pheochromocytoma; hepatic or renal impairment

MAOIs

______ SE are hypotension, GI upset, urinary hesitancy, headache, myoclonic jerks, edema, suicidal ideation

MAOIs

**_____ run the risk of hypertensive crisis when consuming foods with tyramine

MAOIs

_____ Used as second-line treatment for depression due to side effects. Also treat anxiety disorder, pain disorders such as neuropathy and headaches. Low doses usually work well

TCAs: Tricyclic Antidepressants

_____ MOA inhibits reuptake of 5-HT and norepinephrine (NE)

TCAs

(Tertiary/Secondary) Amines: are more potent in blocking 5-HT reuptake than NE reuptake

tertiary amines

(Tertiary/Secondary) Amines: are more potent in blocking NE reuptake than 5-HT reuptake

secondary amines

What are the tertiary amines?

Amitriptyline (Elavil)** Doxepin (Silenor)** Imipramine (Tofranil), Clomipramine (Anafranil), Trimipramine (Surmontil)

What are the secondary amines?

**Nortriptyline (Pamelor) - metabolite of amitriptyline **Desipramine (Norpramin) - metabolite of imipramine Protriptyline (Vivactil)

_____ patients may respond to very low doses

TCAs

_____ should not be used within 2 weeks of an MAOI; use in acute recovery phase of an MI

TCAs

______ SEs are anticholinergic; drowsiness; sexual dysfunction; diaphoresis; tremor; weight gain; increased appetite

TCAs

**_____ medication class is at risk of cardiotoxicity (prolonged QT) and high potential for fatality in overdoses

TCAs

When are TeCAs typically used?

refractory or atypical depression

How are TCAs and TeCAs different?

TeCAs have an extra ring when compared to TCAs

What drugs are included in the TeCAs?

Maprotiline (Ludiomil) Amoxapine (Asendin)

_____ MOA blocks reuptake of NE and 5-HT (more potent for 5-HT)

Maprotiline (Ludiomil)

_____ MOA blocks reuptake of NE; blocks dopamine receptors (antipsychotic). Sometimes classified as secondary amine TCA

Amoxapine (Asendin)

TCAs vs TeCAs: TeCAs have (more/less) anticholinergic SE and (more/less) antihistamine-like SE than TCAs. Still have risk for suicidal ideation

less anticholinergic SE but more antihistamine SE

_____ often used in bipolar; may also be helpful for unipolar depression. Why are people hesitant to prescribe it?

lithium Numerous side effects, risk for toxicity Not as efficacious as antidepressant drugs

____ are typically used as an add-on to antidepressants. Name some drugs in the class?

Antipsychotics Aripiprazole (Abilify) brexpiprazole (Rexulti) quetiapine (Seroquel) Symbyax (fluoxetine + olanzapine)