Mood disorders- PHARM- Exam 2 Flashcards
_____ Naturally occurs in the body; may raise dopamine levels
Can be used as an adjunctive option for mild to moderate.
S-Adenosylmethionine (SAMe)
S-Adenosylmethionine (SAMe) may trigger ____
manic episodes
____ Natural precursor to serotonin. What are the SE?
5-Hydroxytryptophan (5-HTP)
GI upset, serotonin syndrome, eosinophilic myalgia syndrome
_____ works better if combined with antidepressant, may increase risk of bleeding
Omega-3 Fatty Acids
_____ increases serotonin, and possibly norepinephrine and dopamine levels
St. Johns Wort
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
_____ may help with depression but risk of GI upset, mania, bleeding; can be fatal at high doses
Saffron
____ Improved mood in pts being treated for memory loss; may increase sensitivity to serotonin, may increase risk of bleeding
Ginkgo biloba
**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
**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
What are the 3 classes of antidepressants that fall under the first generation?
What are the 5 classes of antidepressants that fall under the second generation?
______ 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
What are the drugs that fall into the SSRI category?
Sertraline (Zoloft)
Citalopram (Celexa)
Escitalopram (Lexapro)
Fluoxetine (Prozac)
Paroxetine (Paxil)
Fluvoxamine (Luvox)
When are SSRIs usually dosed? What is the 1/2 life?
Typically QAM (½ life approx. 24 hrs.)
SSRIs are metabolized in the ____
liver
**If your pt is on a SSRI and want to change to MAOI, how long do you need to wait?
2 weeks
**If your patient is on Fluoxetine and you want to start an MAOI, how long do you need to wait?
5 weeks
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**
When does Serotonin syndrome typically occur?
within 24 hours (often within 6 hours) of starting/changing a medication or overdosing
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
True/False: If you are concerned about serotonin syndrome you can order a 5-HT level test
FALSE, 5-HT levels do not correspond
What is the treatment for serotonin syndrome?
Supportive care
D/C serotonergic medications
Sedation with benzodiazepines
Normalize vitals and hydration status
_____ is more likely to cause GI upset than others in the class, esp. diarrhea
Sertraline (Zoloft)
_____ 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)
