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competency 10/11 > neuro: depression > Flashcards

neuro: depression Flashcards

1
Q

TCA egs and moa

A

amitriptyline -> nortriptyline
imipramine -> desipramine
dothiepin
clomipramine

block reuptake of NE and 5HT + anticholinergic + H1 and a-adrenergic antagonism

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2
Q

TCA side effects

A

GI and sexual dysfunction
anticholinergic, sedation, orthostatic hypoTN, arrhythmias, seizure
FATAL on overdose

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3
Q

clomipramine indicated for

A

OCD

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4
Q

SSRI eg and moa

A

fluoxetine -> norfluoxetine
fluvoxamine
escitalopram/citalopram
sertraline
paroxetine

blocks reuptake of 5HT selectively

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5
Q

SSRI adr

A

gi and sexual dysfunction
headache, transient nervousness during initiation
hyponatremia (SIADH)
bleeding risk

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6
Q

escitalopram/citalopram

A

qtc prolongation, esp in elderly women at high doses

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7
Q

paroxetine

A

most anticholinergic, sedating, incr weight, t1/2 short

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8
Q

fluvoxamine dosing

A

on, sedating

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9
Q

fluoxetine

A

OM: alerting
t1/2 long 4-6d, then 4-16d for norfluoxetine

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10
Q

SNRI egs and moa

A

venlafaxine -> desvenlafaxine
duloxetine

blocks reuptake of NE and 5-HT

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11
Q

SNRI moa

A

(same as SSRI)
gi and sexual dysfunction
headache, transient nervousness during initiation
hyponatremia (SIADH)
bleeding risk

  • venlafaxine: incr bp!!!!
  • duloxetine: urinary hesitation
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12
Q

duloxetine indicated for

A

diabetic peripheral neuropathy, fibromyalgia, chronic musculoskeletal pain

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13
Q

SMS

A

serotonin modulator and stimulator

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14
Q

SMS egs and moa

A

vortioxetine

altering the activity of various post-synaptic serotonin (5-HT) receptors, in addition to inhibiting the reuptake of serotonin via the same mechanism as selective serotonin reuptake inhibitors (SSRIs)
- vortioxetine is also a 5HT1a agonist

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15
Q

SMS adr

A

gi and sexual dysfunction
headache, transient nervousness during initiation
low Na levels (SIADH)
bleeding risk

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16
Q

NaSSA

A

Noradrenergic and specific serotonergic antidepressants

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17
Q

NaSSA eg and moa

A

mirtazapine

a2-adrenergic antagonist, incr 5HT and NE, 5HT2&3 + H1 antagonism

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18
Q

NaSSA adr

A

somnolence, incr appetitie, weight gain

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19
Q

NaSSA is able to ____________________ of SSRI/SNRI

A

reverse SI and sexual SE

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20
Q

NDRI

A

norepinephrine–dopamine reuptake inhibitor

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21
Q

NDRI egs and moa

A

bupropion

blocks reuptake of NE and DA

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22
Q

NDRI adr

A

seizure, insomnia, psychosis

not suitable for eating disorder

decr sexual SE of SSRI/SNRI

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23
Q

bupropion also used for

A

smoking cessation aid

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24
Q

MAOI

A

moclobemide: reversible MOAI-B

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25
Q

trazadone

A

blocks reuptake of 5HT
antagonises 5HT2A,H1 and a1-adrenoceptor

used for insomnia than depression
same adr as ssri + sedation _ orthostatic hypoTN + rare SE: priapism

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26
Q

agomelatine

A

MT-1, MT-2 agonist
5HT2c antagonist

adr: GI, incr LFTs (check at baseline at week 3,6,12,24)

c/i: fluvoxamine, ciprofloxacin

27
Q

for all antidepressants, what is a transient side effect?

A

jittery (sudden release of neurotransmitter at synapse)
- to start at a lower dose for pt w anxiety issue

28
Q

for all SSRI, what is a SE to take note for

A

hyponatremia (particularly common and bad in the elderly - check renal panel at baseline, 2 weeks, 4 weeks, 3 months)
> SIADH: cramps, muscle twitching, confusion, seizures

29
Q

BZD moa

A

potentiates GABA
- anxiolytic
- hypnotic
- muscle relaxant
- anticonvulsant
- amnesia

30
Q

BZD side effects

A

sedation, drowsiness
muscle weakness, ataxia, amnesia
less commonly: slurred speech, vertigo, headache, confusion

31
Q

how to minimise risk for dependence of BZD?

A

limit to 2 weeks PRN, short course therapy, at lowest effective dose

32
Q

Z-hypnotics

A

zolpiclone (Imovane 7.5) - hypnotic + anxiolytic

zolpidem (Stilnox 6.25) - hypnotic only

preferentially binds to bzd-binding sites with y and a1 subunits, causes sedation

33
Q

z-hypnotics adr

A

n/v, dizziness, drowsiness, dry mouth, headache
rarely: amnesia, confusion, hallucinations, nightmares, complex sleep-walking behaviours

zolpiclone: taste disturbance

34
Q

antihistamine

A

H1 antagonism

adr: sedation, anticholinergic (dry mouth, constupation)

35
Q

SGA

A

second gen antipsychotics
5HT2a antagonishm, 5HT1a partial agonism

aripiprazole/brexpiprazole: EPSE
quetiapine, olanzapine: metabolic SE

36
Q

Spravato nasal spray

A

Esketamine, NMDA receptor antagonist

adr: dissociation, dizziness, nausea, sedation, anxiety, incr BP

37
Q

first line antidepressant

A

monotherapy: SSRI, SNRI, mirtazapine, bupropion

38
Q

switch to alt antidepressant when

A

ineffective or intolerable to adequate dose in 1-4wks

39
Q

if cross-titration, watch for

A

serotonin syndrome, if combining serotonergic agents

40
Q

if direct switch

A

one SSRI can be stopped totally and the next serotonergic agent initiated

41
Q

If switching from a Serotonergic antidepressant used daily for the past 2 months to a Nonserotoninergic
agent (e.g. switching from SSRI/SNRI 􀁯 to Bupropion),

A

gradual cross-tapering
over several weeks can reduce risk of Antidepressant Discontinuation Syndrome

42
Q

washout period required for MAOIs

A

􀂱 If switching from Moclobemide to another antidepressant: 24 hour washout.
􀂱 If switching from another antidepressant

43
Q

approaches to manage partial/no response

A

switching, augmentation, treatment-resistant depression

44
Q

treatment-resistant depression

A

Symbyax oral capsule: olanzapine 6mg + fluoxetine 25mg per cap
Spravato Nasal Spray (Esketamine 28mg per vial), as an adjunct to ssri/snri treatment

45
Q

breastfeeding

A

may consider sertraline or mirazapine

46
Q

elderly

A

avoid TCAs and anticholinergic, CNS, hypotensive or other SE

47
Q

post-MI depression

A

may consider sertraline

48
Q

hepatic impairment

A

avoid agomelatine
if mild-moderate: consider vortioxetine

49
Q

renal impairment

A

may consider vortioxetine

50
Q

bipolar depression

A

lithium, lamotrigine, lurasidone, quetiapine

51
Q

pregnancy

A

may consider nortriptyline in late pregnancy

52
Q

antidepressant with fewer CYP interactions

A

mirtazapine, escitalopram, venlafaxine, desvenlafaxine, vortioxetine

53
Q

serotonin syndrome

A

acute onset: within 6-8hrs
causes: concomittant rx of high-dose serotonergic meds (eg. triptans, sibutramine, opioids, dextromethorphan, linezolid, ritonavir)

mild: insomnia, anxiety nausea, diarrhea, HTN, tachycardia, hyper-reflexia
moderate: agitation, myoclonus, tremor, mydriasis, flushing, diaphoresis, low fever<38.5
severe: severe hyperthermia, confusion, rigidity, resp failure, coma, death

54
Q

SSRIs: incr risk of bleeding by at least 1-2 folds

A

higher risk in elderly on NSAID, warfarin, steroids
- consider adding PPI
- consider stopping serotonergic antidepressant 2 weeks before surgery if high bleeding risk
- agomelatine safest

55
Q

BZD + opioids

A

incr mortality, cns depression
- avoid combi if possible, or limit doeses and duration

56
Q

antidepressant discontinuation syndrome

A

worse with abrupt discontinuation of long-term regular therapy
- esp w short t1/2 antidepressants: paroxetine, venlafaxine
- onset: 36-72hrs
- duration: 3-7 days but typically resolves over 1-2 weeks without treatmentd

FINISH
- flu-like sx: fatigue, muscle aches, headache
- insomina
- nausea
- imbalance: dizziness
- sensory: electric shock sensations, paresthesia
- hyperarousal: anxiety, agitation

57
Q

if you need to stop a long-term antidepressant therapy after daily tx >= 8 weeks

A

recommend to gradually taper over at least 4 weeks
- fluoxetine, bupropion: generally unnecessary because of their v long t1/2
- for the rest, taper by 25% every 1-2 weeks, or as gradually as clinically indicated

58
Q

bzd: gradual discontinuation of long-term. high-dose use

A

decr dose by 25% weekly until reaching 50% dose, thenr educe 1/8 every 4-7 days, or as gradually as clinically indicated

59
Q

space alc how long apart from antidepressants

A

4-6hrs

60
Q

antidepressants w less sexual dysfunction side effect

A

mirtazapine, bupropion, agomelatine

61
Q

antidepressants order

A

SSRI, SNRI, NaSSA > bupropion > agomelatine, vortioxetine > TCA > MAOIs

62
Q

mirtazapine may be beneficial for

A

insomnia and poor appetite: can cause sedation and weight gain

63
Q

bupropion not suitable for

A

h/o seizures, psychosis or eating disorder

64
Q
A

competency 10/11 (31 decks)

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