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BNF/Pre-Reg 2017-2018 U > NS: Antidepressant drugs > Flashcards

NS: Antidepressant drugs Flashcards

1
Q

Which are the antidepressants of choice?

A

SSRIs are better tolerated and are safer in overdose than other classes of antidepressants and should be considered first-line for treating depression.

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2
Q

What antidepressant can be used in patients with unstable angina or recent MI?

A

Sertraline

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3
Q

Tricyclic antidepressants have similar efficacy to SSRI’s but more what?

A

side effects, more likely for treatment to be discontinued due to side effects than SSRIs

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4
Q

What benefits do SSRIs have over TCAs?

A

Tricyclic antidepressants have similar efficacy to SSRIs but are more likely to be discontinued because of side-effects; toxicity in overdosage is also a problem. SSRIs are less sedating and have fewer antimuscarinic and cardiotoxic effects than tricyclic antidepressants.

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5
Q

Why should MAOIs be reserved for use by specialists?

A

MAOIs have dangerous interactions with some foods and drugs, and should be reserved for use by specialists.

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6
Q

How frequently should patients be reviewed at the start of antidepressant treatment?

A

1-2 weeks.

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7
Q

Treatment should be continued for at least how long with antidepressants before considering whether to switch antidepressant due to lack of efficacy?

A

4 weeks (6 weeks in the elderly)

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8
Q

In cases of a partial response to antidepressant treatment, how long should treatment be continued for before completely ruling it out?

A

a further 2-4 weeks (elderly patients may take longer to reply)

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9
Q

Following remission, antidepressant treatment should be continued at the same dose for at least how long?

A

6 months (about 12 months in the elderly), or at least 12 months in patients receiving treatment for generalised anxiety disorder (as the likelihood of relapse is high).

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10
Q

Following remission, how long should patients with a history of recurrent depression receive maintenance treatment?

A

At least 2 years.

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11
Q

Hyponatraemia (usually in the elderly and possibly due to inappropriate secretion of antidiuretic hormone) has been associated with all types of antidepressants, what type most frequent?

A

SSRIs.
Hyponatraemia should be considered in all patients who develop drowsiness, confusion, or convulsions while taking an antidepressant.

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12
Q

What are the symptoms of hyponatraemia? (3)

A

Drowsiness
Confusion
Convulsions

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13
Q

Severe serotonin syndrome toxicity is a medical emergency which usually occurs with a combination of serotonergic drugs, one of which is generally what?

A

An MAOI.

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14
Q

The characteristic symptoms of serotonin syndrome fall into 3 main areas. What are these?

A

Neuromuscular hyperactivity: tremor, hyperreflexia, clonus, myoclonus, rigidity.

Autonomic dysfunction: tachycardia, blood pressure changes, hyperthermia, diaphoresis, shivering, diarrhoea.

Altered mental state: agitation, confusion, mania.

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15
Q

Failure to respond to initial treatment with an SSRI can be treated how? (3)

A

Increase the dose
Switch to a different SSRI
Switch to mirtazapine.

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16
Q

What are the second-line choices for treatment of depression after the failure of SSRIs or mirtazapine alone? (3)

A

Lofepramine: TCA
Moclobemide: reversible MOA inhibitor
Reboxetine: Inhibitor of norepinephrine reuptake (NRI)

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17
Q

When should TCAs (other than Lofepramine) and venlafaxine be considered in the treatment for depression?

A

Failure to respond to initial treatment with an SSRI may require an increase in the dose, or switching to a different SSRI or mirtazapine. Other second-line choices include lofepramine, moclobemide, and reboxetine. Other tricyclic antidepressants and venlafaxine should be considered for more severe forms of depression; irreversible MAOIs should only be prescribed by specialists.

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18
Q

Failure to respond to a second antidepressant may require the addition of another antidepressant of a different class, or use of an augmenting agent (such as what? 5 options, which of these are licensed?)

A
  1. Lithium - licensed.
  2. Aripiprazole - unlicensed.
  3. Olanzapine - unlicensed.
  4. Quetiapine - licensed.
  5. Risperidone - unlicensed.
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19
Q

Management of acute anxiety generally involves the use of what?

A

Benzodiazepine or buspirone hydrochloride: Selective serotonin subtype 1A (5-HT1A) partial agonist, with activity at both presynaptic and postsynaptic 5-HT1A receptors.

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20
Q

For chronic anxiety (of longer than 4 weeks’ duration) it may be appropriate to use what type of drug?

A

Antidepressant.

Combined therapy with a benzodiapine may be required until the antidepressant takes effect.

21
Q

Patients with generalised anxiety disorder, a form of chronic anxiety, should be offered psychological treatment before initiating an antidepressant. If drug treatment is needed, what type of drug should be used?

A

An SSRI such as escitalopram, paroxetine, or sertraline [unlicensed].

22
Q

What serotonin and noradrenaline reuptake inhibitors are recommended for the treatmet of generalised anxiety disorder? (2)

A

Duloxetine

Venlafaxine

23
Q

If a patient with generalised anxiety disorder cannot tolerate SSRIs (escitalopram, paroxetine, or sertraline [unlicensed]) or noradrenaline reuptake inhibitors (duloxetine, venlafaxine) what treatment can be considered?

A

Pregabalin

24
Q

Panic disorder, obsessive-compulsive disorder, post-traumatic stress disorder, and phobia states such as social anxiety disorder are treated with what drugs?

A

SSRIs

25
Q

What drugs can be used second-line in panic disorder [unlicensed] if SSRIs not appropriate?

A

Clomipramine and imipramine.

26
Q

What drug can be used second-line for obsessive-compulsive disorder?

A

Clomipramine, second-line after SSRIs

27
Q

What MAOI is licensed for social anxiety disorder?

A

Moclobemide

28
Q

Tricyclic antidepressants can be roughly divided into those with and without what properties?

A

Additional sedative properties and those that are less sedating.

29
Q

Tricyclic and related antidepressants block the reuptake of both serotonin and noradrenaline to different extents. Clomipramine is more selective for what type of transmission?

A

Tricyclic and related antidepressants block the re-uptake of both serotonin and noradrenaline, although to different extents. For example, clomipramine hydrochloride is more selective for serotonergic transmission, and imipramine hydrochloride is more selective for noradrenergic transmission.

30
Q

Agitated and anxious patients tend to respond best to what type of TCA/related compound?

A 
Sedating ones:
Amitriptyline
Clomipramine
Dosulepin
Doxepin
Mianserin
Trazodone
Trimipramine
31
Q

Withdrawn and apathetic patients will often obtain most benefit from less sedating TCAs/related compounds. What are examples of these?

A

Imipramine
Lofepramine
Nortriptyline

32
Q

Lofepramine has a lower incidence of side-effects and is less dangerous in overdose than other TCA/related compounds, but it is infrequently associated with what?

A

Hepatic toxicty

33
Q

Imipramine use is well established but it has more marked what?

A

antimuscarinic side-effects than other TCAs

34
Q

Amitriptyline and dosulepin are effective but why should they not be used for the treatment of depression?

A

Particularly dangerous in overdose:

- dosulepin hydrochloride should be initiated by a specialist.

35
Q

In most patients taking TCAs, why is once-daily administration, at night, usually sufficient?

A

Long half-life

36
Q

Why are MAOIs used less frequently than TCAs/SSRIs etc?

A

Because of the dangers of dietary and drug interactions and the fact that it is easier to prescribe MAOIs when TCAS have been unsuccessful rather vice versa. Washout period of ~2-4 weeks can be needed before initiating a new antidepressant.

37
Q

Tranylcypromine has a greater stimulant action than phenelzine or isocarboxazid and is more likely to cause what?

A

A hypertensive crisis.

38
Q

Isocarboxazid and phenelzine are more likely t cause what side effect than tranylcypromine?

A

Hepatotoxicity

39
Q

Other antidepressants should not be started for how long after treatment with MAOIs has been stopped?

A

Other antidepressants should not be started for 2 weeks after treatment with MAOIs has been stopped (3 weeks if starting clomipramine or imipramine).

40
Q

Other antidepressants should not be started for 2 weeks after treatment with MAOIs has been stopped. When is this 3 weeks?

A

If starting clomipramine or imipramine.

41
Q

MAOIs should not be started until how long after a previous MAOI has been stopped?

A

at least 2 weeks after a previous MAOI has been stopped (then started at a reduced dose)

42
Q

MAOIs should not be started until how long after a TCA or related antidepressant has been stopped?

A

at least 7–14 days after a tricyclic or related antidepressant (3 weeks in the case of clomipramine or imipramine) has been stopped

43
Q

MAOIs should not be started until at least how long after stopping an SSRI? What is the exception?

A

at least a week after an SSRI or related antidepressant (at least 5 weeks in the case of fluoxetine) has been stopped

44
Q

Vortioxetine is an antidepressant thought to work how?

A

Directly modulate serotonergic receptor activity and inhibit the re-uptake of serotonin. Recommended in patients whose condition has responded inadequatley to 2 antidepressants within the current episode.

45
Q

What is agomelatine?

A

A melatonin receptor agonist and a selective serotonin-receptor antagonist; it does not affect the uptake of serotonin, noreadrenoline or dopamine.

Can’t be used in dementia, or patients over 75 years of age.

46
Q

What colour can amitriptyline colour the urine?

A

Blue-green

47
Q

Why are there no dietary restrictions with the use of MAO-B inhibitors?

A

MAO-B inhibition results in decreased breakdown of dopamine and phenethylamine.

MAO-A inhibition - in contract - results in decreased breakdown of serotonin, norepinephrine, dopamine and tyramine.

As a result, there are no dietary restrictions with MAO-B.

48
Q

What can excess tyramine consumption, if taken with MAO inhibitors, cause?

A

Hypertensive crisis.

This is because tyramine increases the release of norepinephrine, leading to pronounced vasoconstriction.

49
Q

What foods are high in tyramine?

A

Fermented foods, meats.

Chocolate :(
Alcoholic drinks :(
Most cheeses :(
Soy sauce
Bananas
Teriyaki sauce
Peanuts

BNF/Pre-Reg 2017-2018 U (144 decks)

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