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1
Q

Antidepressant Classes

A 
SSRI 
SNRI 
TCA 
MAOi 
others: mirtazapine, buproprion, trazadone 
Atypical Antipsychotics
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2
Q

SSRI:

  • first line tx for what?
  • med names
  • MOA
A

First line tx for depressive disorders.

Med:

  • Prozac (fluoxetine) (1st line for children)
  • Zoloft (sertraline)
  • Paxil (paroxetine
  • Celxa (Citalopram)
  • Luvox (Fluvoxamine)
  • Lexapro (Escitalopram)
  • all of these begin at 20mg except for lexapro you start at 10mg.

MOA:
block reuptake of serotonin, increasnig the serotonin in the synaptic cleft and down regulating 5HT1A receptors on post synaptic neuron, so less inhibition of that neuron leading to more firing and increased serotonin release.
*efficacy of all of these drugs is the same, its the half life and SE that differ.

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3
Q

SSRI

  • half lives; longest and shortest
  • which SSRIs have the least drug interactions d/t their decreased inhibition of liver enzymes?
  • what are some medications to use caution with d/t drug interactions?
  • which Med is CI?
A

Longest: Prozac up to 3 days, shortest is Luvox 15hrs

Citalopram (Celexa) Escitalopram (lexapro)

Use caution with:

  • azole antifungals
  • macrolide abx
  • omeprazol e
  • hepatic impairment

MAOis are CI if taking within 2wks d/t risk of serotonin syndrome.

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4
Q

SSRI:

  • SE
  • withdrawal sx
  • which medications are more common to have withdrawal sx? why?
  • time to effect?
  • administration directions
  • duration of therapy
A

SE:

  • sexual dysfunction
  • drowsiness
  • dizziness
  • wt gain
  • insomnia
  • anxiety
  • diaphoresis
  • hyperprolactinemia
  • n/v/d
  • increased appetite

Withdrawal:

  • dysphoria
  • dizziness
  • GI distress
  • fatigue
  • chills
  • myalgias

Fluvoxamine (Luvox) and Paroxetine (Paxil) are more likely to have withdrawal sx d/t such short half lives.

4-6wks

Admin:
-QD dosing, if makes sleepy take at night, if insomnia take in AM

-duration of thearpy is lifelong, if you d/c the med make sure to continue it for 1 yr after resolution of sx for recurrence of severe depressive episode.

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5
Q

Which SSRI has least problems with wt gain? Most wt gain?

Which SSRI is most likely to cause diarrhea?

T/F SSRI increase the risk of abnormal bleeding?

A

Least prob w/ weight gain = prozac.

Most wt gain = Paxil

Diarrhea = Zoloft

True, they inhibit platelet function. ..also they increase bone fxs..

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6
Q

SNRI

  • medications
  • act on what NT?
  • MOA
  • when to use these?
  • what can decrease the rate of absorption of these?
A

Meds:

  • effexor (Venlafaxine)
  • Cymbalta (duloxetine)
  • Pristiq (desvenlafaxine)

-act on Serotonin and NE

MOA: inhibit reuptake of NE and serotonin, acts same as SSRI otherwise.

Use as 2nd line therapy if unable to use SSRI.

Taking these with food will decrease the rate of absorption but not the degree of absorption.

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7
Q

SNRI:

-SE

A

SE:

  • nausea*
  • dizziness*
  • diaphoresis*
  • sexual dysfunction
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8
Q

Pristiq
-MC SE

Cymbalta:

  • CI
  • indications
  • SE

Effexor:

  • SE
  • whats unique about this one?
A

Pristiq SE: nausea, HTN

Cymbalta:
-CI: uncontrolled angle closure glaucoma, severe or renal or liver impairment.

Indicated: diabetic neuropathy and fibromyalgia

SE: weight gain!!!!

Effexor:

  • SE: HTN, QT prolongation
  • unique: at low doses this is basically an SSRI, you need higher doses to pick up the NE component.
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9
Q

TCAs:

  • what are the meds
  • do we prescribe these?
  • MOA
  • half life
  • cardiac SE
A

Tertiary amines:

  • Amitriptyline
  • Clomipramine
  • Doxepin (silenor)
  • Imipramine
  • trimipramine
  • more potent at blocking uptake of serotonin

2ndry amines:

  • desipramine
  • nortriptyline
  • protroptyline
  • more potent at blocking uptake of NE.

No, try to avoid them.

MOA: inhibit reuptake of serotonin and NE.

Half life 24hrs

Cardiac SE:
-heart block, ventricular arrhythmias, sudden death

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10
Q

TCAs

-SE

A

SE:

  • sedation
  • increase appetite
  • confusion
  • anticholinergic
  • orthostatic hypotension
  • Lethal in overdose.
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11
Q

MAOi’s

  • meds
  • why are these dangerous?
A

Meds: Phenelzine (Nardil) Tranylcypromine (Parnate)

Dangerous: drug-drug interactions, dietary restrictions, HTN crisis, serotonin syndrome.

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12
Q

Other meds used in tx of depression

A 
Trazodone (desyrel) 
Bupropion (Wellbutrin) 
Mirtazapine (remeron) 
Vilazodone (Viibryd) 
Vortioxetine (Brintellix)
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13
Q

Trazodone

  • good for tx of what at low and high doses?
  • SE

Wellbutrin:

  • uses
  • avoid use with what disorders?
  • SE
A

Low dose = sleep
high dose = antidepressant

SE: sedation, orthostasis, priapism (prolonged erection)

Wellbutrin:

  • Uses= smoking cessation, ADHD, depression
  • add on therapy to SSRI (for tx of sexual SE & augmentation therapy)

Avoid with bulemia and may lower seizure threshold.

SE: no sexual SE.

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14
Q

Mirtazapien (Remeron)

  • MOA
  • SE
A

MOA: blocks adrenergic receptors leading to increased release of NE and serotonin.

SE: sedation, weight gain (good for elderly), less sexual SE, good for pts with nausea.

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15
Q

Serotonin Syndrome:

  • what is this?
  • cause
  • what are some drugs that can cause this?
A

What; constellation of sx caused by excess of serotonin, ranges from mild to fatal.

Cause;

  • simultaneous admin of two serotonergic agents
  • initiation of a single serotonergic drug or increasing the dose.

Drugs:
Psych meds: any of them.

Pain meds: demerol, tramadol, fentanyl

Migraine meds: triptans

Neurology: levodopa, carbipoda-levodopa, valproate, carbamezepine

OTC: tobitussin

Anti-emetics: zofran

Street drugs: cocaine, meth

ADHD; amphetamine derivatives, dexxtroamphetamine

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16
Q

Serotonin Syndrome:

  • onset
  • PE findings
  • signs and SE
A

onset: usually rapid onset, present within 24hrs and most within 6hrs of change in dose or initiation of a drug.

PE:
HARM = hyperthermia, autonomic instability (delirium), rigidity, myoclonus (tremor/muscle spasm)

-ocular clonus, tremor, dilated pupils,

Signs and Sx:

  • mental status changes; anxiety, agitation, disorientation
  • autonomic: diaphoresis, tachycardia, HTN, vomtiing, diarrhea
  • neuromuscular hyperactivity: hyperreflexia, bilateral babinski sign
17
Q

What is the Hunter criteria for serotonin syndrome?

A

Has taken a serotonergi agent PLUS(1):

  • spontaneous clonus
  • inducible clonus AND agitation or diaphoresis
  • ocular clonus AND agitation or diaphoresis
  • tremor and hyperreflexia
  • hypertonia AND temp greater than 38C AND ocular clonus or inducible clonus.

KNOW THIS!

18
Q

Tx serotonin syndrome

How long until sx resolution?

A

first line is D/C serotonergic agents

  • sedate using benzo (lorazepam)
  • fluids
  • cardiac monitor
  • if benzo dont improve agitation the antidote is cyproheptaide
  • if tem is greater than 41C immediate intubation and sedation (DONT give tylenol, do not treat fever at all)

Often resolves within 24hrs of d/c serotonergi agent.
*MAOis carry the greatest risk of this and sx can persist for several days!

19
Q

Seasonal Affective Disorder:

  • MC in which region?
  • sx
  • tx
A

MC in northern hemisphere

Sx completely mimic depression but have cyclical pattern.

Tx: UV light

Psych (13 decks)

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