Pharm - Depression Flashcards
MDD criteria?
At least five symptoms almost every day for at least two weeks, one of which must be depressed mood.
(Anhedonia, sleep disturbances, guilt/worthlessness, psychomotor retardation, etc).
Persistent Depressive Disorder criteria?
Chronic depressed mood for more days than not for the last two years
Monoamine hypothesis of depressive disorders
It’s caused by an insufficiency of Serotonin, norepinephrine and dopamine
SNRIs MOA
Side effects as a class
Selectively block serotonin and norepinephrine
Each one seems to have it’s own SEs, but the class has very few anticholinergic symptoms.
TCAs MOA?
SEs as a class?
What alternate problems can they be used for?
Blockade of norepinephrine and serotonin
Anticholinergic effects Sedation (take at bedtime) Cardiotoxicity (don’t use with heart disease) Orthostatic hypotension Lots of DDIs.
Can be used for pain, migraines and anxiety as well as depression.
MAOIs MOA?
SEs as a class?
Block monoamine oxidase in brain (increasing DA, 5HT, NOR)
CNS stimulation (agitation, anxiety, mania)
Orthostatic hypotension
Hypertensive crisis d/t tyramine-rich foods
DDIs!!!
SSRIs MOA?
SEs as a class?
Selectively block serotonin reuptake
Sexual dysfunction
CNS stimulation
LT weight gain
DDIs and Serotonin syndrome risk.
What would you tell a patient to watch for with Serotonin syndrome?
Sweating and fever
Sudden difficulty concentrating
CNS stimulation (anxiety, agitation, tremors, hyperreflexia)
Sudden poor coordination
What would you tell a patient to watch for with hypertensive crisis?
Severe headache and stiff neck
Nausea
Pounding heart (increased HR) and high BP
Nortriptyline:
Class
Unique SEs?
TCA
Standard SEs, but low for OH.
Moderate ACH, sedation, cardiotoxicity
Selegeline
Class?
SEs?
Anything unique?
MAO inhibitor
Available as a patch - less hypertensive crisis risk than oral MAOs.
Tyramine restriction occurs at doses over 9mg.
Same SEs as class: OH and CNS stimulation
Fluoxetine:
Class?
What’s unique?
SSRI
Used for OCD, too
Has an extra-long half life (1-4 days)
Activating (not sedating)
Sertraline:
Class?
What’s unique?
SSRI
Activating, not sedating
Vilazodone:
Class?
SEs?
What’s unique?
Atypical antidepressant (works on serotonin)
SEs: nausea and diarrhea
Unique because it is less likely to mess with sex life
Don’t use if there’s a history of seizures, though.
Vortioxetine:
Class?
What’s unique?
Atypical antidepressant: works on serotonin
Improves cognitive function
Trazodone:
Class?
SEs?
What’s unique?
Atypical antidepressant: works on serotonin
OH and Sedation (sometimes used for insomnia)
Warn about priapism (rare)
No ACH effects or cardiotoxicity.
Nefazodone
Class?
SEs?
What’s unique?
Atypical antidepressant (nor and serotonin)
Few sexual SEs and very little OH
But, you have to take 2x/day and it can mess up your liver.
Venlafaxine (and desvenlafaxine)
Class?
SEs?
SNRI
(Will act as an SSRI at a low dose)
GI upset
Increase in BP as dose increases
Very few anticholinergic effects, like the rest of the class.
Levomilnacipran:
Class?
SEs?
SNRI
(Milnacipran is used for fibromyalgia, but levomilnacipran is only depression)
Hyponatremia
Increased bleeding risk
Mertazapine:
Class?
SEs?
Unique?
Atypical antidepressant: alpha receptor antagonist and serotonin
Great for if depression includes low appetite
Sedative, but only at low doses Weight gain (increased appetite) Constipation Insomnia at high doses
Bupropion:
Class? NTs?
SEs?
Atypical antidepressant: inhibits DA and NOR reuptake
Insomnia
CNS stimulation (anxiety, irritability, psychosis, but also increased concentration, increased energy)
Appetite suppressant
Not good for people with seizure disorders - increases risk.
Amitriptyline:
Class?
SEs?
TCA
Pretty high side-effects across the board:
- ACH
- Sedation
- Orthostatic hypotension
- Cardiotoxicity
Why do tricyclics cause cardiotoxicity?
Because they block sodium and calcium channels, which affects the heart.
Why is orthostatic hypotension a common side effect with TCAs and some other antidepressants?
Because of the blockade of norepinephrine - affects the blood vessels’ ability to vasoconstrict, especially in the veins.
Can you use TCAs in patients with seizure disorders?
No, they decrease the seizure threshold.
Why do tricyclics cause sedation?
Because they also act on histamine receptors.
Duloxetine:
Class?
SEs?
Unique?
SNRI
Also used for peripheral neuropathy (diabetes), fibromyalgia
Increases BP
Can cause liver toxicity or renal problems: don’t use if there’s severe renal impairment.
Does have anticholinergic effects
(Known as cymbalta)
Imipramine:
Class?
SEs?
TCA
Standard SEs:
Moderate ACH and sedation
High OH and cardiotoxicity
Desipramine:
Class?
SEs?
TCA
Low sedation and ACH effects
Moderate OH and cardiotoxicity
What would TCA toxicity look like?
Tx?
Heart problems: blocks, dysrhythmias, fibrillation, tachycardia
Tx: gastric lavage, activated charcoal, IV sodium bicarbonate.
What would you advise a patient experiencing anticholinergic effects?
Chew gum Wear sunglasses Eat high fiber foods Drink 2-3L/day Void right before taking your meds
What class is Tranylcypromine?
MAO
What class is Phenelzine?
MAO
What class is Isocarboxazid?
MAO
What are the most common interactions for MAOIs?
OTC decongestants
Antidepressants
Antihypertensives
What should you know about switching from or to MAOs?
Wait two weeks before starting the next drug
If you’re stopping Prozac, wait 5-6 weeks.
Why does a hypertensive crisis happen with MAOs?
Tyramine releases accumulated norepinephrine stores: creates massive vasoconstriction and cardiac stimulation.
Escitalopram: Class?
SSRI
What should we warn older adult patients on diuretics who are starting an SSRI?
Can cause hyponatremia.
We should obtain baseline serum sodium levels and monitor frequently.
Which SNRI is likely to cause anticholinergic effects?
Duloxetine
What are the first-line agents for depression?
SSRIs, SNRIs, bupropion and mirtazapine
What would short term remission look like?
At least three weeks with no depressed mood/anhedonia and no more than 3 remaining symptoms of depression.
How long could it take to see a response? Remission?
Up to 8 weeks for a response
Up to 12 weeks for remission
Which drug inhibits 1A2?
Fluvoxamine
Which drug inhibits 3A4?
Nefazodone
Which drugs inhibit 2D6?
Bupropion
Fluoxetine
Paroxetine
