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Behavioral Health > Pharm - Mood Disorders > Flashcards

Pharm - Mood Disorders Flashcards

1
Q

What patient should be considered for lifelong maintenance therapy for major depression?

A
  • < 40 years old with 2+ episodes

- Any age with 3+ episodes

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2
Q

What is the goal of therapy?

A
  • to prevent recurrence to prevent lifelong treatment
  • Acute: 6-12 weeks, goal: remission
  • Continuation: 4-9 months, goal: eliminate residual symptoms/prevent relapse
  • Maintenance: 1-3 years, goal: prevent recurrence
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3
Q

What is the preferred medication for the initial treatment of major depression?

A

-combo of pharmacotherapy and psychotherapy or either alone (dependent on patient willingness/ability)

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4
Q

What is the initial choice and why is it preferred?

A
  • initial choice is empirical
  • SSRI usually preferred d/t more benign side effects and minimal risk of lethal effects when taken for intentional suicide
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5
Q

What is the initial tx for pt with comorbid anxiety disorders?

A

start on lower dose SSRI than normal and titrate up to minimal usual total daily dose (therapeutic dose)

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6
Q

What is the timeline for evaluating pt response to tx?

A
  • early improvement/response is usually apparent in 1-2 weeks in unipolar major depression patients
  • early improvement during initial treatment predicts eventual remission
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7
Q

What is the duration of adequate trial?

A
  • Unipolar major depression: 6-12weeks before deciding if they’ve worked
  • if they show little improvement (<25% reduction in sx) after 4-6 weeks, move to next-step tx
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8
Q

List the SSRIs

A
  • citalopram
  • escitalopram
  • fluoxetine
  • paroxetine
  • sertraline (drug of choice)
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9
Q

List the SNRIs

  • newer-generation
  • tricyclic antidepressants
A

Newer generation:

  • desvenlafaxine (active metabolite of venlafaxine)
  • venlafaxine (immediate release-IR and extended release-XR)
  • levomilnacipran
  • milnacipran
  • duloxetine (IR and XR)

Tricyclic:

  • amitriptyline
  • imipramine
  • doxepine
  • nortriptyline
  • desipramine
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10
Q

List the NE/dopamine reuptake inhibitor

A

bupropion (IR, SR, XR)

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11
Q

List the serotonin/α2-adrenergic receptor antagonist

A

mirtazapine

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12
Q

List the MAOIs

A
  • phenelzine
  • selegiline transdermal
  • tranylcypromine
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13
Q

List the serotonin modulators

A
  • nefazodone
  • trazodone
  • vilazodone
  • vortioxetine
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14
Q

Compare the half-life of fluoxetine with other SSRIs

A
  • Fluoxetine has really long half-life: usually 2-4 days, most SSRIs are about 1 day
  • Norfluoxetine is 7 to 15-day half-life
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15
Q

What is the advantage of fluoxetine’s half-life?

A
  • treatment adherence; protects from discontinuation syndrome
  • abrupt stop will not cause as many withdrawal symptoms; those are more likely with shorter half-life
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16
Q

List the SSRIs that have significant CYP2D6 inhibition

  • best
  • modest
  • no effect
  • other
A
  • best: fluoxetine and paroxetine
  • modest: sertraline
  • no effect: citalopram and escitalopram less chance for drug-drug interactions
  • Paroxetine
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17
Q

What is unique about Paroxetine?

A

it has non-linear kinetics so a high dose = very high plasma drug concentrations

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18
Q

Which clinical presentation is most associated with SSRI-induced sexual dysfunction?

A
  • MC with paroxetine, moderate risk with remaining

- occurs in both men and women: decreased libido, difficulty achieving orgasm, erectile dysfunction in 37% of males

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19
Q

What is an appropriate tx plan for pts experiencing SSRI-induced sexual dysfunction?

A
  1. switch to non-SSRI: bupropion, mirtazapine, nefazodone (serotonin modulator)
  2. switch to different SSRI
  3. augment SSRI therapy: add bupropion/phosphodiesterase inhibitor (Viagra, sildenafil)
    - -Bupropion not great as monotherapy but great in combination
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20
Q

% of drowsiness with SSRI use

A

17% - daytime sedation leads to malaise, diminished mental energy, emotional blunting

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21
Q

% of weight gain with SSRI use and associated risk for diabetes with long-term use

A
  • 12% - unsure if due to SSRI or remission of depression that causes increased appetite/carb craving and change in serotonin receptor activity
  • MC with paroxetine
  • pt can be twice as likely to get DM 2 when used >24 months
22
Q

% of increased anxiety with SSRI use

-tx

A
  • 11% see increase in anxiety/agitation when starting SSRI
  • need to anticipate this and treat highest-risk patients with antianxiety meds
  • overtime SSRI doesn’t improve anxiety associated with depression
23
Q

Orthostatic hypotension with SSRI use

A
  • all cause low degree

- MC with Paroxetine

24
Q

Nausea, vomiting, and diarrhea with SSRI use

A
  • Nausea = 6%, all SSRIs associated with transient nausea/GI upset during initiation/dose increase
  • MC with paroxetine/sertraline
  • diarrhea: MC with sertraline
25
Q

Cardiac and dosage considerations with citalopram

A

QTC prolongation, limit dose in elderly pts***

  • dose limit in everyone = 40mg/day
  • dose limit in > 60 years old = 20mg/day
  • NOT recommended for patients with bradycardia, hypokalemia, hypomagnesemia, recent MI, uncompensated HF
26
Q

Why are SSRI and SNRI on the Beers list?

A

Because of potential to cause/exacerbate SIADH or hyponatremia - monitor Na2+ closely when initiating/adjusting dose

27
Q

What SSRI drugs are less likely or more common to have withdrawal symptoms?

A
  • less likely with SSRI with longer half life
  • MC with paroxetine, least common with fluoxetine

*taper drugs over 1-2 weeks

28
Q

List the withdrawal symptoms

A
  • sensory sx: paresthesia, numbness, electric-shock-like sensation, palinopsia (visual trails)
  • disequilibrium: light-headedness, dizziness, vertigo
  • general somatic sx: lethargy, headache, tremor, sweating, anorexia
  • affective sx: irritability, anxiety/agitation, low mood, tearfulness
  • GI sx: N/V/D
  • sleep disturbance: insomnia, nightmares, excessive dreaming
29
Q

Mnemonic for withdrawal symptoms

A 
FINISH:
Flu-like symptoms
Insomnia
Nausea
Imbalance
Sensory disturbances
Hyperarousal
30
Q

List the anticholinergic and adrenergic side effects of the older tricyclic antidepressants (SNRIs)

A

Anticholinergic: dry mouth, constipation, blurred vision, urinary retention, dizzy, tachy, memory impairment/delirium (w/high doses)

Adrenergic: orthostatic hypotension, cardiac conduction delay, AV conduction block, sever arrhythmias in overdose

31
Q

List the severe Despiramine (tricyclic antidepressant, SNRI) side effects

A

increase death risk in pts with FHx of sudden cardiac death, cardiac conduction disturbances, dysrhythmias

32
Q

Effects of the SNRI drugs on NE and serotonin reuptake

A
  • inhibit neuronal reuptake of serotonin at low doses
  • inhibit NE at higher doses
  • serotonin inhibition 5x more potent that NE inhibition
33
Q

What does the “washout” period refer to when switching from an SSRI/SNRI to a MAO inhibitor and vice versa?

A
  • SNRIs are contraindicated if take MAO inhibitor in last 2 weeks because drug-drug interactions leading to serotonin syndrome
  • if d/c SNRI and starting MAOI wait 2 weeks b/w last dose of SNRI and first dose of MAOI
34
Q

HTN with SNRI use

  • cause
  • monitoring
A
  • NE increase BP: dose related effect

- BP monitoring ongoing/regularly assessed (esp. if they have pre-existing HTN)

35
Q

Which SNRIs are weight neutral?

A
  • levomilnacipran and milnacipran
  • most of their effect is on NE
  • DON’T use in pt with HTN/CV disease, ESRD, glaucoma
36
Q

Which SNRI increases bleeding in patients on anticoag?

A

Velafaxine

37
Q

What is the role of bupropion in the treatment of unipolar depression?

A

commonly used as augmenting agent in combination with other antidepressants (SNRI or mirtaxepine) for depression treatment

38
Q

Increased risk of seizures with buproprion and when it should be avoided

A
  • side effect of seizures is dose related
  • contraindicated in patients with seizure disorder
  • use with caution in patients on drugs that lower seizure threshold
39
Q

How can you decrease insomnia with buproprion?

A

Educate patient to not take drug too late in the day (example: no later than 2pm)

40
Q

Weight gain with mirtazapine use

A

about 1-3kg weight gain in 10+%

41
Q 
Which drug (and class) is not associated with sexual dysfunction?
-how to use
A

mirtazapine, a serotonin/α2-adrenergic receptor antagonist

-alternate use if pt can’t tolerate SNRI (not an adjunctive therapy)

42
Q

ADR of mirtazapine

A

dry mouth and drowsiness are MC

*sedative action because of activity on histamine receptors

43
Q

Which foods high in tyramine can precipitate a hypertensive crisis in patients taking MAOI?

A
  • cheese
  • wine
  • beer
  • processed meat
  • coffee
  • chocolate
  • raisins
  • fava beans
  • soy sauce
  • sour cream
  • sauerkraut
  • ripe avocado
  • liver
  • sardines
44
Q

Why is there a high incidence of sedation with trazodone use?

A

Due to it being a histamine HI receptor

45
Q

How do you diagnose serotonin syndrome?

A
  • Serotonergic drug + symptom cluster
  • spontaneous clonus
  • inducible clonus AND agitator OR diaphoresis
  • ocular clonus AND agitation OR diaphoresis
  • tremor AND hyperreflexia
  • hypertonia AND temperature >38°C AND spontaneous/inducible ocular clonus

Serotonergic exposure + rigid muscle tone + dry mucous membranes + dilated pupils + increased bowel sounds + hyperreflexia

46
Q

Central management of serotonin syndrome

A

-discontinue serotonergic agents
-supportive care to stabilize vital signs
sedate with benzodiazepine
-administer serotonin antagonists

47
Q

Tx of serotonin syndrome based on severity of illness

-mild

A

Mild: discontinue inciting meds, supportive cares, sedate with benzo

48
Q

Tx of serotonin syndrome based on severity of illness

-moderate

A

Moderate: more aggressive tx of autonomic instability + tx with serotonin antagonist

Autonomic instability: treat HTN/tachy with short acting agents like esmolol/nitroprusside; treat hypotension from MAOIs with low doses of direct acting sympathomimetic amines; control hypothermia (immediate sedation, paralysis, intubation if >41.1°C

49
Q

Tx of serotonin syndrome based on severity of illness

-hyperthermic

A

critically ill - paralysis and ET intubation

50
Q

Tx of serotonin syndrome based on severity of illness

-supportive care

A

O2 to maintain SpO2≥94%, IV fluids for volume depletion, continuous cardiac monitoring, correction of vital signs

51
Q

Benzos in serotonin syndrome

A

used for sedation to control agitation and correct mild increases in BP/HR

Behavioral Health (11 decks)

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