Pharm psych 2 - Anti-Depressants Flashcards
What are the major categories of antidepressants
SSRIs, heterocyclic (TCAs) and tetracyclic antidepressants, MAOIs, miscellaneous
How long should you give a patient an antidepressant for before changing meds
Most meds require trial of at least 3-4 weeks. Some patients respond in 1-2 weeks, others 6-8 weeks. Do trial for 1-2 months.
What kind of withdrawal sx are a/w with antidepressants. Do they need to be tapered
Depends on dose and half life but yes, may need to be tapered. Nausea, headaches, dizziness, insomnia and malaise
What are the most common antidepressant agents used now
SSRIs because of their safety and tolerability but obvious consider all factors before deciding (Cost, reaction profile, sx, side effect, comorbid conditions, suicide ris)
Examples of SSRIs
Fluoxetine (prozac); sertraline (zoloft); paroxetine (paxil); fluvoxamine (luvox); citalopram (Celexa); Escitalopram (lexapro)
Which SSRI has a weekly dosing form available?
Fluoxetine
What SSRI is approved for use only in OCD?
Fluvoxamine (luvox). Also has a lot of drug drug interactions. N/V common.
What SSRI has the fewest drug drug interactions and possibly lower sexual side effects
Citalopram (celexa)
Which SSRI is highly protein bound? Leading to several drug drug interactions?
Paroxetine (Paxil)
Which SSRI has a short half life and incites withdrawal phenomenon if not taken consistenly?
Paroxetine (Paxil)
Which SSRI has more anti-cholinergic side effects?
Sedation, constipation, weight gain => paroxetine
Which SSRI has the longest half life/no need to taper?
Fluoxetine (prozac)
Fluoxetine can/cannot be used in children/pregnancy?
Safe for both
What SSRI can increase levels of neuroleptics?
Fluoxetine -> thereby increasing side effects
What are the side effects of Zoloft?
Highest risk for GI disturbances. More common sleep changes. It has few drug drug interactions.
Sexual side effects of SSRIs can be treated how?
Augment with buproprion, change meds to non-SSRI antidepressant or give sildanefil to men.
What are the main side effects of SSRIs?
Fewer (vs TCAs and MAOIs) side effects because they are selective . Sexual dysfunction in 25-30% - these typically don’t resolve in a few weeks, GI distrubance (N/D), insomnia (vivid dreams, resolves over time), headache, anorexia/weight loss, restlessness- akathisia like state at initiation, seizures 0.2%, serotonin syndrome
Serotonin syndrome is common when?
Serotonergic drugs are used with MAOIs. SSRIs should not be used till at least 2 weeks after stopping MAOIs
How do SSRIs and Warfarin interact?
Increase warfarin levels. Require increased monitoring when starting / stopping these drugs
What are examples of SNRIs
Duloxetine (cymbalta) and venlafaxine (effexor)
What is venlafaxine generally used for?
Brand name - Effexor. Generally used for depression, anxiety disorders like GAD, and may have some use in ADHD
Side effects for venlafaxine?
Increase BP = don’t use in patients with untreated or labile BP, side effects similar to SSRIs, low drug interaction potential.
Is there an extended dose release form for venlafaxine?
Yes thus allowing for once daily dolsing.
What is desvenlafaxine?
New form desvenlafaxine (pritiz) is an active metabolite and expensive just fyi
Side effects of desvenlafaxine?
Similar to SSRIs, but more dry mouth and constipation relating to NE effects
What kind of medication is bupoprion (wellbutrin)
NE-dopamine reuptake inhibitors
What are the side effects of bupoprion?
1) Less sexual side effects compared to SSRIs 2) Can lower seizure threshold - use with caution in patients with epilepsy and eating disorders. 3) increases risk of psychosis at high doses and increase anxiety in some. 4) avoid in people on MAOIs
What kind of drug is trazadone (desyrel) and nefazodone (serzone)
serotonin receptor antagonist and agonist
What is trazodone and nefazodone used for?
Refractory major depression, major depression with anxiety and insomnnia
What are the side effects of trazodone/nefazodone
no sexual side effects of sSRIs and don’t affect REM sleep. Side effects: nausea, dizziness, orthostatic hypotension, cardiac arrythmias, sedation, priapism
What is the major black box warning for nefazodone (serzone)
Liver failure.
What is an example of an alpha 2 adregernic receptor antagonist?
Mirtazapine (remeron)
What is mirtazapine used for?
refractory major depression, especially in patients who need to gain weight.
Side effects of mirtazapine
Weight gain, sedation, dizziness, somnolence, tremor, dry mouth, constipation, and rare agranulocytosis. No sexual side effects and few drug interactions
What is the mainstay of treatment for TCA overdose
IV sodium bicarbonate
Why are TCAs rarely used as first line
higher incidence of side effects, require greater dosage monitoring, and can be lethal in overdose
MOA for TCAs and what is their half life like?
inhibit reuptake of NE and serotonoin, have long half lives so most are dosed daily.
Tricyclic antidepressant examples? Tertiary amines and secondary amines
Tertiary amines: amitryptiline (elavil), imipramine (tofranil), clomipramine (anafranil), doxepin (sinequan). Secondary amines: nortriptyline, desipramine
Use for amitriptyline (elavil)
chronic pain, migraines and insomnia
Use for imipramine (tofranil)
has IM form. Useful for enuresis, and panic disorder
Use for clomipramine (anafranil)
most serotonoin specific, useful in OCD tx
Which tCA is most specific for serotonin?
Clomipramine (anafranil)
Use for doxepin (sinequan)
chronic pain, emerging use as a sleep aid in low doses
What is the side effect difference between tertiary amine and secondary amine TCAs?
Tertiary is more anti-cholinergic and sedating
Use for nortriptyline (paelor, aventyl)
treating chronic pain - least liketly to cause orthostatic hypotension.
Side effects for desipramine
Desipramine (norpramin) is a secondary amine antidepressant. More activating, less sedating and least anticholinergic
What are examples of tetracyclic antidepressants?
Amoxapine (asendin) - metabolite of antipsychotic loxapine, maprotiline (ludiomil) - higher seizure rates, arrythmia and fatalities
Side effects of TCAs are mainly due to?
Lack of specifity and interation with other receptors
Main TCA side effects?
Anti-histaminic (sedation), Anti-adrenergic (cardiovascular properties: orthostatic hypotension, reflex tachycardia, arrythmias, dizziness, EKG changes such as widening QRS, QT, and PR intervals), antimuscarininc effects (urinary retention, blurred vision, constipation, dry mouth, tachycardia, worsening of narrow angle glaucoma), weight gain, very lethal in overdose - must assess suicide risk, seizures (rate of 0.3% more common in clomipramine and tetracyclics), serotenergic effects: erectile dysfunction and female anorgasmia.
What is the moa of MAOIs.
Prevent inactivation of biogenic amines such as NE, serotononine, dopamine, and tyramine. Inhibit MAO-A and MAO-B enzymes.
MAOIs are considered more effective in what kind of depression?
Atypical depression characterized by Hypersomnia, increased appetite, increased sensitivity to interpersonal rejection. Also in refractory depression and refractory panic/anxioety disorder
Which MAOIs are used for refractory depression?
Phenelzine (nardil), tranylcypromine (parnate), isocarboxazid (marplan)
What is selgeline? What is the advantage of using it?
EHSAM patch - MAOI used to treat depression doesn’t require dietary restrictions when used in low dosages. But decongestants, opiates and serotonergic drugs still must be avoided.
How do you treat serotonin syndrome? When you suspect it, what should you do?
D/c drug. Also try calcium channel blockers (oral nifedipine). If carefully monitred, try chlorpromazine or phentolamine
How does serotonin syndrome present?
First with lethargy, restlnessness, confusion, diaphoresis, tremor and myoclonic jerks. May progrss into hyperthermia, hypertonicity, rhabomyolysis, renal failure, convulsions, coma and death.
What is hypertensive process?
Risk when MAOIs are taken with tyramine rich food or sympathomimetics
What are the main side effects of MAOIs?
serotonin syndrome, hypertensive crisis, weigh gain, orthostatic hyptotension, sexual dysfunction, dry mouth, sleep dysfunction, ppl with pyridoxine deficiency can have paresthesias (treat with B6), rare liver toxicity, seizures and edema. Start low and go slow.
What antidepressant is used for OCD
SSRIs in high doses, TCAs (clomipramine)
What antidepressant is used for panic disorder
SSRIs, TCAs (imipramine), MAOIs
What antidepressant is used for eating disorder
SSRIs in high doses, TCAs and MAOIs
What antidepressant is used for dysthymia
SSRIs
What antidepressant is used for social phobia
SSRIs TCAs and MAOIs
What antidepressant is used for GAD
SSRIs, SNRIs (venlafaxine), TCAs
What antidepressant is used for PTSD
SSRIs
What antidepressant is used for IBS
SSRIs TCAs
What antidepressant is used for enuresis
TCAs (imipramine)
What antidepressant is used for neuropathic pain
TCAs (amitryptiline and nortriptyline), duloxeitine
What antidepressant is used for chronic pain
SSRIs, TCAs
What antidepressant is used for fibromyalgia
SSRIs
What antidepressant is used for migraine headaches
TCAs (amitryptiline), SSRIs
What antidepressant is used for smoking cessation
Bupoprion
What antidepressant is used for premenstrual dysphoric disorder
SSRIs
What antidepressant is used for depressive phase of manic depression
SSRIs
What antidepressant is used for insomnia
mirtazipine, TCAs (amitryptiline)
When prescribing lithium, it is important to monitor what levels?
Thyroid, creatinine and lithium
Patients on clozapine should have what tests done routinely?
WBC counts to monitor for agranulocytosis. Perform weekly for first 6 months and then decrease frequency thereafter
