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PHRM 845 exam 5 > Pharmacotherapy of depression Dr. Ott > Flashcards

Pharmacotherapy of depression Dr. Ott Flashcards

1
Q

Risk of recurrence in depression

A

Risk of Recurrence
1 episode: 50-60%
2 episodes: 70%
3 episodes: 90%

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2
Q

Recurrence

A

Risk becomes lower over time as duration of remission increases

Persistent mild symptoms during remission is a predictor of recurrence

Function deteriorates during the episode and goes back to baseline upon remission

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3
Q

DSM-5 diagnostic criteria

A

At least one of the symptoms must be depressed mood or loss of interest or pleasure in doing things

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4
Q

Diagnostic SIGE CAPS

A

Sleep
Interest decreased
Guilt/worthlessness
Energy loss/fatigue
Concentration difficulties
Concentration difficulties
Appetite change
Psychomotor agitation/ retardation
Suicidal ideation

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5
Q

Self- administered rating scales

A

PHQ-9 and MOOD disorder questionnaire

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6
Q

Goals of treatment

A

Reduce or eliminate signs and symptoms of depression

restore occupational and psychosocial functioning to baseline

reduce risk of relapse and recurrence

reduce the risk of harmful consequences

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7
Q

Phases of treatment

A

ACUTE
- 6-12 weeks of remission of symptoms
goal: induce remission
CONTINUATION
- 4-9 additional months, recommended for all patients
goal: prevent relapse
MAINTENANCE
Patient specific duration
Often indefinite treatment if greater than or equaol to 3 major depressive episodes
goal: prevent recurrence

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8
Q

Risk of Suicidality

A

Boxed warning for suicidality in all antidepressant medications for patients aged 24 and younger

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9
Q

Citalopram

A

Celexa
10-40 mg/day
>60 years : do not excess 20 mg
Dose dependent QTc prolongation
substrate of 2C19 and 3A4

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10
Q

Escitalopram

A

Lexapro
5-10mg/day

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11
Q

Fluoxetine

A

Prozac
10-80mg/day
long half life
activating potential
2D6 and 3A4 inhibitor

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12
Q

Fluvoxamine

A

Luvox
50-300mg/day
inhibitor 1A2 and 2C19

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13
Q

Paroxetine/Paroxetine CR

A

Paxil
10-60mg/day
MUST taper due to anticholinergic effects
Weight gain and sedation
septal wall defect risk to the fetus -dont use in prego
Inhibitor 2D6, 2B6

not commonly used

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14
Q

Sertraline

A

Zoloft
25-200mg/day
Most GI upset than other antidepressants - nausea
Inhibitor 2C19, 2D6, 3A4
very commonly used

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15
Q

SSRIs Adverse effects

A

Weight gain - parozetine
Weight loss - fluoxetine
Increased bleeding risk - platelet inhibition
hyponatremia (especially in elderly)
sexual dysfunction

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16
Q

Desvenlafaxine

A

Pristiq
active metabolite of venlafazine
dose limiting side effect: nausea
No major cyp interactions

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17
Q

Duloxetine

A

Cymbalta
slow titration to avoid nausea
FDA warning for hepatotoxicity
Inhibitor 2D6 - liver function testing needed

go to SNRIs

18
Q

Levomilnacipran

A

Fetzima
Must adjust in renal impairment or strong 3A4 Inhibitors
Substrate of 3A4

19
Q

Venlafaxine

A

Effexor
must be >150mg/day to have NE effects
2D6 inhibitor at higher doses

20
Q

SNRIs adverse effects

A

Useful in pain symdrome, musculoskeletal pain, fibromyalgia, and neuropathic pain

Duloxetine - obtain LFTs at baseline when symptomatic or every 6 months

Blood pressure elevation and nausea

21
Q

Amitriptyline

A

Elavil
used to lower doses for neuropathic pain

22
Q

TCAs adverse effects

A

sedation, reduces seizure threshold, confusion, blurred vision, urinary retention, constipation, orthostatic hypotension, tachycardia, weight gain, sexual dysfunction
fatal in overdose as low as 1000mg due to cardiac arrhythmias or seizures

23
Q

MAO inhibitors clinical pearls

A

Must have 2 week washout period before switching antidepressant (5 week washout if switching from fluoxetine)
all require tyramine diet except selegiline 6mg/24hr patch
caution due to hypertensive crisis and serotonin syndrome

24
Q

MAO inhibitors

A

Selegiline
Phenelzine
Isocarboxazid
tranylcypromaine

25
Q

Bupropion

A

Wellbutrin
dopamine and norepinephrine reuptake inhibitor
stimulating - insomnia and appetite suppression
2D6 inhibitor
Contraindicated in active seizure disorder and eating disorders
can be used in combination with SSRI/SNRIS

26
Q

Mirtazapine

A

remeron

sedation and increased appetite occurs with doses less than 15mg/day
warning: agranulocytosis, increased cholesterol
Can be used in combination with SSRI/SNRIs

27
Q

Trazodone

A

Desyrel
Higher doses needed for depression
SE: orthostatic hypotention, risk of priapism - medical emergency

28
Q

Vilazodone

A

Viibryd
primarily SSRI, MAY HAVE SOME 5HT1A agonism which may provide anxiolytic effects
do not use in combination with SSRI/SNRIs

take with food to avoid nausea, and increase bioavailability with food
substrate 3A4

29
Q

Vortioxetine

A

Trintellix
SSRI + 5HT1a agonist + 5HT1a antagonist

do not use in combo with SSRI/SNRI

possibly less sexual dysfunction, substrate 2D6, nausea is common side effect

30
Q

Serotonin syndrome

A

Medical emergency due to excessive amount of serotonin in the CNS

31
Q

Serotonin syndrome treatment

A

Stop the offending agent and get supportive care
could use cyproheptadine as seretonin blocker
70% of patients recover within 24hrs

32
Q

Antidepressant withdrawal syndrome

A

Antidepressants with anticholinergic activity should be tapered no matter what
common with all antidepressants except fluoxetine
Not life threatening

33
Q

Agumentation - Atypical antipsychotics

A

Aripiprazole (Abilify)
Brexpiprazole (rexulti)
Cariprazine (vraylar)
Quetiapine (seroquel)

34
Q

Key counseling points

A

Abrupt discontinuation can lead to antidepressant withdrawal syndrome

Possible increase in suicidal thinking during the first few weeks of therapy

35
Q

Steps to manage depression

A
  1. Dose optimization
  2. Switch antidepressants
  3. Combine antidepressants
  4. Augmentation
  5. Esketamine (ECT,VNS,TMS)
36
Q

2D6 INHIBITORS

A

Fluoxetine
Paroxatine
Sertreline
Duloxetine
Venlafaxine
bupropion
vortioxetine

37
Q

3A4 Inhibitor

A

Fluoxetine
Sertreline

38
Q

3A4 substrate

A

Citalopram
Levomilnacipran
Vilazadone

39
Q

2C19 inhibitor

A

Fluvoxamine
Sertraline

40
Q

2C19 substrate

A

Citalopram

41
Q

1A2 inhibitor

A

Fluvoxamine

PHRM 845 exam 5 (12 decks)

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