Psychiatric Disorders Medications - SSRIs Flashcards
Which Benzo is only available in injectable?
Midazolam
it is the only one that is water soluble
SSRIs clinical uses?
Major depression
Depression in patients with concurrent illnesses, such as coronary artery disease, glaucoma, hypertension
Panic disorder
Used in the treatment of stroke patients, including those with and without symptoms of depression
chronic pain syndrome - more pain = more depressed etc..
stroke and limbic system = more sensitive - tend to use these for treatment of acute depression
Benzodiazepines Prescribing considerations?
DEA schedule IV controlled substance
Beers Criteria in elderly
Addictive property
Not a primary therapy
Not effective comorbid depression
Lethal when used with alcohol or other CNS depressants
Impaired driving / cognitive skills 1mg alprazolam = BAC 0.15
SSRI increase the extracellular level of the neurotransmitter _________ limiting its reabsorption into the ____________ cell, thus increasing the level of _________
serotonin
presynaptic
serotonin
**higher therapeutic concentration inside the cleft **
Why are SSRIs better than other antidepressants?
Act more reliably, act more quickly, and have fewer side effects than other antidepressants
Benzodiazepines are useful in the management of _____ situational anxiety disorder and ___________ disorder
acute
adjustment
people that have panic attacks for lying or driving long distances
SNRIs: Agents with dual serotonin and norepinephrine re-uptake inhibition (SNRIs) are sometimes called ?
non-tricyclic serotonin and norepinephrine reuptake inhibitors
Benzodiazepines has ____________ of panic attacks
rapid control
Nonbenzodiazepine Benzodiazepine Receptor Agonist?
Currently 3 on the market
Zolpidem (Ambien)
Zaleplon (Sonata)
Eszopicclone (Lunesta)
Sleep driving discussed in Neurology
sub cat for benzos
SSRI: Symptoms of serotonin syndrome?
Myoclonus (intermittent jerking or twitching)
Hyperreflexia (greater in upper limbs)
Increased heart rate
Shivering
Sweating
Dilated pupils / slow to react
SNRIs most common adverse effects?
The most common include loss of appetite, weight, and sleep.
There may also be drowsiness, dizziness, fatigue, headache, increase in suicidal thoughts, nausea/vomiting, sexual dysfunction, and urinary retention.
because of nor-epi = watch for urinary retention
Benzodiazepines Prescribing considerations: Possible fetal abnormalities
?
Can affect chromosomes in both sperm and ovum
Can cause birth defects caused by use by mother or father during conception period with active metabolite longer half-life periods
**chromosome disorders prior to inception **
Benzodiazepines Pharmacokinetics: Liver?
Metabolized by liver and active metabolite can be higher in elderly and liver disease
Venlafaxine is?
Effexor
NET ?
norepinephrine transporter (NET)
Midazolam is ___ used as anxiolytic, it is used more as a ________ (nasal) - does not suppress respiratory drive so it is good
NOT
sedative
Duloxetine is?
Cymbalta
Citalopram is?
Celexa
SNRIs sexual side-effects?
Two common sexual side-effects: diminished libido and difficulty reaching climax (anorgasmia)
Benzodiazepines BBW?
watch for seizures with chronic use and withdrawal, prepare seizure management
Prozac HF?
4-6 days,
effects up to 14 days
SSRIs have interactions with other psych meds, including?
MAOI’s
buspirone
diazapam
lithium
TCA’s
**SSRI’s do interact quite a bit with other medications **
What benzos are not metabolized by the liver so they are useful in liver disease?
Oxazepan (Serax)
lorazepam (Ativan)
temazepam (Restoril)
Desvenlafaxine is?
Pristiq
lorazepam is?
Ativan
SNRIs: __________ and ___ monitor blood pressure
Hypertension
CAD
**watch if they have underlying CAD or cardiovascular problems **
SSRI examples?
fluoxetine (Prozac)
more side effects than others
paroxetine (Paxil)
sertraline (Zoloft)
citalopram (Celexa)
escitalopram (Lexapro)
venlafaxine (Effexor) SNRI - bad one?
**everyone will have different reactions when they take them , a lot of people do not tolerate these very well, watch out for in kids and young adults it can enlarge the suicide ideology **
SNRI aka?
Serotonin Norephinephrine reuptake inhibitors
serotonin–noradrenaline reuptake inhibitors
________ poorly absorbed via IM injection
Diazepam
Oral better than injection
Popular PO anxiolytic
Benzodiazepines adverse effects?
Orthostatic hypotension
Constipation, nausea, vomiting, diarrhea
CNS effects of ataxia, drowsiness, dizziness, slurred speech, confusion, somnolence
Respiratory depression
Retrograde amnesia (why midazolam used preoperatively) - Versed
_________ is an efficient property in mediating antidepressant activity
Synergism
Benzos have active ?
metabolites
Benzos have peak blood flow _ to _ hours
1-3 hours
SNRIs: Elevation of norepinephrine levels can sometimes cause ?
anxiety
mildly elevated pulse
elevated blood pressure.
What is the date rape drug and is now banned in the US?
flunitrazepam (Rohypnol)
SSRI adverse reactions?
Serotonin syndrome ( if they are not closely watched)
Aggitation, insomnia, headache, nervousness, sedation, tremor
Nausea / Vomiting
Anorgasmia in both men and women
Ejaculatory disturbances in men
Paroxetine is?
Paxil
The duration of pharmacotherapy of Benzo’s is anticipated to be ________ or less - because of its dependance effect
6 weeks
Benzodiazepines class?
Anxiolytic Class
Benzodiazepines contraindications?
trilazolam (Halcion) and aprazolam (Xanax) reacts with ketoconazole (hepatic)
Concern with history of depression / suicidal ideation
SNRIs: Usually somewhat _____ with the SNRIs in comparison to the SSRIs.
milder
____________________ have improved potency and onset action
Non-tricyclic antidepressants
**do not take 6 weeks for theraputic effect, this one is way shorter **
Due to the active metabolites, Benzos can be placed into one of three groups based on its ?
HF
Benzos active metabolites might causes daytime withdrawal sxs. such as?
next dayrebound anxiety with prolonged usage
** watch for rebound- if they are stopped abruptly they may have more anxiety and more of a panic attack **
SSRI MOA?
Selectively inhibit 5-HT neuronal reuptake at selected nerve terminals in the CNS and inhibit cytochrome P-450
block reuptake into the pre synaptic cleft
SSRIs have a weak or no effect on ______________ reuptake and ________
norepinephrine
dopamine
Benzos HL?
Half-life varies among the 12 US available drugs
Review page 288 half-life chart
Some half-life as much as 100 hours
older people and people with liver disease they may not be able to metabolize it off, maybe alcoholism patients the meds will last a lot longer in
Serotonin syndrome PE?
Mental changes include hypervigilance or insomnia and agitation
include metabolic acidosis, rhabdomyolysis- break down of muscle , seizures and renal failure
abnormalities such as hyperactive bowel sounds, high blood pressure and hyperthermia (HHH)
temperature as high as 40°C (104°F)
Seen in OD and MDMA’s (Ecstasy)
How long can it take for SSRIs to relieve depression?6
can take up to 6 weeks
** more than likely they have side effects and have to get off of it before the 6 weeks **
** this medicine has to be tapered off, high lack of compliance , once they are a therpautic levels they feel fine - if they want to stop to has to be slow and tapered **
SNRI examples?
venlafaxine (Effexor)
duloxetine (Cymbalta)
desvenlafaxine (Pristiq)
Benzodiazepines Prescribing considerations: Benzo overdose TX?
Flumazeril (Romazicon)
0.2 mg IV q min x 1 to 5 doses
- *this is the antidote to benzos
- *
flunitrazepam is?
Rohypnol
because of the ___________ availability of __________ at the receptors… it results in mood _________ and reduced _______
Increased availability of Serotonin at the receptors results in mood elevation and reduced anxiety
What Benzo is water soluble ?
Midazolam
Benzodiazepines Pharmacokinetics: Kidney?
excretion
Active metabolites increase the effective _______?
half-life
Benzos active metabolites have few residual effects if taken before ______, and rebound _________ may occur upon discontinuation
bedtime
insomnia
Benzodiazepines clinical uses?
Adjuvant for anesthesia
fentanyl and versad?
Anxiety disorders
Anticonvulsant
Muscle relaxant for spasticity disorders
Treatment of alcohol addiction and drug withdrawal
Sedative-Hypnotic, Insomnia
Sertraline is?
Zoloft
Escitalopram is?
Lexapro
Agents Used in the Treatment of Anxiety Disorder?
Benzodiazepines
Benzodiazepines Pharmacokinetics: mostly _____ _______ and thus it is taken orally
lipid soluble
SSRI HF?
Half-life 24 hours average
SSRI Pharmacokinetics: Kidney?
excretion
Xanax and Ativan crushed and snorted has no effect since they are __________.
not water soluble
Midazolam is injectable but it can also be given?
intranasal
**Versed is the only water soluble and we give it nasally and it is rapidly absorbed in the nasal mucosa **
Benzodiazepines : Long-acting compounds have a half-life of ___
40–250 hours
**longer acting more for muscle spasms
diazepam is?
Valium
SERT ?
human serotonin transporter (SERT)
Benzodiazepines adverse effects? cont
Rapid withdrawal may cause tremor, cramping, diaphoresis, seizures
Additive effect with other CNS depressants like opioids, alcohol or TCA’s
**if they are on high dosage and they abruptly stop it they can get tremors and seizures so listen to their history **
Benzodiazepines MOA?
Depress all levels of the CNS by enhancing the action of gamma-butyric acid (GABA)
**
increase chloride flow throw the GABA protein and there is more concentration inside the membrane
shuts down stimulation to the brain and limbic areas that does cause the anxiety **
Benzodiazepines : Intermediate-acting compounds have a median half-life of ___.
12–40 hours
What are SERT and NET?
membrane proteins that are responsible for the reuptake of serotonin and norepinephrine
SSRI Pharmacokinetics: Liver?
Significant first pass metabolism by liver
midazolam is?
Versed
Venlafaxine is?
Effexor
What are injectable Benzodiazepines ?
midazolam (Versed)
diazepam (Valium)
lorazepam (Ativan)
_____ are more common the TCAs in the tx of MDD and anxiety disorders
SSRIs
**mainstream tx for depression - a lot safe, easier to dose, more common, less side effects **
Benzodiazepines pharmacokinetics: Absorption?
Well absorbed orally
diazepam onset 30-60 min
Peak effects usually occur in 1 to 2 hours
Duration last 2 to 3 hours
Given IM midazolam and lorazepam onset 1 to 5 min
Benzodiazepines : Short-acting compounds have a median half-life of ___.
1–12 hours
SNRIs ________ the concentration in the synaptic cleft of both _________ and __________ are more successful than single acting agents in the treatment of depression
increase
norepinephrine
serotonin
combination of both seem to be better than just the SSRI
Benzos MOA: ___________ ______ comes from increased action of ____, thereby decreases the effect of any neuronal excitation
Anxiolytic effect
GABA
**Primal emotions fear and anxiety frontal cortex Amygdala = excitation
Passion flower reuptake inhibitor**
What is the single most commonly prescribed psychotropic drug for anxiety
Benzodiazepines
Depression Drugs?
SSRIs
SNRIs
SSRI black box warning?
Increased suicide risk in children, adolescents, and young adults w/ major depressive or other psychiatric disorders
**while they are on it they can get these and if you abruptly stop it it can cause these exacerbations **
