Psychopharmacologic Therapy Flashcards
What is monoamine oxidase? What are its two
subtypes?
Monoamine oxidase is an enzyme that is primarily found on the
outer membranes of mitochondria. Through oxidative
deamination, it serves to inactivate serotonin, dopamine,
epinephrine, and norepinephrine. The subtypes are MAO-A
and MAO-B. MAO-A selectively deaminates epinephrine,
norepinephrine, and serotonin, whereas MAO-B deaminates
phenylethylamine.
Stoelting RK, Hillier SC. Pharmacology and Physiology in
Anesthetic Practice. Philadelphia, PA: Lippincott Williams and
Wilkins; 2006: 405
What drugs interact adversely with MAOIs? What is
the result of these interactions?
Selective serotonin reuptake inhibitors (SSRIs), opioids, tricyclic
antidepressants, and sympathomimetic drugs. Interactions with
these drugs can result in seizures, hypertension, excitation of
the central nervous system, delirium and death.
Stoelting RK, Hillier SC. Pharmacology and Physiology in
Anesthetic Practice. Philadelphia, PA: Lippincott Williams and
Wilkins; 2006: 407.
What dietary restrictions are imposed on patients
taking monoamine oxidase inhibitors (MAOIs)?
What foods fall into this category?
Patients taking MAO inbitors must adhere to a tyramine-free
diet. This includes liver, cheese, avocados, fava beans, red
wine, tap beer, dried sausages, and smoked or pickled fish.
Stoelting RK, Hillier SC. Pharmacology and Physiology in
Anesthetic Practice. Philadelphia, PA: Lippincott Williams and
Wilkins; 2006: 405.
Katzung BG, Masters, SB, & Trevor AJ. Basic and Clinical
Pharmacology. 12th ed. New York: McGraw-Hill; 2012: 537.
List side effects associated with the use of lithium.
Renal impairment (evidenced by polyuria and polydipsia),
hypothyroidism, ECG changes (flattened T waves or inverted T
waves), hand tremors, dermatologic disturbances, memory loss,
slowed cognitive function, edema
Katzung BG, Masters, SB, & Trevor AJ. Basic and Clinical
Pharmacology. 12th ed. New York: McGraw-Hill; 2012: 516-517.
What drugs can cause an increase in the plasma
concentration of lithium?
Thiazide diuretics, nonsteroidal anti-inflammatory drugs
Katzung BG, Masters, SB, & Trevor AJ. Basic and Clinical
Pharmacology. 12th ed. New York: McGraw-Hill; 2012: 516.
What is the drug class of choice for the treatment of mild to moderate depression?
Selective serotonin reuptake inhibitors (SSRIs)
Stoelting RK, Hillier SC. Pharmacology and Physiology in
Anesthetic Practice. Philadelphia, PA: Lippincott Williams and
Wilkins; 2006: 399.
How does dehydration affect patients taking lithium?
Dehydration causes an increase in the plasma concentration of
lithium by as much as 50% due to an increase in the
reabsorption of lithium by the proximal renal tubules.
Stoelting RK, Hillier SC. Pharmacology and Physiology in
Anesthetic Practice. Philadelphia, PA: Lippincott Williams and
Wilkins; 2006: 409
How is lithium excreted?
Lithium is excreted by the kidneys.
Stoelting RK, Hillier SC. Pharmacology and Physiology in
Anesthetic Practice. Philadelphia, PA: Lippincott Williams and
Wilkins; 2006: 408.
If a patient who is taking an SSRI fails to tolerate or
respond to the drug, why should another SSRI be
tried before moving to a different class of drugs?
Each SSRI has different side-effect profiles, therefore patients
who do not respond favorably to one SSRI may have a different
outcome if placed on a different SSRI.
Stoelting RK, Hillier SC. Pharmacology and Physiology in
Anesthetic Practice. Philadelphia, PA: Lippincott Williams and
Wilkins; 2006: 399.
What are the signs and symptoms of an MAOI
overdose?
Tachycardia, mydriasis, hyperthermia, coma, and seizures.
Stoelting RK, Hillier SC. Pharmacology and Physiology in
Anesthetic Practice. Philadelphia, PA: Lippincott Williams and
Wilkins; 2006: 407.
What advantages do SSRIs possess over tricyclic
antidepressants?
SSRIs do not produce postural hypotension, they do not have
anticholinergic properties, and there is a wider safety margin
when taken in excess.
Stoelting RK, Hillier SC. Pharmacology and Physiology in
Anesthetic Practice. Philadelphia, PA: Lippincott Williams and
Wilkins; 2006: 399.
What happens when a patient taking MAOIs for
depression ingests food containing tyramine?
A hyperadrenergic crisis can occur. Patients taking MAOIs
cannot metabolize dietary tyramine and other monoamines.
They enter the systemic circulation, are taken up by nerve
endings of the sympathetic nervous system, and cause a
massive release of endogenous catecholamines. The resulting
hyperadrenergic crisis is characterized by hyperpyrexia, high
blood pressure, and cerebrovascular accident.
Stoelting RK, Hillier SC. Pharmacology and Physiology in
Anesthetic Practice. Philadelphia, PA: Lippincott Williams and
Wilkins; 2006: 407.
What MAOI is used in the treatment of Parkinson’s
disease?
Selegiline
Stoelting RK, Hillier SC. Pharmacology and Physiology in
Anesthetic Practice. Philadelphia, PA: Lippincott Williams and
Wilkins; 2006: 406.
What is the most common adverse side effect of
MAOIs?
Orthostatic hypotension
Stoelting RK, Hillier SC. Pharmacology and Physiology in
Anesthetic Practice. Philadelphia, PA: Lippincott Williams and
Wilkins; 2006: 406.
What are the names of the three MAOIs used in the
United States?
Selegiline, tranylcypromine, phenelzine
Stoelting RK, Hillier SC. Pharmacology and Physiology in
Anesthetic Practice. Philadelphia, PA: Lippincott Williams and
Wilkins; 2006: 405.
List side effects associated with the use of MAOIs
Weight gain, orthostatic hypotension, sexual dysfunction,
restlessness, insomnia, and confusion. Sedation can be seen
in patients taking phenelzine.
Katzung BG, Masters, SB, & Trevor AJ. Basic and Clinical
Pharmacology. 12th ed. New York: McGraw-Hill; 2012: 536.
What is the mechanism of action of MAOIs?
MAOIs increase the availability of neurotransmitters in the
peripheral autonomic nervous system and the central nervous
system by blocking the enzyme (monoamine oxidase)
responsible for their metabolism.
Stoelting RK, Hillier SC. Pharmacology and Physiology in
Anesthetic Practice. Philadelphia, PA: Lippincott Williams and
Wilkins; 2006: 405.
How does lithium affect the kidneys?
Lithium inhibits the formation of intracellular adenosine
monophosphate in the renal tubules. This results in an
impaired renal-concentrating ability that can produce polyuria
and polydipsia.
Sandberg WS, Urman RD, Ehrenfield JM. The MGH Textbook
of Anesthetic Equipment. Philadelphia, PA: Elsevier Saunders;
2011: 408.
Tricyclic antidepressants are structurally similar to
what two classes of drugs?
Phenothiazines and local anesthetics.
Stoelting RK, Hillier SC. Pharmacology and Physiology in
Anesthetic Practice. Philadelphia, PA: Lippincott Williams and
Wilkins; 2006: 401.
What are the signs and symptoms of a tricyclic
antidepressant overdose?
Agitation and seizures that progress to coma, hypotension,
depressed ventilation, hypothermia, widened QRS complexes,
and anticholinergic effects (tachycardia, mydriasis, urinary
retension, and flushed dry skin).
Stoelting RK, Hillier SC. Pharmacology and Physiology in
Anesthetic Practice. Philadelphia, PA: Lippincott Williams and
Wilkins; 2006: 404.
What is the most likely cause of death from an
overdose of tricyclic antidepressants?
Ventricular dysrhythmias and intractable myocardial depression
Stoelting RK, Hillier SC. Pharmacology and Physiology in
Anesthetic Practice. Philadelphia, PA: Lippincott Williams and
Wilkins; 2006: 405.
What withdrawal symptoms accompany the sudden
discontinuation of high doses of tricyclic
antidepressants?
Chills, malaise, skeletal muscle aching, coryza.
Stoelting RK, Hillier SC. Pharmacology and Physiology in
Anesthetic Practice. Philadelphia, PA: Lippincott Williams and
Wilkins; 2006: 404.
What drugs may interact negatively in a patient
taking tricyclic antidepressants?
Anticholinergics, opioids, sympathomimetics, inhaled
anesthetics, and antihypertensives. The catecholamine uptake
blocking properties and anticholinergic effects of tricyclic
antidepressants are responsible for these drug interactions.
Stoelting RK, Hillier SC. Pharmacology and Physiology in
Anesthetic Practice. Philadelphia, PA: Lippincott Williams and
Wilkins; 2006: 403.
What are the central nervous system effects of
tricyclic antidepressants?
Sedation, lowered seizure threshold, fatigue, and weakness.
Fine tremors are seen in approximately 10% of patients treated
with tricyclic antidepressants.
Stoelting RK, Hillier SC. Pharmacology and Physiology in
Anesthetic Practice. Philadelphia, PA: Lippincott Williams and
Wilkins; 2006: 403.
List the cardiovascular effects caused by the use of
tricyclic antidepressants.
Tachycardia, orthostatic hypotension, and depressed
conduction through the atria and ventricles. This depressed
conduction results in flattened T waves, increased P-R
intervals, and widened QRS complexes.
Stoelting RK, Hillier SC. Pharmacology and Physiology in
Anesthetic Practice. Philadelphia, PA: Lippincott Williams and
Wilkins; 2006: 403.
- What tricyclic antidepressant produces the highest
incidence of anticholinergic effects? 2. Which
tricyclic antidepressant is associated with the least?
- Amitriptyline 2. Desipramine
Stoelting RK, Hillier SC. Pharmacology and Physiology in
Anesthetic Practice. Philadelphia, PA: Lippincott Williams and
Wilkins; 2006: 402.
How is lithium toxicity treated in a patient with
adequate renal function?
Osmotic diuretics and IV sodium bicarbonate. Severe lithium
toxicity is a medical emergency and may require hemodialysis.
Stoelting RK, Hillier SC. Pharmacology and Physiology in
Anesthetic Practice. Philadelphia, PA: Lippincott Williams and
Wilkins; 2006: 409.
List the anticholinergic effects associated with the
use of tricyclic antidepressants.
Tachycardia, dry mouth, urinary retention, ileus, blurred vision,
slowed gastric emptying.
Stoelting RK, Hillier SC. Pharmacology and Physiology in
Anesthetic Practice. Philadelphia, PA: Lippincott Williams and
Wilkins; 2006: 402.
How long does the comatose phase of an overdose
from tricyclic antidepressants last?
24 to 72 hours
Stoelting RK, Hillier SC. Pharmacology and Physiology in
Anesthetic Practice. Philadelphia, PA: Lippincott Williams and
Wilkins; 2006: 404.
Which SSRI is more similar to a tricyclic
antidepressant in regards to side effects and
increased overdose risks?
Venlafaxine.
Stoelting RK, Hillier SC. Pharmacology and Physiology in
Anesthetic Practice. Philadelphia, PA: Lippincott Williams and
Wilkins; 2006: 399.
Name 10 SSRIs.
Trazadone, Nefazodone, Sertraline, Fluoxetine, Bupropion,
Escitalopram, Citalopram, Fluvoxamine, Paroxetine, Venlafaxine
Stoelting RK, Hillier SC. Pharmacology and Physiology in
Anesthetic Practice. Philadelphia, PA: Lippincott Williams and
Wilkins; 2006: 399.
What is the most common reason for noncompliance
with an SSRI?
Sexual dysfunction
Stoelting RK, Hillier SC. Pharmacology and Physiology in
Anesthetic Practice. Philadelphia, PA: Lippincott Williams and
Wilkins; 2006: 400.
Describe common side effects associated with the
use of SSRIs.
Agitation, headache, diarrhea, nausea, insomnia, sexual
dysfunction
Stoelting RK, Hillier SC. Pharmacology and Physiology in
Anesthetic Practice. Philadelphia, PA: Lippincott Williams and
Wilkins; 2006: 399-400.
Name 6 tricyclic antidepressants.
Nortriptyline, Doxepin, Protriptyline, Imipramine, Desipramine,
Amitriptyline
Stoelting RK, Hillier SC. Pharmacology and Physiology in
Anesthetic Practice. Philadelphia, PA: Lippincott Williams and
Wilkins; 2006: 402.
What is the advised period of time to taper tricyclic
antidepressants?
Discontinuation of tricyclic antidepressants should be tapered
over a 4 week period.
Stoelting RK, Hillier SC. Pharmacology and Physiology in
Anesthetic Practice. Philadelphia, PA: Lippincott Williams and
Wilkins; 2006: 401.
What two tricyclic antidepressants are useful in the
treatment of chronic neuropathic pain?
Imipramine and amitriptyline
Stoelting RK, Hillier SC. Pharmacology and Physiology in
Anesthetic Practice. Philadelphia, PA: Lippincott Williams and
Wilkins; 2006: 401.
What are the signs and symptoms of lithium toxicity?
The signs and symptoms of lithium toxicity correlate with the
plasma concentrations of the drug. Sedation, skeletal muscle
weakness, ECG changes, and nausea are seen with mild
lithium toxicity. When the plasma concentration of lithium is
greater than 2 mEq per liter, hypotension, dysrhythmias, heart
block, and seizures may occur.
Stoelting RK, Hillier SC. Pharmacology and Physiology in
Anesthetic Practice. Philadelphia, PA: Lippincott Williams and
Wilkins; 2006: 409.
