Section III. Pharmacological Treatment Flashcards
List first line antidepressants [15]:
- Agomelatine
- Bupropion
- Citalopram
- Desvenlafaxine
- Duloxetine
- Escitalopram
- Fluoxetine
- Fluvoxamine
- Mianserin
- Milnacipran
- Mirtazepine
- Paroxetine
- Sertraline
- Venlafaxine
- Vortioxetine
List 2nd line antidepressants [7]:
- Amitriptyline
- Levomilnacipran
- Moclobemide
- Quetiapine
- Selegiline transdermal
- Trazodone
- Vilazodone
List 3rd line antidepressants [3]:
- Phenlezine
- Tranylcypromine
- Reboxetine
Poor response to medication linked to [3]:
- increasing age
- Presence of anxiety
- Long episode duration
What is the suggested treatment for MDD with anxious distress?
Antidepressant with efficacy in GAD (no difference between SSRIs, SNRIs, and Bupropion - Level 2 evidence)
What is the suggested treatment for MDD with catatonic features?
Benzos (Level 3)
What is the suggested treatment for MDD with melancholic features?
No specific antidepressants show superiority (Level 2)
Studies done with TCAs & SNRIs
What is the suggested treatment for MDD with atypical features?
No specific antidepressants show superiority (Level 2)
Older studies show MAOIs superior to TCAs
What is the suggested treatment for MDD with psychotic features?
Use antipsychotic + antidepressant co-treatment (Level 1)
What is the suggested treatment for MDD with mixed features?
Lurasidone (Level 2)
Ziprasidone (Level 3)
What is the suggested treatment for MDD with seasonal patter?
No antidepressants have shown superiority (Level 2 & 3)
Can consider SSRIs, agomelatine, Bupropion, moclobemide
What is the suggested treatment for MDD with cognitive dysfunction?
Vortioxetine (Level 1)
Bupropion (Level 2)
Duloxetine (Level 2)
SSRIs (Level 2)
Moclobemide (Level 3)
What is the suggested treatment for MDD with sleep disturbances?
Agomelatine (Level 1)
Mirtazapine (Level 2)
Quetiapine (Level 2)
Trazodone (Level 2)
What is the suggested treatment for MDD with somatic symptoms?
Duloxetine for pain (Level 1)
Duloxetine for energy (Level 2)
Other SNRIs for pain (Level 2)
Bupropion for fatigue (Level 1)
SSRIs for fatigue (Level 2)
Which medication results in improved processing speed, executive control, and cognitive control?
Vortioxetine
Which antidepressants show superior response in treating MDD?
Escitalopram (Level 1)
Mirtazepine (Level 1)
Sertraline (Level 1)
Venlafaxine (Level 1)
Agomelatine (Level 2)
Citalopram (Level 2)
Which antidepressants show (low quality) evidence of lower risk for sexual side effects [5]?
Agomelatine
Bupropion
Mirtazepine
Vilazodone
Vortioxetine
which medication might have increased risk of suicide [ Black Box morning]?
Paroxetine
what % of adults had reduced risk of suicide went on SSRI?
reduced by:
- 40% in adults
- 50% among elderly people
Exposure to SSRI almost _______ the risk of suicide and suicide attempts among teenagers
Why?
Doubles
Possibly because only the most severely ill teens are prescribed antidepressants to begin with
Which antidepressants require monitoring for prolonged QTC?
- Citalopram
- Escitalopram
- Quetiapine
but our normal ranges for QTC?
normal QT interval is:
- less than 450 ms in men
- less than 460 ms in women
what type of medication which increased risk of falls and fractures?
SSRI
which time frame is a person at increased risk for falls and fractures with an SSRI?
Highest risk is in the first six weeks of SSRI exposure
what antidepressant is hyponatraemia often associated with, particularly in elderly patients?
SSRI
How do SSRIs affect bleeding and clotting?
SSRIs inhibit platelet aggregation by altering platelet serotonin receptors
Therefore, modest increase in risk of GI bleeding
What common OTC medication increases risk of G.I. bleeding when also on SSRIs?
NSAIDs
Should you regularly monitor LFTs when on antidepressant medication?
For which medication in particular should you consider monitoring LFTs?
No, elevation of liver enzymes is uncommon
However, agomelatine can potentially elevate liver enzymes and in some cases, lead to toxic hepatitis
True or false, CANMAT recommends routine use of pharmacogenetics testing
False.
How do you define “early improvement” when starting an antidepressant?
> 20-30% reduction in symptoms from baseline in a depression rating scale after 2 to 4 weeks
how soon might a patient show positive response and even remission with early improvement after starting an antidepressant?
6 to 12 weeks
when should you increase the antidepressant dose for “non-improvers”?
2 to 4 weeks if medication is tolerated
what are the two faces of depression treatment and their definitions?
- Acute treatment [getting to symptomatic remission]
- Maintenance phase [preventing relapse and recurrence]
What duration of time do the guidelines recommend to continue treatment?
And he treated with anti-depressants for 6 to 9 months after teething symptomatic remission
However, those with risk factors for recurrence should have antidepressant treatment extended to 2 years or more
What are the symptoms of discontinuation syndrome/symptoms?
FINISH
Flu-like sxs
Insomnia
Nausea
Imbalance
Sensory disturbances
Hyperarousal
What factors should you consider to maintain treatment with antidepressants for longer than two years? [6]
- Frequent, recurrent episodes
- Severe episodes [psychosis, severe impairment, suicidality]
- Chronic episodes
- Presence of comorbid psychiatric or other medical conditions
- Presence of residual symptoms
- Difficult-to-treat episodes
which medication’s are most likely to be associated with discontinuation effects? [2
- Immediate release paroxetine
- Immediate release Venlafaxine
Which medication’s are least likely to result in discontinuation syndrome and why? [2]
- Fluoxetine
- Vortioxetine
Due to long half-life
what is considered partial response to anti-depressants?
Partial response is 25 to 49% reduction in symptoms scores
what is considered no response to antidepressants?
Less than 25% reduction in symptoms scores is considered a no response outcome
List the first line adjunctive medications for treatment of depression [3]
Aripiprazole
Quetiapine
Risperidone
** all level 1 evidence
List the second line recommended medication’s for adjunct treatment of depression [7]
- Brexpiprazole (level 1)
- Bupropion (level 2)
- Lithium (level 2)
- Mirtazepine (level 2)
- Modafinil (level 2)
- Olanzapine (level 1)
- Triiodothyronine (level 2)
List the third line recommended objective agents for treatment of depression [4]
- Other antidepressants (level 3)
- Other stimulants (methylphendiate, lisdexamphetamine, etc.) (level 3)
- TCAs (level 2)
- Ziprasidone (level 3)
In the CANMAT guidelines, what level 1 evidence medication is suggested as an adjunct for non-response depression treatment?
Ketamine
True or false – adjunctive aripiprazole was inferior to antidepressant switch on efficacy outcomes, including response and remission
False - adjunct of aripiprazole was superior to anti-depressants which
What 5 steps should you take when considering switching to another antidepressant?
- It is the first antidepressant trial
- There are poorly tolerated side effects to the initial antidepressant
- There is no response [<25% improvement] to the initial antidepressant
- There is more time to wait for a response [less severe, less functional impairment]
- Patient prefers to switch to another antidepressant
What are the factors to consider when considering adding an adjunctive medication for treatment of depression [6]?
- There have been 2+ antidepressant trials
- The initial antidepressant is well tolerated
- There is partial improvement [> 25% improvement] to the initial antidepressant
- There are specific residual symptoms or side effects to the initial antidepressant that can be targeted
- There is less time to wait for a response [more severe, more functional impairment]
- Patient prefers to add on another medication
