Segars Antidepressants and Mood Stabilizers Flashcards
SSRIs work by?
Whats the result?
- inhibit pre-synaptic reuptake of Serotonin (via SERT)
- results in enhanced, prolonged serotonergic neurotransmission to post-synaptic receptors
Do TCAs or SSRIs have more side effects?
-TCAs affect more side effects
What are the 5 side effects of SSRIs?
- Sexual dysfunction
- GI issues
- CNS sedation or insomnia
- weight gain/loss
- QT prolongation
What are the acute withdrawal symptoms of SSRIs or all categories of antidepressants for that matter?
How do we avoid this?
- flu like symptoms (Malaise, lethargy, generalized aches)
- taper patients off when switching drugs or stopping drugs
- patients if they forget to take a dose look and feel like death, which is a good thing for compliance I guess
Sweating, Hyperreflexia, Akathisia/Myoclonus, Shivering/Tremors….what is this?
what causes this?
- Serotonin Syndrome
- Patients on SSRIs or any drugs that affect serotonin
What’s the most serious effect of SSRIs that was even worse with the TCAs?
how to avoid?
- suicide, when patients take all of their drug at once. Drinking alcohol makes death even more likely
- avoid this w/ frequent follow up and asking them suicide questions
NMS: Neuroleptic Malignant syndrome
What drugs cause it?
what is it?
treatment?
-seen w/ dopaminergic antipsychotics
-HYPO-reflexia
NORMAL pupils
NORMAL/decreased bowel sounds
-Treatment is GIVING drug dantrolene
Serotonin Syndrome
what causes it?
what is it?
treatment?
-SSRIs, SNRIs, SARAs, TCAs
-HYPER-reflexia
Clonus
DILATED pupils
HYPER-active bowels
-treatment is stopping the drugs
What is the strongest SSRI with high risk of drug-drug CYP450 interaction?
-fluoxetine (broad and strong inhibitor)
What are the SSRIs are least likely to of drug drug CYP450 interaction?
- Citalopram
- Sertraline
- these are mild inhibitors
Difference between secondary and tertiary TCA SNRIs?
- secondary inhibit NE> 5-HT
- Tertiary inhibit NE=5-HT
How do SNRIs work?
-selectively inhibit the pre-synaptic reuptake of serotonin (via SERT) and Norepi (via NET)
Name 3 secondary TCAs
DAN
- Despiramine
- Amoxapine
- Nortriptyline
Name 4 tertiary TCAs
DACI
- Doxepin
- Amitriptyline
- Clomipramine
- Imipramine
ALL TCAs Desvenlafaxine Duloxetine Venlafaxine Levomilnacipran
SNRIs
SNRIs + DA
Amoxapine
Classic TCA side effects?
-3 Cs
Cardiotoxicity (conduction abnormalities)
Coma
Convulsion
What is the “Quinidine-like” effect?
- TCA overdose
- Class 1 antiarrhythmic
- prolongs QRS complex
- slows down phase 0 depolarization
- Na channel blockade
NON-TCA SNRIs have?
-fewer side effects
Which SARAs act like SSRIs?
how do they work?
- trazodone
- Nefazodone
-act like SSRIs and selectively block post-synaptoc a1 receptors on noradrenergic (NE) neurons and post synaptic 5-HT 2a
How does the SARA Mirtazapine work?
- selectively blocks pre-synaptic a2 receptors on noradrenergic (NE) and serotonergic (5HT) neurons
- has no SERT/NET activity
How do NDRIs work?
example?
- inhibits pre-synaptic reuptake of Norepi (via NET) and dopamine (via DAT)
- some evidence of enhancing pre-synaptic release of NE and DA
- Buproprion
What are side effects of the SARAs?
- CNS depression (Traz/Mir)
- orthostatic hypotension (Traz)
- weight gain (Mirt)
side effects of buproprion which are generally stimulating?
- agitation
- insomnia
- weight loss (from depression probably)
- seizure
How do MAOIs work?
Are oral agents reversible or irreversible?
- inhibition of MAO (A/B) increases levels of monoamines in neuronal vesicles and increase amounts of NE, 5-HT, and DA released
- irreversible
Phenelzine
Isocarboxazid
Tranylcypromine
Selegiline
MAOIs
Which MAOI comes in patch form?
How does it work?
How strong is it?
- selegiline
- B-selective unless at high dose
- it is the safest MAOI
Side effects of MAOIs?
- orthstatic hypotension
- sexual dysfunction
- weight gain
- insomnia/agitation/nervousness
What syndrome and crisis can be caused by MAOIs?
- serotonin syndrome
- hypertensive crisis
What must happen before starting a patient on an MAOI?
- must be off other therapies due to the risk of serotonin syndrome or hypertensive crisis
- be careful starting MAOIs after giving fluoxetine because it takes 5 weeks to leave system instead of the average 2 weeks
What is the cause of MAOI hypertensive crisis?
which MAOI probably wont cause this?
- inhibition of MAO-A in the GI leading to a buildup of tyramine
- Selegiline probably wont cause this because it minimally blocks MAO-A in the GI tract
-eating wine and cheese followed by……
headache, vomit/nausea, sweating, nosebleed, tachycardia, chest pain, vision change, SOB, confusion….is what?
-MAOI hypertensive crisis
What class of drugs most likely causes anticholinergic effects?
examples?
- TCAs
- Clomipramine and amitriptyline
What class of drugs most likely causes drowsiness?
what two random exceptions do too?
-TCAs
ie Amitriptyline and Clomipramine
- exceptions
- atypical agent: Mirtazapine
- SARA: Trazodone
What classes of drugs most likely causes insomnia/agitation?
- SSRI: fluox and Sert
- atypical: Buproprion
- SARA: Vilazodone
- TCA: Amoxapine
- MOAI: Trany and Isocarb
What classes of drugs most likely cause orthostatic hypotension?
- > > TCAs: >Imipramine and < Nortriptyline
- MAOI: phenelzine
- SARA: Trazodone
What classes of drugs most likely cause QT prolongation?
-»TCAs
What classes of drugs most likely cause weight gain?
-»TCAs
…nortriptyline and deslpramine have lowest risk
-atypical: mirtazapine
What classes of drugs most likely cause Sexual dysfunction?
- > > SSRIs
- TCAs
- MAOI (not selegeline)
How long does depression therapy take to work?
- takes weeks
- in about 3-4 weeks you usually see 50% reduction in symptoms
Single agent treatment rarely/always achieves remission
-rarely
When do you bail out on a drug?
-8-9 weeks without improvement
All depression drugs must be _______ when taking a patient off of them
-titrated downward
Carbamazepine
Lamotrigine
Divalproate/Valproic Acid
Anti-Seizure agents used for mood stabilizers
How does lithium work?
- inhibits calcium dependent and depolarization provoked release of NE and DA
- inhibits G protein receptors both Gi and Gs
Side effects of Lithium?
How?
- polyuria (polydipsia)
- Nephrogenic Diabetes Insipidus!!!!
-Li competes with Na in the kidneys for reabsorption
Why isn’t Lithium used?
- diabetes insipidus
- NARROW theraputic window
What drugs interact with Lithium
- ACEIs
- NSAIDs (>lisinopril)
- Diuretics (> thiazides)
Lithium can be used for what?
- acute phase and maintenance of mania/bipolar 1 disorder
- augmentation in unipolar depression
- off label: like clozapine it reduces risk of suicide
Carbamazepine is used for what?
-acute and maintenance TX for acute mania and mixed episodes (Bipolar 1)
What is Carbamazepine dangerous?
-major CYP450 inducer
What does Lamotrigine treat?
-only maintenance of Bipolar 1 and 2
What does Divalproex/valproic acid treat?
-acute Bipolar w/o psychotic features
