Segars Antidepressants and Mood Stabilizers Flashcards by Stephen Tulley

SSRIs work by?

Whats the result?

inhibit pre-synaptic reuptake of Serotonin (via SERT)

- results in enhanced, prolonged serotonergic neurotransmission to post-synaptic receptors

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Do TCAs or SSRIs have more side effects?

-TCAs affect more side effects

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What are the 5 side effects of SSRIs?

Sexual dysfunction
GI issues
CNS sedation or insomnia
weight gain/loss
QT prolongation

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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

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Sweating, Hyperreflexia, Akathisia/Myoclonus, Shivering/Tremors….what is this?

what causes this?

Serotonin Syndrome

- Patients on SSRIs or any drugs that affect serotonin

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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

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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

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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

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What is the strongest SSRI with high risk of drug-drug CYP450 interaction?

-fluoxetine (broad and strong inhibitor)

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What are the SSRIs are least likely to of drug drug CYP450 interaction?

Citalopram
Sertraline
these are mild inhibitors

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Difference between secondary and tertiary TCA SNRIs?

secondary inhibit NE> 5-HT

- Tertiary inhibit NE=5-HT

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How do SNRIs work?

-selectively inhibit the pre-synaptic reuptake of serotonin (via SERT) and Norepi (via NET)

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Name 3 secondary TCAs

DAN

Despiramine
Amoxapine
Nortriptyline

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Name 4 tertiary TCAs

DACI

Doxepin
Amitriptyline
Clomipramine
Imipramine

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ALL TCAs
Desvenlafaxine
Duloxetine
Venlafaxine
Levomilnacipran

SNRIs

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SNRIs + DA

Amoxapine

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Classic TCA side effects?

-3 Cs
Cardiotoxicity (conduction abnormalities)
Coma
Convulsion

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What is the “Quinidine-like” effect?

TCA overdose
Class 1 antiarrhythmic
prolongs QRS complex
slows down phase 0 depolarization
Na channel blockade

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NON-TCA SNRIs have?

-fewer side effects

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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

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How does the SARA Mirtazapine work?

selectively blocks pre-synaptic a2 receptors on noradrenergic (NE) and serotonergic (5HT) neurons
has no SERT/NET activity

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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