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SELECTIVE SEROTONIN REUPTAKE INHIBITORS Flashcards

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1
Q

What is the class of drug that is considered first line in the treatment of depression?

A

Selective serotonin reuptake inhibitors (SSRI)

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2
Q

What are the two preferred selective serotonin reuptake inhibitors (SSRIs) as first line in the treatment of depression?

A

Fluoxetine

Citalopram

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3
Q

What is the selective serotonin reuptake inhibitor (SSRI) that is first line in the management of depression post myocardial infarction?

A

Sertraline

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4
Q

What are the common side effect of SSRIs?

A

Gastrointestinal symptoms including GI bleeding - most common

Increased anxiety, insomnia and agitation after starting SSRI

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5
Q

Which class of drug increases the likelihood of GI bleeding in a patient on SSRIs?

A

NSAIDs

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6
Q

Which class of drug should be prescribed to patient on SSRIs if they are also taking NSAIDs?

A

Proton pump inhibitors - eg omeprazole

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7
Q

Which two SSRIs have the highest propensity for drug interactions?

A

Fluoxetine

Paroxetine

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8
Q

Which SSRIs are particularly associated with QT interval prolongation?

A

Citalopram

Escitalopram

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9
Q

In which patients should citalopram be avoided?

A

Those who:

Have congenital long QT syndrome

Have pre-existing QT interval prolongation

Are currently on other medications that prolong QT interval

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10
Q

Other than citalopram and escitalopram, what commonly prescribed drugs are known to prolong QT interval?

A

Class 3 antiarrhythmics - Amiodarone and sotalol

Class 1a antiarrhythmics - Quinine and procainamide

Tricyclic antidepressants - Amitriptyline

Methadone

Chloroquine

Erythromycin

Haloperidol

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11
Q

Which SSRI should patients on antithrombotic agents such as warfarin or heparin be offered?

A

NICE guidelines recommends avoiding SSRIs in those patients on warfarin or heparin due to interactions. They should be offered mirtazapine instead (SNRI).

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12
Q

What are the drugs that should be avoided if possible if a patient is on SSRI, or conversely a patient being on which drugs may contraindicate starting them on a SSRI?

A

NSAIDs - avoid if possible or start on PPI

Warfarin/heparin - offer mirtazapine (SNRI) instead

Triptans - avoid SSRI

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13
Q

How long after starting a patient on a SSRI should the GP review them?

A

2 weeks - most patients

1 week - if under 30 or at an increased risk of suicide

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14
Q

If a patient has a good response to a SSRI, what is the minimum length of time that they should be continued on the medication to reduce chance of relapse?

A

6 months after remission

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15
Q

When stopping a SSRI, how should this be done?

A

Gradual dose reduction over a 4 week period

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16
Q

Which SSRI has a longer half life and therefore does not need gradual dose reduction over 4 weeks when stopping medication?

A

Fluoxetine

17
Q

Which SSRI has the highest incidence of discontinuation symptoms?

A

Paroxetine

18
Q

What are the discontinuation symptoms associated with SSRIs?

A

Increased mood change

Restlessness

Difficulty sleeping

Unsteadiness

Sweating

GI symptoms: pain, cramping, diarrhoea, vomiting

Paraesthesia

19
Q

What is the name of the syndrome associated with SSRI overdose or toxicity?

A

Serotonin syndrome

20
Q

What is serotonin syndrome?

A

A collection of symptoms that results from serotonin build up in the CNS, which usually results from an interactions between two drugs (often an SSRI and another antidepressant such as MOAI). Symptoms include restlessness, tremor, shivering, myoclonus, hyperreflexia, confusion, convulsions and possibly death.

21
Q

What are the features of serotonin syndrome?

A

Restlessness

Tremor

Myoclonus

Hyperreflexia

Confusion

Convulsions

Hyperthermia

Shivering

Serotonin syndrome can be fatal

22
Q

How do we treat someone with serotonin syndrome?

A

Stop drug

Monitor and manage hydration and haemodynamics with fluids

Symptomatic relief of agitation with benzodiazepines

Moderate: Cyproheptadine is a 5HT-2A antagonist which is useful in the acute patient.

Severe: need aggressive treatment and intensive care with early sedation, neuromuscular paralysis and ventilatory support.

23
Q

A 54-year-old man attends his GP. He was started on fluoxetine eight weeks ago for depression and is now requesting to stop his medication as he feels so well. What should be recommended regarding his treatment?

It should be stopped straight away

It should be continued for at least another 6 weeks

It should be continued for at least another 3 months

It should be continued for at least another 6 months

It should be continued for at least another 12 months

A

It should be continued for at least another 6 months

This greatly reduces the risk of relapse. Patients should be reassured that antidepressants are not addictive.

24
Q

A 25-year-old man comes for review of his depression. He has now been taking fluoxetine 20mg od for 4 weeks with no effect on his symptoms. It is decided to switch him to citalopram. How should this be done?

Withdraw fluoxetine with commencement of citalopram the next day

2 week period of overlapping the drugs

Wait 1 week after withdrawing fluoxetine before commencing citalopram

1 week period of overlapping the drugs

Wait 2 weeks after withdrawing fluoxetine before commencing citalopram

A

Wait 1 week after withdrawing fluoxetine before commencing citalopram

25
Q

What are the guidelines regarding switching from a SSRI (apart from fluoxetine) to another SSRI?

A

The first SSRI should be withdrawn through gradual dose reduction before the alternative SSRI is started

26
Q

What are the guidelines regarding switching from fluoxetine to another SSRI?

A

Withdraw then leave a gap of 4-7 days (as it has a long half-life) before starting a low-dose of the alternative SSRI

27
Q

What are the guidelines regarding switching from a SSRI (apart from fluoxetine) to a tricyclic antidepressant?

A

Cross-tapering is recommended - the current drug dose is reduced slowly, whilst the dose of the new drug is increased slowly.

28
Q

What are the guidelines regarding switching from fluoxetine to a tricyclic antidepressant?

A

Should be withdrawn prior to starting TCA

psych (17 decks)

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