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CNS > SSRIs, TCAs, MAOIs > Flashcards

SSRIs, TCAs, MAOIs Flashcards

1
Q

What is TCA?

A

Tricyclic antidepressants

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2
Q

Examples of sedating TCAs?

A
  • Amitriptyline
  • Clomipramine
  • Dosulepin (toxic in overdose)
  • Trazodone (serotonin uptake inhibitor)
  • Trimipramine
  • Doxepin
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3
Q

Who are sedating TCAs normally given to?

A

Agitated and anxious patients

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4
Q

Which TCAs are less sedating?

A
  • Imipramine
  • Lofepramine
  • Nortriptyline
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5
Q

Who are less sedating TCAs normally given to?

A

Withdrawn and apathetic patients

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6
Q

Which TCA has the most antimuscarinic side effect?

A

Imipramine

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7
Q

Examples of antimuscarinic side effects?

A
  • Dry mouth
  • Constipation
  • Urinary retention
  • Agitation
  • Drowsiness
  • Blurred vision
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8
Q

What are some contraindications of TCAs?

A
  • Manic phase of bipolar
  • Arrhythmias
  • Heart block
  • Immediate recovery period after M.I

Note that they are mainly CV related

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9
Q

What are the cautions for TCAs?

A
  • CV disease
  • Diabetes
  • Chronic constipation
  • Epilepsy
  • History of bipolar & psychosis
  • Hyperthyroidism (risk of arrhythmias)
  • Glaucoma
  • Urinary retention
  • Elderly
  • Prostatic hypertrophy
  • Increased intra-ocular pressure
  • Susceptibility to angle closure glaucoma

Stop medication if patient enters manic phase of bipolar

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10
Q

Why is there a caution with elderly and TCAs?
What must be done when being given to them?

A

Because they are more susceptible to side effects.
Give low doses and monitor

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11
Q

What are some common side effects for TCAs?

A

TCAs & D

T - toxicer in overdose than SSRIs
C - cardiac side effects
A - Antimuscarinic side effects
S - Seizures

And drowsiness

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12
Q

Give examples of cardiac side effects with TCAs?

A
  • QT prolongation
  • Heart block
  • Hypertension
  • Arrhythmias
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13
Q

Examples of antimuscarinic side effects?

A
  • Urinary retention
  • Drowsiness
  • Blurred vision
  • Dry mouth
  • Constipation

Can’t Pee, See, Spit and Shit.
- Agitation

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14
Q

What are the symptoms for Anticholinergic Syndrome?

A

ABCD S
- Anorexia
- Blurry vision
- Constipation
- Confusion
- Dry mouth
- Static urine

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15
Q

What are the signs of TCA overdose?

A
  • Dry mouth
  • Coma
  • Hypotension
  • Hypothermia
  • Convulsions
  • Arrhythmias
  • Dilated pupils
  • Urinary retention
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16
Q

Which TCA is less dangerous and has less side effects?

A

Lofepramine

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17
Q

Which TCAs should not be given for depression?

A

Amitriptyline & Dosulepin

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18
Q

Which TCAs are known to be dangerous in overdose?

A

Amitriptyline & Dosulepin

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19
Q

Which TCA is associated with Hepatoxicity?

A

Lofepramine

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20
Q

What are the cautions and contraindications for Lofepramine?

A

Caution in mild-moderate liver impairment

Avoid in severe liver impairment

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21
Q

What are the rules of TCA?

A

TCAs have a long half life, and so should be given once daily at night

Use doses that are high for effective treatment but not too high to be toxic.
But low doses should be used in elderly

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22
Q

Are TCAs effective in treating depression in children?

A

No.

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23
Q

Can TCA aggravate conditions?

A

Yes, esp mania.

24
Q

What are some common TCA interactions?

A
  • Lithium = increased risk of neurotoxicity
  • MAOIs = increased risk of severe toxicity and increased risk of serotonin syndrome
  • Antimuscarinic drugs, antipsychotics & antihistamines = increased antimuscarinic effects
  • Ephedrine = decreases the effects of Ephedrine
  • Phenylephrine = increases effect of Phenylephrine
  • Blood pressure tablets (e.g. CCB, ACEI) = Increased hypotension
  • Diuretics = Increased risk of hyponatremia & hypotension
  • Carbamazepine = Increased hyponatremia
  • SSRI, Sumariptian, MAOI, tramadol = increased risk of serotonin syndrome
  • Antipsychotics, theophylline, amiodarone, sotalol, B2 agonists, citalopram, corticosteroids = increased risk of QT interval prolongation
25
Q

How long should you wait to use a TCA after stopping a MAOI?

A

Avoid for 2 weeks after stopping MAOIs

26
Q

What are SSRIs? And what do they do?

A

Selective serotonin reuptake inhibitors

They selectively inhibit the re-uptake of serotonin

27
Q

Give examples of SSRIs?

A
  • Citalopram
  • Escitalopram
  • Fluoxetine
  • Fluvoxamine
  • Paroxetine
  • Sertraline
28
Q

Which SSRIs can cause QT prolongation?

A
  • Citalopram
  • Escitalopram
  • Fluoxetine
29
Q

Which TCA has a higher withdrawal?

A

Paroxetine

30
Q

Which TCA can be used in children?

A

Fluoxetine (prozac)
Safe for children from 5 years old (5-7 years is unlicensed) but risk of self-harm.

31
Q

Which TCA is safe to use in angina and MI?

A

Sertraline

32
Q

What is first line for antidepressants? And why?

A

SSRIs because they are better tolerated and safer in overdose

They are also safe in patients with unstable angina and recent myocardial infarction

33
Q

What are the contraindications of SSRIs?

A
  • Poorly controlled epilepsy
    (discontinue if convulsions occur)
  • Manic phase
34
Q

What are the cautions of SSRIS?

A
  • CVD
  • Diabetes
  • Epilepsy
  • History of bleeding disorder (esp G.I bleeding)
  • History of mania
  • Susceptibility to angle glaucoma
35
Q

What are the withdrawal symptoms of SSRIs?

A
  • GI disturbances, headache, anxiety
  • Dizziness, electric shock sensation in the head, neck and spine
  • Tinnitus, sleep disturbances, influenza-like symptoms, sweating
  • Palpitations and visual disturbances (occur less)
36
Q

What is the MHRA/CSM advice with SSRIs/SNRI?

A
  • There’s a small risk of postpartum haemorrhage when used in the month before delivery
  • SSRIs increase risk of bleeding due to effects on platelet function
  • Risk is more significant in patients with other risk factors for bleeding disorders
  • Anticoagulant medication in women at high risk of thrombotic events should NOT be stopped, but prescribers should be aware of risk
37
Q

What are the side effects of SSRIs?

A
  • Hyponatraemia
  • Anxiety
  • Arrhythmias
  • Confusion
  • Drowsiness
  • Constipation
  • QT interval prolongation
  • Dry mouth
  • Skin reaction
  • Nausea
  • Less sedating and fewer antimuscarinics effect than TCAs
38
Q

Can SSRIs be used in pregnancy?

A
  • Avoid in pregnancy unless benefit outweighs the risk.
    This is because there’s a small risk of congenital heart defects when taken in early pregnancy
  • In 3rd trimester there is a risk of neonatal withdrawal symptoms and persistent pulmonary hypertension in new-borns
39
Q

What are some SSRI interactions?

A

NSAIDs, antiplatelets, anticoagulants, thrombolytics (like alteplase), phenindione = increased risk of bleeding

Antiplatelets = GI bleeds risk

Phenytoin = Sertraline increases risk of toxicity

Antipsychotics, antimalarials, amiodarone, sotalol = QT interval prolongation, leads to arrhythmias and cardiac death

Theophylline, diuretics, beta2agonists = increases risk of QT prolongation by causing hypokalaemia which increases risk of torsades de pointes

NSAIDs, diuretics, carbamazepine = Hyponatraemia

Tramadol, sumatriptan, ondansetron (5HT antagonist), St John wart = Increases risk of serotonin syndrome

40
Q

What does MAOIs stand for?

A

Monoamine-oxidase inhibitors

41
Q

What are some examples of Irreversible MAOIs?

A

PIT
P - Phenelzine
I - Isocarboxazid
T - Tranylcypromine

42
Q

Give an example of a reversible MAOI?

A

Moclobemide - reserved as 2nd line

43
Q

Which MAOIs cause hepatoxicity?

A
  • Isocarboxazid
  • Phenelzine
44
Q

Which MAOI is more likely to cause a hypertensive crisis?

A

Tranylcypromine due to greater stimulant action.

Discontinue if frequent headache occurs.

45
Q

What is the memory trick for MAOI?

A

MAOOI

M - Massive hypertension crisis risk = massive headache

A - Avoid tyramine (triggers hypertension crisis = stroke/M.I

O - Otc meds (like adrenaline, sympathomimetics) = hypertension crisis

O - Other antidepressants (THEREFORE DO NOT MIX WITH OTHER ANTIDEPRESSANTS) = serotonin syndrome

I - Increased suicide risk

46
Q

What are the withdrawal symptoms of MAOIs?

A
  • Agitation
  • Irritability
  • Ataxia
  • Movement disorders
  • Insomnia
  • Drowsiness
  • Vivid dreams
  • Hallucinations
  • Slowed speech
  • Delusions
47
Q

What are some cautions of MAOIs?

A

Can cause hepatoxicity in patients with hepatic impairment

Increased risk of neonatal malformations when used in pregnancy, unless necessary

48
Q

What are the side effects of MAOIs?

A
  • Postural hypotension (mainly in elderly)
  • Hypertensive responses (can cause severe increase in blood pressure that may cause a stroke)
49
Q

When must MAOIs be discontinued?

A

If palpitations and frequent headaches occur

50
Q

What are the washout periods of different drugs to MAOI? What does this mean?

A

This is how long to wait for, before starting a patient on MAOI after stopping another drug:

Clomipramine & Imipramine = 3 weeks

SSRI = 1 week
TCA = 1-2 weeks
Fluoxetine = 5 weeks
MAOI = 2 weeks

51
Q

What are the washout periods of MAOI to different drugs? What does this mean?

A

This is how long to wait for, before starting a patient on another drug, after stopping a MAOI:

Clomipramine & Imipramine = 3 weeks

Other antidepressants = 2 weeks
MAOI = 2 weeks

52
Q

What are some interactions of MAOI?

A

Hypertensive crisis with:
- Sympathomimetics (ephedrine & pseudoephedrine), noradrenaline & adrenaline
- TCAs (clomipramine & tranylcypromine)
- Dopaminergic drugs (Levodopa, MAO-B inhibitor)

Tyramine effect with foods containing tyramine:
- Tyramine triggers nerve cells to release noradrenaline, which increases blood pressure which causes throbbing headaches

53
Q

Which foods contain tyramine?

A
  • Mature cheese
  • Pickled herring
  • Broad bean pods
  • Bovril, Oxo, Marmite
  • Fermented soya bean extract
54
Q

What are patient n carer advice for Antidepressants?

A
  • Eat only fresh food and avoid stale food or going off food
  • Avoid game
  • Avoid alcoholic drinks & dealcoholized drinks (low alcohol)
  • Danger of drug ad food interaction lasts for 2 weeks after MAOI is stopped
  • Drowsiness may affect skilled task
55
Q

What is Reversible MAOI (RIMA) used for?

A

Moclobemide is used to treat major depression and social anxiety disorder

56
Q

Are the interactions for reversible MAOI, the same as irreversible?

A

No.
Less tyramine effects than irreversible but still avoid large amounts of tyramine rich foods.

Less risk of drug interactions with sympathomimetics

BUT DO NOT GIVE WITH ANY OTHER ANTIDEPRESSANTS

CNS (14 decks)

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