Week 3 depression, anxiety, insomnia Flashcards by India Hofer

What are the first line drugs for the treatment of depression?

SSRI, SNRI’s, Mirtazipine, Wellbutrin(bupropion)

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What are the adverse effects of muscarinic drugs?

dry mouth, worsening of closed angle glaucoma, lethargy, constipation

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What are the adverse effects of histaminergic drugs?

sedation and weight gain

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What drug class do these drugs fall into?
Paroxetine, fluoxetine, citalopram, escitalopram, sertraline

SSRI’s

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what is the mechanism of action for SSRI drugs?

desensitization of the presynaptic 5HT1A autoreceptor. Stops the feedback loop that causes cells to reuptake serotonin. the outcome is increased bioavailability of intrinsic serotonin.

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Why do SSRI’s require 4-6 weeks for therapeutic effect?

Desensitization of the 5-HTP1A receptor takes time therefore there is not immediate bioavailability of endogenous serotonin

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What is the general halflife of SSRI drugs?

generally longer than other classes of drug.

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why are bridge order important for SSIRI’s especially in anxiety patients?

Because the side effects of the medication are nearly immediate however therapeutic effects take weeks to months to show. activation is one side effect that tends to increase anxiety for these patients

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what are the most common side effects of SSRI drugs?

GI: nausea, vomiting, diarrhea. insomnia, sexual dysfunction, migrains, and tension headaches.

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what is a more rare side effect of SSRI drugs

EPS (akethesia, dystonia, parkinsonism, TD)

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What risks are elderly patients more likely to show when taking SSRI?

Extra Pyrimidal effects and falls

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SSRI’s have what effect on weight?

generally weight loss is seen especially in early treatment

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Why do falls happen with SSRI’s?

Bradycardia may occurr

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what bridge orders might help with sleep when initiating SSRI treatment?

Beta Blocker drugs generally help with sleep disturbances and restlessness

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What SSRI has the highest chance of causing serotonin syndrome?

Paroxetine

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What CYP enzyme are fluoxetine and paroxetine heavily metabolized by?

CYP2D6

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What happens when combining tamoxifen with paroxetine or fluoxetine?

The anticancer drug tamoxifen is less effective

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why do we avoid MAOI and SSRI?

because there is increased risk of serotonin syndrome.

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how do you avoid Serotonin syndrome when switching between prozac and a MAOI?

allow for a 4-6 week washout period

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What is the interaction between metoprolol and SSRI’s Prozac and paroxetine?

all are metabolized by the CYP2D6 enzyme. mixing these drugs causes an increase in the bio availability of metoprolol and can cause excessive effects of the beta blocker

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What SSRI carry’s the most cardiac risks?

Citalopram

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What cardiac event may occur when citalopram is used?

increase in the QT interval

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What dose of citalopram is advised and why?

nothing over 40mg/day due to dose depended risk for QT prolongation

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what dose of citalopram is recommended for elderly, or hepato compromised patients?

no more than 20mg/day

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What SSRI is the only SSRI that requires renal adjusting?

Paroxetine

what type of adjustments should be made for SSRI drugs?

always hepatic adjustment and for paroxetine, renal adjustment

What is the most potent SSRI?

citalopram

Venlafazine, desvenlafaxine, and duloxetine fall into what drug class?

SNRI serotonin norepiniphrine re-uptake inhibitors

what is the MOA for SNRI drugs?

inhibit reuptake of serotonin and norepinephrine

What is the general half-life of SNRI drugs

5-12 hours

what adjustments are needed for SNRI drugs

renal AND hepatic adjustments are required for these drugs

what are the adverse effects of SNRI drugs?

similar to those of SSRI with more noradrenergic side effects

what noradrenergic side effects can be expected with SNRI's and when does this occurr?

increased HR, dry mouth, dilated pupils, sweating, constipation

Why is discontinuation syndrome more common in SNRIs than SSRI?

because the halflife is shorter. especially in venlafaxine and desvenlafaxine.

what SNRI can interact with metoprolol and cause overabundance

duloxetine is a strong CYP 2D6 inhibitor similar to some SSRI's it can cause interactions with metoprolol

what is the MOA for mirtazipine?

alpha-2 receptor antagonism. causes RELEASE of serotonin and nor epinephrine.

What are the adverse effects of mirtazipine

dry mouth, sedatio, weight gain, elevated cholesterol, anticholinergic effects.

What are the serious side effects of wellbutrin

lowered seizure threshold, psychosis and cognitive function issues

What is the MOA of Bupropion?

inhibiting reuptake of norephinephrine and dopamine

Wellbutrin is different from the other major classes of antidepressants because of what reason?

it does not have any effect on serotonin, only norepinephrine and dopamine

What is the half life of wellbutrin

10-21 hours

What kind of metabolic adjustments are required for wellbutrin

renal and hepatic

What dose of wellbutrin is especially noted with seizures?

doses over 45mg/day

what patient populations should avoid use of wellbutrin

pt's with seizure history, anorexia or bulemia

what mediations should wellbutrin not be given with and why

fluoxetine, paroxetine, sertraline, despiramine. because of theirCYP2D6 inhibition

how should wellbutrin be titrated

slowly, avoid rapid titration

What drug antidepressant drug classes cause bleeding risk?

SSRI and SNRI's

what is the medication treatment for post-partum depression?

brezanolone which must be given over 60 hour continuous infusion at the hospital with constant monitoring

how does the dosing of prozac for depression differ from the dosing for anxiety

generally depression initial dosing is at 20mg but for anxiety the treatment starts at 10mg

how soon do SSRI and SNRI's take to have effect on anxiety

2-4 weeks

what is the antidote for benzodiazepines

flumazenil

patients with what conditions should avoid the use of benzodiazepines

patient's with COPD and sleep apnea

what are the preferred anti-anxiety benzodiazepines for elderly adults

oxazepam and lorazepam

what birth defect are benzodiazepines associated with

cleft palate

what is one major compliance drawback with buspirone for anxiety

it must be given in divided doses

what is the MOA of buspirone

agonist of the 5-HT1 a receptor which reduces the firing of serotonin neurons

what is the usual onset of effect for buspirone

2-3 week s

what are common adverse effects of buspirone

transient anxiety, HA, dizziness, abodominal pain and nausea

what are the four major classes of sleep medication

benzodiazepines, orexin receptor agonist, NBRA and melatonin receptor agonists

what length of time should sleep medications be prescribed for?

2-4 weeks with PRN use

what is the course length for sleep benzodiazepines

7-10 days with PRN use

what is the ideal benzodiazepine for sleep in elderly populations?

temazepam

after how long do patient's develop tolerance to benzodiazepines?

4 weeks

for long acting benzodiazepines how long does dependency and rebound insomnia occurr

2-4 weeks

for short acting agents how long does benzodiazepine dependence and rebound insomnia tak?

days to weeks

what is the MOA for NBRA

agonism of the gaba receptor the major inhibitory receptor in the body

what popular drug fits into the NBRA category

ambien

what are the side effects of NBRA medications

HA< dizziness, sonmnolence, GI upset, and low birth weight in pregnancy

eszipiclone is a NBRA with what special side effect

dry mouth and foul taste in mouth

what benefits to NBRA's have over benzodiazepines despite similar mechanism?

less sleep cycle disruption, less abuse risk, less withdrawal, tolerance and next day effects, less rebound insomnia

what is Ramelteon?

Ramelteon is a melatonin receptor agonist

what is the MOA of ramelteon (MRA)

regulating sleepiness and phase shift from day to night by activating the melatonin receptors 1 and 2

Can ramelteon be used in patient's with COPD and sleep apnea

it is generally safer for these patients.

patient's on ramelteon should avoid what kinds of diet

high fat diet

can patient's with alcohol use disorder use ramelteon

yes

what is the MOA for orexin receptor antagonists lemborexant and vucorexant

antagonizes orexin receptors. orexin usually causes wakefulness, these drugs block it and inhibit wakefulness

what are the adverse effects of lemborexand and suvorexant?

sleep paralysis, hypnagogic and hynoponbic effects and cataplexy effects

lumborexant and suvorexant should not be taken at what point in the night

when the patient has <7 hours to sleep

orexin antagonists should be taken with what regard to food?

take on an empty stomach

what is the safest prescription sleep medication for elderly patients?

ramelteon