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Pharm Exam 3 > Wk 8 Alzheimer and Depression > Flashcards

Wk 8 Alzheimer and Depression Flashcards

1
Q

cognition measured in Alzheimer Disease (AD) by…

A

Mini-Mental State Exam

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2
Q

neuronal changes seen in AD

A

reduced acetylcholine and acetylcholinesterase

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3
Q

AD pharmacotherapy

A

raise comical acetylcholine levels and dec glutamate-mediated neuronal cell death

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4
Q

main goals of AD therapy

A

minimize behavioral disturbances and improve symptoms

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5
Q

acetycholinesterase inhibitors

A

most effective for tx’ing AD (1st line)
typically result in small improvement in sx’s
most studies involve mild-mod sx’s
may red behavioral disturbances (aggression
may improve cog and behavior
if SE develop, a switch can be initiated 24 hrs after discont of 1st med

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6
Q

adverse effects of AchEl’s

A

related to inc Ach: depression, headache, anxiety, dizziness, stomach pain, bradycardia (underreported!!), syncope and insomnia
minimized with slow dose titration

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7
Q

GI tract effects of AcheEI’s

A

N/V (MC symptom all together), diarrhea, dehydration, dec appetite, weight loss and stomach ulcers

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8
Q

Donepazil

A

first agent approved for mod-severe AD

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9
Q

Galantamine

A

stimulates at a non-act site (allosteric modulation)

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10
Q

conversion to galantamine

A

if poor tolerability with donepezil or rivastigmine: wait until SE subside or allow a day washout period prior to galantamine

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11
Q

conversion to galantamine…

A

no intolerance to donepezil or rivastigmine: begin galantamine the day after stopping donepezil or rivastigmine

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12
Q

high dose PO rivastigmine to patch (Exelon)

A

> 6 mg/day oral

switch directly to 9.5 mg/24 hr

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13
Q

lower dose PO rivastigmine to patch

A

<6 mg/day oral

start on 4.6 mg/24 h

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14
Q

switching from donepezil or galantamine to patch

A

start on 4.6 mg/24 hr

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15
Q

Exelon patch

A 
may cause allergic contact dermatitis 
dont reuse same site for 14 days
recommended sites: upper/lower back 
alternate sites: chest/upper arms
immediate therapeutic
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16
Q

Rivastigmine

A

oral dose is NOT immediately therapeutic (titrate to each new dose)
“pseudoirreversible”
inhibits G1 AChE > G4 AChE
results in fewer drug-drug interactions

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17
Q

Mementine

A

after 5 mg BID go to 10 mg q am and 5 mg q pm, then finally 10 mg BID

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18
Q

Depression NT affected

A

norepinephrine, serotonin (5-hydrozytryptoamine) and dopamine

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19
Q

biogenetic amine hypothesis (Depression)

A

agents blocking reuptake/metab of these amines are effective antidepressants

20
Q

conditions causing depression

A

hypothyroidism, addition/cushing dx, pernicious anemia (B12 def), severe anemia, HIV/AIDS

21
Q

drugs causing depression

A

antihypertensives (Clonidine and diuretics) and oral contraceptives/steroids/ACTh

22
Q

factors inc risk of suicide (in dec order)

A

suicidal plans/attempts, M gender (F attempt more, M succeed more), single/living alone, inpatient status, feelings of hopelessness

23
Q

3 phases of Depression tx

A 
acute phase (lasts 3 months), continuations phase (4-9 months), maintenance phase (12-36 months, prophylaxis) 
duration depends on risk of recurrence
24
Q

acute phase depression tx

A

eval weekly/twice monthly
cont until substantial improvement occurs
start dose low, inc gradually
monitor SE
don’t prescribe large amounts to seriously depressed out-pt’s
all pt’s should complete this phase

25
Q

if < 50% improvement of acute phase after 4 weeks tx

A

change meds (consider non-adherence)

26
Q

continuation phase depression tx

A

all patients should get acute phase + 4 months (min) of continuation phase = 7 months MINIMUM
residual symptoms may indicate recurrence, early release or chronic course
cont tx until symptoms resolve

27
Q

discont of Depression tx

A

consider if no recurrence or release during cont phase
most pt’s quality by 7 months
early discont may –> higher risk of relapse
taper med’s over several wks

28
Q

maint phase of depression tx

A

12-36 months, dec recurrence by 2/3
indicated for pt’s with: yearly episodes, impairment from mild residual symptoms, chronic major depression, severe episodes and high risk suicide

29
Q

nonpharm therapy for depression

A

empty psychotherapy to all those willing

may be 1st line for mild-mod depression

30
Q

antidepressants

A

equiv efficacy when given at comparable doses
initial choice is made based on: previous response hx, pharmacogenetics (fam hx response), presenting symptoms (fatigue vs agitation), drug-drug interaction potential, SE profile, pt pref and cost

31
Q

SSRIs for depression

A

superior to other antidepressants for major depression
fever anticholinergic and cardiovascular adverse effects than TCAs, minimal overdose risk
little diff in efficacy or tolerability among various agents

32
Q

Fluoxetine

A

first SSRI FDA-approved for kids
active metal with longer half life than other SSRIs
one metab lasts for wks so can aggravate manic state in bipolar

33
Q

Citalopram

A

FDA approved to tx major depression
FDA warning >40 mg/d may prolong QT
avoid in: congenital QT syndrome, other drugs causing QT or at high risk of Torsades

34
Q

Escitalopram

A

may help red freq and severity of hot flashes in perimenopausal women

35
Q

SNRI’s/mixed 5-HT/NE reuptake inhibitors

A

newer 2nd gen agents

no cardiac conduction effects like TCAs

36
Q

Desvenlafaxine

A

O-desmethylvanlafaxine (metal) of venlafaxine
~10 x more effective at blocking serotonin than NE uptake
bc both drugs are so similar and potential for cost saving, this drug is insig at txing major depression

37
Q

TCA’s

A 
mixed serotonin/NE reuptake inhibitors
effective for all depressive subtypes
use limited by SE and safer alternatives 
tertiary and secondary amines
high risk of death with overdose
38
Q

SE of TCA’s

A 
anticholinergic effects
sedation 
orthostatic hypotension 
seizures
cardiac conduction abnormalities
39
Q

MAOIs

A

irreversibly, non selectively binding MAO A and B

40
Q

serotonin syndrome

A

potentially life threatening adverse drug run
therapeutic drug use with SSRIs
intentional self poisoning with SSRIs
interaction between 2 drugs (SSRI and other)
tyramine-containing foods while on MAOIs

41
Q

triad of serotonin syndrome

A

mental status change
autonomic hyperactivity
neuromuscular abnormalities
occurs in 14-16% of SSRI overdose

42
Q

Serotonin syndrome clinical presentation

A

notable autonomic findings (shivering, diaphoresis, mydriasis)
labile BP/HTN
hyperthermia (> 41 C is critical)

43
Q

Serotonin Syndrome Tx

A

STOP MED
if temp > 41 C (caused by mm activity): immediate sedation (Benz’s - diazepam), neuromuscular paralysis (vecuronium - non depolarizing) and orotracheal intubation
can also use cyproheptadine
need to monitor and tx hypotension

44
Q

cyproheptadine

A

5-HT antagonist

45
Q

triazolopyradines

A

newer, mixed action agents
less sex and sleep SE
pharm similar to TCA
fewer anticholinergic SE

46
Q

Trazodone

A

limited by dizziness, orthostatic hypotension and sedation

caused by potent a1 blockage

Pharm Exam 3 (3 decks)

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