1. Anti-Depressant Drugs

Question 1

*All antidepressants either are known to be or can be associated with what, in which a slow titrattion downward is recommended, aka as deprescribing?

Answer 1

Withdrawal Syndrome

Question 2

Withdrawal Syndrome has symptoms of the acronym FINISH, which include flu like symptoms, insomnia, nausea, imbalance, sensory distrubances and?

Answer 2

Hyperarousal

Question 3

Antidepressants are used for other indications as well, including nicotine withdrawal (bupropion), enuresis (imipramine) and diabetic peripheral neuropathy, fibromyalgia, chronic MSK pain, and stress incontinence see with what medication?

Answer 3

Duloxetine

Question 4

The following drugs are what kind of antidepressants?
TCAs
Desvenlafaxine
Duloxetine
Venlafaxine
Levomilnacipran

Answer 4

SNRI (serotonin-norepinephrine reuptake inhibitors)

Question 5

The following drugs are what kind of antidepressants?

Amoxapine

Answer 5

SNRI + DA (serotonin norepinephrine reuptake inhibitor + dopamine antagonist)

Question 6

The following drugs are what kind of antidepressants?
Citalopram
Escitalopram
Fluoxetine
Paroxetine
Sertaline
Vilazodone*
Vortioxetine*

Answer 6

SSRIs (selective serotonin reuptake inhibitor)

Question 7

The following drugs are what kind of antidepressants?

Buproprion

Answer 7

NDRI (noradrenergi-dopamine reuptake inhibitor)

Question 8

The following drugs are what kind of antidepressants?
Mirtazapine
Nefazodone
Trazodone
(odones are also SSRIs)

Answer 8

SARAs (serotonin adrenergic receptor antagonists)

Question 9

The following drugs are what kind of antidepressants?
Isocarboxazid
Phenelzine
Selegiline
Tranylcypromide

Answer 9

MAOIs (monoamine oxidase inhibitors)

Question 10

What drug is an SSRI and also a partial agonist on 5HT1a?

Answer 10

Vilazodone

Question 11

What drug is an SSRI and also a partial agonist on 5HT1b and full agonist on 5HT1a, and full antagonist on 5HT1d,3,7?

Answer 11

Vortioxetine

Question 12

What drug is a noradrenergic dopamine reuptake inhibitor NDRI and also shown to increase NE/DA presynaptic release?

Answer 12

Bupropion

Question 13

What drug is a MAOI and also a selective agent at low/moderate doses (higher doses are non-selective)?

Answer 13

Selegiline

Question 14

SSRIs inhibit presynaptic reuptake of serotonin via SERT, resulting in increased/prolonged neurotransmission at post synaptic receptors, what are two SSRIs that have additional MOAs?

Answer 14

Vilazodone
Vortioxetine

*sometimes used as an ‘extra kick’

Question 15

SSRIs have less impact on histamine, muscarinic and adrenergic receptors as compared to TCAs. There are less SE, which include CNS (sedation or insomnia), sexual dysfunction (all anti-d), weight gain or loss, and what?*

Answer 15

Acute withdrawal reactions *star

Question 16

SSRIs have SE that include QT prolongation on high doses or in cardiac patients, hyponatremia, (serious)- suicidality, and what-which is seen when given with multiple serotonin affecting agents, and seen as sweating, hyperreflexia, akathisia/myoclonus, and shivering/tremors?

Answer 16

Serotonin Syndrome (multiple serotonin affecting drugs only)

CLONUS

Question 17

There is variable risk of drug drug interactions (CYP450), with vortioxetine and escitalopram being the least likely to cause interactions, and what is the most likely to inhibit CYP450?

Answer 17

Fluoxetine

Question 18

SNRIs (which include TCAs) inhibit presynaptic reuptake of serotonin via SERT and NE via NET, tertiary amine TCAs inhibit both equally, secondary amine TCAs inhibit NE more than 5HT, and all other SNRIs inhibit what more than the other?

Answer 18

Inhibit 5HT > NE

Question 19

What is an SNRI that also is a dopamine antagnoist?

Answer 19

Amoxapine (one of the two that affects dopamine)

Question 20

Tertiary amine TCA amitriptyline is metabolized in the body to nortriptyline, and tertiary amine TCA imipramine is metabolized in the body to?

Answer 20

Desipramine

Question 21

TCAs along with SNRI (serotonin norepinephrine via SERT/NET reuptake inhibitor), they also have impact on 3 key non-efficacy related receptors including: histamine (H1), muscarinic (cholinergic), and what?

Answer 21

a1 (adrenergic)

Question 22

Since TCAs (tri-cyclic agents) also affect alpha, muscarinic and histamine receptors, there are additional SE, including anticholinergic dry mouth/urinary retention/ blurred vision, CNS (histamine) sedation fatigue dizziness seizures and what- which is the most important?

Answer 22

due to A1 adrenergic receptor agonism you see cardiovascular effects including…
tachycardia
orthostatic hypotension
dysrhythmias*

Question 23

Sort the following TCAs into tertiary and secondary amines...
Amoxapine
clomipramine
Desipramine
doxepin
nortriptyline
imipramine
amitriptyline

Answer 23

Tertiary Amine TCA
amitriptyline
clomipramine
doxepin
imipramine
Secondary Amine TCAs
Amoxapine
nortriptyline
Desipramine

Question 24

Toxic ingestion of TCAs (over dose) leads to 3 C’s, including coma, convulsions and ?

Answer 24

cardiotoxicity such as conduction abnormalities

quinidine-like effect-slow conduction via Na blockade

Question 25

Non-TCA SNRIs have SE relatively similar to SSRIs with LESS risk of sexual dysfunction, these drugs include desvenlafaxine, duloxetine, venlafaxine, and ?

Answer 25

levomilnacipran | also amoxapine but has DA

Question 26

What two agents are SARAs, which act like SSRIs, and which block post synaptic a1 receptors on noradrenergic neurons (NE) and post synpatic 5-HT2 receptors, sometimes also a H1 blockade causing sedation?

Answer 26

Trazodone and Nefazodone

Question 27

What agent is a SARA, which blocks presynaptic a2 receptors on noradrenergic (NE) and serotonergic (5HT) neurons and blocks post-synaptic 5HT2/3 receptors, with no SERT/NET activity and also blocks H1 (sedation), is the MC used med in depression(?) ?

Answer 27

Mirtazapine

Question 28

SARAs has SE due to H1/a1... sedation is seen with trazodone and mirtazapine, orthostatic hypotension with trazodone and what med causes weight gain?

Answer 28

Mirtazapine

Question 29

NDRIs selectively inhibits presynaptic reuptake of NE via NET, and dopamine via DAT, as well as enhanced presynaptic release of NE and DA, which is done via VMAT2... which is the only drug that is in this category?

Answer 29

Bupropion | and amoxipine are the only two that affect dopamine

Question 30

NDRIs have SE that include agitation and insomnia, weight loss, and are given in the morning as a pick me up since they are stimulation, what is the worst major SE which is seen with high doses or with a history?

Answer 30

Seizures (bupropion)

Question 31

MAOIs inhibit MAO (A/B) which increases levels of monoamines in neuronal vesicles and increase amounts of NE, 5HT, and DA released, uncommonly used but may be used in treament resistant depression, drugs include isocarboazid, tranylcypromide, Selegiline and?

Answer 31

phenelzine

Question 32

All oral agents are considered irreversible MAOIs, take 14 days to recover, all agents are non selective, except which MAOI which is B selective?

Answer 32

Selegiline (in a PATCH form)-not oral

Question 33

MAOI tranylcypromide is a stimulant analog used in ADHD as well shown to increase transmitter release, it is irreversible like the others, but also has the shortest recovery time which is around?

Answer 33

3-5 days, compared to the avg. 14 days

Question 34

SE of MAOIs include sexual dysfunction, weight gain, and insomnia/agitation/nervousness (like all antidepressants), and *orthostatic hypotension* is the MC... There are common drug interactions with 5HT/NE affecting drugs, anti-HTNs, amphetamines, SSRIs, TCAs, SNRIs, so remember what?

Answer 34

there is a 2 week wash-out period (fluoxetine is 5 weeks)

Question 35

There is major concern with MAOIs which is hypertensive crisis*, nonselective MAOIs inhibit MAO-A necessary for GI tyramine metabolism, inc tyramine can induce significant catecholamine release- causing HTNsive crisis, however there is low risk of this occuring with?

Answer 35

Selegiline patch/topical (since it only affects MOA B)

Question 36

``` All of the following are signs and symptoms of what? severe headache N/V sweating/anxiety nosebleeds tachycardia chest pain changes in vision shortness of breath confusion ```

Answer 36

Hypertensive Crisis seen with MOAIs Note: tyramines found in aged cheese, fermented things, red wine... etc

Question 37

What is a new miscellaneous antidepressant, an s-isomer of ketamine, NMDA receptor (glutamate) antagonist, indicated for treatment resisitant depression in conjucntion with ongoing anti-d therapy, administer nasally by authorzed physicians, pt observed 2 hours post via BP and sedation?

Answer 37

Esketamine *treatment resistant depression*

Question 38

What is a new miscellaneous antidepressant which is a GABAa receptor positive allosteric modulator, which is identical to endogenous allopregnanolone- levels of which increase during pregnancy and decrease post delivery, therefore used for *POST PARTUM DEPRESSION*?

Answer 38

Brexanolone

Question 39

Brexanolone used for postpartum depression is given via 60 hour IV by authorized physician, and observed during infusion q2hr for somnolence and loss of consciousness, with superior efficacy compared to placebo post 60 hr infusion and the efficacy lasts up to?

Answer 39

30 days post-dose *v expensive-- 35k/infusion

Question 40

Lithium is used as a mood stabilizer because it has effects on brain structure and neurotransmitter modulation... Its effect on brain structures- including anterior cingulate cortex, superior temporal gyrus, ventral prefrontal cortex and hippocampus, are what?

Answer 40

Neuroprotective/Neuroproliferative

Question 41

Lithium also modulates neurotransmitters, including inhibiting DA during mania (increased DA), downregulates NMDA receptor, and lastly it promotes what?

Answer 41

GABAergic neurotransmission - increasing levels of GABA in CSF

Question 42

Lithium is a monovalent ion handled by kidneys similarly to Na/K and competes with Na for Kidney reabsorption. Li enters the principal cell in collecting duct via Na channels and interferes with ADH mediated effects with can lead to ADH resistance which results in? (2)

Answer 42

Polyuria/Polydipsia | Nephrogenic Diabetes Insipidus but with mental issues*

Question 43

Lithium interacts with diuretics (thiazides), ACEIs (lisinopril), and NSAIDs, and is checked via blood levels in which there is a narrow range in which the lithium must be at. MC tested SE of lithium on boards is?

Answer 43

Thyroid Goiter (hypothyroid) because Li inhibits iodination of thyroid hormone

Question 44

Antiseizure agents (mood stabilizers) such as valproic acid and divalproex are used for ACUTE bipolar I, lamotrigine for maintenance of bipolar disorder (I & II), and carbamazepine is used for acute and maintenance treatment of acute mania and mixed episodes (bipolar I), and it is the only one which is a major?

Answer 44

CYP450 inhibitor