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Year 3 Pharmacology > A Practical Guide to Anti-Depressants and Mood Stabilisers > Flashcards

A Practical Guide to Anti-Depressants and Mood Stabilisers Flashcards

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1
Q

Aim in the treatment of depression?

A

Complete resolution of symptoms

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2
Q

1st line treatment for depression?

A

Usually SSRIs; subsequent choices depend on a no. of factors

Anti-depressants may also be given in combination

NOTE - there is no step by step flow chart

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3
Q

Common factors affecting drug choice for depression?

A

What has worked for this patient previously

Indications

Patient’s comorbidities and risk factors

Patient preference

Safety in pregnancy / breastfeeding

Treatment of specific symptoms, e.g: insomnia or psychosis

Risk of overdose

Patient’s willingness to adhere to monitoring and other restrictions

Dose frequency

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4
Q

Efficacy of anti-depressants?

A

Normally take 2-6 weeks to work; consider ECT when a quicker response, that what is achieved with anti-depressants, is required

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5
Q

How to start anti-depressants?

A

Start at a low dose and titrate up, to avoid initiation side effects

NOTE - speed of titration depends on side effects VS the need for a quick response

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6
Q

Treating older patients for depression?

A

Try to avoid polypharmacy

Use lower doses in older patients (usually 1/2 the adult dose)

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7
Q

Cautions for anti-depressants in younger patients?

A

Rarely, can cause agitation leading to suicidal ideation and behaviour

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8
Q

How long does treatment for depression continue for?

A

Continue for:
• 6-12 months after full resolution of symptoms of the 1st episode
• 12-24 months for a recurrence
• Indefinitely, if a 3rd episode has occurred

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9
Q

Treatment of bipolar disorder?

A

Mainstay are mood stabilisers, e.g: lithium, anti-convulsants, anti-psychotics

Lamotrigine is good for bipolar depression

Valproate is good for mania / hypomania

Generally, avoid anti-depressants in bipolar unless short-term for a depressive episode; DO NOT GIVE ANTI-DEPRESSANTS WITHOUT A MOOD STABILISER IN BIPOLAR

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10
Q

Why are anti-depressants not given without a mood stabiliser in bipolar?

A

Can cause switching to mania / hypomania or mood instability

Even if they not cause elevated mood, they are not as effective as mood stabilisers for bipolar depression

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11
Q

Examples of Selective Serotonin Reuptake Inhibitors (SSRIs)?

A

Fluoxetine, sertraline, citalopram, escitalopram, paroxetine

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12
Q

Uses of SSRIs?

A

Usually:
• 1st line in depression
• 1st line if an anti-depressant is required in bipolar

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13
Q

Side effects of SSRIs?

A

GI upset

Anxiety, agitation

Insomnia (taken in the morning to reduce this)

Sexual dysfunction

Hyponatraemia in older patients

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14
Q

Side effects of discontinuation of SSRIs?

A

GI upset, anxiety, agitation, insomnia, myoclonus

NOTE - discontinuation side effects are worse with paroxetine than the other SSRIs; it is rarely used now

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15
Q

How to avoid discontinuation side effects of SSRIs?

A

Taper the drug over weeks

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16
Q

Cautions with SSRIs?

A

Increased risk of GI bleeding if taken with NSAIDs

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17
Q

Situations where different SSRIs are preferred?

A

Sertraline is safest in patients with cardiac issues

Citalopram is safest in epilepsy

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18
Q

Specific issues with citalopram?

A

Assoc. with long QTc interval

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19
Q

Examples of TCAs?

A

Amitriptyline, imipramine

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20
Q

Why are TCAs not used as 1st line for depression?

A

Due to cardiac side effects

They are dangerous in OD

NOTE - they are as effective as SSRIs

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21
Q

Side effects of TCAs?

A

Sedation (taken at night for this reason), confusion, dizziness

Anti-muscarinic effects

Sexual dysfunction

Rarely, cardiac arrhythmias may occur (lofepramine has a lower cardiac risk)

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22
Q

When should use of TCAs be avoided?

A

Cardiac problems

Older people

Suicidal intent

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23
Q

Uses of TCAs other than for depression?

A

Neuropathic pain

OCD

Anxiety disorders

Migraine prophylaxis

Nocturnal enuresis

Cataplexy

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24
Q

Examples of NaSSA (noradrenergic and specific serotonergic anti-depressant)?

A

Mirtazapine

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25
Uses of mirtazapine?
May be used 1st line if patient also has insomnia and/or poor appetite Often used when an SSRI has not worked Relatively safe for those with cardiac issues NOTE - mirtazapine has a good anxiolytic effect
26
Side effects of mirtazapine?
Sedation (taken at night for this reason) Hunger and weight gain Constipation Dizziness, falls Dry mouth Unusual / vivid dreams Rarely - blood dyscrasias, seizures
27
Examples of SNRIs (serotonin and noradrenaline reuptake inhibitors)?
Venlafaxine, duloxetine
28
Uses of SNRIs?
Not usually 1st line due to greater risk of side effects than SSRIs but often used when SSRI and/or mirtazapine have not worked Venlafaxine is very good combined with mirtazapine, when monotherapy has not worked NOTE - duloxetine can also be used for neuropathic pain or bladder instability
29
Side effects of SNRIs?
As for SSRIs Hypertension Cardiac arrhythmias Insomnia (taken in the morning for this reason) Discontinuation side effects are as for SSRIs
30
Types of MAO inhibitors?
Irreversible MAOIs • Phenelzine • Tranylcypromine • Isocarboxazid Reversible MAOIs: • Moclobemide (less side effects but also less effective)
31
Uses of MAOIs?
Very effective anti-depressants; only used in treatment resistant depression (this is because MAOIs require adherence to dietary and medication restrictions) Rarely used in BPAD, due to high risk of switching to mania
32
Side effects of MAOIs?
Postural hypotension, drowsiness, insomnia, fatigue Nausea, constipation Rarely, HYPERTENSIVE CRISIS
33
Issues with tyramine in assoc. with MAOIs?
Tyramine is a potent releaser of norepinephrine, which causes raised BP Normally, MAO breaks down norepinephrine and, if MAO-A is inhibited and a high tyramine meal is taken, norepinephrine can accumulate, leading to a HYPERTENSIVE CRISIS
34
Foods with a high tyramine content?
Cheese Alcoholic drinks, esp. red wine (this inc. alcohol free beer) Dried / smoked / fermented meats Stock cubes, pate, marmite, bovril, black pudding, large amounts of caffeine, broad bean pods, soy, tofu
35
Drugs that interact with MAOIs?
SSRIS / SNRIs Tyrptophan TCAs Mirtazapine Phenylephrine Some opioids Dextromethorphan
36
Symptoms of hypertensive crisis?
Headache SoB Nosebleeds Anxiety
37
Complications of hypertensive crisis?
Arrhythmias, stroke, seizures, death
38
Management of hypertensive crisis?
Phentolamine infusion
39
Examples of SARIs (serotonin 2 antagonist / reuptake inhibitors)?
Trazodone
40
Uses of SARIs?
Often used as an anti-depressant when sedation is required AND/OR To augment other anti-depressants
41
Side effects of SARIs?
GI upset Dizziness, sedation (taken at night for this reason), fatigue Headache Hypotension / syncope In-coordination Oedema Blurred vision Priapism
42
Uses of lithium carbonate?
Most effective treatment for BPAD Also used as an adjunct to anti-depressants in treatment of resistant depression
43
Side effects of lithium carbonate?
GI upset Dry mouth Feeling of weakness / shakiness Sedation (taken at night for this reason) Weight gain Fine tremor Polydipsia and polyuria Ankle swelling Renal impairment Cardiac arrhythmias Hypothyroidism and hypoparathyroidism
44
Drugs that interact with lithium carbonate?
NSAIDs, ACEIs, ARBs, diuretics (more so with thiazides than loops)
45
Ix before initiation of lithium?
U&Es, TFTs ECG
46
Ix during and following initiation of lithium?
Lithium levels (12 hours after last dose) and U&Es every 5 days; this is continued until Li level is stable within the therapeutic range Every 3 months - Li level and U&Es Every 6 months - TFTs If dehydrated from physical illness, generally unwell or if the patient has signs of toxicity, check Li level and U&Es
47
How is hypothyroidism due to Li treated?
Usually with levothyroxine, rather than stopping Li
48
Warning signs of Li toxicity?
GI upset Blurred vision Coarse tremor Drowsiness Ataxia
49
Signs of severe Li toxicity?
Confusion, LoC, seizures, coma, death
50
Causes of Li toxicity?
Increased dose Dehydration (physical illness, lack of fluid intake, alcohol, hot weather, exercise) Drug interactions Reduction in salt intake
51
Management of Li toxicity?
Stop Li IV fluids Monitor renal function In severe cases, dialysis may be required
52
Uses of semisodium valproate?
Effective as an anti-convulsant in bipolar mania / hypomania
53
Mechanism of action of semisodium valproate?
Blocks voltage-activated Na+ channels, increasing GABA levels
54
Side effects of semisodium valproate?
Sedation and fatigue Tremor Dizziness GI upset and weight gain Rarely - hepatotoxicity, pancreatitis, increased in suicidal behaviour
55
In whom should semisodium valproate not be prescribed?
Avoid in women of childbearing age, as it is highly TERATOGENIC (causing neural tube defects)
56
Ix with semisodium valproate prescription?
Platelet count and LFTs prior to initiation
57
Uses of lamotrigine?
Anti-convulsant used in the treatment and prophylaxis of bipolar depression NOTE - it blocks voltage-activated Na+ channels
58
Side effects of lamotrigine?
Rash (advise to see doctor ASAP if this occurs) GI upset Sedation (not common), fatigue and insomnia Dizziness Ataxia Rarely - SJS, blood dyscrasias NOTE - titrate slowly over 6 weeks to reduce risk of rash and SJS
59
Examples of atypical anti-psychotics?
Olanzapine Risperidone Quetiapine Clozapine
60
Uses of atypical anti-psychotics?
For manic / hypomanic and depressed mood states in BPAD Combine with an anti-depressant in psychotic unipolar depression Adjunct to an anti-depressant in unipolar depression without psychotic symptoms
61
Side effects of atypical ADs (except apiprazole)?
Sedation Weight gain (mainly due to increased hunger) Metabolic syndrome EPSE (extra-pyramidal side effects) Constipation QTc prolongation Neuroleptic malignant syndrome NOTE - used more often than typical anti-psychotics, esp. in mood disorders
62
Side effects of apiprazole?
Insomnia GI upset and constipation Agitation Akathisia Orthostatic hypotension Headache
63
Ix with atypical anti-psychotics?
Check the following prior to initiation: • BP and weight • Lipids, BG, FBC, U&Es, LFTs • ECG Then check yearly, or more often depending on results and other risk factors
64
Examples of typical anti-psychotics?
HALOPERIDOL Chlorpromazine
65
Uses of typical anti-psychotics?
Treatment and prophylaxis of both manic / hypomanic and depressed mood states in BPAD Combine with an anti-depressant in psychotic unipolar depression Adjunct to an AD even in unipolar depression without psychotic symptoms
66
Side effects of typical anti-psychotics?
EPSE Sedation Dizziness QTc prolongation Hyperprolactinaemia Neuroleptic malignant syndrome

Year 3 Pharmacology (5 decks)

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