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Psych clerkship > Anti-depressants > Flashcards

Anti-depressants Flashcards

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1
Q

What anti-depressant should be avoided in epileptics?

A

Buproprion (wellbutrin) should be avoided in epileptics because it lowers the seizure threshold

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2
Q

What anti-depressants can cause fever, myoclonus, and mental status changes?

A

SSRIs and/or SNRIs can cause Serotonin Syndrome (fever, myoclonus, and mental status changes)

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3
Q

Which anti-depressant should be used to help patients gain weight?

A

Mirtazapine (Remeron)

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4
Q

Which anti-depressant causes constipation, urinary retention, and dry mouth?

A

TCAs (anti-cholinergic side effects)

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5
Q

Which class of anti-depressants can cause hypertensive crisis?

A

MAOIs

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6
Q

What anti-depressant causes pulmonary hypertension?

A

Paroxetine (Paxil-SSRI)

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7
Q

Which anti-depressants should be used for patients who don’t sleep well?

A

Mirtazapine (Remeron) or Trazodone (Olepto)

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8
Q

Which classes of anti-depressants can be used to also help with chronic pain?

A

TCAs or Atypical anti-depressants

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9
Q

Which anti-depressants has the fewest sexual side effects?

A

Buproprion (Wellbutrin)
Mirtazepine
Trazodone (priapism)
Nefazodone

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10
Q

Which anti-depressant is CONTRAindicated in eating disorders?

A
  • Buproprion => eating disorders as well as Wellbutrin both lower the seizure threshold
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11
Q

Which anti-depressant should not be given to suicidal patients?

A

TCAs => 1 week’s dosage of TCAs can be lethal

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12
Q

Which class of anti-depressants can help with migraines?

A

TCAs (amitriptylline)

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13
Q

What is the mechanism of action of SSRIs?

A

Selectively inhibits serotonin reuptake by serotonin reuptake transporter proteins at presynaptic neuron, causing an increase in synaptic serotonin levels
- NO anticholinergic, antihistamnic (sedation) or anti-α1 adrenergic effects

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14
Q

Why does it take weeks to months for SSRIs to take clinical effect?

A

Clinical effect usually takes weeks to few months due to time needed to down-regulate B1 adrenergic and serotonin receptors in CNS so mechanism goes beyond simply increasing synaptic serotonin levels

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15
Q

What explains the GI effects associated with SSRIs?

A

Serotonin receptors are located throughout the body (especially GI tract)

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16
Q

Why is fluoxetine not a good choice for patients with hepatic disease?

A

Fluoxetine has a long half life (2-4 days), which may allow its active metabolite to build up

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17
Q

SSRIs and MAOIs should be separated by 5 weeks or else they can cause?

A

Serotonin syndrome

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18
Q

Which SSRI is more likely to induce mania?

A

Fluoxetine

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19
Q

Which SSRI should be used in adolescents and pregnant women?

A

Fluoxetine

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20
Q

What is the advantage of the liquid formulation of fluoxetine?

A

Good for low dosages as well as weekly formulations

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21
Q

In addition to having the highest serotonin specificity, Citalopram (celexa) also has effects at which receptor?

A

Citalopram also has anti-histaminic effects.

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22
Q

What is the major precaution that should be taken with Citalopram (celexa)?

A

Dose dependent QT prolongation/Torsades

- do NOT exceed 40mg/day

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23
Q

What are the benefits of the stereoisomer Escitalopram (Lexapro), over citalopram?

A
  • More effective than Citalopram in acute response and remission, primarily in tx of GAD
  • Lower risk of QTc prolongation
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24
Q

What is the primary indication for fluvoxamine (luvox)?

A

OCD (very short half life)

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25
What are the major side effects of fluvoxamine (luvox)?
GI distress, headaches, sedation, weakness
26
What is one advantage sertraline (zoloft) has over paroxetine (paxil)?
Less sedating
27
Maximum absorbency of Sertraline (zoloft) requires....?
Max absorption requires a full stomach
28
What is the major benefit of Paroxetine's (paxil) short half life?
Short half life with no active metabolite means no build-up (good if hypomania develops)
29
What is the primary disadvantage of Paroxetine's short half life?
Significant withdrawal symptoms with missed doses or abrupt d/c of drug - slow taper over 3-4 weeks recommended
30
Which antidepressant causes the most weight gain?
Paroxetine (Paxil)
31
What anticholinergic effects are associated with paroxetine (paxil)?
Constipation, dry mouth – mild anticholinergic effects due to weak muscarinic receptor antagonist activity
32
Which antidepressant has the longest half life and is therefore best for patients who may miss doses?
Fluoxetine
33
What are the withdrawal symptoms of paroxetine and fluvoxamine (due to short half life)?
Withdrawal symptoms: anxiety, irritability, dizziness, insomnia, nausea, dysphoria
34
What are the major side effects of SSRIs?
- Initially: N/V, diarrhea, HA, agitation/irritability - Not resolving with time: decreased sex drive and impaired sexual function (anorgasmia, erectile dysfunction, decreased libido, menstrual irregularity seen up to 30-40% of pt’s on SSRIs) - Some reports of hyperprolocatinemia - Increased anxiety (esp. fluoxetine), rash, apathy, insomnia, sedation, sweating/night sweats, nightmares, tremor, dry mouth and weight gain (esp. paroxetine), bruising
35
What are the black box warnings of SSRIs?
1) Increased suicidal ideation in individuals
36
Which substances/drugs have serotonin activity?
``` SSRIs MAOIs SNRIs TCAs Meperidine (metabolite has serotonergic effects), Sumatriptan St John’s Wort MDMA (ecstasy) LSD OTC cold remedies ```
37
What are the signs of serotonin syndrome?
``` Abdominal pain Diarrhea Tremor Sweating Restlessness Fever Hyperreflexia Tachycadia ``` HTN >> disorientation, muscle rigidity, myoclonus, fever >> coma, shock, seizures >> death
38
How do SSRIs affect other drugs?
SSRI levels usually not altered by other drugs but can potentially increase levels (inhibit metabolism) of certain drugs
39
What medications are helpful in treating the symptom clusters associated with PTSD (reexperiencing, avoidance, hyperarousal)?
SSRI => Sertraline, paroxetine SNRIs (TCAs and MAOIs may also be effective)
40
What medications are first line in dysthymic disorder?
- SSRIs - SNRIs - Bupropion (and don't forget that CBT co-therapy works better than both alone!)
41
What medication should be used to treat bulimia?
SSRIs (fluoxetine and sertraline)
42
Name the 6 atypical antidepressants?
1) Venlafaxine 2) Duloxetine 3) Bupropion 4) Mirtazipine 5) Trazodone 6) Nefazodone
43
What is the mechanism of action of bupropion?
NE and Dopamine reuptake inhibitor – “NDRI”
44
What is the mechanism of action of Mirtazapine (remeron)?
- Complex serotonin receptor antagonism - α2 adrenergic receptor antagonism - Histaminergic H1receptor antagonism
45
SNRIs are useful in what chronic condition (non-psych)?
SNRIs (venlafaxine/effexor and duloxetine/cymbalta) shown effective in chronic neuropathic pain due to NE component at higher doses
46
What atypical anti-depressant can be used in nicotine/tobacco addiction cessation?
Bupropion
47
What type of activity does Venlafaxine/Effexor have at higher doses?
Higher dose, more NE activity
48
What are the advantages of Venlafaxine's short half life?
Short half life and fast renal clearance avoids build-up (good for geriatric populations)
49
What are the disadvantages of Venlafaxine's short half life?
Can cause a bad discontinuation syndrome – slow taper recommended after 2 weeks of administration
50
What are the major side effect concerns of Venlafaxine?
- Significant nausea - Can induce mania - Can cause 10-15mmHg dose dependent increase in blood pressure
51
In what way is duloxetine/cymbalta better than venlafaxine?
Less blood pressure increase (also indicated for depression and neuropathic pain)
52
What are the dose dependent actions of mirtazapine/remeron?
- Sedation & weight gain at lower dose hence given qhs (antihistaminic). - At doses 30 mg and above, it can become activating (NE effect) and require change of administration time to qam
53
What metabolic concerns are associated with mirtazapine?
- increase in cholesterol and triglycerides in some patients
54
What anti-depressant is also a second line treatment for ADHD?
Bupropion
55
Unlike other antidepressants, which drug is NOT also indicated for anxiety?
Bupropion => can actually cause/worsen anxiety, agitation, and insomnia
56
What is the mechanism of action of trazodone?
- Serotonin 5HT2a receptor antagonist and 5HT2c receptor agonist - α1 adrenergic receptor antagonism
57
What are the major side effects of trazodone?
Sedation, weight gain, low blood pressure (due to α1 receptor antagonism)
58
What is the most common use for trazodone?
Off label=> insomnia
59
What is the mechanism of action of TCAs?
- Blocks reuptake of NE and Serotonin at presynaptic neuron (similar to SNRIs) - Antagonists of histamine, muscarinic (anti-cholinergic) and α1-adrenergic receptors in differing ratios
60
What are the tertiary TCAs?
Imipramine, Amitriptyline, Doxepin, Clomipramine
61
What are tertiary TCAs metabolized to?
Tertiary TCA’s get broken down to secondary TCAs, which has less sedating and anticholinergic side effects.
62
What side effects are associated with TCAs?
Anticholinergic SE => dry mouth, constipation, blurred vision and urinary retention, cardiac arrhythmias and conduction changes α1-antiadrenergic => Orthostatic hypotension Antihistaminc => Sedation and weight gain
63
What are the 3 Cs (toxicities) of TCAs and what are they attributed to?
Coma Convulsions Cardiotoxic => QRS and QTc prolongation * Due to lipophilic and protein binding properties
64
Why are TCAs contraindicated for bipolar patients?
Pt’s with undiagnosed bipolar d/o may be pushed into mania or rapid cycling
65
Why should TCAs generally not be used with low potency typical anti-psychotics?
Additive anticholinergic toxicity & hypotension
66
What TCA is used to treat OCD?
Clomipramine
67
What TCA is activating/used for ADHD?
Desipramine
68
What TCA is used for insomnia?
Doxepin
69
What TCA is used for bed wetting (enuresis)?
Imipramine
70
What TCA is used for chronic pain?
Nortriptyline
71
What class of antidepressant requires a baseline EKG?
TCA => due to QT prolongation/torsades
72
What is the mechanism of action of MAOIs?
Bind irreversibly to monoamine oxidase => thereby preventing inactivation and degradation of biogenic amines (norepinephrine, dopamine, and serotonin) leading to increased synaptic levels of monoamines (dopamine, norepinephrine, epinephrine, serotonin)
73
What are the major side effects of MAOIs?
- Orthostatic hypotension - Weight gain - Dry mouth - Sedation - Sexual dysfunction - Sleep disturbance - HTN Crisis - Serotonin syndrome
74
What drug class is particularly good for treating atypical depression?
MAOIs
75
Name some sympathomimetic stimulants.
OTC cold remedies, amphetamines, pseudoephedrine
76
What are tyramine containing foods?
aged cheeses, chocolate, soybeans, dry sausage, caffeine, alcohol, wine, pickles
77
MAOIs combined with what sorts of substances can cause hypertensive crisis?
Tyramine containing foods or sympathomimetic stimulants
78
MAOIs combined with what other drug classes can lead to serotonin syndrome?
- SSRIs - SNRIs - TCAs
79
What are the major MAOIs?
``` MAO Takes => Tranylcypromine Pride => Phenylzine In => Isocarboxazid Shanghai => Selegiline (parkinson's tx) ```

Psych clerkship (13 decks)

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