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Antidepressants Flashcards

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1
Q

What are the three MAJOR groups of antidepressants?

A

1) TCA- Tricyclic and related anti depressants - these increase 5HT,NA levels
2) Selective serotonin reuptake inhibitors - SSRI - Increase 5HT only
3) MAOIs - Monamine oxidase inhibitors -increase 5HT,NA and Dop.

5HT- Serotonin
- other classes are SNRI - Venlafaxine and duloxetine

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2
Q

THE COMMON Tricyclic antidepressants

A

Amitriptyline and Noritriptyline - used for neuropathic pain
- Clomipramine
- Dosulepin
- Imipramine (most antimuscarinic effects)
- Lofepramine (liver toxic)

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3
Q

Tetracyclic antidepressants

A

Trazadone and Manserin

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4
Q

SSRIs!!!!

A

Citalopram
Escitalopram
Fluoxetine - Licensed in children
Paroxetine - High withdrawal symptoms
Sertraline- Safe in unstable angina and MI

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5
Q

MAOIs??

A

Irreversible MOIS (PITS)
Pheneizine
Iscocarboxazid
Tranylcycropromine (hypertensive crises risk)

Reversible Inhibitor (RIMA) - NO WASH OUT PERIOD
Moclobemide - No washout period - licensed fro social anxiety disorder

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6
Q

Antidepressant indications

A
  • Effective for moderate to severe depression
  • Do not use routinely in mild depression (used psychological therapy)
  • How long does it take for antidepressants to take effect - 1-2 weeks
  • Improvemnet in sleep usually 1st benefit of drug therapy
  • there is an increased potential for agitation,anxiety and suicidal thoughts during first few weeks of treatment - paradoxical effects
    -All classes have similar efficacy but different side effects
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7
Q

Which antidepressants are 1st line?

A

Ssri’s are the safest
- better tolerated and safer in overdose than others
- less sedating
- fewer antimuscarinic and cardiotoxic effects
- 1st line for treating depression
- Sertraline is the safest in patients with unstable angina or who have recently had an MI

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8
Q
A
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9
Q

What about TCAs as an option?

A
  • whilst they’re great, they’re not always first line
  • they have similar efficacy to SSRIs but more side effects
  • More sedating
  • Morty antimuscarinic and cardiotoxic side effects
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10
Q

What about MoAis

A
  • Dangerous interactions with some foods and drugs
  • Reserve for use by specialists
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11
Q

SICK FACE.COM = Inhibitors

A

Sodium valporate
Isoniazid
Cimetidine
Ketoconazole
Fluconazole
Alcohol and binge drinking
Chloramphenicol
Erythromycin
Sulfonamides
Ciprofloxicin
Omeprazole
Metronidazole
Grapefruit Juice

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12
Q

CRAP GPS - Induced into madenesssss

A

Carbamazepine
Rifampicin
Alcohol (chronic)
Phenytoin

Griesofulvin
Phenobarbitone
Suphonylureas

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13
Q

St John’s wort - people take it for mild depression ( hypericum perforatum)

A
  • Popular herbal remedy on sale to the public
  • It’s an inducer so it will increase the concentration of drug
  • Don’t recommend because the bad outweigh the good for most patients
  • If a patient is taking St John’s wort, the concentration of interacting drugs may increase, leading to toxicity
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14
Q
A
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15
Q

Antidepressants management-

A
  • review patients every 1-2 weeks at the start of treatment
  • Take at least 2 weeks to work
  • Continue treatment for at least 4 weeks ( 6 weeks for elderly) before switching due to a lack of efficacy
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16
Q

Duration of antidepressants-

A
  • Incase of partial response, continue for a further 2-4 weeks (elderly patients may take longer to respond)
  • patients with a history of recurrent depression should receive maintenance treatment for at least 2 years
  • Take for at least 6 months (12 months in elderly) after remission
  • 12 months for gereneralised anxiety disorder because there is a higher risk of relapse
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17
Q

Antidepressants and hyponatraemia

A
  • Hyponatraemia (salt loss) associated with ALL antidepressants especially in elderly patients - occurs more with SSRIS
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18
Q

What are the signs of Hyponatraemia - SALT LOSS

A

Stupor/coma
Anorexia
Lethargy
Tendon reflexes decreased
Limp muscle- weakness
Orthostatic Hypotension
Seizures and headaches
Stomach cramps

Sodium to do a lot with the mind - confusion,convulsions etc

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19
Q

Suicidal Behaviour and antidepressant therapy

A

Suicidal behaviour is linked to anti depression medication
- children at a young age age and young adults and anyone with suicidal history are at risk
- You need to monitor patients for any suicidal behaviour,self harm, hostility especially at the beginnning of treatment or if there is a dose change

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20
Q

What is Serotonin Syndrome

A

Just a lot of serotonin.

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21
Q

Main things about Serotonin syndrome

A
  • Uncommon adverse reaction with SSRIs, Snris - occurs when serotonin levels are too high, so usually when you’re taking an SSR/SNRI which raises the serotonin levels.
  • symptoms occur days or just hour after initiation, dose increase or overdose of a serotonergic drug,addition of new drug or replacement without allowing enough washout period before starting something new. (Especiallly if its an irreversible MOAI with a long harmful life)
  • Symptoms can range from mild to life threatening
  • severe toxicity occurs with combination of serotonin if drugs one of which is a moai (MAOIs don’t mix)
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22
Q

Symptoms of serotonin syndrome?

A
  • neuromuscular hyperactivity = tremor,hyper reflexes,clonus,myoclonus(muscle spasms), rigidity)
  • Autonomic dysfunction - Tachycardia,blood pressure changes,hyperthermia,diaphoresis, shivering, diarrhoea

-Altered mental state - Agitation,confusion,mania

  • withdraw medication if any of the symptoms occcur
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23
Q

Failure to respond to treatment

Study These Flashcards
A

Increase dose or switch to different SSRI or mirtazapine if initial response to SSRI fails

Second line choices:
- lofepramine,moclobemide and reboxetine
- venlafaxine ( SNRI) reserved for more severe cases
- MAOI require specialist supervision

Third option:
Add another antidepressant class or lithium/antipsychotic

24
Q

Examples of sedating TCAs

Study These Flashcards
A

For agitated and anxious patients:
- amitriptyline
- clomipramine
-dosulepin(toxic in overdose)
- trazadone(serotonin reuptake inhibitor)
- trimipramine
- Doxepin

25
Less sedating antidepressants
For withdrawn and apathetic patients (Nil) - imipramine (most antimuscarinic side effects) - lofepramine - nortriptyline
26
What are the contraindications for TCAs?
- Don’t give in mania - or manic phase of bipolar( if someone is hyper we don’t want to be increasing the serotonin levels and making them even more hyper) - Arrhythmias - Heart block - Immediate recovery period after MI - Mainly CV related - because they are cardio toxic
27
Cautions of TCAs
- CVD - Diabetes -Chronic constipation - Epilepsy - History of Bipolar and psychosis -Hyperthyroidism( risk of arrhythmia) - Glaucoma,urninary retention - Stop if patient enters manic phase of bipolar - elderly pts more susceptible to side effects, give low doses and monitor
28
Common side effec†s of TCAS
T - More toxic in overdose than SSRis C- Cardiac side effects- qt prolongation, heart block and hypertension, arrhythmias A- antimuscarinic sideffects S- seizures Most common - Drowsiness and qt prolongation therefore not recommended in elderly patients.
29
30
What are antimuscarinic side effects?
Can’t pee,can’t see, can’t spit can’t shit
31
Signs of TCA overdose (think hyponatraemia and cardiotoxic and antimuscarinic)
- dry mouth -Coma - Hypotension - Hypothermia -convulsions - arrhythmias -dialtated pupils -urinary retention
32
TCAs have varying antimuscarinic and cardiotoxic side effects in overdose
Lofepramine - less side effects, less dangerous in overdose but associated with hepatoxicity(caution in moderate liver impairment - Imipramine - Has more antimuscarinic effects than TCAs - Amitriptyline and Dosulepin - Effective but dangerous in overdose and not recommended in the treatment of depression
33
TCA Dosage
-10-20% patients fail to respond to drug treatment - use doses which are high for effective treatment but not too high to be toxic - low doses should be used in elderly -TCAs have a long half life so given once daily at night - TCAs not effective in treating depression in children
34
TCA Cautions
- CVD,Chronic constipation. History of bipolar,history of psychosis,hyperthyroidism (risk of arrhythmias), epilepsy and diabetes - Caution in patients with prostatic hypertrophy, constipation and increased intra-ocular pressure,urinary retention or susceptibility to angle closure glaucoma due to antimuscarinic activity of TCAs - TCAs can aggravate conditions,especially mania so stop if patient enters manic phase - start with lower doses to reduce side effects especially with elderly
35
What are the common TCA interactions?
- Lithium (increased risk of neurotoxicity) - Increased risk of severe toxicity when given with MAOIs —Avoid for 2 weeks after stopping MAOIs -increased antimuscarinic effects with antimuscarinic drugs,antipsychotics and antihistamines - decreases effect of ephedrine and increases the effect of phenylephrine (avoid both) - increased hypotension with blood pressure tablets (eg.calcium channel blockers,aces and diuretics) - increased risk of hyponatraemia with diuretics,carbamazepine - Increased risk of QT prolongation with antisychotics,theophylline,amiodarone,sotalol,b2 antagonists, citalopram and corticosteroids - increased risk of serotonin syndrome with SSRIs,sumatriptan,MAOIs and tramadol
36
EXAMPLES OF SSRIs?
Citalopram = QT prolongation Escitalopram = QT prolongation Fluoxetine - Can be given to children Fluvoxamine Paroxetine ( higher withdrawal) Sertraline (safe in angina and MI)
37
SSRIs key points:
- 1st line antidepressants because they are better tolerated and safe in overdose than other classes - safe in patients with unstable angina and recent myocardial infarction - they selectively inhibit the reuptake of serotonin (5-HT)
38
What’s a downside to SSRIs?
Increase in harmful outcomes in children and adolescents - self harm,aggression and suicide risk
39
Which antidepressants are licensed for children and what age?
- fluoxetine - from 5 years old - 7 years old unlicensed - 8-17y/o licensed PROZAC is the Brand
40
SSRIs Contraindications
- poorly controlled epilepsy - discontinue if convulsions occur - manic phase
41
Cautions for SSRIs
- CVD,Diabetes, epilepsy (discontinue if convulsions or history of bleeding esp GI),Mania, susceptibility to glaucomas
42
SSRI withdrawal symptoms:
Higher with Paroxetine - should withdraw over a few weeks - Gi disturbances,headache and anxiety - Dizziness,electric shock sensation in head,neck and spine - Tinnitus,sleep disturbance,influenza like symptoms, sweating - palpitations and visual disturbance (occur less)
43
MHRA advice for SSRI and SNRI?
- SMALL risk of postpartum haemorrhage when used in the month before delivery - SSRI increase the risk of bleeding due to platelet function - risk more significant in patients with other risk factors for bleeding disorders - anticoagulant medication in women at high risk of thrombotic events should NOT be stopped but prescribers should be aware of the risk
44
SSRI side effects
-less sedating and fewer antimuscarinic effects than TCAs - Anxiety,arrhythmias, confusion,drowsiness, constipation, QT interval prolongation,dry mouth,skin reactions,nausea,palpitations HYPONATRAEMIAAAA
45
SSRI and Pregnanct
Avoid in pregnancy, unless benefits outweigh the risks - small risk of congenital heart defects when taken in early pregnancy 3rd trimester - risk of neonatal withdrawal symptoms and persistent pulmonary hypertension in newborns
46
SSRI INTERACTIONNS
- increased risk of bleeding with NSAIDS,antiplatelets(gi bleed risk) and anticoagulants,thrombolytics (eg.alteplase),phenindione - phenytoin: setraline increases the risk of toxicity - QT interval prolongation - leads to arrhythmias and cardiac death- antipsychotics,antimalarials,amiodarone,sotalol - certain drugs will increase the risk of QT prolongation by causing hypokalaemia which increases the risk of tornadoes de pointes eg. Theophylline,diuretics and beta 2 agonists - Hyponatraemia (more common with SSRIs): NSAIDs,diuretics,carbamazepine - increases risk of serotonin syndrome - tramadol,sumatriptan,ondansetron(5HT antagonist), other antidepressants - eg. St John’s wart
47
48
Examples of MAOIs?
Irreversible - Isocarboxazid ( causes hepatoxicity) - Phenelzine ( causes hepatoxicity) - Tranylcyrpromine ( greater stimulant action than above more likely to cause hypertensive crisis) Reversible MAOI: = Moclobemide (reversible) RIMA - reversed as second line
49
MAOOOOOOI
-Massive hypertensive crisis risk - massive headache - Avoid tyrannies (triggers hypertension crisis/mi or even stroke - OTC meds (sympathomimetics/adrenaline etc) - hypertension crisis risk - Other anti depressants (MAOIs do not mix with other antidepressants ) - can cause serotonin syndrome - Increased suicide risk
50
Things to remember about mOAIs
- they are used less due to the frequent interaction with other drugs and food - Easier to prescribe MAOI when TCAs have been unsuccessful than vice versa -Tranylcyrpromine - greater stimulant action, cause hypertensive crisis risk - discontinue if frequent headaches - Isocarboxazid and phenelzine cause hepatoxicity - Moclobemide (reserve as second line treatment)
51
Withdrawal symptoms - MOAIS
- Agitation,irritability (avoid abrupt withdrawal) - hallucinations,slowed speech, delusion - risk of symptoms increased if stopped suddenly after regular admin for 8 or more weeks
52
MAOIS Cautions
Can cause hepatoxicity in patients with hepatic impairment Increased risk of neonatal malformations when used in pregnancy- avoid unless there is a compelling reason - side effects - risk of potential hypotension (mainly in elderly) and hypertensive response (severe increase in blood pressure that may cause a stroke) - disontinue if palpitations or frequent headaches occur
53
MAOI interactions -
Hypertensive crisis with: - Sympathoemetics(ephedrine and pseudoephedrine) ( eg. Cold and flu medication), noradrenaline and adrenaline - TCAs - clomipramine and Tranylcyrpromine - Dpoaminergic drugs - levadopa,MAO-B inhibitors - Tyramine effect - avoid tyramine rich food - Tyramine will trigger nerve cells rp release noradrenaline which increases blood pressure which causes throbbing headaches - interaction of MAOIs with Tyramine rich foods = Hypertensive throbbing headaches
54
Tyramine rich foods?
- Mature cheese - Pickled herring - broad beans - bovril,oxo,marmite - fermented soy beans
55
Patient and carers advice for MOAIS
- eat only fresh food and avoid stale food or going off food - especially meat ,poultry fish or offal) - avoid alcoholic drinks or low alcohol drinks - danger of drug and food interactions last for two weeks after the medication has been stopped - drowsiness my affect skilled tasks
56
Main points about RIMA
Reversible MAOI - Moclobemide for major depression, social anxiety disorder - reversible inhibition of monamine oxidase A - second line treatment Interactions- Less tyramine effect than irreversible but still should avoid sympathoimetics (ephedrine, pseudoephedrine , phenylephrine and adrenaline - don’t give with other antidepressants

Central Nervous System (14 decks)

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