Flashcards in Antidepressants Deck (66):
What is description of depression?
-Depressed/ sad mood
-Anhedonia (diminished interest in normal activities
What is typical management/ monitoring of a patient on a new anti-depressant?
-Close monitoring/ management
-F/u 1-2 weeks for S/I (can be daily)
What is treatment for first depressive episode?
AFTER 1st successful titration continue treatment for 6-12 months
What is treatment for recurring/ chronic depression
Pharm and therapy for life
What main BBW is important regarding the class of antidepressants?
S/I, increase in children, adolescents, and young adults 18-24 most prominently
What effects does serotonin have on the CNS?
Modulates attention, behavior, and thermoregulation
Counseling points for antidepressant use?
A patient must be counseled on suicide risk increase until medication is stabilized
What occurs in serotonin syndrome?
Increase in serotonergic activity in CNS
What causes exist for serotonin syndrome?
-Inadvertent drug reactions b/w drugs
-Intentional self poisoning
What categories are consistent with serotonin syndrome?
1. Mental status change 2. Autonomic manifestations 3. Neuromuscular hyperactivity
What are the main features of mental status change in serotonin syndrome?
What are the main features of autonomic manifestations in serotonin syndrome?
What are the main features of neuromuscular hyperactivity in serotonin syndrome?
What is the typical onset for serotonin syndrome?
Presents within 24 hours and most within 6 hours of change in dose or drug change
What are physical exam findings found in serotonin syndrome?
Deep tendon reflex hyperreflexia, inducible spontaneous muscle clonus, agitation, diaphoresis, flushed, tremor, B/L Babinski sign
What labs are diagnostic of Serotonin syndrome?
No labs are DX
How is serotonin syndrome diagnosed?
Having taken a serotonergic medication and: -Spontaneous muscle clonus (alone)
-Inducible clonus PLUS agitation or diaphoresis
Ocular clonus PLUS agitation or diaphoresis
Tremor PLUS hyperreflexia
Hypertonia PLUS temperature above 38C PLUS ocular clonus or inducible clonus
What treatment is expected in serotonin syndrome?
-Stop the offending agent
-Supportive agents based on vitals
-Sedate with benzos
-And treat with serotonin antagonist
What is the serotonin antagonist to be used in serotonin syndrome?
How does Neuroleptic malignant syndrome differ from Serotonin syndrome?
-Caused by dopamine antagonists
-Onset is days to weeks
- Causes bradyreflexia and severe muscle rigidity
-Resolution days to weeks
-Bromocriptine is antagonist
How do serotonin selective reuptake inhibitors work?
Inhibit serotonin transporter increasing the serotonin concentration in synapse
What disorders are SSRI's indicated for treatment?
-Major depressive D/O
-Bipolar (not when manic)
What are the most common SSRI's?
What drug class has the most serious DDIs with SSRI's?
What DDI is most common with mix of of SSRIs and MAOIs?
High risk of serotonin syndrome
What ADRS exist with use of SSRIs?
-Increased suicidal ideation
-Sexual dysfunction (women decreased libido and in men erectile dysfunction"
-Manifest mania in Bipolar D/O
-Insomnia, HA, anxiety, dizzyness
Use of SSRIs increase risk of ...?
2. Abnormal bleeding
3. Bone loss
What SSRIs are best to use if a patient is taking medications that act on common enzymes (3A4, 2C9, 2C19)?
Escitalopram or Citalopram (no DDI w/ enzymes)
What are individual ADRs with Citalopram ?
FDA warning QT prolongation at higher doses above 40 mg/d (Escitalopram deemed clinically insignificant so no warning)
What is a required before issue of a higher dose of Citalopram?
Baseline ECG (also should be performed if concomittant use of other QT prolongation meds)
What SSRI's should not be used in a pregnant pt due to cause of birth defects?
-Fluoxetine and Paroxetine (worst)
How do SNRI's work?
Inhibit reuptake of NE and 5-HT
What are the SNRI drugs?
What are common ADRs of the SNRI class?
What Drugs should not be prescribed with SNRIs?
-Like SSRIs, do not prescribe MAOIs or other serotonergic drugs
What main ADR does Levomilnacipran have that is not shared by the other SNRIs?
What main ADR does Venlafaxine have that other SNRIs do not?
Increased BP and constipation
What drugs makes up the serotonin modulators?
Vortioxetine and Vilazodone treat what disorders other than depression?
Only indicated for depression
What indications for trazodone use?
Depression and insomnia
What ADRs associated with use of trazodone?
Somnolenece, anticholinergic, and orthostatic hypotension
Rare- but serious = QT prolongation arrythmias and priapism
What is significant about the atypical antidepressants?
They do not work on serotonin
What is the most common atypical antidepressant?
How does Bupropion work?
It blocks reuptake on DA and NE; DOES NOT WORK ON 5-HT
What does Bupropion treat other than depression?
-Hypoactive sexual disorder
What ADRs are associated with Bupropion use?
-Lowers seizure threshold
What are CIs of Bupropion use?
-Use w/ other meds that lower seizure threshold
-Use w/in 2 weeks of MAOI
What benefit does bupropion offer?
Adjunct with SSRI/SNRI to counter act the sx from other drugs (weight loss and sexual dysfunction)
What other atypical anti-depressant exists?
What clientele is Mirtazapine good for use?
Old ladies (frail that don't eat)
What are Mirtazapines ADRs?
What are the "dirtiest" anti depressant drugs?
MAOIs (monoamine oxidase inhibitors)
How do MAOIs work?
Inhibit MAO-A and/or MAO-B enzymes which in turn decreases consumption of monoamines (5-HT, NE, DA)
When are MAOIs indicated?
When should MAOIs be used first line?
What drugs make up the MAOI group?
Why are MAOIs rarely used?
Potentially lethal food and drug interactions
-Tyramine containing diet required
-Causes serotonin syndrome if combined with other anti depressant drugs
-DDis with triptans, tramadol, stimulants, etc.
What drug class is has reserved use if SSRIs/ SNRIs or other anti-depression drugs fail?
What drugs make up the tricyclic antidepressants?
-Imipramine (Clomipramine, Doxepin)
Other than reserved treatent in depression where would you see the use of Amitryptiline or Nortryptiline?
Other than 5-HT and NE, what other effects do tricyclic antidepressants have on the body?
Affect histamine, ACH, and alpha-adrenergic receptors
What ADRs are associated with tricyclic antidepressants?
-Anticholinergic (fatal cardiac arrhythmia)
What is recommended to use when switching antidepressants with different MOA?
Cross taper to prevent withdrawal symptoms and reduce ADRs
When can an immediate change occur in antidepressant medications?
Same neurotransmitter/ mechanism involved
What is the range for a taper schedule when switching antidepressants?