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Flashcards in Antidepressants Deck (66):
1

What is description of depression?

-Depressed/ sad mood
-Anhedonia (diminished interest in normal activities

2

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)

3

What is treatment for first depressive episode?

AFTER 1st successful titration continue treatment for 6-12 months

4

What is treatment for recurring/ chronic depression

Pharm and therapy for life

5

What main BBW is important regarding the class of antidepressants?

S/I, increase in children, adolescents, and young adults 18-24 most prominently

6

What effects does serotonin have on the CNS?

Modulates attention, behavior, and thermoregulation

7

Counseling points for antidepressant use?

A patient must be counseled on suicide risk increase until medication is stabilized

8

What occurs in serotonin syndrome?

Increase in serotonergic activity in CNS

9

What causes exist for serotonin syndrome?

-Therapeutic dosing
-Inadvertent drug reactions b/w drugs
-Intentional self poisoning

10

What categories are consistent with serotonin syndrome?

1. Mental status change 2. Autonomic manifestations 3. Neuromuscular hyperactivity

11

What are the main features of mental status change in serotonin syndrome?

-Anxiety
-Agitation
-Delirium

12

What are the main features of autonomic manifestations in serotonin syndrome?

-Diaphoresis
-Hyperthermia
-Tachycardia
-HTN

13

What are the main features of neuromuscular hyperactivity in serotonin syndrome?

-Clonus
-Hyperreflexia
-Tremor

14

What is the typical onset for serotonin syndrome?

Presents within 24 hours and most within 6 hours of change in dose or drug change

15

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

16

What labs are diagnostic of Serotonin syndrome?

No labs are DX

17

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

18

What treatment is expected in serotonin syndrome?

-Stop the offending agent
-Supportive agents based on vitals
-Sedate with benzos
-And treat with serotonin antagonist

19

What is the serotonin antagonist to be used in serotonin syndrome?

Cyproheptadine

20

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

21

How do serotonin selective reuptake inhibitors work?

Inhibit serotonin transporter increasing the serotonin concentration in synapse

22

What disorders are SSRI's indicated for treatment?

-Major depressive D/O
-Bipolar (not when manic)
-PTSD
-eating disorder

23

What are the most common SSRI's?

-Citalopram
-Escitalopram
-Sertraline
-Fluoxetine

24

What drug class has the most serious DDIs with SSRI's?

MAOIs

25

What DDI is most common with mix of of SSRIs and MAOIs?

High risk of serotonin syndrome

26

What ADRS exist with use of SSRIs?

-Increased suicidal ideation
-Sexual dysfunction (women decreased libido and in men erectile dysfunction"
-Weight gain
-Drowsiness
-Manifest mania in Bipolar D/O
-Insomnia, HA, anxiety, dizzyness

27

Use of SSRIs increase risk of ...?

1. DM
2. Abnormal bleeding
3. Bone loss

28

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)

29

What are individual ADRs with Citalopram ?

FDA warning QT prolongation at higher doses above 40 mg/d (Escitalopram deemed clinically insignificant so no warning)

30

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)

31

What SSRI's should not be used in a pregnant pt due to cause of birth defects?

-Fluoxetine and Paroxetine (worst)

32

How do SNRI's work?

Inhibit reuptake of NE and 5-HT

33

What are the SNRI drugs?

-Duloxetine
-Venlafaxine
-Desveniafaxine
-Levomilnacipran

34

What are common ADRs of the SNRI class?

-N/V
-Diaphoresis
-Sexual dysfunction
-Insomnia
-Withdrawal syndrome

35

What Drugs should not be prescribed with SNRIs?

-Like SSRIs, do not prescribe MAOIs or other serotonergic drugs

36

What main ADR does Levomilnacipran have that is not shared by the other SNRIs?

Orthostatic hypotension

37

What main ADR does Venlafaxine have that other SNRIs do not?

Increased BP and constipation

38

What drugs makes up the serotonin modulators?

-Vortioxetine
-Vilazodone
-Trazadone

39

Vortioxetine and Vilazodone treat what disorders other than depression?

Only indicated for depression

40

What indications for trazodone use?

Depression and insomnia

41

What ADRs associated with use of trazodone?

Somnolenece, anticholinergic, and orthostatic hypotension

Rare- but serious = QT prolongation arrythmias and priapism

42

What is significant about the atypical antidepressants?

They do not work on serotonin

43

What is the most common atypical antidepressant?

Bupropion

44

How does Bupropion work?

It blocks reuptake on DA and NE; DOES NOT WORK ON 5-HT

45

What does Bupropion treat other than depression?

-Tobacco dependence
-Obesity
-Hypoactive sexual disorder

46

What ADRs are associated with Bupropion use?

-Lowers seizure threshold
-Insomnia
-Weight loss

47

What are CIs of Bupropion use?

-Eating disorder
-Seizure D/O
-Use w/ other meds that lower seizure threshold
-Use w/in 2 weeks of MAOI

48

What benefit does bupropion offer?

Adjunct with SSRI/SNRI to counter act the sx from other drugs (weight loss and sexual dysfunction)

49

What other atypical anti-depressant exists?

Mirtazapine

50

What clientele is Mirtazapine good for use?

Old ladies (frail that don't eat)

51

What are Mirtazapines ADRs?

-Weight gain
-Appetite increase
-Drowsiness/sedation

52

What are the "dirtiest" anti depressant drugs?

MAOIs (monoamine oxidase inhibitors)

53

How do MAOIs work?

Inhibit MAO-A and/or MAO-B enzymes which in turn decreases consumption of monoamines (5-HT, NE, DA)

54

When are MAOIs indicated?

Refractory depression

55

When should MAOIs be used first line?

Never

56

What drugs make up the MAOI group?

-Tranylcypromine
-Isocarboxazid
-Phenelzine
-Selegiline transdermal

57

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.

58

What drug class is has reserved use if SSRIs/ SNRIs or other anti-depression drugs fail?

Tricyclic antidepressants

59

What drugs make up the tricyclic antidepressants?

-Amitryptiline
-Nortryptiline
-Imipramine (Clomipramine, Doxepin)

60

Other than reserved treatent in depression where would you see the use of Amitryptiline or Nortryptiline?

-Insomnia
-Chronic pain
-Anxiety disorders

61

Other than 5-HT and NE, what other effects do tricyclic antidepressants have on the body?

Affect histamine, ACH, and alpha-adrenergic receptors

62

What ADRs are associated with tricyclic antidepressants?

-Anticholinergic (fatal cardiac arrhythmia)
-Weight gain
-QT prolongation
-Hypotension
-Sedation
-Seizures

63

What is recommended to use when switching antidepressants with different MOA?

Cross taper to prevent withdrawal symptoms and reduce ADRs

64

When can an immediate change occur in antidepressant medications?

Same neurotransmitter/ mechanism involved

65

What is the range for a taper schedule when switching antidepressants?

2-4 weeks

66

When initiating anti-depressant medications what information must a provider counsel the patient on (not SI related)?

No to abruptly stop taking the drug due to ADRs