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Flashcards in Antidepressants and ADHD Deck (96):
1

Dx MDD

- 5+ sx's for 2 wks that cause significant impairment
- At least one sx must be depressed mood or lack of enjoyment in pleasurable activities

2

Dx persistent depressive disorder

Depressed mood for more days than not for 2+ yrs with 2+ sx's while depressed

3

You just diagnosed a pt with depression. What should you be sure to do before initiating treatment (esp. if it involves an SSRI/SNRI)?

Screen for bipolar disorder. Antidepressants can cause induce mania, mood instability, and can be ineffective for bipolar depression.

4

When would you consider CBT/psychotherapy for depression tx?

- Monotherapy for mild cases
- Adjunct to meds for mod-severe cases

5

1st line pharmacologic tx for depression

SSRIs

6

Which SSRI's are the safest to use and are generally the go-to's?

- Sertraline (Zoloft)
- Escitalopram (Lexapro)

7

What are some common side effects of SSRI's that decrease with use d/t tolerance? (4)

- Headache
- Somnolence
- N/V
- Diarrhea

8

SSRI's can cause headache by activating ______ receptor.

5-HT1

9

SSRI's can cause somnolence (by interrupting sleep cycle) by activating ______ receptor.

5-HT2

10

SSRI's can cause N/V by activating _______ receptor

5-HT3

11

SSRI's can cause diarrhea by activating ______ receptor

5-HT4

12

Which SSRI has highest risk of causing headache?

Sertraline

13

Which SSRI has highest risk of causing somnolence?

Fluvoxamine

14

Which SSRI has highest risk of causing N/V?

Fluvoxamine

15

Which SSRI has highest risk of causing diarrhea?

Sertraline

16

Which SSRI has highest risk of causing sexual dysfunction?

Paroxetine

17

Which SSRI has highest risk of causing QTc prolongation?

Citalopram

18

Which class of antidepressants has highest risk of causing QTc prolongation?

TCAs

19

Which SSRIs inhibit CYP450 2D6?

All except fluvoxamine

20

When would you expect withdrawal to occur after abrupt cessation of an SSRI?

Within 1-10 days

21

Sx's of withdrawal of SSRI

- Dizziness
- Ataxia
- Insomnia
- Irritability
- Flu-like sx's
I.e. Not life threatening!

22

Which SSRI has least propensity of inducing withdrawal syndrome with a missed dose?

Fluoxetine

23

Which SSRIs have greatest propensity for withdrawal syndrome with a missed dose?

Fluvoxamine
Paroxetine

24

You've tried the typical SSRI's but they don't seem to work. What antidepressants could you try next? Why aren't they first line?

Viibryd or Trintillix are SSRI's with additional 5-HT1 modulators (not yet shown to be significant)

25

What is a good antidepressant for pt with comorbid insomnia?

Trazadone
Mirtazapine also hypnotic but more ADRs

26

What DDI is most important/deadly regarding SNRIs?

Serotonin syndrome
Hypertensive crisis

27

SNRIs

Venlafaxine
Desvenlafaxine
Duloxetine
Levomilnacipran

28

Common side effects of SNRIs

- Mild BP (maybe HR) increase
- Nausea, headache

29

Which SNRI is effective for neuropathy?

Duloxetine (Cymbalta)

30

What is important to know regarding levomilnacipran (Fetzima)?

- Available as brand name only
- Closer ratio of 5-HT to NE (i.e. not as effective for depression)

31

You've tried SSRIs and SNRIs for depression tx but they didn't work. What other options do you have?

- Mirtazapine
- Bupropion
- TCAs (like super last line though)

32

Common ADRs of mirtazapine

- Somnolence
- Xerostomia
- Increased appetite
- Hyperglycemia
- HyperTG
- Hypercholesterolemia
- Agranulocytosis

33

What is important to know regarding bupropion (Wellbutrin)?

- Dopamine and NE reuptake inhibitor → does NOT treat comorbid anxiety (need 5HT)
- Seizure risk
- Promotes smoking cessation
- Useful for drug-induced sex dysfunction

34

TCAs

- Imipramine
- Desipramine
- Clomipramine
- Amitriptyline
- Nortriptyline

35

ADRs of TCAs

- Blurred vision, photosensitivity
- Sedation
- Constipation, xerostomia
- Sex dysfunction
- Cognitive impairment
- Lower seizure threshold
- Hyperglycemia
- Tachycardia, arrythmias
- Overdose is deadly

36

Si/Sx's of serotonin syndrome

- Confusion
- Restlessness
- Akathisia
- Tremor
- Hypomania
- Hyperreflexia
- Myoclonus
- Diaphoresis
- Hyperthermia
- Death via anoxia, aspiration, organ failure

37

Tx serotonin syndrome

- Cyroheptadine (5HT antagonist)
- Serotonine syndrome resolves after 24 hrs once proserotonergic agents have been d/c

38

Which antidepressants have a risk of serotonin syndrome, esp. when combined with MAOIs?

All of them except bupropion
- SSRI
- SNRI
- Mirtazapine
- TCs

39

Which antidepressants have a risk of hypertensive crisis, esp. when combined with MAOIs?

- SNRI
- TCA
- Mirtazapine
- Bupropion

40

Antidepressants can cause orthostasis if combined with _______

Alpha-1 antagonists (-zosin)

41

Can pregnant pts take antidepressants?

Technically yes, but if possible taper the med. to 0 and then immediately restart on postpartum day 1.

42

Which antidepressants are safest in pregnancy?

- Fluoxetine
- Bupropion if no cardiac or seizure comorbidities

43

Which antidepressant should NOT be taken in pregnancy?

Paroxetine

44

Which antidepressants are not transferred in breastmilk?

- Sertraline
- Paroxetine

45

Tx algorithm for antidepressants

- Meet with pt after 10-14d to assess tolerability and suicidal thoughts
- Meet at wk 4 to assess efficacy → if partial response, increase dose; if no response, switch to diff. class
- Meet at wk 6-8 to measure maximal response
- Meet every month for next 4-9 months

46

How long does it take for maximal response to antidepressants to occur?

At weeks 6-8

47

How long should pts take antidepressants for?

- At least one year if 1st depressive episode
- Longer or indefinitely if depression returns

48

How would you treat refractory depression pts?

- Try diff. class for monotherapy
- Add 2nd antidepressant from diff. class
- Augment with non-antidepressant (e.g. Li, T3, atypical antipsychotic)

49

Your pt is refractory to tx and has tried 3 different antidepressant monotherapies. You want to try a dual Rx therapy. What combos must you AVOID?

Combos of SSRI, SNRI, TCA should be avoided d/t risk of serotonin syndrome or hypertensive crisis

50

Which antidepressant is FDA approved for ages 12-17?

Escitalopram (Lexapro)

51

Which antidepressant is FDA approved for ages 8-17?

Fluoxetine (Prozac)

52

Which antidepressant should not be given to pediatric pts due to inefficacy and poor tolerability?

Paroxetine

53

What is the most important ADR associated with antidepressant use in pediatric pts?

Suicide risk → monitor vigilantly for suicidal ideation during first 12 wks (every week for 4 wks then every other for 4 wks)

54

Tx depression in pediatric pts

- Mild → supportive care
- Mod-severe → SSRI + CBT for at least 1 yr
- If SSRI doesn't work, try bupropion, mirtazapine, duloxetine, or venlafaxine

55

Depression is often comorbid with what other condition?

Anxiety

56

Adjustment disorder should resolve within ________ after an identifiable stressor. If it doesn't, you could consider anxiety/depression dx.

6 months (but some stressors may be chronic)

57

Benzodiazepines

Triazolam
Clonazepam
Alprazolam
Lorazepam
Diazepam
Oxazepam

58

ADRs of BZDs

- Sedation
- Cognitive impairment (permanent)
- Ataxia/incoordination
- Respiratory depression (for high doses or when combined with other CNS depressants)
- Anterograde amnesia
- Paradoxical agitation (rare)

59

Do pts develop tolerance to sedative effect of BZDs?

Yes, after 2 wks of daily use

60

Why is use of BZDs risky?

- Withdrawal
- Disinhibition
- Cognitive impairment
- Substance abuse → add to other drugs to enhance/prolong high or avert withdrawal

61

Does tolerance develop to anxiolytic and muscle relaxant effects of BZDs?

No - if pt needs frequent dose increase, probably sign of misuse

62

What is the 1st line pharmacologic tx of generalized anxiety disorder?

SSRIs (esp. fluoxetine or sertraline)

63

What is the difference between dosing of SSRIs for GAD vs panic disorder?

- Goal doses used to treat GAD are similar to those for MDD
- Goal doses used to treat panic disorder are higher than those for MDD

64

Why should you titrate SSRIs slowly in pts with anxiety?

Antidepressants can worsen anxiety during 1st week of tx

65

You tried SSRIs for treated GAD pt but didn't work. What other options do you have?

- SNRI (duloxetine)
- Buspirone
- BZD
- Pregabalin → last-line

66

What should you know about buspirone?

- Only treats anxiety, no depression
- Takes 2-6 wks for full effect
- As effective as BZDs but less ADRs and abuse potential

67

How long would it take antidepressants to take effect in treating anxiety disorder?

2-6 weeks

68

1st line tx for panic disorder

SSRIs

69

Tx algorithm for ADHD

- Stimulants → 1st line
- Atomoxetine
- Guanfacine or clonidine → alpha 2 agonists

70

Are stimulants contraindicated in seizure pts with ADHD?

No

71

2 general ADRs of stimulants

- Negative effect on growth in first few months of use
- Low elevations in BP and HR (no ECG changes)

72

How can you decrease the negative effect on growth seen with stimulant use for ADHD tx?

Don't take med. on non-school days

73

Since stimulants can increase BP and HR, what precautions should you take when prescribing them?

- Baseline ECG
- BP/HR monitoring for pts with cardiac failure risks

74

1st line tx for ADHD

Methylphenidate

75

Onset of stimulants

Within 1st day

76

Dosage forms of methylphendiate

- PO
- Transdermal

77

How long does transdermal methylphenidate last?

9 hours

78

How long does it take for transdermal methylphenidate to peak?

7 hours

79

Precautions for transdermal methylphenidate

- Variability in absorption → incr. absorption rate with chronic use or heated/inflamed skin
- Skin irritation

80

If you suddenly remove a transdermal methylphenidate patch, how long does the medication remain in system?

1 hr

81

ADRs of methylphenidate

- Insomnia
- Anorexia
- Stomachache
- Headache
- Irritability

82

What schedule is methylphenidate?

Schedule II

83

Methylphenidate should not be taken with what meds (DDIs)

- TCAs
- MAOIs
- Other stimulants
- Antipsychotics
- CYP450 2D6 meds (e.g. most SSRIs)

84

Which amphetamine should NOT be used for ADHD tx? Why?

Methamphetamine - abuse risk

85

Precautions should be taken when prescribing stimulants for pts with these conditions (4)

- CVD
- Psychosis
- Glaucoma
- Pregnancy → teratogenic

86

Which amphetamine has least risk of abuse?

Lis-dexamfetamine

87

If ADHD pt has CV abnormalities or diversion risk, what medication should you prescribe?

Atomoxetine

88

Onset of atomoxetine

Few days

89

ADRs of atomoxetine

- GI upset
- Xerostomia
- Anorexia
- Insomnia
- ED
- Initial growth slowing

90

Which ADHD meds are metabolized by CYP450 2D6?

- Methylphenidate
- Amphetamines
- Atomoxetine

91

Atomoxetine should be avoided in combo with what meds?

Meds that affect NE uptake
- MAOIs
- SNRIs
- Alpha-1 antagonists

92

When might you use clonidine or guanfacine for ADHD tx?

Pt refractory to stimulants and atomoxetine OR as adjunct to stimulants

93

ADRs of guanfcine and clonidine?

- Decrease BP/HR
- Sedation/somnolence
- Fatigue

94

What would you prescribe an ADHD pt with tics?

- Methylphenidate
- Alpha-2 agonists (clonidine, guanfacine)

95

Nutritional supplements for ADHD

- iron
- zinc
- omega 3 fatty acids

96

What would you prescribe an ADHD pt with substance use disorder?

- Atomoxetine
- Transdermal stimulants may have less abuse potential
- Long acting stimulants less abuse potential