Flashcards in Antidepressants and ADHD Deck (96):
- 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
Dx persistent depressive disorder
Depressed mood for more days than not for 2+ yrs with 2+ sx's while depressed
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.
When would you consider CBT/psychotherapy for depression tx?
- Monotherapy for mild cases
- Adjunct to meds for mod-severe cases
1st line pharmacologic tx for depression
Which SSRI's are the safest to use and are generally the go-to's?
- Sertraline (Zoloft)
- Escitalopram (Lexapro)
What are some common side effects of SSRI's that decrease with use d/t tolerance? (4)
SSRI's can cause headache by activating ______ receptor.
SSRI's can cause somnolence (by interrupting sleep cycle) by activating ______ receptor.
SSRI's can cause N/V by activating _______ receptor
SSRI's can cause diarrhea by activating ______ receptor
Which SSRI has highest risk of causing headache?
Which SSRI has highest risk of causing somnolence?
Which SSRI has highest risk of causing N/V?
Which SSRI has highest risk of causing diarrhea?
Which SSRI has highest risk of causing sexual dysfunction?
Which SSRI has highest risk of causing QTc prolongation?
Which class of antidepressants has highest risk of causing QTc prolongation?
Which SSRIs inhibit CYP450 2D6?
All except fluvoxamine
When would you expect withdrawal to occur after abrupt cessation of an SSRI?
Within 1-10 days
Sx's of withdrawal of SSRI
- Flu-like sx's
I.e. Not life threatening!
Which SSRI has least propensity of inducing withdrawal syndrome with a missed dose?
Which SSRIs have greatest propensity for withdrawal syndrome with a missed dose?
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)
What is a good antidepressant for pt with comorbid insomnia?
Mirtazapine also hypnotic but more ADRs
What DDI is most important/deadly regarding SNRIs?
Common side effects of SNRIs
- Mild BP (maybe HR) increase
- Nausea, headache
Which SNRI is effective for neuropathy?
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)
You've tried SSRIs and SNRIs for depression tx but they didn't work. What other options do you have?
- TCAs (like super last line though)
Common ADRs of mirtazapine
- Increased appetite
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
ADRs of TCAs
- Blurred vision, photosensitivity
- Constipation, xerostomia
- Sex dysfunction
- Cognitive impairment
- Lower seizure threshold
- Tachycardia, arrythmias
- Overdose is deadly
Si/Sx's of serotonin syndrome
- Death via anoxia, aspiration, organ failure
Tx serotonin syndrome
- Cyroheptadine (5HT antagonist)
- Serotonine syndrome resolves after 24 hrs once proserotonergic agents have been d/c
Which antidepressants have a risk of serotonin syndrome, esp. when combined with MAOIs?
All of them except bupropion
Which antidepressants have a risk of hypertensive crisis, esp. when combined with MAOIs?
Antidepressants can cause orthostasis if combined with _______
Alpha-1 antagonists (-zosin)
Can pregnant pts take antidepressants?
Technically yes, but if possible taper the med. to 0 and then immediately restart on postpartum day 1.
Which antidepressants are safest in pregnancy?
- Bupropion if no cardiac or seizure comorbidities
Which antidepressant should NOT be taken in pregnancy?
Which antidepressants are not transferred in breastmilk?
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
How long does it take for maximal response to antidepressants to occur?
At weeks 6-8
How long should pts take antidepressants for?
- At least one year if 1st depressive episode
- Longer or indefinitely if depression returns
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)
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
Which antidepressant is FDA approved for ages 12-17?
Which antidepressant is FDA approved for ages 8-17?
Which antidepressant should not be given to pediatric pts due to inefficacy and poor tolerability?
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)
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
Depression is often comorbid with what other condition?
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)
ADRs of BZDs
- Cognitive impairment (permanent)
- Respiratory depression (for high doses or when combined with other CNS depressants)
- Anterograde amnesia
- Paradoxical agitation (rare)
Do pts develop tolerance to sedative effect of BZDs?
Yes, after 2 wks of daily use
Why is use of BZDs risky?
- Cognitive impairment
- Substance abuse → add to other drugs to enhance/prolong high or avert withdrawal
Does tolerance develop to anxiolytic and muscle relaxant effects of BZDs?
No - if pt needs frequent dose increase, probably sign of misuse
What is the 1st line pharmacologic tx of generalized anxiety disorder?
SSRIs (esp. fluoxetine or sertraline)
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
Why should you titrate SSRIs slowly in pts with anxiety?
Antidepressants can worsen anxiety during 1st week of tx
You tried SSRIs for treated GAD pt but didn't work. What other options do you have?
- SNRI (duloxetine)
- Pregabalin → last-line
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
How long would it take antidepressants to take effect in treating anxiety disorder?
1st line tx for panic disorder
Tx algorithm for ADHD
- Stimulants → 1st line
- Guanfacine or clonidine → alpha 2 agonists
Are stimulants contraindicated in seizure pts with ADHD?
2 general ADRs of stimulants
- Negative effect on growth in first few months of use
- Low elevations in BP and HR (no ECG changes)
How can you decrease the negative effect on growth seen with stimulant use for ADHD tx?
Don't take med. on non-school days
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
1st line tx for ADHD
Onset of stimulants
Within 1st day
Dosage forms of methylphendiate
How long does transdermal methylphenidate last?
How long does it take for transdermal methylphenidate to peak?
Precautions for transdermal methylphenidate
- Variability in absorption → incr. absorption rate with chronic use or heated/inflamed skin
- Skin irritation
If you suddenly remove a transdermal methylphenidate patch, how long does the medication remain in system?
ADRs of methylphenidate
What schedule is methylphenidate?
Methylphenidate should not be taken with what meds (DDIs)
- Other stimulants
- CYP450 2D6 meds (e.g. most SSRIs)
Which amphetamine should NOT be used for ADHD tx? Why?
Methamphetamine - abuse risk
Precautions should be taken when prescribing stimulants for pts with these conditions (4)
- Pregnancy → teratogenic
Which amphetamine has least risk of abuse?
If ADHD pt has CV abnormalities or diversion risk, what medication should you prescribe?
Onset of atomoxetine
ADRs of atomoxetine
- GI upset
- Initial growth slowing
Which ADHD meds are metabolized by CYP450 2D6?
Atomoxetine should be avoided in combo with what meds?
Meds that affect NE uptake
- Alpha-1 antagonists
When might you use clonidine or guanfacine for ADHD tx?
Pt refractory to stimulants and atomoxetine OR as adjunct to stimulants
ADRs of guanfcine and clonidine?
- Decrease BP/HR
What would you prescribe an ADHD pt with tics?
- Alpha-2 agonists (clonidine, guanfacine)
Nutritional supplements for ADHD
- omega 3 fatty acids