depression and anxiety in practice Flashcards

Question

when should you avoid use of citalorpam and escitalopram?

Answer 1

– congenital long QT syndrome – known pre-existing QT interval prolongation – or in combination with other medicines that prolong the QT interval

Answer 2

electrolyte distrubances

Answer 3

– 40 mg for adults – 20 mg for patients older than 65 years – 20 mg for those with hepatic impairment

Answer 4

older than 65 years is now reduced to 10 mg/day

Answer 5

further dose reductions in the first two weeks of treatment is recommended

Answer 6

omeprazole= NICE recommends gastroprotection with SSRI in patients at risk of bleeding disorder

Answer 7

small increased risk of fractures associated with the use of TCAs and SSRIs, and should take this risk into account in their discussions with patients and in prescribing decisions

Answer 8

SRI/SNRI antidepressant medicines: small increased risk of postpartum haemorrhage when used in the month before delivery (January 2021)

Answer 9

* Potential for an initial increase in agitation, anxiety on starting tx * Suicidal thoughts and suicide attempts have been reported for all antidepressants early in treatment or after stopping treatment * Hyponatraemia (see next slide) * Sexual dysfunction * Withdrawal effects

Answer 10

if the person develops dizziness, drowsiness, confusion, nausea, muscle cramps, or seizures

Answer 11

Normally occurs within 30 days of starting antidepressant but can take months

Answer 12

• Urgent care if severe (Na < 125mmol/L)

Answer 13

If identified stop antidepressant & sodium levels should normalise within 1-2 weeks

Answer 14

• Once sodium normalised, choose different antidepressant (try different class)

Answer 15

By reducing the uptake of serotonin by platelets, SSRIs reduce the ability of platelets to aggregate and thereby increase the risk of haemorrhage, particularly gastrointestinal bleeding.

Answer 16

– Elderly – Patients with a history of peptic ulcers – Excessive use of alcohol – Co-administration with other drugs associated with the risk of bleeding • NSAIDs, antiplatelet drugs, corticosteroids, and warfarin

Answer 17

– Avoid SSRIs/ SNRIs if possible if at increased risk – Avoid concomitant drugs which increase bleeding risk – If no suitable alternative can be found, consider gastroprotection – NICE suggests gastroprotection in older people who are taking NSAID/aspirin

Answer 18

• Drug/drug interactions which may increase QT prolongation risk • Drugs with affect the metabolism of concurrently prescribed medication (CYP450 inhibitors/inducers) • Drug/drug interactions which may increase risk of serotonin syndrome • Drug/drug interactions which may increase bleeding risk • Interactions with warfarin • Potential to antagonise the effect of anticonvulsants • Drugs that increase the risk of sedation (TCAs) • Drugs that increase the risk of anticholinergic side effects (TCAs)

Answer 19

may be used in patients who do not respond to other antidepressants may be useful in patients refractory to other treatment

Answer 20

there are signifigant food and drug interactions Hypertensive crisis adverse reactions, which have sometimes been fatal; can occur if an MAOI is taken in combination with food or drink that has a high tyramine content.

Answer 21

Associated with withdrawal symptoms | • May cause hepatic impairment

Answer 22

aged cheeses wine soy sauce dried and aged sausages

Answer 23

MAOIs must not be prescribed alongside SSRIs, or other substances with serotonin reuptake inhibition effects (including SNRIs, trazodone, and clomipramine), due to the risk of inducing serotonin syndrome

Answer 24

ertain analgesics, opioids (e.g. tramadol), and some triptan migraine medications. Some non-prescribed substances taken by patients have SSRI-like properties, including St John’s Wort, and so also must be avoided

Answer 25

ust ensure there is a suitable washout period of at least five half-lives of the particular SSRI. This would typically be approximately seven days for most SSRIs,

Answer 26

around six weeks for fluoxetine due to its much longer half-life

Answer 27

2–3 weeks is always advised after stopping a MAOI, before commencing an alternative antidepressant. This includes when switching from one MAOI to another MAOI.

Answer 28

due to the potential risk of synergistic effects on blood pressure.

Answer 29

For surgical procedures needing general anaesthetic, input from an anaesthetist should be sought well in advance, as it is likely the MAOI will need to be discontinued at least 10 days prior to surgery. as can have serious interaction

Answer 30

over-the-counter cold remedies and/or anti-congestants (including nasal sprays). This is because some of these can interact with MAOI effects, and increase levels of noradrenaline and/or serotonin. In turn, this can increase the risk of high blood pressure or serotonin syndrome.

Answer 31

altered mental status, neuromuscular hyperactivity, and autonomic instability

Answer 32

agitation, confusion, delirium, and hallucinations

Answer 33

profound shivering, tremor, teeth grinding, myoclonus, and hyperreflexia

Answer 34

– Tachycardia, fever, and hypertension or hypotension | – Flushing, diarrhoea, and vomiting are also common

Answer 35

In severe cases, drowsiness, coma, seizure, hyperthermia, rhabdomyolysis, renal failure, and coagulopathies may develop

Answer 36

Concomitant use of antidepressants with other serotonergic drugs (tramadol, triptans) or dopaminergic drugs (selegiline) can increase the risk – Close monitoring is advised if co-prescribed, alternative drugs would be a better option

Answer 37

TCAs and venlafaxine

Answer 38

to incrementally reduce the dose of the first antidepressant and discontinue it before starting the second antidepressant. This is not always possible. In severely depressed patients who have failed to respond to one antidepressant, or in cases of severe adverse reaction, it may be necessary to shorten the process of substitution. Cross-tapering is an option for some switches but should always be done cautiously.

Answer 39

• Reduce gradually over 4-weeks to minimise discontinuation symptoms

Answer 40

– Include dizziness, nausea, anxiety, diarrhoea, flu-like symptoms, headache – Usually occur within 5 days of stopping treatment – Often mild and self-limiting, rarely lasting for more than 1–2 weeks.

Answer 41

– longer treatment courses – antidepressants with a short half-life (paroxetine) – people who developed anxiety symptoms at the start of treatment – people taking other centrally-acting drugs.

Answer 42

– original antidepressant may be reintroduced and tapered slowly – monitor symptoms

Answer 43

• Symptoms of anxiety may initially worsen • Antidepressants do take time to work • Continue for at least 6 months following remission of symptoms as this reduces risk of relapse • Sleep hygiene advice if having trouble sleeping • Remember drug specific counselling aspects e.g. dose, common side-effects, any monitoring

Answer 44

* Statement 1. People with a suspected anxiety disorder receive an assessment that identifies whether they have a specific anxiety disorder, the severity of symptoms and associated functional impairment. * Statement 2. People with an anxiety disorder are offered evidence-based psychological interventions. * Statement 3. People with an anxiety disorder are not prescribed benzodiazepines or antipsychotics unless specifically indicated. * Statement 4. People receiving treatment for an anxiety disorder have their response to treatment recorded at each treatment session.

Answer 45

decide which is the main problem and treat this first.

Answer 46

• May see worsening of anxiety Sx at beginning of tx –monitor closely for A/E • Titrate dose slowly; final effective dose may go above usual depression dose • Watch out for withdrawal Sx, suicidal ideation in younger patients as above • Generally expect to see a response to antidepressants usually within 6 weeks; usually continued for at least 6-12m

depression and anxiety in practice Flashcards

(70 cards)