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701 > Exam 3: Depresso > Flashcards

Exam 3: Depresso Flashcards

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1
Q

Serotonin syndrome definition

A
  • mental status changes
  • autonomic instabiltiiy
    - diaphoresis
    - hypersalivation
  • neuromuscular aboramlity
  • GI symptoms
  • hyperrefleia, clonus
  • dilated pupils
  • hyperactive bowel sounds
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2
Q

Serotonin syndrome cause

A

conmittant use of serotonergic drugs

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3
Q

Neuroleptic malignant syndrome definition

A

da agents more likely to cause this (vs. serotonin agents)
- lead pipe rigidity in all muscle gorups
- hyporeflexia
- normal pupils
- normal or decreased bowel sounds

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4
Q

Neuroleptic malignant syndrome causes

A

Dopamine D2 receptor antagonism

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5
Q

Types of depressive disorders

A

Major depressive disorder (MDD)
Adjustment disorder w/ depressed mood
Seasonal affective disorder (SAD)
Substance-induced mood disorder

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6
Q

New depressive disorders in DSM 5

A

PMDD (different from PMS)
Bereavement if >2 months

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7
Q

MDD risk factors

A

Comorbidities (61% psych, 60% medical)
Family history
Age (bimodal: 12-16/elderly)
Medical (hypothyroidism)
Untreated pain

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8
Q

MDD etiology

A

unknown/complicated
probably due to altered neurotransmitters
- anatomical changes on imaging
- receptor change = delay onset of antidepressant

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9
Q

Biological markers of MDD

A

neuroendocrine abnormality
hypersecretion of cortisol - chronic stress
Depletion of BDNP
decreased neurogenesis
Substance P released during stress

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10
Q

Presentation of MDD

A

Initial sx: days-weeks
- anxiety sx appear first (if u have them)
Can last 4 months if untreated
MDD may remit, partially 35%, or never 15%
Repeat. episodes are common
RULE OUT MEDICAL DISORDERS
- get TSH, CBC, electrolytes

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11
Q

Emotional sx of MDD

A

cont. diminished capacity to experience pleasure in activities used to be enjoyed
Life stressors trigger depression
Anxiety sx present in 90% of people
if psychosis, tx with APS/hospitalize

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12
Q

Physical sx MDD

A

Psychomotor: slowed physical movement, speech, agitation, pacing, purposelessness

More common in elderly = chronic fatigue, pain, sleep disorders (early wake, daytime sleepy), appetite changes

watch for residual symptoms: if untreated, can be disabling (partial remission)

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13
Q

Medical causes of depression (6)

A
  1. hypothyroidism
  2. anemia
  3. HIV/AIDs/STDs
  4. Autoimmune disease
  5. CV disease
  6. Neuro disorder: EPILEPSY, Huntington’s, Parkinson’s, Alzheimers, post-stroke
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14
Q

Medications that can Induce Depression

A

CV: BB, CCB
Hormone: OC, steroids
AED: topiramate, levetiracetam
Opioids
Stimulants

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15
Q

Suicide risk features

A

Male
single/living alone
describes feelings of hopelessness/suicide
substance misuse
unusual behavior: missed work, giving away personal items
Initial therapy: increased energy to act on (suicide) plans

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16
Q

Black Box Warning on AD

A
  1. risk in children/teens with depression
  2. increased suicidality (thoughts/behaviors) in 18-24 y/o, ESPECIALLY AT EARLY STAGE OF TREATMENT
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17
Q

Counseling AD

A
  1. have patient/family monitor closely at start of treatment
  2. possible ADR: agitation, irritation, anxiety
  3. Deal with subject of suicide directly
  4. get help immediately
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18
Q

SSRI drugs

A

citalopram
escitalopram
fluoxetine
fluvoxamine
paroxetine
sertraline

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19
Q

SNRI drugs

A
  1. desvenlafaxine
  2. duloxetine
  3. levominacipran
  4. venlafaxine
  5. milnacipran
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20
Q

Serotonin modulator agents

A

nefazodone
trazodone
vilazodone (viibryd)
vortioxetine (trintellex)

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21
Q

TCA agents

A

-tyline
* amitripltyline
* nortriptyline
* protriptyline

amoxapine
doxepin

-amine
* clomipramine
* desipramine
* trimipramine

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22
Q

MAOI agents

A

Phenelzine
tranylcypromine
selegeline
rasagiline

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23
Q

Misc AD agents

A
  • brexanolone
  • bupropion
  • buspirone
  • esketamine
  • mirtazapine
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24
Q

Auvelity (dxm/bupropion) indication

A

the only PO NMDA receptor antagonist
for MDD

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25
DXM
Noncompetitve NMDA receptor antag Sigma-1 receptor Agonist rapid/extensive cyp2D6 metabolism post 5HT2A stimulation, some 5HT reuptake inhibition
26
Bupropion
FDA approved for depression/smoking CYP2D6 inhibitor (inhibit DXM metabolism) Weak inhibitor of NE and DA reuptake Does NOT inhibit MAO or 5HT reuptake
27
DXM/Bupropion Contraindications
- Seziure disorder (bupropion) - Current/hx bulimia or anorexia nervousa abrupt d/c etoh, benzo, barbituates, AED - Concurrent use w/in 15 days of d/c maoi - Elevated BP and HTN (DxM) - Activation of mania/hypomania - Angle closure galucoma - Dizziness - Embryo-fetal toxicity - Serotonin syndrome
28
Most common ADRs of DXM/Bupropionv (auvelity)
1. dizzy 2. headache 3. diarrhea 4. somnolence 5. dry mouth 6. hyperhidrosis
29
Aripiprazole (abilifty) Indications? (4)
1. schizophrenia 2. Bipolar disorder 3. MDD augmentation 4. Sx of autism/tourette's
30
brexpiprazole (Rexulti) indicagtions
1. Schizophrenia 2. MDD 3. dementia induced agitation
31
olanzapine (Zyprexa) indications
1. Schizophrenia 2. MDD 3. Bipolar
32
olanzapine (Zyprexa) indications
1. Schizophrenia 2. Bipolar disorder 3. MDD when used with fluoxetine
33
quetiapine (Seroquel) indications
1. Schizophrenia 2. Bipolar disorder 3. MDD
34
desvenlafaxine indications
MDD
35
Duloxetine indications
1. MDD 2. GAD 3. pain
36
levomilnacipran indications
MDD
37
citalopram indications
MDD
38
escitalopram indnications
1. MDD 2. GAD
39
fluoxetine indications
1. MDD 2. OCD 3. Panic 4. PMDD 5. bulimia nervosa 6. BPD
40
fluvoxamine indications
OCD
41
paroxetine indications
1. MDD 2. GAD 3. OCD 4. panic 5. PTSD 6. PMDD 7. SAD
42
setraline indications
1. MDD 2. OCD 3. panic 4. PTSD 5. PMDD 6. SAD
43
First line treatments for depression
- SSRI, SNRI - Bupropion - Mirtazapine - Vortioxetine (Trintellix)
44
AD effect expectations after 1 week
decreased anxiety improved sleep improved appetite
45
AD effect expectations after 1-3 weeks
Increased activity, sex drive, self care, memory thinking/movements becoem normal Sleeping/eating become normal
46
AD effect expectations after 2-3 weeks
Relief of depressed mood thoughts of suicide subside a little
47
How to tell the difference between Serotonin Syndrome and NMS?
NMS will show elevated CPK | >>>>???/
48
49
Antidepressants that DO NOT cause anxiety NOR agitation as ADR
- Escitalopram __ - Levomilnacipran __ - Befazodone - Trazodone - Vilaxodone - Vortioxetine __ - Buspirone - Mirtazapine
50
Antidepressants that DO NOT cause anxiety but CAN cause agitation as ADR
- Fluoxetine - Desvenlafaxine
51
Antidepressants that can CAUSE agitation/anxiety as ADR
- Bupropion __ - Duloxetine - Venlafaxine __ - Citalopram - Fluvoxamine - Paroxetine - Sertraline
52
When should you avoid using paroxetine?
pregnancy elderly bone fracture risk
53
AD to avoid in QTc prolongation?
Citalopram (FDA) Escitalopram maybe
54
Fluoxetine DDIs
2D6 inhibition (TCA) 3A4 inhibition (Carbamazepine)
55
Sertraline contraindicated in
Hepatic failure
56
DDI that can cause serotonin syndrome
Triptans tramadol or fentanly nausea products (zofran, reglan) BUSPIRONE Linezolid Ritonavir Drugs that impair 5HT metabolism
57
Venlafaxine ADR/DDI
2D6 Causes abnormal bump in BP give with food preferred over desvenlafaxine
58
SNRI general traits
More energy boosting variable indications same bleed risk and activation to mania as SSRI
59
Desvenlafaxine FDA indication
MDD
60
Duloxetine FDA indication
- MDD - GAD - Fibromyalgia - Musculoskeletal pain - neuropathic pain
61
Venlafaxine FDA indication
1. MDD 2. GAD 3. panic disorder 4. social phobia
62
Levomilnacipran FDA indication
MDD
63
TCA warning
over dose can be fatal Highly anticholinergic higher doses for inpatient/hospitalized
64
TCAs indicated for depression
Amitriptyline amoxapine desipramine Doxepin Imipramine Notrtyptiline Maprotiline
65
TCA with additional indicatins
Clomipramine - OCD only Doxepin - also for insomnia
66
MAOI washout for fluoxetine
5 weeks d/t long half life
67
MAOI washout for vortioxetine
3 weeks
68
MAOI washout for most AD
2 weeks
69
MAOI use for AD
last resort drug has many fussy requirements
70
Tyramine foods
cheese, dairy wine, beer herring, sardine, anchovy processsed meat MSG fermented foods Dried fruits Soy sauce chocolate coffee ripe avocado
71
5HT modulators
Nefazodone Trazodone Vilazodone Vortioxetine
72
Nefazodone (serzone) BBW
associated with severe hepatic failure
73
Trazodone (Desyrel) caution
more anticholinergic more bleed risk shouldn't be used as sedation, but often is risk of pripaism --> damage --> ED
74
Bupropion m ADR/risk
seizures eating disorders AUD (Bulimia, purging = electrolyte abnormal- seizures) HTN Insomnia Activation Anxiety
75
Mirtazapine pearls
Very sedating Weight gain common (good for thin, insomniac) ODT FYI: "inverse relationship with dose and sedation"
76
Spravato (esketamine) nasal spray indication
For ADULTS in COMBO with other ORAL AD MUST HAVE FAILED 2 other AD
77
Spravato (esketamine) nasal spray MOA
NMDA receptor antagonist
78
Spravato (esketamine) nasal spray C/I
Hx of aneurysmal vascular disease, intracerebral hemorhage
79
Spravato (esketamine) nasal spray ADR
- HTN - cognitive impairment - impaired ability to drive/operate - embryo/fetal tox
80
Spravato (esketamine) nasal spray BBW
Sedation dissociation abuse/misuse suicidal thoughts/behaviors REMS PROGRAM - must be taken in front of hcp and monitor 2hrs post administration
81
Brexanolone (zulresso) formulation
IV infusion only, takes 60 hours stay at clinic 2.5 days NOT ORAL
82
Brexanolone (zulresso) ADR
Hypoxia - get pulse Ox Excessive sedation - every 2 hr monitor
83
Brexanolone (zulresso) indication
post partum depression not C/I in preg but also not recommended
84
Brexanolone (zulresso) MOA
allosteric modulation GABA A
85
If patient has seizures you should avoid
bupropion
86
If patient has substance abuse you should avoid
benzos
87
If patient has Cardiac complications you should avoid
TCAs
88
If patient has Gi bleed or anticoag you should avoid
SSRI
89
Elderly patient AD choices
1. SSRI initial best 2. Bupropion, venlafaxine 3. mirazapine: sleep, anxiety, apetite stimulation (watch cholesterol) AVOID TCAs avoid paroxetine - very anticholinergic
90
Augmentation agents for AD
Lithium - first line for depressive episodes that fail monotherapy SGAs: adjunct to AD
91
Which second gen antipsychotics are used as augmentation agents for depression??
aripiprazole brexpiprazole quetiapine olanzapine+fluoxetine monitor metabo
92
Controversial natural products
omega3 folate, lmethylfolate s-adensoyl methione St. johns wort
93
What can trigger Serotonin syndrome?
when on ≥3 serotonergic meds
94
What to counsel for serotonin syndrome?
1. GI sx, mms, autonomic instability, NM abnormal VERY RARE CAN BE FATAL 2. avoid concomitatnt use of 5HT drugs/metabolism impair
95
Treatment for resistant depression
no universal guidelines - switch drug MOA - augment with APS - 2+ fail try esketamine spray in addition

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