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Brain and Behavior > Lecture 76: Antidepressants > Flashcards

Lecture 76: Antidepressants Flashcards

1
Q

MAOIs (key, 3)

A

Phenelzine, tranylcypromine, selegiline

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2
Q

What is special about selegline?

A

Patch delivery

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3
Q

Are MAOIs first line? What population might they be used?

A

No–after trying other anti-depressants first; atypical depression: sleep/eat a lot

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4
Q

MAOI mechanism

A

MAO located in presynaptic neuron and degrades monoamines –> MAOIs inhibit enzyme, inhibiting degradation of monoamines

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5
Q

Important MAOI mechanism notes

A

More NT in both presynaptic neuron AND cleft; irreversible (MAOIs take 2 weeks to recover)

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6
Q

Describe types of MAOs and targeted catecholamines. Which one is in the gut? Which one degrades tyramine? Which are targeted by MAOIs?

A

MAOa: 5-HT, NE, Epi, DA; MAOb: DA; MAOa; both; both

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7
Q

2 MAIN (scary) side effects of MAOI and mechanism

A
  1. Also inhibit breakdown of Tyramine –> NE release (hypertensive crisis) if combined with tyramine diet or adrenergic agonists; 2. Serotonin syndrome if combined with other serotonergic drugs
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8
Q

Other SEs of MAOIs (5)

A

Orthostatic hypotension, weight gain, insomnia, sexual dysfunction, rare hepatoxicity

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9
Q

Describe symptoms serotonin syndrome (11)

A

Abdominal pain, diarrhea, sweating, hyperthermia, tachycardia, hypertension, myoclonus, tremor, irritability, delirium, death

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10
Q

What can you NOT take with MAOIs because of serotonin syndrome (3)

A

Other antidepressants, dextromethorphan (cough medicine) and opiates

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11
Q

What else can you NOT take with MAOIs? Why?

A

Decongestants, stimulants because they can cause hypertensive crisis (BP > 120 mm Hg) due adrenergic agonists

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12
Q

What food items must be avoided with MAOIs? Why?

A

Tyramine inhibition in GUT via MAOa but if tyramine gets access to NE sympa neurons, these MAOa are ALSO blocked leading to NE release; soy, beer, red wine, aged cheese, dried sausage, liver, smoked fish, sauerkraut

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13
Q

How long must a patient wait to resume normal diet after stopping MAOI?

A

2 weeks

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14
Q

Describe Selegiline’s hope

A

At low doses only inhibits MAOb, but turns out at antidepressant levels, also inhibits MAOa so STILL requires dietary restriction

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15
Q

TCAs (key, 1) and secondary amines (key, 2)

A

Amitriptyine; nortriptyline, desipramine

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16
Q

Mechanism of TCAs (?)

A

Inhibit re-uptake of NE and 5-HT

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17
Q

TCA therapeutic uses (4)

A

Depression, neuropathic pain, anixety, migraine

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18
Q

How are tertiary amines different?

A

Also inhibit 5-HT reuptake

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19
Q

TCA SEs via receptor

A

H1 blocker: sedation, weight gain; Alpha1 blockers: orthostatic hypotension; M1 blocker (anticholinergic) constipation/urinary retention, dry mouth, blurred vision; Na channel blockers: type 1 antiarrythmic effects; Serotonin Reuptake inhibitors (same as SSRIs)

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20
Q

Problem with TCAs being a NA channel blocker (2)

A
  1. If you have bad ischemic heart disease, TCA can CAUSE arrythmias; 2. Can lead to overdose
21
Q

Which TCAs are the LEAST anticholinergic and alpha1 blockers

A

Secondary amines

22
Q

TCA: avoid in…

A

People with narrow angle glaucoma, recent cardiac events, children, elderly (orthostatic hypotension –> falling)

23
Q

TCA is active in what liver system?

A

Metabolized BY cytochrome p450

24
Q

SSRIs (key, 5)

A

Fluoxetine, sertraline, paroxetine, citalopram, escitalopram

25
SSRIs major indications (4)
MDD, anxiety, OCD, bulimia
26
SSRI mechanism (main)
Inhibit reuptake of 5-HT into presynaptic neuron --> more 5-HT in synapse
27
SSRI secondary effects. Important?
Some NE and DA reuptake effects; potential SEs
28
Paroxetine secondarily
Inhibits NE reuptake
29
Sertraline secondarily; why important
Inhibits DA reuptake --> activating good for tired patients
30
SSRIs common SE
GI, weight gain, tremor, headache, sweating, sexual
31
SSRIs less common SE
Dry mouth, bruising/bleeding (important for surgery), hyponatremia, vivid dreams, serotonin syndrome, mania if underlying BP disorder
32
Fluoxetine has the most...What else is special about this drug (2)?
Drug:drug interactions due to p450 inhibition; longest half-life (once weekly formula, best for people who don't take drugs daily); "activating" --> insomnia
33
Citalopram and Escitalopram has the fewest...importance?
Drug:drug interactions; perhaps fewest SEs
34
Paroxetine half-life is...causing...What else is noteworthy about this drug?
Short; withdrawal symptoms; NE reuptake blockade and anticholinergic activity; more sedation, dry mouth, weight gain
35
Describe SSRI withdrawal and how long. Drug least and most likely
Abrupt discontinution of SSRI --> dizziness, nausea, paresthesias, flu-like, muscle aches, headaches; 3 weeks; fluoxetine = least and paroxetine = most
36
SSRI advantages
Standard dosing, clinical response at starting dose, not lethal in OD, no arhythmias, no changes in BP, no seizures, fewer drug-drug interactions
37
Problem with SSRIs and new drugs?
Perhaps SSRIs are not effective enough because of the lost of NE, but trying to be less dirty (= SNRIs)
38
SNRIs (key, 2)
Venlafaxine, duloxetine
39
SNRI therapeutic use (3)
Neuropathic pain, depression, anxiety
40
SNRI SEs
Increases diastolic BP at higher doses, otherwise similar to SSRIs
41
Duloxetine (describe and 2 SEs)
Affinity for 5HT and NE at all doses with many pain and psych indiactions; small amount get hepatoxicity and elevated BP is possible
42
Advantage of Buproprion and therapeutic use. Mechanism? Avoid in what 3 patients?
No weight gain/sex issues; MDD, smoking cessation, ADHD; weak NE and DA inhibitor AND inhibits nACh but NOT 5-HT; avoid in anxious patients, alcoholics (seizure), eating disordered
43
Buproprion SEs (scary one and others)
Seizures at high doses; anxiety, rare psychosis
44
Mirtazapine mechanism. Avoids what SEs but not?
Alpha2 antagonist (presynaptic) --> more NE and 5-HT NT but blocks 5-HT subtypes that causes SEs (GI, sexual); avoids sexual and GI SEs but STILL causes sedation/weight gain
45
Mirtazapine should be used in what patients...
People who are NOT eating or sleeping
46
Trazadone is too...so now just used for? SEs?
Sedating; insomnia; priapism
47
Anti-depressant response rate (%)
60%
48
Four theories for antidepressant action
1. Therapeutic delay --> downregulation of receptors; 2. Enhance neuronal regeneration; 3. Restore cortical dendrites; 4. Increase expression of neurotrophic factors
49
Comorbid pain, think...
SNRIs

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