MOOD 9

Question 1

Which TCA has the highest serotonergic effect, therefore is used treatment of OCD?

Which TCA is the most anti-histamine and sedating?

Answer 1

Clomipramine.

Doxepin

Question 2

Which TCA is used for Enuresis?

Answer 2

Imipramine.

Question 3

Which TCA imparts the highest risk of seizures?

Answer 3

Clomipramine.

Question 4

What receptors do TCAs affect and what affect does it cause?

Answer 4

1. Serotonin and NE reuptake blockade (antidepressant)
2. Anticholinergic (blocks Ach)
   - Think Red as a beet, dry as a bone, hot as a hare, full as a flask, mad as a hatter and blind as a bat.
3. Alpha 1 blockade
   - orthostatic hypotn
4. Antihistamine (H1 blockade)
   - Sedation, weight gain.
5. Inhibit voltage gated sodium channel
   - arrhythmia, heart block
   - analgesic effect

Question 5

What is the mechanism of action of MOAIs

Answer 5

Inhibit Monoamine oxidase (the enzyme that catabolizes monoamines) –> resulting in an increase in 5-HT, NE and DA.

Question 6

To prevent hypertensive crisis with MOAIs you need a 2 week flush out period except with what antidepressant medication? How long of a flush out do you need?

Answer 6

Fluoxetine - 5 weeks required.

Question 7

MAOIs can be classified as classic non-selective MAOIs (inhibit both MAO-A and MAO-B) or Selective MOA-B inhibitors.

Which 3 MAOI medications are non-selective and irreversibly inhibit both MAO-A and MAO-B?

Which drug is a selective MAO-B inhibitor?

Answer 7

NON-selective MAOIs

1. Phenelzine
2. Tranylcipromine
3. Isocarboxazid

Selective MOA-B inhibitors:
1. Selegiline (but at higher dose inhibits both A and B)

(think “B SELective”

Question 8

What are the notable differences to know between these three TCAs?

Phenelzine vs Tranylcipromine vs Selegiline

Answer 8

Phenelzine = most sedating

Tranylcipromine = most activating bc of amphetamine-like effect.

Selegiline = At low doses don’t need a tyramine free diet (bc at low dose it is a selective MAO-I B inhibitor only)

Question 9

How do Tyramine rich foods cause HTN crisis in patients who are taking non-selective MOAIs (Phenylzine, Tranylcipromine, isocarboxazid)?

Answer 9

MAOI-A in the gut metabolizes Tyromine which has monoamine like effects. If MAOI-A is inhibited you can get HTN crisis.

Question 10

Other than MDD, mania and psychosis…what are the three rare indications for ECT?

Answer 10

Parkinsons Disease
NMS
Refractory Epilepsy

Question 11

What % of individuals starting Lamotrigine develop a BENIGN rash?

Answer 11

10%