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competency 10/11 > neuro: depression > Flashcards

neuro: depression Flashcards

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1
Q

TCA egs and moa

A

amitriptyline -> nortriptyline
imipramine -> desipramine
dothiepin
clomipramine

block reuptake of NE and 5HT + anticholinergic + H1 and a-adrenergic antagonism

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2
Q

TCA side effects

A

GI and sexual dysfunction
anticholinergic, sedation, orthostatic hypoTN, arrhythmias, seizure
FATAL on overdose

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3
Q

clomipramine indicated for

A

OCD

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4
Q

SSRI eg and moa

A

fluoxetine -> norfluoxetine
fluvoxamine
escitalopram/citalopram
sertraline
paroxetine

blocks reuptake of 5HT selectively

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5
Q

SSRI adr

A

gi and sexual dysfunction
headache, transient nervousness during initiation
hyponatremia (SIADH)
bleeding risk

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6
Q

escitalopram/citalopram

A

qtc prolongation, esp in elderly women at high doses

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7
Q

paroxetine

A

most anticholinergic, sedating, incr weight, t1/2 short

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8
Q

fluvoxamine dosing

A

on, sedating

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9
Q

fluoxetine

A

OM: alerting
t1/2 long 4-6d, then 4-16d for norfluoxetine

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10
Q

SNRI egs and moa

A

venlafaxine -> desvenlafaxine
duloxetine

blocks reuptake of NE and 5-HT

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11
Q

SNRI moa

A

(same as SSRI)
gi and sexual dysfunction
headache, transient nervousness during initiation
hyponatremia (SIADH)
bleeding risk

  • venlafaxine: incr bp!!!!
  • duloxetine: urinary hesitation
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12
Q

duloxetine indicated for

A

diabetic peripheral neuropathy, fibromyalgia, chronic musculoskeletal pain

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13
Q

SMS

A

serotonin modulator and stimulator

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14
Q

SMS egs and moa

A

vortioxetine

altering the activity of various post-synaptic serotonin (5-HT) receptors, in addition to inhibiting the reuptake of serotonin via the same mechanism as selective serotonin reuptake inhibitors (SSRIs)
- vortioxetine is also a 5HT1a agonist

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15
Q

SMS adr

A

gi and sexual dysfunction
headache, transient nervousness during initiation
low Na levels (SIADH)
bleeding risk

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16
Q

NaSSA

A

Noradrenergic and specific serotonergic antidepressants

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17
Q

NaSSA eg and moa

A

mirtazapine

a2-adrenergic antagonist, incr 5HT and NE, 5HT2&3 + H1 antagonism

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18
Q

NaSSA adr

A

somnolence, incr appetitie, weight gain

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19
Q

NaSSA is able to ____________________ of SSRI/SNRI

A

reverse SI and sexual SE

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20
Q

NDRI

A

norepinephrine–dopamine reuptake inhibitor

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21
Q

NDRI egs and moa

A

bupropion

blocks reuptake of NE and DA

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22
Q

NDRI adr

A

seizure, insomnia, psychosis

not suitable for eating disorder

decr sexual SE of SSRI/SNRI

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23
Q

bupropion also used for

A

smoking cessation aid

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24
Q

MAOI

A

moclobemide: reversible MOAI-B

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25
trazadone
blocks reuptake of 5HT antagonises 5HT2A,H1 and a1-adrenoceptor used for insomnia than depression same adr as ssri + sedation _ orthostatic hypoTN + rare SE: priapism
26
agomelatine
MT-1, MT-2 agonist 5HT2c antagonist adr: GI, incr LFTs (check at baseline at week 3,6,12,24) c/i: fluvoxamine, ciprofloxacin
27
for all antidepressants, what is a transient side effect?
jittery (sudden release of neurotransmitter at synapse) - to start at a lower dose for pt w anxiety issue
28
for all SSRI, what is a SE to take note for
hyponatremia (particularly common and bad in the elderly - check renal panel at baseline, 2 weeks, 4 weeks, 3 months) > SIADH: cramps, muscle twitching, confusion, seizures
29
BZD moa
potentiates GABA - anxiolytic - hypnotic - muscle relaxant - anticonvulsant - amnesia
30
BZD side effects
sedation, drowsiness muscle weakness, ataxia, amnesia less commonly: slurred speech, vertigo, headache, confusion
31
how to minimise risk for dependence of BZD?
limit to 2 weeks PRN, short course therapy, at lowest effective dose
32
Z-hypnotics
zolpiclone (Imovane 7.5) - hypnotic + anxiolytic zolpidem (Stilnox 6.25) - hypnotic only preferentially binds to bzd-binding sites with y and a1 subunits, causes sedation
33
z-hypnotics adr
n/v, dizziness, drowsiness, dry mouth, headache rarely: amnesia, confusion, hallucinations, nightmares, complex sleep-walking behaviours zolpiclone: taste disturbance
34
antihistamine
H1 antagonism adr: sedation, anticholinergic (dry mouth, constupation)
35
SGA
second gen antipsychotics 5HT2a antagonishm, 5HT1a partial agonism aripiprazole/brexpiprazole: EPSE quetiapine, olanzapine: metabolic SE
36
Spravato nasal spray
Esketamine, NMDA receptor antagonist adr: dissociation, dizziness, nausea, sedation, anxiety, incr BP
37
first line antidepressant
monotherapy: SSRI, SNRI, mirtazapine, bupropion
38
switch to alt antidepressant when
ineffective or intolerable to adequate dose in 1-4wks
39
if cross-titration, watch for
serotonin syndrome, if combining serotonergic agents
40
if direct switch
one SSRI can be stopped totally and the next serotonergic agent initiated
41
If switching from a Serotonergic antidepressant used daily for the past 2 months to a Nonserotoninergic agent (e.g. switching from SSRI/SNRI 􀁯 to Bupropion),
gradual cross-tapering over several weeks can reduce risk of Antidepressant Discontinuation Syndrome
42
washout period required for MAOIs
􀂱 If switching from Moclobemide to another antidepressant: 24 hour washout. 􀂱 If switching from another antidepressant
43
approaches to manage partial/no response
switching, augmentation, treatment-resistant depression
44
treatment-resistant depression
Symbyax oral capsule: olanzapine 6mg + fluoxetine 25mg per cap Spravato Nasal Spray (Esketamine 28mg per vial), as an adjunct to ssri/snri treatment
45
breastfeeding
may consider sertraline or mirazapine
46
elderly
avoid TCAs and anticholinergic, CNS, hypotensive or other SE
47
post-MI depression
may consider sertraline
48
hepatic impairment
avoid agomelatine if mild-moderate: consider vortioxetine
49
renal impairment
may consider vortioxetine
50
bipolar depression
lithium, lamotrigine, lurasidone, quetiapine
51
pregnancy
may consider nortriptyline in late pregnancy
52
antidepressant with fewer CYP interactions
mirtazapine, escitalopram, venlafaxine, desvenlafaxine, vortioxetine
53
serotonin syndrome
acute onset: within 6-8hrs causes: concomittant rx of high-dose serotonergic meds (eg. triptans, sibutramine, opioids, dextromethorphan, linezolid, ritonavir) mild: insomnia, anxiety nausea, diarrhea, HTN, tachycardia, hyper-reflexia moderate: agitation, myoclonus, tremor, mydriasis, flushing, diaphoresis, low fever<38.5 severe: severe hyperthermia, confusion, rigidity, resp failure, coma, death
54
SSRIs: incr risk of bleeding by at least 1-2 folds
higher risk in elderly on NSAID, warfarin, steroids - consider adding PPI - consider stopping serotonergic antidepressant 2 weeks before surgery if high bleeding risk - agomelatine safest
55
BZD + opioids
incr mortality, cns depression - avoid combi if possible, or limit doeses and duration
56
antidepressant discontinuation syndrome
worse with abrupt discontinuation of long-term regular therapy - esp w short t1/2 antidepressants: paroxetine, venlafaxine - onset: 36-72hrs - duration: 3-7 days but typically resolves over 1-2 weeks without treatmentd FINISH - flu-like sx: fatigue, muscle aches, headache - insomina - nausea - imbalance: dizziness - sensory: electric shock sensations, paresthesia - hyperarousal: anxiety, agitation
57
if you need to stop a long-term antidepressant therapy after daily tx >= 8 weeks
recommend to gradually taper over at least 4 weeks - fluoxetine, bupropion: generally unnecessary because of their v long t1/2 - for the rest, taper by 25% every 1-2 weeks, or as gradually as clinically indicated
58
bzd: gradual discontinuation of long-term. high-dose use
decr dose by 25% weekly until reaching 50% dose, thenr educe 1/8 every 4-7 days, or as gradually as clinically indicated
59
space alc how long apart from antidepressants
4-6hrs
60
antidepressants w less sexual dysfunction side effect
mirtazapine, bupropion, agomelatine
61
antidepressants order
SSRI, SNRI, NaSSA > bupropion > agomelatine, vortioxetine > TCA > MAOIs
62
mirtazapine may be beneficial for
insomnia and poor appetite: can cause sedation and weight gain
63
bupropion not suitable for
h/o seizures, psychosis or eating disorder
64

competency 10/11 (31 decks)

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