NSG 533 Module 4 Flashcards
1
Q
When a patient has depressive symptoms, it is necessary to investigate the possibility of a medical, psychiatric, and/or drug-induced cause. You will find these exclusions also listed in DSM5. All depressed patients should have a complete physical examination, mental status examination, basic laboratory work-up and suicide risk evaluation (There is an increased risk of suicide at the beginning of the antidepressant therapy)
A
-
2
Q
Pharmacological causes of depression
- Antihypertensive drugs (propranolol, methyldopa, clonidine)
- Hormones (oral contraceptives, glucocorticoids)
- Acne therapy (isotretinoin)
A
-
3
Q
Antidepressants are used in treatment of depression, as well as some anxiety, pain and eating disorders, but not B______ D_______.
A
bipolar disorder
4
Q
- All antidepressants take ______ weeks to achieve their full effect. Adequate trial is necessary prior to making changes.
A
4-6
5
Q
Principles: Most studies find combination of pharmacotherapy + cognitive therapy more efficacious than either therapy alone. Efficacy of different antidepressants is generally comparable across and within classes.
A
-
6
Q
For patients with unipolar major depression who are initially treated with antidepressants, newer agents such as SSRIs / SNRIs rather than other antidepressants should be tried. It is critical to take into account patient specific factors such as prior response to a given class of medications, tolerability of adverse effects, comorbid conditions (eg. avoiding anticholinergics in glaucoma or BPH; avoiding bupropion in seizure disorders), etc
A
-
7
Q
- There is an increased risk of suicide at the beginning of the antidepressant therapy
A
-
8
Q
- Potential for withdrawal symptoms with abrupt discontinuation of antidepressant therapy.
A
-
9
Q
- In patients with mild to moderate major depression who obtain little symptom relief from an initial antidepressant, switching to an antidepressant from a _______________ as first-line treatment, rather than augmenting the initial antidepressant with a second drug is recommended (After an adequate trial)
A
different class
10
Q
- For patients who obtain little symptom relief despite repeated (eg, one to three) antidepressant switches, augmentation with a ________ medication is recommended.
A
second
11
Q
- For patients who obtain definite symptom relief that is not satisfactory and can tolerate the initial antidepressant, we suggest augmentation as first-line treatment
A
-
12
Q
______ - Selective serotonin re-uptake inhibitor
A
SSRIs
13
Q
- Currently most often prescribed initial drug of choice because of low side effect profile and not lethal if overdose as single agent
_________ (psych drug class)
A
SSRIs - Selective serotonin re-uptake inhibitor
14
Q
- Nearly all SSRIs undergo hepatic oxidative (P450) metabolism with fluoxetine having an extremely long T 1/2 because of its active metabolite. In fact, the “wash out period” for fluoxetine is about ___ weeks (eg to prevent serotonin syndrome if starting a MAOI, John’s Wort, etc)
A
5
15
Q
o Fluvoxamine inhibits CYP1A2, 3A4, 2C9, 2C19
o Fluoxetine and paroxetine inhibit CYP2C9 and 2D6
A
-
16
Q
o Citalopram, escitalopram and sertraline do not block P450 enzymes
A
-
17
Q
_______ (psych drug class)
- Generally well tolerated.
o May be associated with n/v, weight gain (especially paroxetine), etc.
o 30-40% of patients report loss of libido, delayed orgasm or diminished arousal
o Class effect
A
SSRIs
18
Q
- Fluoxetine and TCAs have greatest ________________ safety
A
reproductive
19
Q
SNRIs block both SER-T and NE-T (re-uptake of serotonin and norepinephrine)
A
-
20
Q
examples of this drug class include venlafaxine, duloxetine, desvenlefaxine
A
SNRIs
21
Q
- Similar indications and side effect profile to SSRIs with different MOA
A
SNRIs
22
Q
- Higher doses of some agents (venlafaxine) may be associated with increases in DBP, but not seen with others (duloxetine).
Which psych drug class?
A
SNRIs
23
Q
- Not only indicated in MDD, but also used in treatment of chronic pain disorders (including neuropathies and fibromyalgia), generalized anxiety, stress urinary incontinence (duloxetine), and vasomotor symptoms of menopause
SN______ (psych drug class)
A
SNRIs
24
Q
Because of their side effects and potential for lethal overdose (even if taken alone), _________ have essentially been replaced (ie. NOT initial therapy) by SSRIs and SNRIs as the first choice for treatment of depression. They still are used in refractory cases and for other indications (enuresis, migraine prophylaxis, neuropathies, etc).
A
TCAs
25
Significant anticholinergic effects
mnemonic "Anti-SLUD" -
salivation (dry mouth), lacrimation (dry eyes/blurred vision), urination (urinary retention), defecation ( constipation).
Can't see, pee, spit, or shit.
___________ (psych drug class)
TCAs
26
T_________ ADs (psych drug class)
* Avoid in:
o Patients with benign prostate hyperplasia
o Patients with closed-angle glaucoma
o Patients with cardiac disease
o Patients with hepatic impairment
o Elderly patients
TCAs
27
Side effects of ______ (psych drug class):
* Alpha-blocking properties - orthostasis, falls
* H1 blocking properties - drowsiness, sedation, weight gain
* Sexual side effects
* QTc prolongation
* CNS depression, especially if combined with other CNS depressants (benzo's, EToH, opiates)
TCAs
28
Trazodone was among most commonly prescribed antidepressants before introduction of SSRIs. Use now primarily limited to insomnia
Drug class?
5H_______ (psych drug class)
5HT2 antagonists
29
* Bupropion - Also known as norepinephrine-dopamine reuptake inhibitor (NDRI) (also used in smoking cessation)
main drug class?
Unicyclic / tetracyclic antidepressants
30
o Blockade of 5-HT2A, 5-HT2C and 5-HT3 * receptors
o Also blockade of H1 receptors and presynaptic α2-adrenoreceptors
* Mirtazapine
Unicyclic / tetracyclic antidepressants
31
o good choice if weight loss part of clinical picture and weight gain is desired
(mi________, psych med)
* Mirtazapine
Unicyclic / tetracyclic antidepressants
32
o Significant sedative effects, weight gain, dizziness
does NOT cause sexual dysfunction
mi_________ (psych med)
* Mirtazapine
Unicyclic / tetracyclic antidepressants
33
o Reasonable 1st line option in select patients where weight gain is a concern, patients w/ ADRs from SSRIs (eg. sexual dysfunction), where smoking cessation is also a consideration, etc.
b____________ (psych med)
Bupropion
34
o Active metabolites (including amphetamine-like compounds)... note side effects in relation to this fact and yes, this will cause a positive urine test
CNS stimulant effects, such as decreased appetite, anorexia,[weight loss], insomnia, agitation, tremor, seizures
b____________ (psych med)
Bupropion
35
May NOT be a good choice for monotherapy if anxiety is part of the clinical picture
b___________ (psych med)
Bupropion
36
o Contraindications: seizure disorder; history of anorexia/bulimia; patients undergoing abrupt discontinuation of ethanol or sedatives, including benzodiazepines, barbiturates, or antiepileptic drugs --> because ______________ lowers seizure threshold!
Bupropion
37
o Very Low likelihood of sexual dysfunction. Sometimes used as add on therapy to offset the sexual dysfunction caused by other antidepressants or in place of other antidepressants
bup___________ (psych drug class)
Bupropion
38
MAOI:
Mono-amine oxidase inhibitors
39
Used only for refractory cases of MDD
________ (psych drug class)
MAOI
40
* By blocking the enzyme that breaks down 5-HT, NE and DA, MAO inhibitors increase the levels of these NTs in the brain
MAOI
41
* This drug class (psych drug class) has several significant drug interactions, one being hypertensive crisis.
o Drugs that can precipitate a hypertensive crisis include: Ephedrine, pseudoephedrine, phenylephrine
MAOI
42
Washout period of 14 days necessary when switching from an ______ (AD drug class) to another antidepressant or from another antidepressant to an ______ (AD drug class) (5 week washout when switching from fluoxetine to an ______(AD drug class))
MAOI
43
Which psych drug class? (M____)
Several significant drug interactions
o Serotonin syndrome with other antidepressants, narcotic analgesics (esp. meperidine (Demerol®)), St. John’s wort, linezolid (Zyvox®)
MAOI
44
o Drug -food interactions precipitating hypertensive crisis
The "Wine and Cheese Reaction"
MAOI
45
o Drug -food interactions precipitating hypertensive crisis
Aged cheeses
smoked/pickled meats
yeast extracts
red wines
italian broad beans
MAOIs
46
Regarding anxiety:
Primary therapy should address underlying issues and should be managed accordingly (i.e. with SSRIs,SNRIs, etc.)
-
47
Citalopram, sertraline, fluvoxamine, and fluoxetine are not FDA-approved for the treatment of GAD. However, the efficacy of SSRIs in GAD appears to be a class effect, and there is uncontrolled data to support the use of all SSRIs in the pharmacotherapy of GAD.
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48
Generally, treatment of GAD should be continued for at least one year
-
49
BZDs:
Benzodiazepines
50
o Most prescribed agents for the acute treatment of anxiety (and in conditions such as depression with there is an anxious component -"bridge therapy")
o Efficacy is similar among the available agents
BZD - Benzodiazepines
51
BZ___ tapering: 25% per week reduction until 50% of dose is reached, then decrease by 1/8th every 4-7 days.
> 8 weeks of therapy: 2-3 week taper
>6 months of therapy: 4-8 week taper
> 1 year of therapy: 2-4 month slow taper
BZD - Benzodiazepines
52
o Use should be limited to short term (2-6 weeks) until "other therapies (SSRI, SNRI)" takes effect
B__s
BZD - Benzodiazepines
53
Should not be used in patients with past or current substance and/or alcohol abuse or dependence
BZD - Benzodiazepines
54
Prefer those agents with longer half-life due to better coverage of anxiety (this is not the same in elderly patients or for insomnia)
BZD - Benzodiazepines
55
May paradoxically produce an increase in irritability and aggression in some individuals (particularly if short- acting drugs are given (triazolam)
B________ (psych drug class)
BZD - Benzodiazepines
56
________ (psych drug class), shown to affect memory, can produce anterograde amnesia (i.e., a loss of memory for events occurring forward in time). Following the ingestion of a _______ (drug class), short-term memory is not affected, but long-term memory is impaired.
BZD - Benzodiazepines
57
Caution: patients are often prescribed _______ (psych drug class) for different reasons (muscle spasm, anxiety, insomnia, etc) by different providers. Always be aware of potential therapeutic duplications
BZD - Benzodiazepines
58
All BZ______ (psych drug class) are lipid soluble (easy access to the CNS) and can cause profound CNS depression, especially if combined with other CNS depressants
BZD - Benzodiazepines
59
o Duration of action:
Short-acting: alprazolam, triazolam
BZD - Benzodiazepines
60
o Duration of action:
Intermediate-acting: lorazepam, oxazepam
BZD - Benzodiazepines
61
o Duration of action:
Long-acting: diazepam, flurazepam, chlordiazepoxide ... The half lives of the parent compound and active metabolites are extensive (up to 100 hours)and can accumulate.
AVOID in the elderly.
(psych drug class)
BZD - Benzodiazepines
62
Anxiolytic drug, but NO sedative, hypnotic, anticonvulsant or muscle relaxant properties
Buspirone
63
o Comparable efficacy to benzodiazepines in the treatment of GAD, but some trials reported inconsistent findings. Considered second line overall
Buspirone
64
o Abrupt discontinuation of buspirone does not cause withdrawal effects as seen in BZDS
Buspirone
65
Slow onset of action (2-3 weeks)
b_________ (psych med)
Buspirone
66
o lack of activity against comorbid conditions (e.g., depression, panic disorder, social phobia) is a drawback in some patients.
Buspirone
67
_____________________ (drug class) may be helpful in patients with physical symptoms (e.g., palpitations and other cardiovascular complaints) but are not effective for the treatment of GAD.
β-Adrenergic antagonists (e.g., propranolol)
68
* Basic principles for the rational treatment of ______________ are to use the lowest effective dose, use intermittent dosing (2-3 nights/wk), use short term (2-3 wk at a time), discontinue after slow taper if the patient has been taking it regularly, and use agents with short and/or intermediate half-life to minimize daytime sedation
insomnia
69
Dosage, pharmacokinetic properties, and risk-benefit ratio are the key factors in selecting the most appropriate medication for ____________.
insomnia
70
Regarding _____________:
Choice of agents should be based on alleviating particular sleep problems (Eg difficulty falling asleep, decreased TST, early awakening, etc). Short-acting agents are recommended for patients with difficulty falling asleep, while intermediate-acting drugs are indicated for problems with sleep maintenance.
insomnia
71
o Examples of short-acting medications (duration of effect ≤8 hours) include zaleplon, zolpidem, triazolam, lorazepam, and ramelteon.
Short-acting agents taken at bedtime can result in both early-morning wakening and rebound insomnia the following night
may be beneficial if intermediate or longer acting agents result in "hangover" or excessive daytime (morning) sedation
good choice when sleep induction
-
72
o Examples of longer-acting medications include zolpidem extended release, eszopiclone, temazepam, estazolam
Used for sleep maintenance
Long-acting agents taken at bedtime can result in daytime sedation the following day leading to falls, etc
-
73
o Avoid ____________ sleep agents, especially in older people, because they cause daytime sedation and impair cognition, thereby increasing the risk of falls.
long-acting
74
Risks of using long-term sleep agents.
Influence of manual skills (such as driving performance) due to drowsiness, confusion, amnesia and impaired coordination
enhancement of depressant action of other drugs (in a more than additive way)
-
75
o Caution and close monitoring is needed in the administration of ___________ to older people and to patients with hepatic, renal, or pulmonary disease.
hypnotics
76
Treatment of insomnia in older adults requires careful attention to the role of medical, neurologic, sleep, and psychiatric comorbidities. Vulnerability to side effects increases with age, and medications for insomnia often exacerbate existing age-related impairments such as gait instability, sedation, cognitive dysfunction, urinary and bowel dysfunction, and cardiac arrhythmias. Older adults may have slower drug metabolism, and thus maximum and next-day serum concentrations will be increased.
-
77
* 5 BZDs marketed for insomnia
o Flurazepam, triazolam, temazepam, estazolam, quazepam
78
* 5 BZDs marketed for insomnia
o Flurazepam, triazolam, temazepam, estazolam, quazepam
o No respiratory depression in healthy patients, but respiratory depression in patients with COPD or obstructive sleep apnea
o Note: Any BZD can be used for sleep.
-
79
* "Z Hypnotics" - Zolpidem, zaleplon, eszopiclone. Act on the BZD receptor similar to traditional benzodiazepines
o no effect on sleep architecture
o minimal rebound insomnia
o no anti-convulsant or muscle relaxing properties (as do typical BZDs)
-
80
* "Z Hypnotics" - Act on the BZD receptor similar to traditional benzodiazepines
Zolpidem, zaleplon, eszopiclone.
81
* __________________ - blocks the binding of wake-promoting neuropeptides orexin A and orexin B to receptors OX1R and OX2R, which is thought to suppress wake drive.
o Increased levels in women and obese patients
o An increased risk for hazardous sleep-related activities such as sleep-driving; cooking and eating food, making phone calls, or having sex while asleep have also been noted
Suvorexant
82
* Ramelton - Ramelteon is a melatonin receptor agonist that specifically targets the MT1 and MT2 receptors in the brain, believed to be critical in the regulation of the body's sleep-wake cycle
o Reduced the latency of persistent sleep with no effects on sleep architecture and no rebound insomnia or significant withdrawal symptoms
o Drowsiness, dizziness, increased prolactin levels
o NO ABUSE POTENTIAL or Cross tolerance with other CNS depressants(including alcohol)
-
83
* 1st generation antihistamines (eg. diphenydramine, hydroxyzine). For insomnia.
o Generally safe but have anticholinergic adverse effects, such as dry mouth, blurred vision, urinary retention, and confusion in older patients
-
84
Regarding this insomnia med drug class and the Elderly.
These medications, a_____________________ (drug class), are a concern and should be avoided in patients with BPH and glaucoma, among others
1st generation antihistamines (eg. diphenydramine, hydroxyzine).
85
Mr. Sime was recently diagnosed with depression. As you are discussing his recent paroxetine prescription, he states that he is not happy that it isn't working. He has been taking it for about 5 days. Which of the following actions is most appropriate?
- Refer to provider to change paroxetine to a different antidepressant
- Refer to provider to change paroxetine to add an additional antidepressant
- Explain to the patient that the medication takes up to a couple of weeks to begin to take effect
- Contact the pharmacy to ensure he received the medication
Explain to the patient that the medication takes up to a couple of weeks to begin to take effect
This patient is likely adherent to the medication as he states it isn't working indicating that he is likely taking it. 5 days would be too soon to assess the efficacy and the provider is unlikely to change the medication or add a new one unless there are obvious adverse effects. The patient should be educated that it may take up to a couple of weeks to begin working and up to several weeks for maximum effect.
86
Which of the following antidepressants has the least sexual adverse effects?
Venlafaxine
Paroxetine
Duloxetine
Bupropion
Bupropion
Bupropion is the least likely to cause sexual adverse effects of the antidepressants listed. Both SSRIs and SNRIs are associated with sexual dysfunction.
87
Which of the following antidepressants is classified as an SNRI?
Venlafaxine
Amitriptyline
Citalopram
Doxepin
Venlafaxine
An SNRI is a selective norepinephrine reuptake inhibitor. Venlafaxine has activity at norepinephrine receptors, as well as serotonin receptors.
88
Of the following, which antidepressant tends to be most sedating?
Zoloft
Celexa
Wellbutrin
Trazodone
Trazodone
Although several antidepressants can be sedating, trazodone, through its mechanism of action, can have sedative effects. It is often used off-label to help with insomnia and sleep maintenance.
89
Which antidepressant can be used to aid with smoking cessation?
Paroxetine
Bupropion
Citalopram
Trazodone
Bupropion
Wellbutrin (bupropion) has activity at nicotinic receptors and inhibits them, which is thought to contribute to its efficacy as a smoking cessation aid.
90
Mr. Rist is a 55-year-old math teacher who struggles with urinary retention symptoms during the day due to a history of BPH. Which antidepressant would be most likely to contribute to this issue?
Trazodone
Mirtazapine
Bupropion
Amitriptyline
Amitriptyline
Amitriptyline should be avoided in patients who have urinary retention. It is highly anticholinergic and has significant sedative properties. It is on the Beers Criteria and should be avoided in elderly patients as well.
91
KM is a 42-year-old female who recently stopped taking her sertraline. Which symptoms would be inconsistent with antidepressant withdrawal symptoms?
Constipation
Anxiety
Nausea
Insomnia
Constipation
Nausea, dizziness, anxiety, headaches, and diarrhea are more likely to be symptoms of withdrawal from antidepressants.
92
Which of the following medications is an SSRI?
Duloxetine
Trazodone
Escitalopram
Buspirone
Escitalopram
Venlafaxine is an SNRI but does have activity on serotonin receptors in addition to norepinephrine receptors. Trazodone is a serotonin modulator. Buspirone is an anxiolytic agent. Escitalopram is the only true SSRI.
93
JS is a 78-year-old female with anxiety associated with end-of-life cares. She has been taking lorazepam 0.25 mg every 6 hours by mouth as needed for anxiety. Her caregiver has tried it about 5 times in the last 3 days and they report no effect. What is the likely reason for this?
Poor oral absorption
Dose is too low
It has to be taken with food
It has to be taken regularly to work
Dose is too low
Lorazepam (Ativan) should work on an as-needed basis and typically has adequate oral absorption. Taking it with food wouldn't have a significant impact and it can be taken as needed. The most likely issue preventing efficacy is that the dose is too low.
94
Which SSRI is most likely to cause drug interactions?
Sertraline
Paroxetine
Fluoxetine
Fluvoxamine
Fluvoxamine
Fluvoxamine interacts with several CYP isoenzymes and has nonselective inhibition, leading to a high potential for drug-drug interactions.
95
Food containing what substance can cause problems while taking an MAOI?
Thiamine
Folic acid
Gluten
Tyramine
Tyramine
Tyramine-rich foods can increase norepinephrine release, which can lead to life-threatening hypertensive crises or serotonin syndrome. Foods can be high in tyramine when they have been aged, fermented, pickled or smoked, and some red wines and beers.
96
Which of the following is NOT a likely symptom of serotonin syndrome?
Muscle rigidity
Fever
Confusion
Bradycardia
Serotonin syndrome is more likely to cause tachycardia than bradycardia.
Bradycardia
Serotonin syndrome is more likely to cause tachycardia than bradycardia.
97
LG is a 30-year-old female in the clinic for a routine visit. When reviewing her medication list, she adds that she started taking St. John’s Wort for her depression about two weeks ago. She is also taking fluoxetine 20 mg daily, ibuprofen 200-400 mg as needed, vitamin D3 5,000 units daily, Junel Fe 1/20 daily, and cetirizine 10 mg as needed for allergies. What are some important counseling points for LG regarding her medications? Select all that apply.
- Ibuprofen use while taking an SSRI can increase the risk of GI bleed
- There is an increased risk of serotonin syndrome while taking St. John’s Wort
- St. John’s Wort can reduce oral contraceptive efficacy
- All of the above are important counseling points
All of the above are important counseling points
St. John’s Wort should not be used with other serotonergic agents as it can increase the risk of serotonin syndrome. NSAID use while taking an SSRI can increase the risk of GI bleed. St. John’s Wort can reduce the effectiveness of oral contraception.
98
What is the primary mechanism of action of antipsychotic medications?
Block acetylcholine
Block dopamine receptors
Increase acetylcholine
Increase norepinephrine
Block dopamine receptors
The primary mechanism of most antipsychotic medications is to decrease dopamine activity and help control psychosis.
99
Which of the following extrapyramidal symptoms (EPS) is correctly paired with its definition?
- Dystonia: lack of muscle tone and contractions
- Parkinsonism: muscle rigidity and painful muscle spasms
- Akathisia: restlessness with anxiety and unable to remain still
- Tardive dyskinesia: a state of catatonia due to untreated seizures
Akathisia: restlessness with anxiety and unable to remain still
Dystonia is prolonged muscle contraction, including painful muscle spasms. Parkinsonism symptoms look similar to Parkinson's disease, with tremors, abnormal gait, and bradykinesia. Tardive dyskinesia is abnormal facial movements but can also involve the trunk and arms.
100
KY is a 24-year-old male with bipolar I disorder taking lithium 600 mg twice daily. He works in construction and sometimes works long days outdoors. What are some counseling points for KY regarding his lithium?
- Avoid prolonged sun exposure since lithium can lead to sunburns
- Take on an empty stomach at least 2 hours before a meal
- Lithium can alter thyroid function and labs should be monitored
- He should avoid any salt intake as it can cause dehydration with lithium
Lithium can alter thyroid function and labs should be monitored
Prolonged exposure to heat/sun can cause dehydration, which can increase lithium levels and side effects. Salt intake should remain consistent as too little or too much can affect lithium levels. Lithium should be taken with food or at the end of a meal to reduce nausea. Hypothyroidism is a possibility with the use of lithium and TSH and other thyroid labs should be monitored.
101
A lithium level greater than _____ mEq/L can cause what symptoms? Select the correct pairing.
- 1.5 mEq/L; sedation, constipation, depression
- 2.5 mEq/L; CNS depression, arrhythmia, seizures
- 1 mEq/L; persistent diarrhea, confusion, sedation
- 0.8 mEq/L; seizures, coma, death
2.5 mEq/L; CNS depression, arrhythmia, seizures
The therapeutic range for lithium is 0.6-1.2 mEq/L (trough level). At levels above 1.5 mEq/L, lithium toxicity may manifest as ataxia, coarse hand tremor, vomiting, persistent diarrhea, confusion, and sedation.
102
A melatonin receptor agonist. Indicated for insomnia characterized by difficulty with sleep onset. __________ is not a controlled substance and can be a viable option for pts with a history of substance abuse.
Ramelteon
103
_________________: an orexin receptor antagonist. It is the first medication that turns off wakefulness mechanisms instead of stimulating pathways that induce sleepiness. _____________ is indicated for both difficulty initiating and maintaining sleep, and like BZDRAs, it is classified as a Schedule IV controlled substance.
Suvorexant
104
_____________ is indicated for both difficulty initiating and maintaining sleep, and like BZDRAs, it is classified as a Schedule IV controlled substance.
Suvorexant
105
_________________: an orexin receptor antagonist. It is the first medication that turns off wakefulness mechanisms instead of stimulating pathways that induce sleepiness.
Suvorexant
106
___________________: These drugs, such as diphenhydramine, are frequently used (usual doses 25-50 mg) for difficulty sleeping. Benadryl is FDA-approved for the treatment of insomnia and can be effective at reducing sleep latency and increasing sleep time. However, Benadryl produces undesirable anticholinergic effects and carry-over sedation that limits its use, especially in the elderly.
1st class antihistamines
107
- All antidepressants: _______ weeks to work
For patients who show little improvement (eg, reduction of baseline symptoms ≤25 percent) after four to six weeks, it is reasonable to administer next-step treatment
4-6
108
Caution and close monitoring is needed in the administration of H___________ (psych drug class) to older people, pregnancy and to patients with hepatic, renal, or pulmonary disease (including sleep apnea)
hypnotics
109
Avoid long-acting sleep agents, especially in ______ people, because they cause daytime sedation and impair cognition, thereby increasing the risk of falls.
older
110
Examples of longer-acting medications include ____________________________. (x4)
zolpidem extended release, eszopiclone, temazepam, estazolam
111
Examples of short-acting medications (duration of effect ≤8 hours) include ____________________. (x5 AD hypnotics?)
zaleplon, zolpidem, triazolam, lorazepam, and ramelteon.
112
Short-acting sleep agents are recommended for patients with difficulty _______________, while intermediate-acting drugs are indicated for problems with sleep maintenance
falling asleep
113
Drug: __________ (Ambien)
(non-BZD; aka Z-hypnotic)
Indication: Sleep onset
Zolpidem (Ambien)
114
Drug: __________________
(non-BZD; aka Z-hypnotic)
Indication: Sleep onset, sleep maintainence
Zolpidem ER
115
Drug: ________ (Sonata)
(non-BZD; aka Z-hypnotic)
Indication: Sleep onset
Zaleplon (Sonata)
116
Drug: _________ (Lunesta)
(non-BZD; aka Z-hypnotic)
Indication: Sleep maintenance
Eszopliclone
117
Drug: _________ (Rozerem)
(Melatonin receptor agonist)
Indication: Sleep onset
Ramelteon
118
__________________: (including traditional BZDs, zolpidem, zaleplon, and eszopliclone) and ramelteon are approved by the FDA for the treatment of insomnia and are first-line therapies.
BZD receptor agonists (BZDRAs) aka Z-hypnotics
119
_______________, a 5-HT1A partial agonist, is thought to exert its anxiolytic effects by reducing presynaptic 5-HT (serotonin) firing. Unlike BZDs, _____________________ does not have abuse potential, causes withdrawal reactions, or potentiate alcohol and sedative hypnotic effects. It has a gradual onset (2 weeks) of action and does not provide immediate anxiety relief. Data is inconsistent regarding its efficacy in chronic GAD or GAD with comorbid depression. It may be less effective in patients who have been treated previously (4 weeks to 5 years) with BZDs. _________________ is well tolerated and most common SEs include dizziness, nausea, and headache. _______________ elimination is affected significantly by drugs that inhibit (verapamil, diltizem, itraconazole, fluvoxamine) or induce (e.g., rifampin) CYP34A. _____________ may increase BP when co-administered with an MAOI.
Buspirone (Buspar)
120
bus____________ (psych med), a 5-HT1A partial agonist, is thought to exert its anxiolytic effects by reducing presynaptic 5-HT (serotonin) firing.
Buspirone (Buspar)
121
Unlike BZDs, bu_____________________ (psych med) does not have abuse potential, causes withdrawal reactions, or potentiate alcohol and sedative hypnotic effects. It has a gradual onset (2 weeks) of action and does not provide immediate anxiety relief. Data is inconsistent regarding its efficacy in chronic GAD or GAD with comorbid depression. It may be less effective in patients who have been treated previously (4 weeks to 5 years) with BZDs.
Buspirone (Buspar)
122
_________________ is well tolerated and most common SEs include dizziness, nausea, and headache.
Buspirone (Buspar)
123
b_______________ (psych med) elimination is affected significantly by drugs that inhibit (verapamil, diltizem, itraconazole, fluvoxamine) or induce (e.g., rifampin) CYP34A.
Buspirone (Buspar)
124
bu_____________ (psych med) may increase BP when co-administered with an MAOI.
Buspirone (Buspar)
125
With regards to BZDs and anxiety related disorders:
Should be used only for ______ weeks until the antidepressant begins to work
2-4
126
Long-term use is not recommended due to concerns regarding dependence and withdrawal symptoms
Which drug class?
(B__s)
benzodiazepines
127
Because of the potential for abuse, ______________ (psych drug class) should not be used in patients with past or current substance and/or alcohol abuse or dependence
benzodiazepines
128
________________ inhibit the enzyme responsible for the breakdown of 5-HT (serotonin), NE, and DA. Dietary restrictions limiting the consumption of tyramine are necessary for orally available ______________ due to inhibition of MAO-A in the gut. Drinking wine or eating cheese will cause a sudden and dangerous rise in BP (hypertensive crisis).
MAOIs
129
Because l________ and o_________ bypass hepatic oxidation and are conjugated only, they are the preferred agents for patients with reduced hepatic function secondary to aging and disease.
(two different psych meds)
lorazepam and oxazepam
130
All ______ (psych drug class) are on the BEERs list.
BZDs
131
BZD shortest half-life: ___________ and ___________
oxazepam and temazepam
132
BZD longest half-life: ____________ and ____________
Chlorazepate and valium
133
Best BZDs for the elderly are ______, ______, ______, and ______. ("ALOT")
oxazepam, lorazepam, alprazolam, temazepam
("ALOT")
134
Worst BZDs for patients over 65 years old (VCCC):
_________, _________, _______, ________
clonazepam, chlordiazepoxide, valium, chlorazepate.
135
____________ is also known as norepinephrine-dopamine reuptake inhibitor (NDRI) and is used in MDD (major depressive disorder) and smoking cessation therapy.
Bupropion
136
Good characteristics of bup______________: Decreased appetite, less likely to lower libido than other ADs, and not sedating.
Bupropion
137
Bad characteristics of b________________ (psych med): Causes insomnia, nightmares, decreased appetite, anxiety, tremors, and seizures.
Bupropion
138
Regarding __________________ (psych med):
Seizures are the most concerning AE. Because of the risk for seizures, patients with a CNS lesion, history of seizure disorder, head trauma, anorexia, or bulimia should not receive this medication.
Bupropion
139
Besides the possibility of being lethal in an overdose, what side effects are commonly associated with T____________ (psych drug class) now almost exclusively limits use to refractory cases and other non-depressive indications?
These SEs include sedative, anticholinergic, and cardiovascular SEs.
TCAs
140
You need really high doses to treat depression.
Which drug class?
TCAs.
141
________ - Blocks both 5-HT and NE. Often seen as an alternative to SSRIs.
SNRIs
142
At higher doses ----> Noradrenergic effects more prominent relative to serotonergic activity ----> dose dependent ’s in diastolic BP
(SN__s)
SNRIs
143
Similar AEs to SSRIs, except more incidence of BP elevation with _________.
SNRIs
144
d_______________ (psych med), an SRNI: unique beneficial treatment for physical pain associated with depression.
duloxetine (Cymbalta)
145
___________ (psych drug class) can be lethal in an overdose.
TCAs
146
Don't start a patient with uncontrolled high BP on an ______.
SNRI
147
Common SE of ________ (psych drug class) is diarrhea, and constipation after quitting.
SSRIs
148
________________________: Blocks 5-HT. Currently most often prescribed initial drug of choice because of low side effect profile and not lethal if overdose as single agent.
SSRIs
149
_________ : an SSRI metabolized into an active metabolite norfluoxetine with a long half-life
Fluoxetine
150
_________________ (psych med) has to be stopped (wash-out period) 4-5 weeks before MAO inhibitors can be started
Fluoxetine
151
Characterized by confusion, restlessness, fever, abnormal muscle movements, hyperreflexia, sweating, diarrhea, and shivering. It may result when a serotogenic agent is added to any other serotogenic agent. MAOIs are strongly associated with severe cases of _______________. _____________ is complicated by (a) an unawareness by clinicians of the diagnosis and (b) the fact that many implicated drugs are not serotonergic in nature, such as dextromethorphan, meperidine, tramadol, linezolid, and methylene blue. Avoid by avoiding causative drug interactions.
Serotonin syndrome
152
In general, the dose of an antidepressant should be tapered by no more than _______% per week to minimize the risk of withdrawal symptoms.
25%
153
_____________________ is a good example of a problematic herbal product.
St. John's Wort
154
____________ syndrome: almost all ADs can produce withdrawal syndromes if DC'd abruptly or tapered too rapidly, especially ADs with shorter half-lives (e.g., venlafaxine IR, paroxetine, and fluvoxamine).
Discontinuation
155
Tapering and DC of ADs can be completed over __-__ months.
2-3
156
ADs take about __-__ weeks to feel less depressed.
2-4
157
All antidepressants: __-__ weeks to work
4-6
158
Regarding _______________:
For patients who show little improvement (eg, reduction of baseline symptoms ≤25 percent) after four to six weeks, it is reasonable to administer next-step treatment
ADs
159
Regarding _________ (and PPIs and PDE-5s):
All equally effective at equipotent dose
ADs
160
Regarding _____:
Usual trial of 8-12 weeks at therapeutic doses before deciding whether antidepressants have sufficiently relieved symptoms
ADs
161
___________ is the "worst" for sedation. Never give in the morning.
(mi______)
Mirtazapine
162
The two "worst" activators (makes patient move): b_____________, f______________ (x2 psych meds)
Bupropion, fluoxetine
163
____________ is the "worst" med for weight loss (causing weight loss).
Bupropion
164
When considering treatment, bu_________ (psych med) may be useful for both lowering alcohol cravings and preventing some of the withdrawal symptoms associated with alcohol consumption (Cherney, 2019).
buspirone
165
Taking St._____________ (for depression), when combined with some other antidepressants can lead to increased serotonin, or serotonin syndrome (causing high temperature, confusion, twitchiness, tachycardia, nausea, and even coma).
St. John's Wort
166
A______ B________ (BP med for BPH)
- fairly ra[id onset (2-4 weeks) with relatively rapid symptom resolution, durable effect (years), with AUA symptom index (AUASI) improving 30-45%. No effect on prostate size or disease progression.
Can cause ED.
--osin medications
tamsulosin
silodosin
alfuzosin
doxazosin
terazosin
prazosin
Alpha Blockers
167
Alp_______ (drug class: PgE1 analog for ED)
Alprostadil
168
Var_______ (PDE51 for ED)
Prolonging of QT interval with this class, especially this med.
Vardenafil
169
5-alpha reductase inhibitors (5ARIs):
f__________
d__________
Mgmt of mod-severe BPH in patients with enlarged prostate glands.
Reduce prostate size and thus outlet obstruction.
ADR: decreased libido, impotence and ejaculatory disorder, breast tenderness/enlargement.
finasteride
dutasteride
170
tad______ (can treat both ED and BPH)
- don't use with nitrates
tadalafil
171
Mir_______ (agonist of the beta-3 adrenergic receptor)
Relaxes the detrusor smooth muscle during the storage phase of the urinary bladder fill-void cycle.
- it reduces irritative voiding symptoms
ADRs: HA, HTN, tachycardia, constipation, nasopharyngitis
mirabegron
172
Bup______ lowers seizure threshold.
Bupropion
173
Bup______ is not a good choice for monotherapy if anxiety is part of the clinical picture.
Bupropion
174
Mir________ is a good choice if weight loss is part of clinical picture and weight gain is desired.
Mirtazapine
