Pharm - Antidepressants

Question 1

describe the symptoms of withdrawal syndrome

Answer 1

FINISH

• F: flu-like sx
• I: insomnia
• N: nausea
• I: imbalance
• S: sensory disturbances
• H: hyperarousal

Question 2

in addition to major depressive disorder, Buproprion can be used for _______

Answer 2

nicotine withdrawal

Question 3

in addition to major depressive disorder, Imipramine can be used for _______

Answer 3

enuresis (repeated inability to control urination)

Question 4

in addition to major depressive disorder, Duloxetine can be used for _______

Answer 4

• diabetic peripheral neuropathy
• fibromyalgia
• chronic MSK pain
• stress incontinence

Question 5

list the SNRIs

Answer 5

(TDDVL)

• TCAs
• desvenlafaxine
• duloxetine
• venlafaxine
• levomilnacipran

Question 6

list the SSRIs

Answer 6

CFSEPVV

• citalopram
• fluoxetine
• sertraline
• escitalopram
• paroxetine
• vilazodone
• vortioxetine

Question 7

list the NDRIs

Answer 7

bupropion

Question 8

list the SARAs

Answer 8

MNT

• mirtazapine
• nefazodone
• trazodone

Question 9

list the MAOIs

Answer 9

TIPS

• tranylcypromine
• isocarboxazid
• phenelzine
• selegiline

Question 10

list the SNRI that also affects dopamine receptors

Answer 10

amoxapine

Question 11

MOA SARAs

Answer 11

serotonin-adrenergic receptor antagonists

Question 12

MOA vilazodone

Answer 12

serotonin-selective reuptake inhibitor

- ALSO partial agonist on 5-HT-1A

Question 13

MOA vortioxetine

Answer 13

serotonin-selective reuptake inhibitor

ALSO:

• partial agonist on 5-HT-1B
• full agonist on 5-HT-1A
• full antagonist on 5-HT-1D,3,7

Question 14

MOA bupropion

Answer 14

NDRI (noradrenergic-dopamine reuptake inhibitor)

ALSO:
- shown to increase NE/DA presynaptic release

Question 15

why do SSRIs have less side effects and risks compared to TCAs

Answer 15

less impact on histamine, muscarinic, and adrenergic receptors

Question 16

“normal” side effects of SSRIs

Answer 16

• CNS: sedation, insomnia, agitation, nervousness
• sexual dysfunction
• weight gain
• acute withdrawal reactions

Question 17

rare, dose-dependent, toxic setting side effects of SSRIs

Answer 17

• QT prolongation
• hyponatremia
• serotonin syndrome
• suicidality

Question 18

describe sx of serotonin syndrome

Answer 18

• sweating
• hyperreflexia
• akathisia/myoclonus
• shivering/tremors

Question 19

compare the different SSRIs in terms of their likelihood of drug-drug interactions

Answer 19

most likely: fluoxetine

low/milk: citalopram, sertraline, vilazodone

least: vortioxetine and escitalopram

Question 20

compare tertiary amine TCAs and secondary amine TCAs to the other SNRIs

Answer 20

tertiary: inhibits both NE and 5-HT equally
secondary: inhibits NE more than 5-HT

other SNRIs: inhibit 5-HT more than NE

Question 21

what are the 3 key TCA system-based side effects

Answer 21

1) cardiovascular (from alpha receptor antagonism)
- tachy, orthostatic hypotension, dysrhythmias

2) anticholinergic
- dry mouth, urinary retention, constipation, blurred vision

3) CNS (from histamine receptor antagonism)
- sedation, fatigue, dizziness, seizures

Question 22

what are the 3 C’s of TCA toxic ingestion

Answer 22

• coma
• cardiotoxicity
• convulsions

Question 23

compare SNRIs’ side effects to SSRIs’

Answer 23

SNRIs have similar side effects with less risk for sexual dysfunction

Question 24

MOA trazodone and nefazodone

Answer 24

SARAs

• selectively block POST-synaptic ALPHA 1 receptors on NE neurons
• selectively block POST-synaptic 5-HT-2 receptors

Question 25

MOA mirtazapine

Answer 25

SARA - blocks PRE-synaptic ALPHA 2 receptors on NE and 5-HT neurons - blocks POST-synaptic 5-HT- 2/3 receptors

Question 26

side effects of SARAs

Answer 26

- CNS: sedation - orthostatic hypotension - weight gain

Question 27

side effects NDRIs

Answer 27

- agitation, insomnia - HTN, tachy, tremors - weight LOSS - seizures

Question 28

which MAOIs are non-selective and which are selective

Answer 28

- selegiline is B-selective | - all others are non-selective (A/B)

Question 29

what is the anti-depressant form of selegiline

Answer 29

a patch

Question 30

side effects MAOIs

Answer 30

- orthostatic hypotension - sexual dysfunction - weight gain - insomnia/agitation/nervousness

Question 31

drug interactions with MAOIs

Answer 31

- anti-hypertensives, amphetamines, SSRIs/TCAs/SNRIs **there must be a 2 week wash-out period from an SSRI before starting an MAOI**

Question 32

what is the major concern of using MAOIs

Answer 32

hypertensive crisis

Question 33

how do MAOIs cause hypertensive crisis what MAOI should you use for the lowest risk

Answer 33

non-selective MAOIs inhibit MAO-A necessary in GI for tyramine metabolism --> increased tyramine --> significant catecholamine release --> hypertensive crisis lowest risk: low-dose selegiline patch

Question 34

signs/sx of hypertensive crisis | can be seen with MAOI use

Answer 34

- severe HA - N/V - sweating/severe anxiety - nosebleeds - tachy - CP - vision changes - SOB - confusion

Question 35

MOA esketamine

Answer 35

NMDA-receptor antagonist

Question 36

indications for esketamine

Answer 36

treatment-resistant depression in conjunction with ongoing antidepressant therapy

Question 37

administration and observation for esketamine

Answer 37

administration: nasal observation: for 2 hours post-dose

Question 38

MOA brexanolone

Answer 38

GABA-A receptor positive allosteric modulator

Question 39

indications for brexanolone

Answer 39

post-partum depression

Question 40

administration, observation, and efficacy of brexanolone

Answer 40

administration: 60 hour IV administration observation: every 2 hours for somnolence and LOC efficacy: superior efficacy to placebo at 60 hours (1 dose) and lasts up to 30 days

Question 41

list the 3 anti-seizure meds

Answer 41

- carbamazepine - lamotrigine - divalproex/valproic acid

Question 42

lithium's effect on doapmine neurotransmission

Answer 42

interferes with both stimulatory and inhibitory G proteins to keep them in inactive state

Question 43

lithium's effect on NMDA receptor

Answer 43

downregulates the NMDA receptor

Question 44

effect of lithium on GABA neurotransmission

Answer 44

lithium promotes GABAergic neurotransmission - increases GABA in CSF - presynaptically facilitates GABA release - postsynaptically upregulates GABA-B receptors

Question 45

effect of lithium on phosphoinositide cycle

Answer 45

inhibits IPPase and IMPase

Question 46

effect of lithium on PKC, MARCKS, and GSK-3

Answer 46

inhibits them

Question 47

describe lithium's effects on the kidney

Answer 47

lithium enters prinicpal cells of collecting duct --> accumulation of lithium in these cells --> resistance to ADH --> polyuria and polydipsia

Question 48

patient presenting with nephrogenic diabetes insipidus with a mood disorder was most likely prescribed:

Answer 48

lithium

Question 49

drug interactions with lithium

Answer 49

- diuretics (thiazides) - ACEIs (lisinopril) - NSAIDs

Question 50

side effects of lithium

Answer 50

- polyuria/polydipsia - tremors - mental confusion/dizziness/sedation - thyroid goiter - leukocytosis - seizures/serotonin syndrome

Question 51

indications for lithium

Answer 51

- acute and maintenance tx of mania/bipolar I | - augmentation in unipolar depressive pts

Question 52

indications for valproic acid/divalproex

Answer 52

acute bipolar I

Question 53

indications for lamotrigine

Answer 53

maintenance of bipolar disorder I and II

Question 54

indications for carbamazepine

Answer 54

acute and maintenance tx of acute mania and mixed episodes (bipolar I)

Question 55

which mood stabilizer is a major CYP450 inducer

Answer 55

carbamazepine