Pharm: Antidepressants and Mood Stabilizers

Question 1

Which anti-depressant is used off-label for diabetic peripheral neuropathy, fibromyalgia, chronic MSK pain, and stress incontinence?

Enuresis?

Answer 1

Duloxetine

Enuresis = imipramine

Question 2

List the 8 SSRIs

Answer 2

• Citalopram + Escitalopram
• Fluoxetine + Paroxetine + Vortioxetine
• Sertraline
• Vilazodone
• Fluvoxamine

Question 3

List the 5 SNRI’s used as anti-depressants

Answer 3

• All TCA’s
• Desvenlafaxine + Venlafaxine
• Duloxetine
• Levomilnacipran

Question 4

TCA-based SNRI’s have impact on what 3 key non-efficacy related receptors?

Answer 4

• Histamine (H1)
• Muscarinic (cholinergic)
• α1-adrenergic

Question 5

Amitriptyline should not be combined with what other drug class; why?

Answer 5

MAO inhibitors –> hypertensive crises, severe convulsions, and death

Question 6

What are the 3 C’s of toxic ingestion with TCA’s?

Answer 6

• Coma
• Cardiotoxicity (Conduction abnormalities)
• Convulsions

Question 7

What are the AE’s associated with TCA’s antagonizing α1-adrenergic receptors?

Answer 7

CV –> Tachycardia + Orthostatic hypotension + Dysrhythmias

Question 8

What are the AE’s associated with TCA’s antagonizing H1 receptors?

What about anticholinergic receptors?

Answer 8

Histamine:

• Sedation/Fatigue
• Dizziness/Seizures

Muscarinic:

• Dry mouth
• Urine retention
• Blurred vision

Question 9

Which 4 TCA’s are 3° amines?

What is their MOA?

Answer 9

• Clomipramine
• Amitriptyline
• Doexpin
• Imipramine

MOA = inh both NE/5-HT equally

Question 10

Which 3 TCA’s are 2° amines?

What is their MOA?

Answer 10

• Amoxapine
• Nortriptyline
• Desipramine

MOA = inhibit NE more than 5-HT

Question 11

What is a black box warning associated with the TCA, Amoxapine?

Answer 11

Both adults and ped’s pt’s may experience worsening of their depression and/or emergence of suicidal ideation and behavior (suicidality) or unusual changes in behavior

Question 12

Which class of anti-depressants is associated with little to no GI-related AE’s?

Answer 12

TCA’s

Question 13

What is important to consider when discontinuing the SSRI, Escitalopram?

Answer 13

Should be tapered down

All SSRI will cause acute withdrawal sx

Question 14

Which drug class may interact with antidepressants and migraine medicines to cause serotonin syndrome?

Answer 14

Opioids

Question 15

Which drug in the SSRI class is the broadest and strongest inhibitor of CYP450?

Which is the least?

Answer 15

Fluoxetine = strong

Vortioxetine & escitalopram = least

Question 16

Which 3 drugs in the SSRI class are only mild inhibitors of CYP450s?

Answer 16

Citalopram, Sertraline, Vilazodone

Question 17

Which 4 rare SEs of SSRI’s are of concern?

Answer 17

1. Serotonin syndrome = sweat, hyperreflexia, akathisia, shiver, tremor

2. Suicidality = higher risk w kids and YA

3. QT prolonged
4. Hyponatremia from SIADH

Question 18

What are the major AE of the SARA’s?

Mirtazapine, Trazodone, Nefazodone?

Answer 18

Sedation = Trazodone and Mirtazapine

Weight gain = Mirtazapine

Question 19

Which MAO inhibitor has the least amount of AE’s associated with it?

What is the major concern w MAOIs?

Answer 19

Selegiline

Hypertensive crisis w ingestino of tyramines = major concern

Question 20

Misc antidepressants MOA

1. Esketamine
2. Brexanolone

Answer 20

1. Esketamine = NMDA rec antagonist. Nasal admin
2. Brexanolone = GABAa rec modulator

Question 21

Which 3 antidepressant drugs are not associated with sexual dysfunction?

Answer 21

• Buproprion
• Nefazodone
• Selegiline

Question 22

If a patient does not respond to a given antidepressat after an 8 week trial on an adequate dose, what should be done?

Answer 22

Switch to another antidepressant with a different MOA (incl. ‘antipsychotics)

Question 23

When is it okay to use a monotherapy of antidepressants?

Answer 23

ONLY for unipolar depression

Question 24

What are 5 AE’s associated with Lithium?

Answer 24

• Polyuria (polydipsia): nephrogenic DI
• Tremor
• Mental confusion/dizziness/sedation: take at bedtime
• Thyroid goiter (hypothyroidism)
• Leukocytosis
• Seizures and serotonin syndrome

Question 25

Which drug interactions must you be aware of when treating with Lithium?

Answer 25

- **Diuretics**, via preferential Na⁺ loss and Li⁺ reabsorption - **ACEIs**: especially _lisinopril_ (renally excreted) - **NSAIDs**

Question 26

What are 2 main indications for use of Lithium and what is an off-label use?

Answer 26

- For **acute** and **maintenance** tx of **mania/bipolar I** disorder - For **augmentation** in **unipolar depressive** pt's with _inadequate_ response to antidepressant therapy - **Off label:** reduced risk of *suicide* and all-cause mortality in pt's with mood disorders

Question 27

Which anti-seizure mood stabilizer is used for acute **bipolar 1** (with or w/o psychotic features)?

Answer 27

**Divalproex/Valproic Acid**

Question 28

Which anti-seizure mood stabilizer is used for **acute** and **maintenance** tx of acute mania and mixed episodes (bipolar 1)?

Answer 28

**Carbamazepine**

Question 29

Which anti-seizure mood stabilizer is used for **maintenance** of bipolar disorder (I and II)?

Answer 29

**Lamotrigine**

Question 30

What mood stabilizer is a major CYP450 inducer?

Answer 30

Carbamazepine

Question 31

Recovery versus Remission? Relapse versus Reccurence?

Answer 31

**Remission** = no sx **Recovery** = remission for 2-6mo **Relapse** = return of sx after remission BEFORE recovery **Recurrence** = return of sx after recovery

Question 32

What med is an SNRI and DA agonist?

Answer 32

Amoxapine

Question 33

What SSRI is used only for OCD?

Answer 33

Fluvoxamine

Question 34

MOA of **Vilazodone**? MOA of **Vortioxetine**?

Answer 34

Both are SSRI's via **SERT** **Vilazodone** = partial agonist of 5-HT1A **Vortioxetine** = partial agonist of 5-HT1B and full agonist of 5-HT1A. Full antagonist of 5-HT3

Question 35

**NMS** versus **Serotonin syndrome**

Answer 35

NMS = DA agents like antipsychotics. Hyporeflexia! SS = Serotonergic agents like SSRI/SNRI/TCA/MOA. Hyperreflexia

Question 36

What med is an **NDRI**? This med also inc the pre-syn release of NE and DA. How does it do this? What is the SE of this med?

Answer 36

Buproprion MOA = acts on **VMAT2** to inc pre-syn release of NE and DA SE = seizures

Question 37

Before starting an MAOI for resistant depression, what should we do first?

Answer 37

Allow for a 2 week wash out period of other drugs (TCA, SSRI, SNRI) To avoid SS and hypertensive crisis