Brainscape's Knowledge GenomeTM

Browse over 1 million classes created by top students, professors, publishers, and experts.


See full index

Therapeutics P2 Winter Semester > PHRM 845-FINAL EXAM > Flashcards

PHRM 845-FINAL EXAM Flashcards

Pharmacotherapy of depression

1
Q

Should we wait to start pt on antidepressant med until the criteria are met?

A

No; not if someone can really benefit from them

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

Risk factors for depression

A

-Female
-White
-Physical disability
-Prior episode/suicide attempt
-Middle age
-Low socioeconomic status
-Lack of social support
-Co-morbid medical disorder
-Single marital status
-Unemployed
-Stressful life events/adverse childhood experiences
-Co-morbid SUD

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

Risk of recurrence for depression

A

1 episode: 50-60% chance of having another episode
2 episodes: 70%
3 episodes: 90%

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

We want to treat patient to remission. Many patients will respond better if dose is ___. Many patients ___ (do/do not) get the dose they need.

A

Increased
Do not

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

Disease course

A

-Occurs at any age, but commonly seen in early adulthood 20s and 30s
-Symptoms may develop over days to weeks
-Usually see a response to treatment, but not aggressive enough to achieve remission

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

What is remission?

A

A period of 2 or more months with no symptoms or only 1-2 symptoms. –Remember that as humans, we all have sad/down days at some point in our lives.
**For depression diagnosis, 5-6 symptoms are needed.
**Remission is possible and is the tx goal

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

Recurrence

A

-Risk becomes lower over time as duration of remission increases
-Persistent, mild symptoms during remission is a predictor of recurrence
-Function deteriorates during the episode and goes back to baseline upon remission–help a patient remember their baseline and try to get back there.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

DSM-5 diagnosis criteria for depression

A

At least one of the symptoms must be depressed mood or loss of interest or pleasure in doing things.
**Must cause clinically significant impairment in functioning
**No hx of mania or hypomania (Bipolar disorder)
**Not attributed to physiological effects of a substance of another condition

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

DSM-5 Diagnostic criteria mnemonic: SIGE CAPS

A

S: Sleep (insomnia/hypersomnia)–difficulty sleeping even though they are in bed all the time
I: Interest decreased (anhedonia)
G: Guilt/worthlessness
E: Energy loss/fatigue
C: Concentration difficulties – if this is the biggest complaint, check for depression (if not the biggest complaint, remember this can be a sx of ADHD or other mental health disorders)
A: Appetite change (increase or decrease)
P: Psychomotor agitation (revved up/restless) or retardation (no energy to get up and get around)
S: Suicidal ideation (QPR)–Question, plan, resources

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

Self-administered rating skills for depression

A

-Patient Health Questionnaire (PHQ-9)
-Quick inventory of depressive symptomatology self-report (QIDS-SR-16)
-Mood disorder questionnaire (MDQ)–to determine depression and rule out bipolar disorder

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

Goals of depression tx

A
  1. Reduce or eliminate signs and symptoms of depression
  2. Restore occupational and psychological functioning to baseline
  3. Reduce the risk of relapse and recurrence
  4. Reduce the risk of harmful consequences (suicidal ideation)
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

Choosing pharmacotherapy

A

**Similar efficacy between and within antidepressant classes
-Pt preference
-Prior med response: how pt used it, SE experienced, concerns for trying again, etc.
-Safety, tolerability, SE
-Co-occurring psychiatric and medical conditions
-Pharmacological properties
-Cost

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

Phases of treatment

A

Acute:
-6-12 weeks
-Goal: induce remission
Continuation:
-4-9 additional months (recommended for all pts)
-Goal: prevent relapse
Maintenance:
-pt specific duration
-often indefinite tx if greater than or equal to 3 major depressive episodes
-Goal: prevent reoccurrence

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

Risk of suicidality

A

Boxed warning for suicidality in ALL antidepressant medications (for pts 24 y/o or younger)
**Closely monitor pt for increased suicidality and changes in behavior during first 1-2 months of therapy and after any dosage changes

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

Pharmacological classes of antidepressants

A

-SSRI (widely used)
-SNRI (widely used)
-TCA
-MAO-i
-Novel agents/others
-Augmentation agents

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

Citalopram
*Drug Class
*Important info

A

SSRI
-Dose-dependent QTc prolongation
-Substrate for 2C19 and 3A4

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
17
Q

Fluoxetine
*Drug Class
*Important info

A

SSRI
-Long half-life (96-144 hours)
-Activating potential
-ONLY ONE THAT DOES NOT HAVE TO BE TAPERED
-2D6 and 3A4 inhibitor (norfluoxetine is the metabolite)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
18
Q

Fluvoxamine
*Drug class
*Important info

A

SSRI
-Only SSRI for OCD
-1A2 and 2C19 inhibitor

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
19
Q

Paroxetine
*Drug class
*Important info

A

SSRI
-MUST taper dose due to anticholinergic effects *only 1 that is anticholinergic
-Weight gain, sedation
-Septal wall defect risk to fetus (NOT USED FOR PREGNANT PATIENTS OR PATIENTS <18 Y/O)
-2D6 and 2B6 inhibitor

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
20
Q

Sertraline
*Drug class
*Important info

A

SSRI
-More GI upset than other antidepressants

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
21
Q

SSRI adverse events and key points

A

-Onset of action: 1-2 weeks
-4-6 weeks for full dose response
-Variable sedation
-Weight gain (Paroxetine)
-Weight loss (Fluoxetine)
-Increased bleeding risk (platelet inhibition)
-Hyponatremia (especially in elderly)
-Sexual dysfunction (70-75%)
-Anxiety/agitation upon initiation
-Emotional blunting
-Decreased BMD

22
Q

Desvenlafaxine
*Drug class
*Important info

A

SNRI
-Active metabolite of venlafaxine
-Dose-limiting side effect: N/V
-No major CYP interactions

23
Q

Duloxetine
*Drug class
*Important info

A

SNRI
-Slow titration or divided dosing to help with nausea
-FDA warning for hepatotoxicity (MUST get liver function test)
-2D6 inhibitor
-Obtain LFTs at baseline and when symptomatic or q6mos

24
Q

Levomilnacipran
*Drug class
*Important info

A

SNRI
-MUST adjust in renal impairment or strong 3A4
-3A4 substrate

25
Q

Milnacipran
*Drug class
*Important info

A

SNRI
-Not FDA approved for depression in the US

26
Q

Venlafaxine
*Drug class
*Important info

A

SNRI
-Must be <150 mg/day to have NE effects (SSRI until they get to ~ 150 mg/day)
-2D6 inhibitor at high doses

27
Q

SNRI adverse events and key points

A

-Onset of action in 1-2 weeks (full effect in 4-6 weeks)
-Useful in pain syndrome, musculoskeletal pain, fibromyalgia, and neuropathic pain
-Blood pressure elevation (from adrenergic SE)
-Sweating
-Variable sedation
-Increased bleeding risk (platelet inhibition)
-Hyponatremia (especially in elderly)
-Sexual dysfunction
-Anxiety and agitation
-Nausea (from adrenergic SE)
-Decreased BMD

28
Q

TCA (essentially SNRI)
-MOA
-Example

A

-Blockade of reuptake transporter (DAT, SERT, NET)–inhibits reuptake of serotonin, NE and DA
-Amitriptyline is a tertiary amine with a normal dose between 50-300 mg/day
~Used to lower doses for neuropathic pain

29
Q

TCA adverse effects and key points

A

-More often used for neuropathic pain syndromes than depression (amitriptyline and nortriptyline)
-Side effects often limit higher doses (why we are concerned about them)
~CNS: sedation, reduced seizure threshold, confusion
~Anticholinergic: blurred vision, urinary retention, constipation
~Cardiovascular: orthostatic hypotension, tachycardia
~Other: weight gain, sexual dysfunction
-Narrow therapeutic index: fatal in OD as low as 1000 mg (4-10 tablets) due to cardiac arrhythmias or seizures.

30
Q

MAO-i key points

A

-Not used very often
-Very effective
-Should always be used by themselves (not in combo)
-All increase monoamines

31
Q

Examples of MAO-i

A

-Isocarboxazid
-Phenelzine
-Selegiline
-Tranylcypromaine

32
Q

What is the only patch formulation of antidepressant?

A

Selegiline

33
Q

Clinical pearls of MAO-i

A

-Must have 2 week washout period before switching antidepressants (5 week washout if switching from fluoxetine)
-All require tyramine-restricted diet except selegiline 6 mg/24 hr patch
-Caution due to HTN crisis and serotonin syndrome

34
Q

Selegiline patch

A

-Selective MAO-B inhibitor at lower doses
-Rotate patch daily to prevent irritation
-Do not cut patch
-Do not expose patch to direct heat while wearing
-Tyramine-restricted diet is not required for 6 mg patch (is required for 9 and 12 mg)
-Adverse events: hypotension, dry mouth, insomnia, HA, GI upset

35
Q

MAO-i contraindications

A

-Pheochromocytoma (fluctuating BP)
-Hepatic/renal dysfunction
-Cerebrovascular disease
-Excessive caffeine use
-Elective surgery
-Concomitant sympathomimetics
-CVD
-Use of other serotonergic meds

36
Q

Bupropion
-MOA
-Dosing
-Clinical Pearls

A

-DA and NE reuptake inhibitor (only one that does not impact 5HT)
-Stimulates insomnia and appetite suppression
-Available in SR/XL dosing: XL is preferred because SR has lots of peaks and troughs that fluctuate too much and could lead to a seizure (if using SR, must give second dose no later than 4 pm)
-2D6 inhibitor
-C/I in active seizure disorder and eating disorder
-Can be used in combo with SSRI/SNRI

37
Q

Mirtazapine
-Not an SSRI
-MOA
-Dosing
-Clinical pearls

A

MOA: presynaptic alpha-2 blockade, 5HT2, 5HT3, and H2 blockade
Dosing: Sedation and increased appetite occur with doses less then or equal to 15 mg/day
Pearls: Warning for agranulocytosis and increased cholesterol (not common to routinely get lipid profiles or CBC count)
~Can be used in combo with SSRI/SNRI

38
Q

Trazodone
-MOA
-Dosing
-Side effects

A

-MOA: selectively inhibits neuronal reuptake of serotonin and acts as 5HT1, 5HT2, H1, and alpha 1 antagonist
-Dosing: higher doses are needed for depression
-Side effects: Orthostatic hypotension, risk of priapism generally from doses > 200 mg (medical emergency)

39
Q

Vilazodone
-MOA
-Clinical pearls

A

-MOA: Primarily SSRI, may have some 5HT1a agonism which may provide anxiolytic effects
**DO NOT COMBINE WITH SSRI/SNRI
-Pearls: Take with food because of significant nausea and bioavailability is increased with food
-3A4 substrate

40
Q

Vortioxetine
-MOA
-Clinical pearls

A

-MOA: SSRI + 5HT1A agonist + 5HT3 antagonist
**DO NOT USE IN COMBO WITH SSRI/SNRI
-Pearls: possibly less sexual dysfunction, 2D6 substrate, likely to cause nausea

41
Q

What is serotonin syndrome?

A

Medical emergency due to excessive amounts of serotonin in the CNS
-May be caused by OD, combined use of serotonergic meds, or drug interactions

42
Q

Serotonergic agents

A

Lithium, Linezolid, serotonin agonists (triptans), fentanyl, serotonergic antidepressants, amphetamines, St. John’s Wort, cocaine, buspirone, dextromethorphan, tramadol, LSD

43
Q

Treatment for serotonin syndrome

A

-Stop offending agent and use supportive care
-Potentially could use serotonin blockers (cyproheptadine–has variable efficacy)
-70% of pts recover within 24 hours

44
Q

Sx of serotonin syndrome

A

Diarrhea, agitation, diaphoresis, abdominal pain, ataxia, hyperpyrexia, mental status change, labile BP, hyperreflexia, anxiety, confusion, muscle rigidity, myoclonus, nausea, restlessness/hyperactivity, tachycardia, tachypnea, tremor
**Serotonin increases GI peristalsis which causes N/V

45
Q

Antidepressant withdrawal syndrome

A

-Occurs from abrupt cessation of antidepressant
-Common with ALL antidepressants (except FLUOXETINE)
-Risk can be minimized by slow dose taper over 1-2 weeks
-Antidepressants with anticholinergic activity should be tapered NO MATTER WHAT
-Symptoms can mimic those of depression (agitation, irritability, GI disturbances, “brain zaps”)
-NOT life-threatening, but extremely uncomfy

46
Q

Augmentation-atypical antipsychotics (good adjuncts)

A

Aripiprazole (abilify) - partial agonist
Brexpiprazole - partial agonist
Cariprazine - partial agonist
Quetiapine

47
Q

Antidepressants for PPD

A

-Allosteric modulator of alloprenanolone
~Brexanolone: IV only, 60 hour infusion, excessive sedation boxed warning, REMS
~Zuranolone: PO dosing, 14-day dosing, boxed warning for impaired driving (CNS depression)

48
Q

What to use for tx-resistant depression

A

Esketamine nasal spray: NMDA receptor antagonist
-Also used for MDD with suicidal ideation
-Induction and maintenance phases, REMS program to give in clinic, stay in clinic for 2 hours post-dose because can cause BP fluctuations

49
Q

Overall key counseling points

A

-Need to continue med for 6-9 months to decrease risk of recurrence
-Abrupt discontinuation can lead to antidepressant withdrawal syndrome
-Possible increase in suicidal thinking in first few weeks of therapy
-NO paroxetine for pregnant women

50
Q

Non-pharmacological therapy

A

-Psychotx is the most common (individual or group)
-Mild depression or episodes without psychosis, may use psychotx without drug therapy if they have a hx of response, pt prefers it, med contraindication, or pregnancy
**SSRI have not shown teratogenic effect–better outcome if mom is treated for depression

51
Q

Other non-pharm options

A

-Vagus nerve stimulation (VNS)
-Transcranial Magnetic stimulation (TMS)

52
Q

Steps to manage depression

A

-Dose optimization
-Switch antidepressant
-Combine antidepressants
-Augmentation
-Esketamine/ECT/VNS/TMS

**Pt-specific so pt can choose which one they try first

Therapeutics P2 Winter Semester (29 decks)

Brainscape helps you reach your goals faster, through stronger study habits.
© 2024 Bold Learning Solutions. Terms and Conditions