Antidepressant categories, which is 1st line?
SSRI (First line)
SNRI
TCA
MAOI
Why are SSRI first line for depression?
Low SE profile, low OD risk
Fluoxetine dose
20 - 80mg Qday
When should you take Fluoxetine
morning, can increase energy
Fluoxetine SE
- Insomnia
- HA
- Nervousness (!)
- Decrease libido
- Somnolence
- N/D
- Anorexia
- Dry mouth
Fluoxetine uses
- OCD
- Bulimia
- Panic DO
- Premenstrual dysphoric DO
Symbyax MOA
combo fluoxetine + olanzapine (zyprexa)
Symbyax use
depression associated with bipolar
How should most all psych drugs be discontinued?
Gradual taper - rebound depression is common because they bottom out the receptors
Sertraline (Zoloft) dose
50 - 200 mg Qday
Sertraline (Zoloft) uses
- OCD
- Panic DO
- PTSD
- Social anxiety
- Nocturnal eating (!)
- Premestrual dysphoric DO
Parozetine (Paxil) dose
20 - 60 mg Qday
- CR 12.5 - 7 mg/d
Sertraline, Parozetine, Duloxetine SE
- Insomnia
- HA
- Dizziness (!)
- Fatigue (!)
- Decrease libido
- Somnolence
- N/D
- Anorexia
- Dry mouth
SSRIs
- Fluoxetine (Prozac)
- Sertraline (Zoloft)
- Parozetine (Paxil)
- Citalopram (Celexa)
- Escitalopram (Lexapro)
Parozetine (Paxil) uses
- Panic DO
- OCD
- GAD
- PTSD
- Social anxiety DO
- Premenstrual dysphoric DO
Parozetine (Paxil) special SE
associated with more wt gain than other SSRI
What SSRI is best for depression with anxiety?
Parozetine (Paxil)
Citalopram (Celexa) dose
20 - 40 mg Qday
Escitalopram (Lexapro) dose
10 - 20 mg Qday
Escitalopram (Lexapro) SE
- Insomnia
- Somnolence
- HA
- N
- Ejaculator DO
Escitalopram (Lexapro) uses
- GAD
SNRIs
- Venlafaxine (Effexor)
- Desvenlafaxine (Pristiq)
- Duloxetine (Cymbalta)
Venlafaxine (Effexor) dose
- Immediate and XR
- 37.5 - 225 mg Qday
Venlafaxine (Effexor), Desvenlafaxine (Pristiq) SE
- Diaphoresis (!)
- Increase BP (!)
- Insomnia
- Somnolence
- HA
- Nervousness
- Dizziness
- N/D/C
- Anorexia
- Dry mouth
- Abn ejaculation/orgasm
How should you take Venlafaxine (Effexor)?
with food
Desvenlafaxine (Pristiq) dose
50 mg Qday
Duloxetine (Cymbalta) dose
40 - 60 mg Qday
Drug used for pain associated with DM neuropathy and fibromyalgia
Duloxetine (Cymbalta)
Duloxetine (Cymbalta) CI
Liver dz
Buproprion (Wellbutrin) MOA
Dopamine re-uptake inhibitor
Buproprion (Wellbutrin) dose
- 100 mg TID
- 150 - 200mg BID
- 150 - 450 mg Qday
How do you start Buproprion (Wellbutrin)?
with extended release dose
Buproprion (Wellbutrin) SE
- Insomnia
- HA
- Wt loss (!)
- Tachycardia (!)
- dry mouth
- dizziness
- HA
Which drug is associated with less sexual SE?
- Buproprion (Wellbutrin)
- Mirtazapine (Remeron)
Which drug should be avoided by people with seizure d/o or anorexia?
Buproprion (Wellbutrin)
Interesting uses of Buproprion (Wellbutrin)
- SAD
- Smoking cessation (Zyban)
- Decrease drug cravings
Mirtazapine (Remeron) MOA
Alpha-2 Antagonist
- Enhances noradrenergic and serotonergic transmission
Mirtazapine (Remeron) dose
7.5 - 45 mg
Mirtazapine (Remeron) SE
- Increase appetite (!)
- Wt gain (!)
- Increase cholesterol (!)
- Constipation
- Dry mouth
Which drug is used in elderly pts to help with depression, sleep and or appetite/wt?
Mirtazapine (Remeron)
How long does it take most antidepressants to work?
2 - 8 weeks
What adjunct should be recommended in depression?
Group therapy
When do SE tend to resolve?
Usually resolve after 1 week
What may happen if pt does not complete a full course of therapy?
Relapse
What should you advise pts about d/c’ing meds?
Do not stop antidepressant before discussing it with clinician first
What is the most appropriate follow up after starting antidepressant?
1 - 2 weeks
What should you watch out for when starting med?
- Suicide (esp in first 1 - 2 months)
- Mania due to bipolar
Recommended length of tx
4 - 9 months after determining therapeutic dose
How long should pts at risk for recurrence be on meds?
1 - 3 yrs of maintenance
Who is recommended to be on indefinite tx?
- pts with hx of multiple episodes (> 3)
- Comorbid psychiatric or general med DO
When d/cing antidepressant, do so over ________.
2 - 4 weeks
Who should be hospitalized?
- Suicidal or homicidal ideations
- Severe psychomotor retardation or agitation
- Associated psychosis
Nociceptive pain
Tissue damage/injury
- Somatic - muscle, bones, joints
- Visceral - internal organs
How do you treat nociceptive pain? Acute vs Chronic
- Acute: NSAIDs up to short-acting opioids
- Chronic: long-acting + SSRI/SNRIs
Neuropathic pain
- Nerve damage or inflammation
How do you tx neuropathic pain?
- Neurontin
- NSAIDs
- Opioids
Central: Clonidine/Baclofen
Peripheral: Lidocaine, SSRI/SNRI, long-acting opioids
Mild pain
- ASA
- Acetaminophen
- NSAIDs
- with adjuvants
Moderate pain
- Acet/Codeine
- Acet/Hydrocodone
- Acet/Oxycodone
- Acet/Dihydrocodeine
- Tramadol
- with adjuvants
What moderate pain med lowers seizure threshold?
Tramadol
Severe pain
- Morphine
- Hydromorphone
- Methadone
- Fentanyl
- Oxycodone
- with adjuvants
Acetaminophen dose
1000 mg Q 8 hrs
Acetaminophen SE
Hepatotoxicity
Acetaminophen, max dose
3 g/day
NSAIDs SE
- GI bleeding, use with PPI
- Nephrotoxic
MOA
SSRI
How long can you use Ketorolac (Toradol)?
Ibuprofen, max dose
600 mg Q 6 hrs
NSAIDs
- Ketorolac (Toradol)
- Ibuprofen
Codeine dose
15 - 60 mg Q 4 hrs
Hydrocodone dose
5 - 7.5 mg Q 4-6 hrs
Oxycodone dose
5 mg Q 4-6hrs
Caution with codeine preparations
- May contain acetaminophen
- 325-1000mg per pill
- Hepatotoxicity
- Do not exceed 3g/day
Tramadol (Ultram) MOA
opioid
Tramadol SE
- Decreases seizure threshold
- Addictive
Long acting severe pain meds, used in
Acute and chronic pain
Short acting severe pain meds, used in
break through pain
Morphine dose
10 mg Q 4 hrs
Hydromorphone dose
4mg Q 4 hrs
Major SE of severe pain meds,
- N/V
- Constipation (Rx laxative with potent opioids)
- Dry mouth
- AMS
- Respiratory distress (this is what kills people)
- Tolerance ( dose for pain relief, not for dose to cause miosis or constipation, use least effective oral dose)
- Dependence
Dependence ______ addiction
does NOT equal
With DEA cert and SP approval, how many days worth can PA rx Schedule II and III?
30 days
Without DEA cert, how many days can PA rx?
- 72 hrs max, except if “dealing with potential loss of life or limb or major acute traumatic pain”
Max ___ rx in 6 months for CIV an CV
5
A primary neurobio dz characterized by impaired control over drug use, craving, compulsive use, and continued use despite harm
Addiction
Behaviors that appear to indicate addiction, but actually reflect untreated pain
Pseudoaddiction
A state of adaptation to a drug class that results in withdrawl signs and symptoms if the drug is abruptly stopped or the dose decreased significantly
Physical dependence
A physiologic state resulting from regular use of a drug in which an increased dose is needed to produce a specific effect, or a reduced effect is observed with a constant dose over time
Tolerance
Typical drug seeking behaviors
- Overreporting symptoms
- Vague, multiple symtoms
- Insist on specific meds
- Convenient allergies
- Demand brand name
- High tolerance
- First visit req
- Veiled or overt threats
- Flattery followed by req
- Early refill req
- Doctor shopping
Solutions and boundaries
- Screen for chemical dependency
- Document meds
- ID common sense
- Communicate with pharmacy
- Write careful rx
- Use alternatives if possible
- Get pharmacy and med hx
- Don’t be cynical!
