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40 Cards in this Set
- Front
- Back
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pharm for MDD basics
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-1st sx to improve are appetite and sleep patterns
-noticeable effects may take 3-4 wks or more -risk of suicide! -Titrate to target dose in first week and maintain that level for 6 weeks (trial) to determine efficacy or make changes |
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MAOIs
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MOA: Inhibits MAO, enzyme that degrades NE, DA, and serotonin leading to increased levels of these biogenic amines
-act in CNS, ANS, liver and GI tract -Phenelzine (Nardil) -Tranylcypromine (Parnate) |
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pharm for MDD basics
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-1st sx to improve are appetite and sleep patterns
-noticeable effects may take 3-4 wks or more -risk of suicide! -Titrate to target dose in first week and maintain that level for 6 weeks (trial) to determine efficacy or make changes |
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MAOIs pahrm
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-short half life
-irreversibly inactivate MAO so effects last 2 wks -MAOIs inhibit metabolism of tyramine --> precursor to NE which can cause HTN crisis! -dietary tyramine restriction is essential! (cheese, fish, alcohol) -dont use with other antidepressants! |
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MAOIs
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MOA: Inhibits MAO, enzyme that degrades NE, DA, and serotonin leading to increased levels of these biogenic amines
-act in CNS, ANS, liver and GI tract -Phenelzine (Nardil) -Tranylcypromine (Parnate) |
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MAOI AE
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1. wt gain
2. orthostatic hypotension! 3. edema 4. sexual dysfunction 5. insomnia 6. taper dose to avoid withdraal sx 7. avoid tyramine containing foods |
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MAOIs pahrm
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-short half life
-irreversibly inactivate MAO so effects last 2 wks -MAOIs inhibit metabolism of tyramine --> precursor to NE which can cause HTN crisis! -dietary tyramine restriction is essential! (cheese, fish, alcohol) -dont use with other antidepressants! |
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MAOI DI
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1. SSRIs
2. meperidine and fentanyl 3. wait at least 14 days after MAOI dose before beginning other antidepressants 4. When switching from antidepressant to MAOI wait 10-14 days and 5 weeks for Prozac (fluoxetine) |
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MAOI AE
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1. wt gain
2. orthostatic hypotension! 3. edema 4. sexual dysfunction 5. insomnia 6. taper dose to avoid withdraal sx 7. avoid tyramine containing foods |
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TCAs
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1. tertiary amines - more AE
Amitriptyline Clomipramine Doxepin Imipramine 2. secondary amines Desipramine Nortriptyline Protriptyline |
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MAOI DI
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1. SSRIs
2. meperidine and fentanyl 3. wait at least 14 days after MAOI dose before beginning other antidepressants 4. When switching from antidepressant to MAOI wait 10-14 days and 5 weeks for Prozac (fluoxetine) |
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TCAs MOA
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-block reuptake of NE and 5HT (inhibit transporters)
-affect other receptors: 1. anticholinergic 2. alpha-one blockade 3. antihistamine actions 4. cat C/D |
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TCAs
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1. tertiary amines - more AE
Amitriptyline Clomipramine Doxepin Imipramine 2. secondary amines Desipramine Nortriptyline Protriptyline |
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TCA pharm
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-oral
-liver metabolism -Secondary amines are better tolerated due to less sedation, anticholinergic effects, orthostasis and conduction abnormalities |
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TCAs MOA
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-block reuptake of NE and 5HT (inhibit transporters)
-affect other receptors: 1. anticholinergic 2. alpha-one blockade 3. antihistamine actions 4. cat C/D |
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TCA AE
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1. orthostasis and reflex tachycardia
2. conduction abnormalities 3. sedation 4. wt gain 5. myoclonus, seizures 6. anticholinergic effects |
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TCA pharm
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-oral
-liver metabolism -Secondary amines are better tolerated due to less sedation, anticholinergic effects, orthostasis and conduction abnormalities |
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TCA AE
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1. orthostasis and reflex tachycardia
2. conduction abnormalities 3. sedation 4. wt gain 5. myoclonus, seizures 6. anticholinergic effects |
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TCA DI
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1. MOAs esp with clomipramine --> HTN crisis
2. P450 inducers 3. Cimetidine, SSRIs, oral contraceptives and inhibitors of P450 can increase plasma TCA levels 4. Caution with antiarrhythmics |
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TCA DI
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1. MOAs esp with clomipramine --> HTN crisis
2. P450 inducers 3. Cimetidine, SSRIs, oral contraceptives and inhibitors of P450 can increase plasma TCA levels 4. Caution with antiarrhythmics |
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monitoring TCAs
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-plasma monitoring
-pt may not see effects for 3-4 wks or longer -6 wks at target dosage is considered adequate trial -6 wks at target dosage is considered adequate drug trial -EKG: C/I in long QT syndrome -monitor pt frequently (weekly initially and than less frequently) |
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TCA overdose
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-onset of sx within 2 hrs
-life threatening complications occur within 6 hrs 1. tachycardiac 2. hypotension 3. confusions or hallucinations 4. mydriasis 5. dry mucous membranes and skin 6. rales 7. dec bowel sounds 8. urinary retention 9. seizures |
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Trazodone
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-MOA: block 5HT reuptake, changes beta receptor sensitivity in presynaptic neurons
-Cat C -AE: 1. dizziness, HA 2. sedation 3. nausea 4. xerostomia 5. blurred vision 6. erectile dysfunction, BP changes, edema |
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Nefazodone
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-MOA: inhibits NE and 5-HT reuptake and 5HT2 and alpha antagonist effects
-AE: liver failure |
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Mirtazapine (Remeron)
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-alpha2 antagonist --> inc 5HT and NE
-anticholinergic, antihistmaine AE: 1. somnolence 2. constipation 3. dry mouth 4. inc appetite and wt gain 5. inc cholesterol 6. rare agranulocytosis |
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Venlafaxine (Effexor)
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-SNRI
-Inhibits 5-HT AND norepinephrine reuptake also weak inhibitor of dopamine reuptake (mixed NE, 5-HT effects) AE: 1. cat C 2. HA, somnolence, dizziness 3. insomnia, nervousness 4. nausea 5. weakness 6. inc BP |
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Pristiq
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-desvenlafaxine...an active metabolite of venlafaxine
-AE: nausea |
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Duloxetine (Cymbalta)
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-SNRI
-AE: 1. Cat C 2. insomnia, somnolence 3. dizziness 4. HA 5. nausea, constipation, dry mouth 6. dec appetite |
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Buproprion (Wellbutrin, Zyban)
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-affects DA and NE transport
-3 oral forms: IR, SR, XL -not good for anxious depressed person -cat B -AE: 1. also used for smoking cessation 2. dizziness, HA, insomnia 3. nausea** -C/I in pt with seizure disorder, anorexia/bulimia |
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SSRIs
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MOA: inhibit transport, 5HT cannot bind
-often 1st drug of choice for most cases of MDD AE: 1. Nausea 2. sexual dysfunction 3. Serotonin syndrome can result from use of other serotonergic drugs |
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Fluoxetine (Prozac)
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-MOA: SSRI
-long half life -aval in combo with olanzapine for bipolar depression AE: 1. insomnia, HA, anxiety, nervousness 2. dec libido 3. nausea. diarrhea |
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Paroxetine (Paxil)
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-SSRI
-AE: 1. HA, somnolence, dizziness 2. sedation 3. nausea, C/D 4. sex dysfunction |
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Sertraline (Zoloft)
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-SSRI
-good for post partum depression -AE: 1. diarrhea, N** 2. insomnia, somnolence, dizzines 3. ejaculatory disturbances |
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Fluvoxamine (Luvox)
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-highest risk for DI due to strong inhibitor of CYP 450
-used for OCD -AE: 1. HA, somnolence, insomnia, nervousness 2. nausea 3. weakness 4. sexual dysfunction |
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Citalopram (Celexa)
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-SSRI
-less DI -oral -AE: 1. somnolence, insomnia 2. N 3. less sexual dysfunction |
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Escitalopram (Lexapro)
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-SSRI
-fewer DI AE: 1. HA, somnolence, insomnia 2. N 3. ejaculation disorder -may be best tolerated SSRI |
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therapeutic considerations
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-SSRIS generally 1st line
-titrate to target dose in one week for most antidepressants -in acute phase see pt one or more times per week -keep pt at target dose for 4-8 wks before considering changes to regimen -After remission continue meds at same dosage for 16-20 weeks at least |
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changing antidepressants
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-Antidepressant treatment at an adequate dose for at least four to eight weeks is necessary before deeming a patient nonresponsive or only partially response to a medication.
-Generally, switching from one SSRI to another can be done by a direct substitution of one drug for the other. -Cross taper with bupropion, TCAs, -MAOI- allow 14 day washout |
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Kids and antidepressants
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-Fluoxetine is approved for treating MDD in pediatric pts
-Clomipramine, fluoxetine, fluvoxamine, and sertraline are approved for OCD in pediatric patients. |
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pregancy and antidepressants
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-Paroxetine- Cat D
-all other SSRIs and serotonin norepinephrine reuptake inhibitors are pregnancy category C -Moderate to severe depression during pregnancy can be treated with sertraline -Try to wait to become pregnant for 6-12 mths after they achieve euthymia |
