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166 Cards in this Set
- Front
- Back
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What neurotransmitter may be the most important one involved with feelings of well being
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serotonin (5HT)
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Name all the neurotransmitters that are affected by drugs that treat depression
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Serotonin
dopamine acetylcholine norepinephrine epinephrine |
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Give the DSM IV diagnosis of depression
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Must contain at least 5 of the following criteria within the same 2 week period and MUST have number 1 and 2:
1. depressed mood 2. marked diminished interest/pleasure 3. significant weight loos or weight gain 4. insomnia or hypersomnia 5. psychomotor agitation or retardation 6. fatigue or loss of energy 7. Feeling of worthlessness 8. diminished ability to concentrate 9. recurrent suicidal ideation |
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How long does it take symptoms of depression to improve?
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-energy will improve in 2 weeks
-psychological symptoms such as low mood may take 4-6 weeks or longer |
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Name the medications that can cause or worsen depression
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1. beta blockers
2. clonidine 3. corticosteroids 4. cyclosporine 5. ethanol 6. isotretinoin 7. indomethacin 8. interferons 9. low vitamin D levels 10. methadone 11. methyldopa 12. methylphenidate/other ADHD stimulants/atomoxetine: monitor mood 13. procainamide 14. reserpine 15. varenicilin 16. antidepressants should be monitored for worsening mood |
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Name medical conditions that can be contributory to depression
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1. stroke
2. Parkinsons 3. dementia 4. multiple sclerosis 5. thyroid disorder (more hypothyroidism) 6. metabolic conditions (hypercalcemia) 7. malignancy 8. infectious diseases |
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What do guidelines state about selecting the initial choice of an agent to treat depression
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-the effectiveness of the drug classes are comparable
-a selection should be made based on the SE profile, safety concerns and the patient specific symptoms |
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What are the most preferred antidepressants for initial selection
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SSRI
SNRI mirtazapine bupropion |
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Which class of antidepressants have restricted use and why? Name these drugs
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MAOI's have restricted use because of the drug drug and drug food interactions that occur with them.
the MAOIs are: phenelzine tranylcypromine isocarboxazid |
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How should antidepressants be stopped and why?
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they should be tapered off because they run a high risk of withdrawal symptoms
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Give withdrawal symptoms
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anxiety
agitation insomnia dizziness flu like symptoms |
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Name antidepressants that have a high risk of withdrawal symtpoms
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Paroxetine (Paxil)
Venlafaxine (Effexor) Desvenlafaxine (Pristiq) |
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Name 2 things that must be true in order for it to be determined that a drug treatment is not working well to treat depression
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1. the patient must have been on the medication for 6 weeks
2. the dose of the medication must be therapeutic |
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What is the goal of therapy when treating depression
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remission
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What can be done if a patient is having an incomplete response to antidepression treatment
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1. increase the dose
2. use a combination of antidepressants 3. augment with buspirone (Buspar) 4. augment with ATYPICAL antipsychotic |
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Name the atypical antipsychotics that are approved for augmentation when treating depression
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1. Quetiapine ext rel (Seroquel XR)
2. Aripiprazole (Abilify) 3. Olanzapine + Fluoxetine (Symbyax) |
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What is buspirone (BuSpar) used for besides augmentation in depression
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anxiety
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Name natural products that can be used to treat depression and how are they rated in the natural medicine database
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St Johns Wort
SAMe (S adenosyl L-methionine) **rated as likely effective" |
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What must the medguide issued with antidepressants say
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antidepressants increase the risk when compared to placebo of suicidal thinking and behavior in children, adolescents and young adults....
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Name the SSRI's and what does it stand for
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Selective Serotonin Reuptake Inhibitor: 6
Fluoxetine (Prozac, Sarafem) Paroxetine (Paxil, Pexeva) Fluvoxamie (Luvox) Sertraline (Zoloft) Citalopram (Celexa) Escitalopram (Lexapro) |
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What is symbyax and when should it be used
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olanzapine + fluoxetine
-used for resistant depression |
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Name the SSRI approved for PMDD: premenstrual dysphoric disorder and how is it dosed
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Fluoxetine under the brand name Sarafem
-Dosed: daily weekly 14 days or 7 days prior to menses |
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Which SSRI is not approved for depression and what is it used for?
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Fluvoxamine (Luvox)
-obsessive compulsive disorder -social phobias |
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What time of the day should Fluoxetine be given and why?
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give in the morning because it is activating
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What is a side effect that may be seen by all SSRI
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akathisia (restlessness)
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Give the sexual side effects that occur due to SSRI
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-decrease in libido
-ejaculation difficulties -anorgasmia |
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Give SE of SSRIs (selective serotonin reuptake inhibitors)
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1. akathisia (restlessness)
2. sexual side effects 3. increased weight 4. restless leg syndrome 5. increased bleeding risk 6. increased fall risk 7. SIADH |
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Which SSRI causes the most weight gain
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Paroxetine (Paxil)
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When do SSRIs have an increased bleeding risk
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when taken with other drugs that increase bleeding such as warfarin, dabigatran, rivaroxaban, antiplatelets
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in which pts should you worry about increased fall risk of SSRI
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in frail pts, osteopenia, osteoporosis
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What is the max dose of citalopram (Celexa) that can be used per day and why
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do not use > 40mg/day due to QT risk
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Name a lethal drug interaction with SSRIs
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with MAOIs
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What effects can be seen if an SSRI is stopped suddently
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anxiety
insomnia flu like w/drawal symptoms |
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Which SSRI can be stopped with less of a taper and why
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fluoxetine (Prozac)
-bc it has a long half life |
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Give the generic name of Viibryd
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Vilazodone
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Give the brand name of Vilazodone
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Viibryd
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Give the MOA of Vilazodone (Viibryd)
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inhibits CNS neuron serotonin uptake with minimum or no reuptake of NE or dopamine.
-binds selectively to serotonin receptors and acts as a partial agonist |
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What should be taken with vilazodone (Viibryd)
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take each dose with food
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what do all SSRIs have a black box warning for
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increased suicidal thinking and behavior
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Does Viibryd have more or less sexual side effects compared to SSRIs and SNRIs
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less sexual side effects
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Give SE of vilazodone (Viibryd)
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-D/N/V
-dry mouth -insomnia -decreased libido -increased bleeding risk when taken with drugs that increase bleeding |
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What and why is there an interaction b/t MAOI and SSRI
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the interaction can cause hypertensive crisis, serotonin syndrome and psychosis because if MAOI will prevent the breakdown of the neurotransmitters and the other drugs cause an increase in the neurotransmitters...leaving too much neurotransmitter
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How long is the half life of fluoxetine
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at least 7 days
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How long is the wash out period when switching from MAOI to SSRI or vice versa
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the wash out period is when switching from MAOI to SSRI is 2 weeks and when switching from SSRI to MAOI the wash out period is 2 weeks except for when using fluoxetine the wash out is 5 wks
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How long is the wash out period when switching from fluoxetine to MAOI and why
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5 wks because fluoxetine has a very long half life of 7 days
(normally the washout is 2 wks) |
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Name the SSRIs that inhibits 2D6
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fluoxetine
fluvoxamine paroxetine |
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Name the enzymes inhibited by fluoxetine
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2D6
2C19 |
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Name the CYP enzymes inhibited by fluvoxamine
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inhibits the most CYP enzymes of all the SSRIs
1A2 2D6 2C9 2C19 3A4 |
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Name the CYP enzyme inhibited by paroxetine
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2D6
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Name the antidepressants that cause decreased effectiveness of tamoxifen
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fluoxetine
paroxetine sertraline buproprion duloxetine |
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What is the caution with SSRIs and anticoagulants?
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increased risk of bleeding
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Effect that SSRIs have on the INR when using warfarin?
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the INR may remain unchanged although the pt may experience increased bleeding
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What drugs should be cautioned when used with SSRIs due to the risk of falls
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-drugs that cause orthostasis
-drugs that cause CNS depression |
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Give the SE of other drugs that would cause you to caution use of that drug with citalopram
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QT prolongation or inhibition
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What time of day should SSRIs be taken
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Take SSRIs at bedtime, with the exception of fluoxetine it should be taken in the morning
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Can antidepressants be taken only when the patient needs them...PRN?
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no, they do not work if they are taken as needed
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How should the pt be counseled on when they will begin to feel better once started on an SSRI
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1.it may take 1 to 2 wks before you start feeling a benefit
2. it may take 6 to 8 weeks to feel the full effect on your mood |
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Name the SNRIs brand and generic and give the MOA
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-venlafaxine (Effexor, XR)
-duloxetine (Cymbalta) -Desvenlafaxine ER (Pristiq) MOA: inhibitor of serotonin and norepinephrine reuptake and duloxetine and venlafaxine also have weak inhibition of dopamine reuptake |
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Give the FDA approvals for the use of venlafaxine
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depression
GAD (general anxiety disorder) |
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Give the FDA approved uses of duloxetine
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1. GAD
2. depression 3. peripheral neuropathy 4. fibromyalgia 5. chronic low back pain 6. chronic osteoarthritis pain (chronic musculoskeletal pain is how back and arthritis are grouped) |
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Which SNRI is a good choice if the pt has pain and depression
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duloxetine (cymbalta)
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Name the SE of SNRIs that are similar to SSRI
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N/V
sexual dysfunction |
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What would cause SNRIs to have different SE from SSRIs and name these SE
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based on the increase in NE caused by SNRIs
SE: -increase in pulse -dilated pupils -dry mouth -excessive sweating and constipation -increased blood pressure |
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Which SE of SNRIs is dose related/dependent
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increase in blood pressure
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Which SNRI has the greatest risk of increased blood pressure as a SE and why
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venlafaxine when used in doses >150mg/day
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Give ways to treat the increased blood pressure that may be caused by SNRIs
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-dose reduction
-antihypertensive -change in therapy |
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With what drug classes do SNRIs have a potentially lethal drug interaction
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SSRIs and MAOI
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Give the BBW that ALL antidepressants carry
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increased risk of suicide in children, adolescents and young adults...this is for ALL antidepressants (SSRI, SNRI, MAOI, Tricyclics, buproprion, mirtazapine, trazodone, nefazodone)
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What age range is considered a young adult for the BBW carried by all the antidepressants?
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for increased suicide risk in children, adolescents, young adults
young adults are age 18-24 |
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How long is the wash out period when going to and from and MAOI with SNRIs
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2 weeks
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Name the enzyme that is inhibited by duloxetine (Cymbalta)
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2D6
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Why should use of anitcoagulants be cautioned when using SNRIs
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because of increased bleeding risk even though the INR may be in therapeutic range
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Which SNRI requires special counseling and what is the counseling
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desvenlafaxine
tell the pt if they see something that looks like a tablet in the stool this is ok, it is the empty shell from the tablet after the medicine has be absorbed by your body |
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How should pts taking SNRIs be counseled on when they will begin to feel effects
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1 to 2 weeks may feel some benefit may take 6 to 8 weeks to feel the full effect on your mood
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Give the MOA of Tricyclic antidepressants
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inhbits the reuptake of NE and serotonin
and also block ACh and histamine receptors |
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What does SNRI stand for
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serotonin norepinephrine reuptake inhibitors
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How do Tricyclics differ from SNRIs
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bc not only do Tricylics inhibit the reuptake of NE and Serotonin like SNRIs they also block ACh and histamine receptors
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What characteristic of Tricyclics contributes to the SE profile
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that they block ACh and histamine receptors also
(along with NE and serotonin reuptake inhibition) |
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Give the typical dosing range of venlafaxine (Effexor)
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150-375mg
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Give the typical dosing range of duloxetine
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60-120mg/day
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Give the typical dosing range of desvenlafaxine
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50mg typically
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Name the Tricyclic tertiary amines brand and generic
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Amitriptyline (Limbitrol, Elavil)
Doxepin (Sinequan, Zonalon) Clomipramine (Anafranil) Imipramine (Tofranil) Trimipramine (Surmontil) |
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Name the Tricyclic secondary amines brand and generic
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-Amoxapine (Asendin)*
-Desipramine (Norpramine) -Maprotiline (Ludiomil)* -Nortriptyline (Pamelor) -Protriptyline (Vivactil) *indicates that the brand is N/A |
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What is the difference between the secondary and tertiary amines for Tricyclic antidepressants
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-Secondary are more selective for NE
-Tertiary may be more effective but have worse SE |
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Give generic of Etrafon and what is it used for
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amitriptyline + perphenazine
-used for depression + severe anxiety |
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Give brand name of amitriptyline + perphenazine and what is it used for
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Etrafon and it is used for depression + severe anxiety
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Give the generic of Zonalon and what is its use
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doxepin and it is used for prurutis
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What is the doxepin cream called and what is it used for?
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Zonalon used for pruritus
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Give the FDA approved uses of Amitriptyline
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neuropathic pain
migrane prophylaxis depression |
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Give the difference in doses of amitriptyline based on its use
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1) neuropathic pain and migraine prophylaxis dose = 10-50mg at bedtime
2) depression dose = 100-150mg BID |
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Why is there an increased fall risk especially in the elderly when using Tricyclics
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because it causes orthostasis and sedation
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Name SE of tricyclics
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1. cardiotoxicity **
2. increased fall risk 3. anitcholinergic SE ** 4. weight gain 5. sedation 6. orthostasis 7. tachycardia 8. vivid dreams 9. myoclonus |
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What type of cardiotoxicity is seen with tricyclics
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QT prolongation with OVERDOSE
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How should the risk of QT prolongation be monitored with Tricyclics
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get ECG at baseline if:
1. cardiac risk 2. > 50 years |
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Give anticholinergic SE that can be seen with Tricyclics
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dry mouth
dry eyes blurry vision urinary retention constipation |
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Give the difference b/t peripheral and CNS anticholineric SE
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peripheral:
dry mouth and eyes, blurry vision, urinary retention, constipation CNS: disorientation, dizziness, confusion |
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What could myoclonus seen with Tricyclics be a result of
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drug toxicity
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Give the wash out period if going to or switching from an MAOI when using Tricyclics
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2 weeks
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What SE of drugs should be avoided when taking Tricyclics
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those that cause QT prolongation
**also avoid with citalopram |
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By what CYP enzyme are Tricylcis metabolized by
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2D6
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What type of SE is constipation seen with tricylcics and how should the pt be counseled if constipation occurs
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it is an anticholinergic SE (remember tricyclics block ACh receptors)
-pt may need to take stool softener or laxative |
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How should pt be counseled on dry eyes or blurry vision that can occur with Tricyclics
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may need to use an eye drop lubricant
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What change in the blood pressure is seen with tricyclics and how does this compare with SNRIs
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tricyclics may cause orthostasis/a drop in blood pressure
-SNRIS may cause an increase in blood pressure at higher doses |
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How should the pt be counseled on blood pressure changes caused by tricyclics
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may cause a drop in BP, caution when changing from lying down or sittin gto a standing position
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Name the top 3 tricyclics that are used
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Amitriptyline (Elavil)
Doxepin (Sinequan) Nortriptyline (Pamelor) |
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Give the MOA of MAOIs (mono amine oxidase inhibitors)
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inhibit the enzyme monoamine oxidase which prevents the break down of catecholamines 5HT (serotonin), NE, EPI, and DA
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What can happen if the neurotransmitters that are increased by MAOIs are increased dramatically (in large amounts)
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can cause hypertensive crisis
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Name the MAOIs brand and generic
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Isocarboxazid (Marplan)
Phenelzine (Nardil) Tranylcypromine (Parnate) Selegiline transdermal (Emsam) |
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Which MAOI is MAO I B selective for inhibition
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selegeline transdermal (Emsam)
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How often is the selegeline transdermal patch changed
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daily
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Give the SE of the MAOIs
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Anticholinergic effects
orthostasis sedation (exept tranylcypromine) sexual dysfxn weight gain head ache insomnia |
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How does tranylcypromine differ from the other MAOIs
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causes stimulation rather than sedation
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What drug interactions can cause hypertensive crisis when using MAOI
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TCAs
SSRI SNRI tyramine rich foods and other drugs |
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Give SE for selegiline patch
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consitpation
dry mouth gas loss of appetite sexual problems |
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Give a contraindication for the selegiline patch, when does this not apply
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avoid tyramine rich foods and drinks while using the 9mg and 12mg/day patch
-there are no dietary issues w/ the 6mg/day patch |
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How long should you avoid tyramine rich foods and drinks after stopping the selegiline patch
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2 weeks
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What is the possible result of using MAOIs with drugs that prevent the break down of MAOIs
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hypertensive crisis
serotonin syndrome psychosis |
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Name drugs that have an effect on EPI, NE, srotonin and dopamine that can cause fatal SE of MAOI
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1) bupropion
2) ephedrine and analogs (pseudoephedrine) 3) levodopa 4) linezolid 5) lithium 6) meperidine 7) SSRIs, SNRIs, TCAs 8) tramadol 9) mirtazapine 10) dexromethorphan 11) cyclobenzaprine (and other skeletal muscle relaxants) 12) St Johns Wort |
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Name tyramine rich foods
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-aged cheese
-pickled herring -yeast extract -air dried meats -sauerkraut -soy sauce -fava beans -red wines -tap beer (little or no tyramine is found in bottled, canned, or pasteurized beer) |
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When can foods become high in tyramine
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when they have been aged, fermented, pickled or smoked
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Give symptoms of serotonin syndrom
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1. vomitting
2. rapid changes in BP 3. palpatations 4. feeling hot 5.agitation/restlessness 6. diarrhea 7. hallucinations 8. loss of coordination |
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How many symptoms of serotonin syndrome should the pt report to the doctor immediately.
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3 or more symptoms
1. agitation/restlessness 2. rapid changes in BP 3. palpatations 4. vomiting 5. diarrhea 6. loss of coordination 7. halucinations 8. feeling hot |
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How often is the Emsam patch changed
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every day at the same time
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What areas of the body can the Emsam (selegiline) patch be applied to
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upper chest
back (below the neck, above the waist) outer surface of upper arm upper thigh |
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How often should the site of the Emsam patch be rotated
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do not use the same site 2 days in a row
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Give the brand name of bupropion
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Wellbutrin **
Budeprion Aplenzin Zyban |
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Explain the MOA of bupropion (Wellbutrin, Zyban)
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-not fully understood
-thought to be dopaminergic -weak inhibitor of NE and dopamine reuptake******* -does not inhibit reuptake of serotonin -does not inhibit monoamine oxidase enzyme |
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How many times a day are the Wellbutrin IR, SR and XL dosed
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IR-TID
SR- BD XL- QD |
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How is Aplenzin dosed and why
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once daily, it is an extended release formulation of bupropion
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Give equivalent doses of Aplezin and Wellbutrin
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174mg is equivalent to 150mg of wellbutrin
348mg is equivalent to 300mg of wellbutrin |
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Give SE of bupropiont
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dry mouth
insomnia tremors/seizures weight loss |
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What SE of bupropion is dose related
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tremors/seizures
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Why does bupropion not cause sexual dysfunction like other antidepressants
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bc it has not effect of serotonin
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Give contraindications to the use of bupropion
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1. do not use in seizure disorder
2. do not exceed 450mg/d due to increase seizure risk |
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What is the max dose of bupropion and why
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450mg/day due to increase risk of seizures
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What is the use of the brand name Zyban
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used for smoking cessation
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Can Zyban and Wellbutrin be used at the same time
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No, they are the same drug
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Give brand name of mirtazapine
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Remeron
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Give generic name of Remeron
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mirtazapine
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Give the MOA of mirtazapine
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NE and serotonin reuptake inhibitor
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Give most common uses of mirtazapine (Remeron)
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used in oncology and skilled nursing because:
1. it helps with sleep 2. causes weight gain (makes it good for the frail elderly) |
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What time of the day is mirtazapine given
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HS (at bedtime)
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Give SE of mirtazapine
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sedation
increase in appetite weight gain rarely agranulocytosis |
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Give the brand name of trazodone
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Desyrel
Oleptro |
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What is the difference in Desyrel and Oleptro
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Oleptro is the ER (extended release) formulation of trazodone
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Give the MOA of trazodone
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Desyrel, Oleptro
MOA: inhibits reuptake of serotonin and blocks alpha 1 adrenergic and histamine |
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Which form of trazodone is less sedating
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Oleptro the extended release formulation
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Give the SE of trazodone and which is most common
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-sedation**most common
-orthostasis -sexual dysfunction -priapism=medical emergency |
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why is trazodone rarely used as an antidepressant and what is its most common use
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rarely used as an antidepressant because of sedation
-used off label for sleep |
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Give the MOA of nefazodone
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-inhibits reuptake of serotonin and norepi
-blocks serotonin and alpha receptors |
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What drug is nefazodone similar to and what are the differences
|
trazodone
-nefazodone is less sedating but has more hepatoxicity |
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Why is nefazodone rarely used
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due to increased risk of hepatotocity
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Why do you not want to use bupropion in patients that have an increased seizure risk
|
bc buproprion decreases the seizure threshold
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What is the max dose of bupropion at each dose if using the immediate release formulation and why
|
at each dose of immediate release bupropion the max dose is 150mg because the total daily max dose is 450mg
-the IR formulation is given TID 150*3=450mg |
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Give 3 counseling tips to patients taking mirtazapine
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-should be taken at night
-should increase appetite -is sedating |
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Give 4 options for treatment of resistant depression
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1. rule out bipolar disorder
2. make sure antidepressant is at optimal dose 3. use combination of antidepressants 4. augment with other options such as antipsychotics |
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Name the antipsychotics that are approved for treatment of resistant depression
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**NOTE this is an option for treatment resistant depression only
1. Abilify (Aripiprazole) 2. Seroquel XR (quetiapine ER) 3. Symbyax (Olanzapine/fluoxetine) |
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Give the black box warning associated with the antipsychotics used to treat resistant depression
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elderly treated with antipsychotics due to dementia related psychosis (losing touch with reality) are at increased risk of death compared to placebo
-and must also have BBW for increased risk of suicide in children, adolescents and young adults (18-24) |
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What time of the day is aripiprazole taken
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in the morning
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What time of day is quetiapine taken
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at night
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What time of the day is Symbyax taken and explain the action of each drug
|
at night
fluoxetine is activating but olanzapine is sedating |
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Give SE that are caused by most antipsychotics and explain each
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1. metabolic issues- dyslipidemia, weight gain, diabetes
2. neuroleptic malignant syndrome - muscle rigidity, fever, delirium 3. tardive dyskinesia- uncontrollable movements of voluntary muscles 4. leukopenia, neutropenia, agranulocytosis 5. orthostasis/dizziness |
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What effect does olanzapine have on weight
|
olanzapine causes weight gain
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Give the MOA of aripiprazole
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partial agonists at D2 and 5HT1A receptors
-antagonist at 5HT2A receptors |
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Give the MOA of olanzapine
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antagonist at dopamine, serotonin, histamine and alpha receptors
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|
|
Give the MOA of quetiapine
|
atypical antipsychotic
-antagonist at dopamine, serotonin, histamine and alpha receptors |
