Psych Mod Exam 2 (Dr. Ehret -- Depression)

Front 1

Most adrenergically active SNRI?

Back 1

levomilnacipran [Fetzima]

Front 2

Max dose of desvenlafaxine [Pristiq] for MDD?

Back 2

50 mg/day

Front 3

SNRI that binds to both 5-HT and NE at lowest dose?

Back 3

duloxetine [Cymbalta]

Front 4

Dr. Ehret's favorite antidepressant?

Back 4

duloxetine [Cymbalta]

- also indicated for pain, fibromyalgia
- weight loss can be a "good" side effect

Front 5

Target dose for duloxetine [Cymbalta] for MDD?

Back 5

60 mg/day

Front 6

Of the 4 SNRI's approved for MDD, which is the only one that has an effect on CYP?

Back 6

duloxetine [Cymbalta]

- moderate inhibitor of 2D6

Front 7

SSRI with the longest half-life?

Back 7

fluoxetine [Prozac]

- 96-144 h for fluoxetine
- 96-384 h for active metabolite (norfluoxetine)

Front 8

In general, are SSRIs "activating"?

Back 8

Yes. They can cause insomnia. This is why SSRIs are usually taken in the morning.

Front 9

Fluoxetine is a potent inhibitor of which CYP?

Back 9

2D6

Front 10

Which SSRI is most likely to cause diarrhea?

Back 10

sertraline [Zoloft]

(Take with food.)

Front 11

SSRI that is not FDA-approved for MDD but is as effective as other SSRIs for treating MDD?

Back 11

fluvoxamine [Luvox]

(OCD is the only FDA-approved indication.)

Front 12

SSRI with the shortest half-life?

Back 12

fluvoxamine [Luvox]

15 h

Front 13

Fluvoxamine [Luvox] is a strong inhibitor of which CYPs?

Back 13

1A2, 3A4

(also 2C19 to a lesser extent)

Front 14

Max dose of sertraline [Zoloft]?

Back 14

200 mg/day

Front 15

Max dose of fluvoxamine [Luvox]?

Back 15

300 mg/day

Front 16

Effective dosing ranges for sertraline and fluvoxamine?

Back 16

100-200 mg/day for both

Front 17

The only SSRI that is Pregnancy Category D?

Back 17

paroxetine [Paxil]

- causes pulmonary HTN in infants

Front 18

Paroxetine is a potent inhibitor of which CYP?

Back 18

2D6

Front 19

SSRI with mild anticholinergic effects?

Back 19

paroxetine [Paxil]

Front 20

The most CELEctive SSRIs?

Back 20

RS-citalopram [CELExa]
S-citalopram [Lexapro]

= less likelihood of sexual dysfunction due to greater selectivity

Front 21

Max dose of citalopram [Celexa] for MDD?

Back 21

40 mg/day

- anything higher may cause QTc prolongation

Front 22

Max dose of escitalopram [Lexapro]?

Back 22

20 mg/day

Front 23

Which are more likely to cause HTN: SSRIs or SNRIs?

Back 23

SNRIs

(increased NE = adrenergic effects)

Front 24

Max dose of desvenlafaxine [Pristiq] for MDD?

Back 24

50 mg/day

50 mg QOD for ESRD since it's metabolized by UGT and excreted renally

Front 25

SNRI that may cause dose-related MINOR elevations in BP?

Back 25

venlafaxine [Effexor]

Front 26

SNRI that may cause SIGNIFICANT elevations in BP?

Back 26

levomilnacipran [Fetzima]

(= the most adrenergically active SNRI)

Front 27

Newest SNRI on the market?

Back 27

levomilnacipran [Fetzima]

Front 28

The one SNRI that is NOT a CYP substrate?

Back 28

levomilnacipran [Fetzima]

(It's renally excreted.)

Front 29

Can levomilnacipran [Fetzima] ER capsules be crushed or opened?

Back 29

No.

Front 30

Dosing range for levomilnacipran [Fetzima]?

Back 30

40-120 mg/day

Front 31

If you have "ants in your pants," what condition are you experiencing?

Back 31

Akathisia

(= internal restlessness)

Front 32

The mildest symptom in serotonin sydrome?

Back 32

Akathisia

Front 33

The most severe/life-threatening symptom in serotonin syndrome?

Back 33

Hyperthermia

Front 34

Is it a good idea to give a SSRI to someone with a GI bleed risk?

Back 34

No. SSRIs decrease 5-HT uptake from the blood to platelets.

Think about it:

- 5-HT2A receptors are found on platelets, smooth muscle and the cerebral cortex
- Activation of 5-HT2A on platelets leads to platelet aggregation

- SSRIs block the uptake of 5-HT by platelets from the blood-- platelets do not synthesize 5-HT, so 5-HT must come from somewhere else.

- Thus, SSRIs cause less 5-HT to be taken up by platelets from the blood. In effect, there is less aggregation of platelets, leading to bleeding. This is more likely to occur in the GI than in the skin.

Front 35

What are the two hormones that are stored in/released from the posterior pituitary "gland"?

Back 35

antidiuretic hormone; aka vasopressin, aka arginine vasopressin (AVP)

oxytocin

Front 36

Does hyponatremia occur because a person has a deficiency in sodium or because a person is retaining excess water?

Back 36

Hyponatremia results from an excess of water, not a deficiency in sodium. It may result from an inappropriate secretion of antidiuretic hormone (SIADH), which results in water retention.

Front 37

Clinical presentation of SIADH?

Back 37

Confusion
Lethargy
Dizziness
Delirium
Fatigue
Anorexia

Front 38

Onset of SIADH?

Back 38

3 days to 4 months

Front 39

How long does it take for hyponatremia to resolve after d/c the offending agent?

Back 39

2 weeks

Front 40

Discontinuation syndrome is aka what?

Least likely to occur with the SSRI ____ and most likely to occur with the SSRI _____ due to the drug's long and short half-life, respectively.

Back 40

Withdrawal

fluoxetine
fluvoxamine, paroxetine

Front 41

Symptoms of d/c syndrome mimic symptoms of what illness?

Back 41

Flu

Front 42

Sexual dysfunction is most likely to occur with increased activity of what NT/type of neuron?

Back 42

5-HT/serotonergic neurons

Front 43

Pharmacologic class of bupropion [Wellbutrin]?

Back 43

NDRI

(= NE/DA reuptake inhibitor)

Front 44

Best times to dose bupropion [Wellbutrin] if giving BID?

Back 44

7 am and 1 pm

(NOT q 12 h due to activating effects!)

Front 45

Is it a good idea to give bupropion [Wellbutrin] to someone who suffers from anorexia, bulimia or epilepsy?

Back 45

No. Bupropion may LOWER seizure thresholds.

Front 46

Psychosis is a side effect of bupropion. Why do you think this occurs?

Back 46

Bupropion is a NDRI. Increasing DA in the limbic system may cause psychosis. Think about the pathophys. of schizophrenia-- DA hyperactivity in the mesolimbic pathway.

Front 47

Bupropion inhibits which CYP?

Back 47

2D6

Front 48

T/F? Bupropion may be useful for treating ADHD since it is a stimulating drug.

Back 48

True.

Front 49

Pharmacologic class of mirtazapine [Remeron]?

Back 49

alpha-2 antagonist

(aka SNDI = "serotonin and NE disinhibitor")

Front 50

Antidepressant that may be useful for an elderly patient who has a decreased appetite and trouble sleeping?

Back 50

mirtazapine [Remeron]

Potent antagonist of:
- central H1 = sedation; inc. appetite
- 5-HT2 (5-HT2C, which is in the hypothalamus) = inc. appetite
- 5-HT3, which is on parasympathetic nerves = sympathetic-type effects, such as dry mouth, constipation

Moderate antagonism of:
- peripheral alpha-1-adrenergic receptors
- peripheral muscarinic receptors

Front 51

Starting dose of mirtazapine?

Back 51

7.5-15 mg qhs

Front 52

Effective dose range of mirtazapine?

Back 52

15-45 mg

Front 53

Max dose of mirtazapine?

Back 53

60 mg

Front 54

2 MAOIs that Dr. Ehret mentioned?

Back 54

- phenelzine [Nardil]
- tranylcypromine [Parnate]

Front 55

Class of antidepressants that have the highest rate of switching from depression to mania?

Back 55

MAOIs

Front 56

CV effects of MAOIs?

Back 56

- Decreased QTc interval
- Decreased HR
- HYPOtension

Front 57

2 things that can cause hypertensive crisis-- a concern in patients taking MAOI?

Back 57

- tyramine-containing foods
- concomitant use of sympathomimetics

Front 58

Tyramine increases the release of which NT in the periphery?

Back 58

NE

(Tyramine is a naturally occurring monoamine that is derived from tyrosine. It cannot cross the BBB.)

Front 59

If switching from a MAOI to an SSRI, how long must you wait before starting the SSRI?

Back 59

2 weeks

(This is how long if takes for MAO to regenerate.)

Front 60

If switching from an SSRI to a MAOI, how long must you wait before starting the MAOI?

Back 60

Wash-out period of SSRI depends on its half-life.

(Fluoxetine has a long half-life, so wait 5 weeks.)

Front 61

Drugs to avoid while taking MAOI?

Back 61

- Indirect/direct sympathomimetics
- Other antidepressants
- Buspirone
- Meperidine
- Dextromethorphan
- Cocaine

Front 62

The name "TCA" reflects the structure of the drug class. What is the actual pharmacologic class?

Back 62

SNRI

Front 63

Antidepressant drug class that is used mostly for treating pain and not depression?

Back 63

TCA

Front 64

Antidepressant drug class with the most anticholinergic effects?

Back 64

TCA

Front 65

Common AEs of TCAs?

Back 65

- sedation
- orthostatic hypotension
- anticholinergic effects

Front 66

Serious AEs of TCAs?

Back 66

- switching
- arrhythmias
- seizures
- death

Front 67

Plasma concentration monitoring is (RARELY) done for which 2 TCAs?

Back 67

- nortriptyline: 50-150 ng/mL
- desipramine: 125-300 ng/mL

(These two are secondary amines, metabolites of tertiary amines that are also commercially available.)

Front 68

Which antidepressant drug class has lots of drug-drug interactions, i.e. things that can either increase or decrease levels of antidepressant?

Back 68

TCA

Front 69

Antidepressant that has black box warning for potential to cause hepatic failure?

Back 69

nefazodone

Front 70

Nefazodone inhibits which CYP?

Back 70

3A4

Front 71

Rare but serious AE of nefazodone?

Back 71

Priapism

("nefazoBONE")

Front 72

Rare but serious AE of trazodone?

Back 72

Priapism

("trazoBONE")

Front 73

Pharmacologic class of trazodone?

Back 73

SARI with strong antihistamine effects

(= serotonin antagonist and reuptake inhibitor)

Front 74

Dosing for trazodone ER for treating depression?

Back 74

150 or 300 mg ER tab hs on empty stomach

Front 75

MOA of vilazodone [ViiBRYD]?

Back 75

It's a HYBRID: SSRI and partial 5-HT1A agonist

Front 76

Newest SSRI on the market?

Back 76

vortioxetine [Brintellix]

Front 77

MAO of vortioxetine [Brintellix]?

Back 77

- SSRI
- agonist at 5-­HT1A receptor
- partial agonist at 5-­HT1B receptors
- antagonist 5-HT3, 5-HT1D, 5-HT7 receptors

Front 78

Can ECT be used in pregnant women?

Back 78

Yes.

(GA's are flushed out of the body quickly.)

Front 79

MOA of lithium?

Back 79

Increases presynaptic transmission of 5-HT

Front 80

Therapeutic level of lithium?

Back 80

> 0.5 mEq/L

Front 81

When is lithium used?

Back 81

Bipolar disorder
Augmentation strategy in resistant depression

Front 82

Which is more effective as an augmentation strategy in resistant depression: T3 or lithium?

Back 82

T3

(also has less side effects)

Front 83

The two atypical antipsychotics that may be used as adjunctive therapies in resistant MDD?

Back 83

- aripiprazole (preferred), (15 mg/day)
- quetiapine XR (150-300 mg/day)

Front 84

Efficacy of ECT in MDD?

Back 84

80-90%!

Front 85

MOA of St. John's Wort?

Back 85

- "affinity for" GABA-A, GABA-B, 5-HT1, 3, 4
- SRI
- mild MAOI

Front 86

Effective dose of St. John's Wort?

Back 86

300 mg TID

Front 87

What does "SAMe" stand for and what does it do?

Back 87

S-adenosyl methionine

Serves as a methyl donor in the synthesis of phospholipids, catecholamines, serotonin.