Session 3 Pharm -6- Antidepressants

Front 1

What two areas of the brain are proposed to be the sites where depression reside because of the high levels of NE and 5-HT receptors in these locations

Back 1

Raphe Nuclei and Locus Ceruleus

Front 2

Where do 90% of NE neurons in the brain originate from

Back 2

locus ceruleus or the sky blue place involved in arousal, stress and panic

Front 3

What portion of the brain has extensive projection to the rest of the brain and is responsible for regulation of mood, appetite and sleep

Back 3

raphe nuclei

Front 4

What is the main tx for depression

Back 4

psych counseling is necessary drugs are only adjunct to treatment

Front 5

Why does it take up to several weeks for antidepressants to work

Back 5

you have to get desensitization of the alpha 2 and 5ht receptors on the presynaptic terminal to prevent feedback inhibition of NE and serotonin release from the presynaptic auto receptors. This takes time

Front 6

TCAs have a different adaptive change than the other anti depressants to reach therapeutic levels what is the difference

Back 6

TCAs alpha 1 receptors do not desensitize instead it is postsynaptic Beta receptors that are desensitized

Front 7

Why is depression treatment split into three phases, acute phase, continuation phase and maintenance phase

Back 7

each phase has a different goal. Acute phase is first 6- 8 weeks needed to see reduction of symptoms, Continuation phase is 6 months of continued tx to avoid relapse, and maintenance phase is more therapy for recurring depression pt

Front 8

What phase of depression tx if aimed at preventing relapse and is set at about 6 months of continued depression therapy after tx of symptoms

Back 8

continuation phase

Front 9

What is the 1st line tx for depression

Back 9

SSRIs

Front 10

What type of drug is fluoxetine (Prozac)

Back 10

SSRI

Front 11

What type of drug is Sertraline (Zoloft)

Back 11

SSRI

Front 12

What type of drug is Citalopram (Celexa)

Back 12

SSRI

Front 13

What type of drug is Escitalopram (Lexapro)

Back 13

SSRI

Front 14

What type of drug is Fluvoxamine (Fluvox)

Back 14

SSRI

Front 15

What type of drug is Paroxetine (Paxil)

Back 15

SSRI

Front 16

Pt is taking TCAs and you want to switch them over to SSRI what two SSRI should you not prescribe this patient because you could induce a TCA toxicity

Back 16

Paroxetine (Paxil) and Fluoxetine (Prozac)

Front 17

What are the possible S/E of SSRIs

Back 17

SEXUAL DYSFUNCTION, GI problems such as abdominal cramp/pain, belching, bloating, constipation, diarrhea, dyspepsia, indigestion, flatulence. S/E reduce with continued treatment are not permanent

Front 18

Pt is experiencing S/E from the SSRI you just prescribed a couple of days ago what should you tell them

Back 18

The S/E are likely to diminish if possible they should try and continue taking the drug and see if they decrease

Front 19

Pt is completely cured of depression what needs to be done with their SSRI tx

Back 19

they need to be tapered of slowly to avoid withdrawal effects

Front 20

What are the signs of SSRI withdrawal

Back 20

FLUSH- Flu like fatigue, diarrhea, nausea, diaphoresis, Lightheadedness, Uneasiness, Sleep/Sensory disturbances, Headache

Front 21

Your Pt figured if one anti depression med was good two would be even better and decided to combine their current SSRI with another one they had in the house what complication could this cause

Back 21

Serotonin syndrome- a potentially fatal hyperserotonergic state marked by severe muscle rigidity and myoclonus, hyperthermia, cardiovascular instability, marked CNS stimulatory effects such as seizures

Front 22

A Pt just arrive in the ER suffering from Serotonin Syndrome what tx are you going to give

Back 22

d/c serotonergic meds, give an antiseizure drug and 5-HT blockers

Front 23

What type of drug is Venlafaxine (Effexor)

Back 23

SNRI

Front 24

What type of drug is Duloxetine (Cymbalta)

Back 24

SNRI

Front 25

When would you likely use and SNRI over an SSRI

Back 25

major depressive disorder or depression with neuropathic pain (SSRIs are not useful for neuropathic pain), can be used to treat GAD

Front 26

What are the S/E of SNRI

Back 26

same as SSRI GI symptoms and SEXUAL dysfunction

Front 27

Sexual Dysfunction a S/E of SSRIs and SNRIs can lead a patient to be non compliant what can you prescribe them that has less side effects

Back 27

atypical antidepressants such as mirtazapine, Trazodone, nefazodone, bupropion. You can also give sildenafil (Viagra) along with the antidepressants as an option

Front 28

What type of drug is imipramine (Tofranil)

Back 28

Tertiary TCA

Front 29

What type of drug is clomipramine (Anafranil)

Back 29

Tertiary TCA

Front 30

What type of drug is Trimipramine (Surmontil)

Back 30

Tertiary TCA

Front 31

What type of drug is Amitriptyline (Elavil)

Back 31

Tertiary TCA

Front 32

What type of drug is Doxepin (Adapin)

Back 32

Tertiary TCA

Front 33

What is the MOA of the tertiary TCAs

Back 33

non selective inhibition of NE and 5HT reuptake except Clomipramine (Anafranil) which selectively blocks 5-HT reuptake

Front 34

What is the MOA of secondary TCAs

Back 34

inhibit NE reuptake except Amoxapine which inhibits NE and DA reuptake

Front 35

What type of drug is Desipramine (Norpramin)

Back 35

Secondary TCA

Front 36

What type of drug is Amoxapine (Asendin)

Back 36

Secondary TCA

Front 37

What type of drug is Maprotiline (Ludiomil)

Back 37

Secondary TCA

Front 38

What type of drug is Nortriptyline (Pamelor)

Back 38

Secondary TCA

Front 39

What type of drug is protriptyline (Vivactil)

Back 39

Secondary TCA

Front 40

What class of anti depressant has the MOA of non selectively blocking reuptake of NE and 5-HT but has higher S/E profile because it also blocks H1-histamine receptors, muscarinic receptors and alpha 1 receptors

Back 40

TCAs

Front 41

Because TCAs block Alpha 1 receptor what S/E do you see

Back 41

orthostatic Hypotension

Front 42

Because TCAs block muscarinic receptors what S/E do you see

Back 42

dry mouth (xerostomia), Blurred vision, Constipation

Front 43

What S/E do you see in TCAs due to their blockade of histamine receptors

Back 43

sedation

Front 44

What are two concerning S/E for patients that they are most likely to notice with TCAs

Back 44

Weight Gain, Sexual Dysfunction

Front 45

If a patient has a dysfunctional CYP2D6 gene what problem might they have

Back 45

may have a hard time metabolizing certain TCAs so you may want to be selective in which drug you prescribe them

Front 46

Since TCAs have a higher S/E profile than SSRIs or SNRIs when would you want to use them

Back 46

depression resistant to SSRIs and SNRIs, good for nocturnal enuresis in children over 12, approved for ADD/ADHD in children over 6 and Clomipramine is used for OCD

Front 47

When are TCAs contraindicated

Back 47

Pt with glaucoma as it can aggravate it, epileptic patients, caution in elderly patients or patients with recent MI

Front 48

Why do you want to be careful in how big of a dose of TCA you prescribe a Pt

Back 48

There is a high overdose potential that can be potentially fatal especially with imipramine. Signs are confusion, mania, cardiac dysrhythmias

Front 49

What do you have to caution patient against using while taking TCAs because they can potentiate the sedative effects of the TCAs

Back 49

EtOH and Anesthetics

Front 50

What type of drug is Mirtazapine (Remeron)

Back 50

Atypical Antidepressant

Front 51

What type of drug is Trazodone (Desyrel)

Back 51

Atypical Antidepressant

Front 52

What type of drug is Nefazodone (Serzone)

Back 52

Atypical Antidepressant

Front 53

What type of drug is Bupropion (Wellbutrin)

Back 53

Atypical Antidepressant

Front 54

What type of drug is Atomoxetine (Strattera)

Back 54

Atypical Antidepressant

Front 55

What class of antidepressant has no common MOA but generally are believed to non selectively antagonize presynaptic receptors enhancing release of NE and 5-HT

Back 55

Atypical Antidepressant

Front 56

Which Atypical antidepressant blocks 5HT 2alpha receptor and inhibits reuptake of 5HT and NE used as an antidote to sexual dysfunction associated with SSRI and SNRIs but can cause hepatotoxicity

Back 56

Nefazodone (Serzone)

Front 57

Which atypical antidepressant doesn’t actually treat depression very well and has been repackaged to treat nicotine addiction. It has a short half life can cause dry mouth, sweating, tremor, seizures at high doses

Back 57

Bupropion (Wellbutrin)

Front 58

what tx might you consider for a pt with major depression that has resisted SSRIs, SNRIs and TCA treatment

Back 58

MAOI

Front 59

What are the two isoenzymes of MAO

Back 59

MAO-A and MAO-B MAO-A preferentially deaminates NE, EPI, Serotonin. MAO-B deaminates Dopamine and Tyramine

Front 60

What type of drug is Phenelzine (Nardil)

Back 60

Non specific irreversible MAOI

Front 61

What type of drug is Isocarboxazid

Back 61

Hydrazine class irreversible inhibitor of MAOIs

Front 62

What type of drug is Tranylcypromine (Parnate)

Back 62

Non specific irreversible MAOI amphetamine derivative

Front 63

What type of drug is Moclobemide

Back 63

MAOI specific for MAO-A isoenzyme (targets NE, EPI and Serotonin preferentially)

Front 64

What type of drug is Selegiline (EMSAM, Selegiline patch)

Back 64

MAO-B specific MAOI (preferentially targets dopamine and tyramine)

Front 65

What are the S/E of MAOIs

Back 65

sedation, orthostatic hypotension, CNS stimulation, Weight Gain, Decreased sexual function, GI s/e and N/V

Front 66

What dietary education do you have to give a pt when you prescribe them MAOIs

Back 66

avoid cheese, wine and preserved foods as they contain tyramine and have an interaction with MAOIs

Front 67

Can you give MAOIs as a adjunct to SSRI therapy or TCA therapy

Back 67

No, it can cause serotonin syndrome if you combine them

Front 68

What SSRI, SNRI or TCA would you most likely prescribe for ADD/ADHD

Back 68

Imipramine (Tofranil) a tertiary amine or Atomoxetine (Strattera) an atypical antidepressant

Front 69

What SSRI, SNRI or TCA would you most likely prescribe for OCD

Back 69

SSRIs; Fluvoxamine (Fluvox), Fluoxetine (Prozac): TCA- Clomipramine (Anafranil)

Front 70

What SSRI, SNRI or TCA would you most likely prescribe for nocturnal enuresis (bed wetting )

Back 70

Desipramine (Norpramin) secondary TCA (not first line though)

Front 71

Pt is suffering from neuropathic pain what antidepressants would you likely use for their depression

Back 71

TCAs or SNRIs remember SSRIs aren't very effective for neuropathic pain

Front 72

what type of bipolar disorder is marked by manic episodes

Back 72

bipolar I

Front 73

what type of bipolar disorder is marked by hypomanic states

Back 73

bipolar II

Front 74

What is the tx for bipolar generally include

Back 74

Lithium, Carbamazepine or Valproic acid, antipsychotics, antidepressants

Front 75

What is the main prophylactic tx for bipolar disorder

Back 75

Lithium

Front 76

What is the MOA of lithium

Back 76

interferes with resynthesis of PIP2

Front 77

Pt is bipolar and taking a thiazides what interaction might occur if the pt is prescribe lithium for their bipolar disorder

Back 77

lithium gets retained in situation that cause depletion of Na+. Thiazides cause diuresis and therefore lithium will get retained you have to monitor this as lithium has a low therapeutic index and can become toxic

Front 78

Why do you need to monitor patients lithium levels

Back 78

lithium has a low therapeutic index and can be toxic causing vomiting, diarrhea, coarse tremor, ataxia, coma, convulsions chronic intoxication can cause neurologic damage

Front 79

Is there an antidote to lithium toxicity

Back 79

No dialysis is the most effective tx

Front 80

What are some s/e of lithium at normal doses

Back 80

Nausea, diarrhea, drowsiness, polyuria, polydipsia, weight gain, decreased thyroid function