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24 Cards in this Set
- Front
- Back
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1. Identify clinical signs and symptoms
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SIGECAPS
Sleep Interest Guilt Energy Concentration Appetite Psychomotor Suicide idealation ****At least 5 of the sx every day for 2 weeks AND a change in previous function*** **** At least 1 is Anhedonia or depressed mood*** |
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2. I dentify chronic illnesses which may cause depressive symptoms
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CCAEO
---CNS, CV, Autoimmune, Endocrine, Other-- 1. CNS - alzheimers, parkinsons 2. Cardiovascular - HF, stroke, post-MI 3. Autoimmune - Lupus, RA 4. Endocrine - hypothyroidism, addisons, DM 5. Other - anemia, malnutrition, mono |
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3. Describe pathophysiologic theories
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1. Biogenic-amine
--- decreased NE &/or 5HT in synaptic cleft 2. Receptor-sensitivity --- dysregulation in the sensitivities of receptors 3. Cortisol --- Overstimmulation of cortisol. (which reduces and down regulate receptors -> decreased uptake of 5HT & NE) |
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4a. List antidepressants by class
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1. TCAs
- Tertiary: amitriptyline, Imipramine, doxepin, Trimipramine) - Secondary: nortriptyline, desipramine, protriptyline) 2. MAOIs - Phenylzine (Nardil), Tranylcypromine (Parnate), Selegiline (Emsam) 3. SSRIs - Fluoxetine (prozac), Sertraline (Zoloft), Paroxetine (paxil), Citalopram (Celexa), Escitalopram (Lexapro) Fluvoxemine (Fluvox) 4. Modified SSRIs - Vilazodone (Viibryd) 5. SNRIs - Venlafaxine (Effexor), Desvenlafaxine (Pristiq), Duloxetine (Cymbalta) 6. Aminoketone - Bupropion (Wellbutrin) 7. Tetracylic - Mirtazapine (Remeron) 8. Triazolopyridine - Nefazodone (Serzone) - Trazodone (Deseryl) |
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4b. List antidepressants by MOA
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1. TCAs
- Inhibition of presynaptic REUPTAKE of NE & 5HT - Changes in receptor sensitivity 2. MAOIs - Inhibition of MAO (irreversible) - Reduces the breakdown of NE, 5HT, and DA 3. SSRIs - 5HT reuptake inhibitor. Selective. 4. Modified SSRIs - 5HT reuptake inhibitor. Selective. - Partial 5HT.1A agonist 5. SNRIs - 5HT & NE reuptake inhibitor 6. Bupropion (Wellbutrin) - Weak DA & NE reuptake inhibitor (?) 7. Mirtazapine (Remeron) - Alpha 2 receptor antagonist - Post synaptic block of 5HT2 & 5HT3 receptors 8. Nefazodone (Serzone) & Trazodone (Desyrel) - 5HT >> NE reuptake inhibitor - 5HT2 antagonist |
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5i. Identify potential AEs and CIs of TCAs. Pregnancy category
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AEs of TCAs
1. Anticholinergic - Constipation, Urinary retention, Dry mouth, Blurred vision, Memory dysfunction, Tachycardia 2. Antihistaminic - Sedation, Weight gain, Orthostasis hypotension 3. Lower seizure threshold 4. Cardiac adverse events --> arrhythmias *CI --> 1 or 2 heart block! *Pregnancy category B or C |
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5ii. Identify potential AEs and CIs of MAOIs
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AEs:
- Orthostatic hypotension - Anticholinergic - Sedation/Stimulation - Weight gain - Sexual dysfunction - Hepatic complications Drug/Food Interactions - Serotonin syndrome (Mental status changes, N/V, tremors, sweating, ataxia, CV changes, etc.) - Hypertensive crisis (Tyramine containing foods, direct sympathomimetics) BP >180/120. goal: dec by 25% |
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5iii. Identify potential AEs and CIs each of the SSRIs (6). Also initial dose and dose range
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1. Fluoxetine (Prozac)
- Initial (5-20mg/d), range (20-80mg/d) - Activating - CYP 2D6 - Insomia, sweating, HA, N/D, Sex, anxiety. SEs resolves by 2-4 wks. 2. Sertraline (Zoloft) - Initial (25-50mg/d), range (50-200mg/d) - Activating - Low DIs (CYP2D6 & 3A4) - Similar SEs to Prozac. However, MORE GIs --> May be good for geriatric. 3. Paroxetine (Paxil) --> The only one category D - 5-20mg/d. 20-60mg/d - POTENT CYP 2D6 - MOST sedating SSRIs. 4. Citalopram (Celexa) - 10- 20mg/d; 20-40mg/d - Middle range btwn activating & sedating - Minor DIs - Same SEs 5. Escitalopram (Lexapro) - 5-10mg/d. 5-20mg/d - S-enantionmer. Less cholinergic & histaminic SEs 6. Fluvoxamine (Luvox) - 50-300mg/d - HIGH DIs & SEs!! (CYP1A2 & 3A4) |
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5iv. Identify potential AEs and CIs of modified SSRI. Advantage over SSRIs?
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Vilazodone (viibryd)
- Initial:10mg/d, Range: 20-40mg/d - Take w/food to maximize absorption - DI: CYP3A4 inhibitor (max 20mg/d if taking w/potent CYP3A4 inhibitor) - AEs: Diarrhea, nausea, insomnia - Advantage: Possibly fewer sexual SEs than SSRIs. |
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5v. Identify potential AEs and CIs for each of the SNRIs (3)
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1. Velafaxine (Effexor)
- 5HT> NE. - 75-375 mg/d. >375mg, NE selective (slight increase in BP ~5mmHg) - If dose BID, give higher dose at hs. No cardio toxicity with OD, but can get serotonin syndrome. - DIs: CYP2D6 - AEs: Similar to SSRIs but less (antichol., somnolence, N, dry mouth, sedation..) - DECREASE DOSE IN RENAL & HEPATIC IMPAIRMENT 2. Desvenlafaxine (Pristiq) - 5HT & NE. More NE selective ! - 50-400 mg/d 3. Duloxetine (Cymbalta) - 5HT & NE RI - 20mg BID; 40-60mg BID! - Has an indi. for fibromyalgia & other pain disorders - DI: CYP1A2 & 2D6 - AE: Antichol properties (somm, sexual dys) - Must be TAPERED OFF to avoid withdrawal effects (shorter T1/2) |
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5vi. Identify potential AEs and CIs of Bupropion (Wellbutrin)
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Bupropion (Wellbutrin)
- 150-450mg/d. NTW 450mg --> SEIZURE - Activating! - AEs: mild, less DIs, N/V (serotonin syndrome SEs), less wt gain. but hand tremors that may not go away CI in Seizure disorders, Anorexia/Bulimea |
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5vii. Identify potential AEs and CIs of Mirtazapine (Remeron)
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Mirtazapine (Remeron)
- 15-45mg/d - Less N. However, HIGH (54%) sommnolence & sedation, also weight gain. - For sleep & weight gain (HIV, cancer pts) - >45mg/d --> activating! may cause insomnia --> dose AM |
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5viii. Identify potential AEs and CIs of Nefazodone (Serzone)
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-MOA: 5HT>>>NE RI, 5HT2 Antag.
-Rarely used, taken off the USA Market -DIs: potent CYP3A4 Inhibitor, will increase benzo levels. BBW: hepatotoxicity |
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5ix. Identify potential AEs and CIs of Trazodone (Desyrel)
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Trazodone (Desyrel)
-MOA: Weak 5HT RI, 5HT2 antag. -Dosing: up to 600 mg. For sleep: 50-200 mg (b/c it becomes activating at higher doses) -AE: priapism (rare) -must titrate VERY slowly, because it is very sedating |
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5x. List some augmentation strategies (4)
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1. Lithium
2. Liothyronine (T3) 3. Buspirone (Buspar) 4. ECT (Resistant pts!) |
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6. Educate pts regarding depression and agents used
---6 counseling pts |
1. Treat pt with empathy
2. Don't be afraid to discuss symptpms (sex, wt gain) 3. Be sensitive to pt regarding stigma 4. Do not patronize 5. Compare depression to other medical illness (DM, HTN) 6. Discuss compliance and time to effects, discontinuing therapy etc. |
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1. First line agents?
2. How long does it take for full effect to be seen? 3. How long does transient SEs lasts? 4. If AEs do not resolve, ? |
1. SSRis considered 1st line
2. Antidepressants take 4-8 wks for full benefits to occur 3. Transient SEs may last 2 wks 4. If AEs do not resolve, see if pt can tolerate or reassess therapy. |
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Fluoxetine (Prozac)
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1. Fluoxetine (Prozac)
- Initial (5-20mg/d), range (20-80mg/d) - Activating - CYP 2D6 - Insomia, sweating, HA, N/D, Sex, anxiety. SEs resolves by 2-4 wks. |
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Sertraline (Zoloft)
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2. Sertraline (Zoloft)
- Initial (25-50mg/d), range (50-200mg/d) - Activating - Low DIs (CYP2D6 & 3A4) - Similar SEs to Prozac. However, MORE GIs --> May be good for geriatric. |
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Paroxetine (Paxil)
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3. Paroxetine (Paxil) --> The only one category D
- 5-20mg/d. 20-60mg/d - POTENT CYP 2D6 - MOST sedating SSRIs. |
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Citalopram (Celexa) / Escitalopram (Lexapro)
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4. Citalopram (Celexa)
- 10- 20mg/d; 20-40mg/d - Middle range btwn activating & sedating - Minor DIs - Same SEs 5. Escitalopram (Lexapro) - 5-10mg/d. 5-20mg/d - S-enantionmer. Less cholinergic & histaminic SEs |
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Fluvoxamine (Luvox)
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6. Fluvoxamine (Luvox)
- 50-300mg/d - HIGH DIs & SEs!! (CYP1A2 & 3A4) |
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Venlafaxine (Effexor) / Desvenlafaxine (Pristiq)
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1. Velafaxine (Effexor)
- 5HT> NE. - 75-375 mg/d. >375mg, NE selective (slight increase in BP ~5mmHg) - If dose BID, give higher dose at hs. No cardio toxicity with OD, but can get serotonin syndrome. - DIs: CYP2D6 - AEs: Similar to SSRIs but less (antichol., somnolence, N, dry mouth, sedation..) - DECREASE DOSE IN RENAL & HEPATIC IMPAIRMENT 2. Desvenlafaxine (Pristiq) - 5HT & NE. More NE selective ! - 50-400 mg/d |
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Duloxetine (Cymbalta)
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3. Duloxetine (Cymbalta)
- 5HT & NE RI - 20mg BID; 40-60mg BID! - Has an indi. for fibromyalgia & other pain disorders - DI: CYP1A2 & 2D6 - AE: Antichol properties (somm, sexual dys) - Must be TAPERED OFF to avoid withdrawal effects (shorter T1/2) |
