Sig: E Caps
S and the other s
Sleep disturbances
Suicide
Sig: E Caps
i
Loss of interest
Sig: E Caps
g
Guilt
Sig: E Caps
e
lack of Energy
Sig: E Caps
c
lack of Concentration
Sig: E Caps
a
Appetite changes
Sig: E Caps
p
Psychomotor retardation/agitation
decreases in DOPAMINE cause
anhedonia ↓ motivation apathy ↓ attention cognitive slowing
decreases in NOREPINEPHRINE cause
lethargy
↓ alertness
decreases in SEROTONIN cause
Obsessive-compulsive symptoms
Causes of Depression: Pharmacologic
Steroids- oral contraceptives, anabolic Methyldopa Clonidine Montelukast Beta blockers- propranolol
Causes of Depression: Immunologic
SLE
RA
Causes of Depression: Nutritional
Vitamin deficiency-B12, C, folate, B1, B6
Causes of Depression: Infectious
Tertiary syphilis
AIDS
TB
Causes of Depression: Neoplastic
Pancreatic cancer
Causes of Depression: Endocrine
Hypothyroidism Post-partum Menses-related Cushing’s Addison’s
Causes of Depression: Neurological
MS Parkinson’s Head trauma Stroke Dementia Sleep apnea
Outcome of Treatment for Major Depressive Disorder - 5- R’s
Response Remission Recovery Relapse Recurrence
Duration of therapy: First depressive episode
6-9 months
Duration of therapy: Second episode
4-5 years
Duration of therapy: Third episode
indefinitely
Acute Phase
6-12 weeks
Goal: remission
Continuation Phase
additional 4-5 months
Goal: management of residual symptoms and relapse prevention
Maintenance Phase
at least 1 year
Goal: prevent recurrence
1st line for MDD
Fluoxetine (Prozac) Citalopram (Celexa) Escitalopram (Lexapro) Paroxetine (Paxil) Sertraline
In addition to depression, SSRIs can be used for
Anxiety disorders Panic disorders OCD PTSD Perimenopausal vasomotor symptoms bulimia
SSRI adverse effects
N/V/D
Sexual dysfunction
Bleeding risk (decr PLT aggregation)
Hyponatremia (elderly)
SSRI Discontinuation Syndrome
Flu-like symptoms Agitation Vivid dreams Poor concentration GI headache
Serotonin Syndrome is aka
Hyperpyrexic Crisis
Serotonin Syndrome Symptoms- FLUSH
Flu-like: fatigue, fever, sweating, myalgia, N/V
Lightheaded, dizzy
Uneasiness, agitation, tremor, hyperreflexia
Sleep and sensory disturbances, confusion
Headache
Treatment for serotonin syndrome
cyproheptadine
SSRIs pregnancy category
most are C, but paroxetine is D
SSRIs: monitor for
sexual dysfunction, hepatic and/or renal dysfunction
SNRI examples
Duloxetine (Cymbalta)
Venlafaxine (Effexor)
Levomilnacipran (Fetzima)
SSRI uses
Major depression
Chronic pain disorders
Fibromyalgia
Perimenopausal symptoms
Duloxetine is first line for
Diabetic peripheral neuropathic pain (DPNP) GAD Fibromyalgia Chronic musculoskeletal pain Stress urinary incontinence (SUI)
What do you recommend for
Diabetic peripheral neuropathic pain (DPNP)
What do you recommend for
GAD
What do you recommend for
Fibromyalgia
What do you recommend for
Chronic musculoskeletal pain
What do you recommend for
Stress urinary incontinence (SUI)
Duloxetine ADRs
Dry mouth Insomnia Dizziness Incr LFTs INcr BP Sexual dysfunction Decr appetite
Duloxetine: Monitor/ Caution:
HTN
Not recommended in patients with substantial alcohol use
Chronic liver disease
Levomilnacipran is an SNRI approved for
fibromyalgia
Levomilnacipran ADRs
Hyperhidrosis Sexual dysfunction Urinary hesitancy Incr heart rate and BP N/V/C
Levomilnacipran: you have to limit the MDD when used with
a strong CYP3A4 inhibitor
Tricyclic Antidepressants (TCA) are divide into 2 groups:
Tertiary amines
Secondary amines
Tricyclic Antidepressants (TCA), Tertiary amines description
More intolerable anticholinergic and sedative adverse effects
Tricyclic Antidepressants (TCA), Secondary amines description
More potent on a mg to mg basis
Tricyclic Antidepressants (TCA), ADRs
Anticholinergic Alpha 1 blockade Orthostatic hypotension, sedation, sexual dysfunction Histamine blockade Sedation, weight gain Fast sodium channel blockade Cardiac-arrythmias
Tricyclic Antidepressants (TCA), overdose treatment
sodium bicarbonate
Tricyclic Antidepressants (TCA) are the preferred medication for
Pregnancy pain/fibromyalgia, migraine Insomnia Severe depression Parkinson’s
Tricyclic Antidepressants (TCA), use caution with
Elderly Daytime sedation Dementia Suicidal Overweight, bipolar Cardiac abnormalities
Serotonin Modulators, 3 examples
Trazodone
Nefazodone
Trazodone (Serotonin Modulator) Adverse effects:
Sedation N/V/C Orthostasis Headache Asthenia Priapism
Nefazodone (Serotonin Modulator) Adverse effects:
Sedation N/V/C Hepatotoxicity Orthostasis Headache Asthenia
Trazodone, Vortioxetine, and Nefazodone (Serotonin Modulator) are preferred meds for
Patients with depression-related anxiety and agitation
Insomniacs
Sexual dysfunction with other agents
Trazodone, Vortioxetine, and Nefazodone (Serotonin Modulator) need to be used cautiously with
Noncompliant patients
Hepatic dysfunction
Vortioxetine (Serotonin Modulator) Adverse effects
N/V/C
Serotonin syndrome
Risk of bleeding
bilpolar-> risk of activation of mania
Vortioxetine (Serotonin Modulator), has several medications inhibit the metabolism of vortioxetine
Bupropion, fluoxetine, paroxetine, quinidine
Vortioxetine (Serotonin Modulator), there are 3 medications that induce the metabolism
Rifampin, carbamazepine, phenytoin
Unicyclic medication example
Bupropion
Tetracyclic medication example
Mirtazapine
Bupropion drug class
Unicyclic
Mirtazapine drug class
Tetracyclic
Bupropion ADRs
Insomnia, anxiety, agitation, nausea, anorexia, seizures
Bupropion: One of the ADRs is seizures, what factors make the risk of seizure higher?
Head trauma, history of sz, CNS tumor, bulimia/anorexia, alcoholics
Bupropion is preferred for
Intolerant to SSRI
+SSRI to reverse sexual dysfunction
Smoking cessation
With Bupropion be careful with people who have
Abrupt d/c of alcohol/sedatives
Seizure
Hepatic dysfunction
Mirtazapine ADRs
Sedation Weight gain Constipation Incr TG, cholesterol Dizziness
Mirtazapine is preferred for
Mixed panic disorder/depression
Mixed anxiety/depression
Mirtazapine use caution for
Hepatic dysfunction
Overweight
Cognitive slowing
MAOIs examples
Phenelzine
Tranylcypromine
Selegiline
Describe MAOIs in 2 words
irreversible and nonselective
To whom would you recommend an MAOI
someone that didn’t respond to anything else, its last resort
MAOI ADRs
Anticholinergic effects Hypertensive Crisis (noradrenergic syndrome)
MAOI: Hypertensive Crisis (noradrenergic syndrome) is caused by
Tyramine rich foods- red wine,beer, sardines, aged cheeses, shrimp, chocolate
Medicaitons- amphetamines, linezolid, dopamine, decongestants, DM, meperidine
MAOI 3 instructions related to interactions
Avoid foods high in tyramine and for 2 weeks after d/c
14 day wash out- SSRIs, SNRIs, TCA + MAOI
5 week wash out fluoxetine + MAOI
MAOI: Avoid foods high in
tyramine and for 2 weeks after d/c
MAOI: 14 day wash out-
SSRIs, SNRIs, TCA + MAOI
MAOI: 5 week wash out
fluoxetine + MAOI
Selegiline (MAOI) Metabolites include
amphetamine and methamphetamine
MAOIs are preferably used for what conditions
Atypical depression (mood reactivity, irritability, psychomotor retardation, hypersomnia Refractory depression Associated panic attacks Bulimia Compliant patients
MAOIs should be used cautiously with
Non compliant patients
Insomniacs
agitation