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PHAR 557 > Major Depressive Disorder - Antidepressant AEs, TRD, Serotonin Syndrome, D/C Syndrome > Flashcards

Major Depressive Disorder - Antidepressant AEs, TRD, Serotonin Syndrome, D/C Syndrome Flashcards

1
Q

What GI AEs result from antidepressants?

A

N/D, stomach upset, constipation

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2
Q

When are N and stomach upset usually experienced by the majority of pts on antidep tx?

A

Up to the 2nd week of tx

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3
Q

Which antidepressants are most assoc w/ nausea?

A

Venlafaxine > SSRI > buproprion > moclobemide > mirtazapine

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4
Q

How to manage N/upset stomach?

A
  1. divide doses
  2. reduce SSRI dose if pt is stable
  3. take some food w/ the medication
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5
Q

Antideps most assoc w/ constipation?

A

paroxetine, TCAs

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6
Q

How to manage antidep-induced constipation?

A

Activity, fibre

-Should resolve on its own (3 months)

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7
Q

How to manage antidep-induced diarrhea?

A

Should resolve on its own (3 months)

Antidiarrheal okay

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8
Q

What AE is possible within the first 2 months of antidepressant tx in pts under 24 yrs old?

A

Suicidal thoughts or behaviour

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9
Q

Which antidepressant showed best efficacy in preventing/reducing suicidality in adults?

A

sertaline

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10
Q

In <18 pts, which antidepressants showed the best efficacy for reducing suicidality?

A

fluoxetine and citalopram

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11
Q

Which antidep categories are most assoc w/ sexual dysfn?

A

SSRIs, SNRIs, and TCAs

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12
Q

Which antidepressants are assoc w/ the least amt of sexual dysfn?

A
  1. bupropion
  2. mirtazapine
  3. moclobemide
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13
Q

Best strategies for dealing w/ sexual dysfn due to antidepressants?

A
  1. add-on bupropion or mirtazapine
  2. PDE-5 inhibitor (sildenafil/tadalafil)
  3. switch to bupropion or mirtazapine (lowest rates of sexual dysfn)
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14
Q

When should follow-up take place to assess adherence, tolerability, response, and suicidality?

A

q1-2 weeks in the first 8 weeks

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15
Q

What should we do if the pt doesn’t improve following 8 weeks of adequate tx?

A

We can either

  1. switch, or
  2. augment w/ alternate mechanism antidep
  3. psychotx
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16
Q

When there has been a partial response to antidep tx, what should we do if there has been <50% improvement in sx’s after 8 weeks of tx?

A

Switch antidep

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17
Q

When there has been a partial response to antidep tx, what should we do if there has been ≥ 50% reduction in sx’s after 4 weeks of tx?

A

Increase dose and continue for 12 weeks > re-evaluate at 6, 8, and 12 wks

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18
Q

Define treatment resistant depression

A

Lack of improvement (< 20% reduction in depression scores) after adequate trials of ≥ 2 antidepressants) (CANMAT)

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19
Q

Approaches to dealing with treatment-resistant depression

A
  1. switch (again)
  2. augmentation tx
  3. combining antideps
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20
Q

When is switching antideps preferred?

A

When there’s little to no improvement in sx’s despite 4-8 wks of adequate tx/intolerable AEs

21
Q

When is augmenting preferred?

A

If there has been partial response to tx within 4-8 wks

22
Q

T or F: When switching, it’s best to switch to an antidep belonging to a diff class.

A

F

Comparable outcomes regardless of whether you switch within a class or b/w classes (though clinicians prefer to try diff classes)

23
Q

How to switch to SSRI from another SSRI?

A

Direct switch or cross taper

24
Q

How to switch b/w venlafaxine and duloxetine (both SNRIs)?

A

Direct switch or cross taper

25
Q

How to switch from SSRI to MAOI?

A

Stop SSRI 2 weeks before starting MAOI (5 weeks for fluoxetine)

26
Q

How to switch b/w drugs of different MOAs?

A

Cross taper

27
Q

List the pharmacological augmentation agents that could be used in treatment-resistant depression

A
  1. bupropion
  2. lithium
  3. triiodothyronine (T3)
  4. 2nd gen antipsychotics (aripiprazole, brexpiprazole, quetiapine, olanzapine/fluoxetine)
28
Q

Target lithium levels for treatment-resistant depression?

A

0.5-1.0 mEq/L

29
Q

Recommended trial of Li augmentation tx for treatment-resistant depression?

A

3-4 weeks

30
Q

T or F: Li is safe in overdose

A

F (it can cause death)

31
Q

Why might triiodothyronine be preferred in treatment-resistant depression?

A

It’s better tolerated

32
Q

T or F: Using T3 for treatment-resistant depression can result in significant side effects due to hyperthyroidism side effects.

A

F

The dose is so low in treatment-resistant depression tx, so it rarely results in hyperthyroidism-like side effects

33
Q

T or F: Doses of atypical antipsychotics used in treatment-resistant depression are HIGHER than those used in schizophrenia or bipolar disorder.

A

F

Lower doses are used in treatment-resistant depression

34
Q

What’s the advantage of combining antideps in treatment-resistant depression?

A

Not losing any benefit derived from the first antidepressant

35
Q

When are SSRI/SNRI + bupropion combinations usually used?

A

Reducing the sexual dysfn induced by SSRIs/SNRIs

36
Q

What combination of antideps is used in ppl who suffer from insomnia?

A

SSRI/SNRI + mirtazapine

37
Q

When is serotonin syndrome likely?

A

When using multiple serotonergic agents

38
Q

T or F: Serotonin syndrome is life threatening.

A

T

39
Q

Describe serotonin syndrome.

A

Triad of…

  1. mental status changes
  2. autonomic hyperactivity
  3. neuromuscular abnormalities
40
Q

Serotonin syndrome tx?

A
  1. supportive
  2. d/c serotonergic agents
  3. cyproheptadine (serotonin antagonist)
41
Q

Who is discontinuation syndrome more likely to occur in?

A

Those who’ve been on antidep tx for >6-8 weeks

42
Q

Which antidepressant will NOT cause d/c syndrome?

A

Bupropion

43
Q

Why doesn’t bupropion not cause d/c syndrome?

A

It has no serotonergic activity

44
Q

Sx’s of d/c syndrome?

A

FINISH

flu-like sx’s, insomnia, nausea, imbalance, sensory disturbances (pins and needles, electric shock sensations), hyperarousal (anxiety, agitation)

45
Q

When do sx’s of d/c syndrome usually resolve?

A

within 1-2 weeks

46
Q

How to avoid d/c syndrome?

A

TAPER dose down slowly

47
Q

What can we do if slowly tapering doesn’t help with avoiding d/c syndrome?

A

Substitute current med for fluoxetine (it has a long half-life, hence less d/c sx’s)

48
Q

When would you consider extending antidepressant tx for MDD pts (>2 yrs)?

A
  1. freq, recurrent episodes
  2. severe episodes (psychosis, severe impairment, suicidality)
  3. chronic episodes
  4. presence of comorbid psychiatric or other med conditions
  5. presence of residual sx’s
  6. difficult-to-tx episodes

PHAR 557 (36 decks)

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