· additive effects with other CNS depressants (barbituates, alcohol, antihistamines, neuroleptics)
Benzodiazepines (Xanax, Klonopin, Serax) can cause increased drug levels of
TCAs or digitalis
Labs needed to monitor for Xanax
Liver function, CBC
What drug will increase Haldol levels due to competitive metabolism?
What might happen if you give Buspar (buspirone) with Trazadone?
In what drug class is Prozac (fluoxetine)?
What is Prozac (fluoxetine) indicated for?
Premenstrual dysphoric disorderOCDPanic disorder
T/F: You should see results of antidepressants in less than 3 weeks.
False. Response in <3 weeks is a placebo effect.
How long does it take Prozac (fluoxetine) to reach steady state?
What do antidepressants have a black box warning for?
antidepressants may increase the risk of suicide in people younger than 25
most likely to occur in first 2 months of tx
MOA for Prozac?
NE (0), 5-HT (+++++), ACh (+), H (+), a1 (+)
Metabolism of Prozac (fluoxetine)?
Liver via cytochrome P450
caution in elderly, liver dysfunction
Half-life of Prozac (fluoxetine)?
2-7d (longest for SSRIs)
slow elimination distinguishes it from other antidepressants
ONLY SSRI THAT DOES NOT REQUIRE SLOW TAPER OF DOSE
T/F: You have to taper Prozac gradually when stopping treatment, as it can result in abrupt withdrawal syndrome if stopped suddenly .
False. Side effects of the fluoxetine discontinuation are uncommon and mild. One of the recommended strategies for the management of discontinuation syndrome with other SSRIs is to substitute fluoxetine for the original agent, in cases where tapering off the dose of the original SSRI is ineffective
What pregnancy category is Prozac?
C (epocrates), B (ppt slide)
(not recommended during lactation)
T/F: It is best to give Prozac before bed due to the sedation side effect.
Fasle. It will cause insomnia, so it is best to take it in the morning.
Major contraindication for fluoxetine (Prozac)?
MAOI - either concurrent or within 14 days
What is a fatal side effect of Prozac?
Serotonin syndrome if given with triptans, tramadol or other serotonergic agents (antidepressants, dopamine agonists, analgesics)
What are some S&S of serotonin syndrome and when do you see them?
How long will abrupt withdrawal syndrome last without intervention?
a couple of weeks
T/F: Routine vital signs and lab reports are needed in SSRI treatment for healthy individuals.
False. Need to watch electrolytes in the elderly.
T/F: Since antidepressants require an adequate trial of up to maximum dosing of 8 weeks, the first prescription should be written for 8 weeks.
False. Never give >4 weeks for the first perscription. You want to see them in 4 weeks to assess the response of the medication.
T/F: SSRI's (like Prozac or Lexapro) increase the risk of thromboemboli.
False. They increase the risk of bleeding.
2x the volume of blood loss during surgery
4x higher risk for blood transfusions
T/F: Escitalopram (Lexapro) causes sedation.
What antidepressant do you avoid if sexual dysfunction is a concern?
70% of pts on Prozac develop sexual dysfunction
What drug class is phenelzine (Nardil) in?
(MAO is an enzyme that metabolize dopamine, NE, 5HT)
Who should prescribe MAOIs (Nardil/phenelzine)?
low safety margin/potential lethal effects
What dietary problems result from MAOIs?
tyramine, phenylethylamine... ↑ HTN
Avoid tyramine-rich foods (yeast, yogurt, cheese, fish or meat, caviar, figs, bananas, raisins, avocados, wine, soy sauce)
Avoid foods with vasopressors too (fava beans, caffeine, chocolate, alcohol)
What is the big risky side effect of MAOIs (like Nardil)?
HTN/sympathomimetic crisis with concurrent anticholinergic, sympathomimetics, & stimulants
DO NOT GIVE WITH PROZAC
MAOIs are first-line treatment for depression but have a long half-life.
No. SSRIs or SNRIs are first-line treatment.
relatively SHORTER half-life
Treatment for MAOI HTN crisis?
Monitor what lab test for MAOIs?
LFTs, d/c if abnormal
Take their BP too!
Common ADRs of MAOIs
insomnia, anxiety, agitation (due to dopamine)
Anticholinergic SE (can't see, can't spit, can't pee, can't shit)
dizziness, HA, insomnia, restlessness, orthostatic hypotension
Your patient on Nardil (phenelzine) was just diagnosed with CAD on his 60th birthday. Also, he says, "Now that I'm 60, I'm gonna do whatever I want!". What's next?
MAOIs are contraindicated in arteriosclerotic disease or CHF, age ≥60, and in the impulsive, cognitively impaired, and those unable to follow the diet. Need to d/c, but need to taper down. Consult with psychiatrist.
PS- it's also CI for liver or kidney disease
What is the MOA of Klonopin (clonazepam)?
binds to benzodiazepine receptors; enhances GABA effects
What is clonazepam (Klonopin) indicated for and what class is it in?
a benzodiazepine drug (gaba-ergic)
Clonazepam (Klonopin) has anxiolytic, anticonvulsant, muscle relaxant, sedative, and hypnotic properties
Does clonazepam (Klonopin) cause dependency?
Yes. Tolerance, dependence, & withdrawal syndrome occur in 1/3 of people on clonazepam for > 4 weeks
PS-APN, what is clonazepam (Klonopin) used to treat?
Periodic leg movement
Major adverse reactions for clonazepam (Klonopin)?
Drowsiness and other CNS effects
"hangover effect" - long half life
sexual side effects
Contraindications of clonazepam (Klonopin)?
contraindicated if liver disease
do not drink alcohol
In what drug class is oxazepam (Serax)?
What is an advantage of clonazepam (Klonopin)?
long half life means daily dosing
What is an advantage of Serax (oxazepam)?
good for detox, easy on liver
First-line therapy for anxiety?
Regarding SSRIs, which s/s resolve first (anxiety versus depression)?
Anxiety resolves earlier, but higher doses are needed for anxiety than for depression.
When is the full therapeutic effect of SSRIs realized?