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TCAs - actions / uses
inhibit the reuptake of NE and 5HT. rarely 1st line because of SE and lethality of OD
Used in: OCD, Panic, PTSD, IBS, Neuropathic pain, Migraines, insomnia
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TCA examples
Imipramine (Tofranil), Amitriptykine (Elavil), Trimipramine (Sumontil), Doxepin (sinequan)
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TCA SEs
- (anti HAM)
- 1. antiHistamine -> sedation
- 2. antiAdrenergic -> CV, orthostatic hypoTN (most life threatening), tachycardia, arrhythmias
- 3. antiMuscarinic -> dry mouth , constipation, urinary retention, blurred vision, tachy
- 4. Weight gain
- 5. Lethal OD
- Major complications - 3C's: convulsions, coma, cardiotoxicity
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TCA toxicity
WIDENED QRS (>100 msec)
tx OD = IV sodium bicarb
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Nortriptyline (Pamelor)
TCA, least likely to cause orthostatic HypoTN
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Desipramine (Norpramin)
TCA - least sedating, least anticholinergic SEs
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Clomipramine (Anafranil)
TCA - most serotonin specific -> used in tx of OCD
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MAOI's - actions
- prevent inactivation of amines like NE, 5HT, DA, tyramine (tyrosine -> NE)
- MAOI -A deactivates 5HT
- MAOI-B deactivates NE/Epi
- Both deactivate DA/tyramine
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MAOI's - uses
- Panic d/o
- Eating d/o
- Social Phobia
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MAOI's - examples
Phenelzine (Nardil), tranylcypromine (Parnate) isocarboxazid (marplan)
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MAOI's - SEs
- 1. common = orthostatic hypotn, drowsiness, weight gain, sexual dysfunctions, dry mouth, sleep dysfunctions
- 2. Serotonin syndrome
- 3. HYPERTENSIVE CRISIS = MAOI's + sympathomimetics OR tyramine rich foods (wine/cheese/meat) cause an increase in stored catecholamines,
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serotonin syndrome
SSRI + MAOI -> lethargy, restlessness, confusion, flushing, diaphoresis, tremor, myoclonic jerks...
can progress to hyperthermia, hypertonicity, rhabdo, renal failure, convulsions, coma, death
***why you should wait 2 wks before switching from SSRI to MAOI
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SSRI's - action and uses
inhibit presynaptic serotonin pumps
- most commonly used because of decreased SE's , no food restrictions, safer in OD
- OCD, Panic, Eating d/o. Dysthymia, social phobia, PTSD, IBS, Migraines, Autism, PMDD, Depression in manic depression
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Fluoxetine (Prozac)
SSRI's - longest half-life with active half-life, don't need to taper
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Sertraline (Zoloft)
highest risk for GI disturbances
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Paroxetine (Paxil)
SSRI's - serotonin specific, most activating (stimulant)
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Fluvoxamine (Luvox)
SSRI - only OCD
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Citalopram (Celexa)
SSRI, also Escitalopram (Lexapro)
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SSRI's -SE
Fewer because 5HT specific:
Sexual dysfunction (25-30%), GI, Insomnia, HA, Anorexia, weight loss, serotonin syndrome (w/ MAOI's)
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Venlafaxine (Effexor)
SNRI's - treat refractory depression and CAP
SE's like SSRI's plus increase BP
w/drawl sxs - seen with 1-3 missed doses = flu-like sxs and electric shocks/zaps
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Bupropion (Wellbutrin)
NDRI's - tx seasonal affective d/o, ADHD
SE's + like SSRI's plus increased sweating and increase risk seizures and psychosis. (+) no sexual SE's
not in pts with seizures, actie eating d/o, on MAOI's
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Nefazodone (Serzone) and Trazodone (Desyrel)
SARI's - tx refractory depression, major depression with anxiety, and insomnia
SE's = nausea, dizziness, orthostatic hypotn, cardiac arrythmias, sedation, priapism
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Mirtazapine (Remeron)
NASA - (NE and 5HT antagonist) - tx refractory major depression (esp if pt needs weight gain)
SE - sedation, weight gain, dizziness, somnolence, tremor, agranulocytosis
Dosage - max sedation at < 15 mg (> 15 = NE effects)
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