pharmacotherapy exam 3 pct of depression

  1. what are dx criteria for major depressive disorder
    • SIG E CAPS
    • sleep, interest, guilt, energy, concentration, appetite, psychomotor, suicidal ideaation
  2. what does 5HT2 stimulate?
    • 5HT2-- sexual side effects, akathisia, agitation, insomnia
    • 5HT3-- GI Adverse effects--nausea, diarrhea
  3. what are sexual side effects of antidpressants and how treat?
    • delayed orgasm, decreased libido, erectile dysfunction
    • change drugs, skip or reduce dose, sildenafil, tadafil, vardenafil
  4. what are drugs/doses of MAOis, Primary concern?
    • phenelzine 15-90 mg
    • tranylcypromine 20-60 mg
    • isocarboxazid (nonselective) 20-60 mg
    • HYPERTENSIVE CRISIS--can occur when combine with high tyramine foods or sympathomimetic drugs
  5. what is receptor blockade adn SE of MAOis
    • ACH effects-- dry mouth, constipation, urinary retention, blurred vision
    • Antihistamine effects- sedation, weight gain
    • Alpha 1 adrenergic blockade orthostatic hypotension
    • ADVERSE EFFECTS--sexual dysfunction, mild anticholinergic effects, ortho static hypo, sedaction insomnia
  6. What are differences between TCA?
    • secondary amines--desipramine, nortriptyline --greater NE relative to 5HT activity
    • Tertiary amines--amitriptyline, clomipramine, imipramine, doxepine, trimipramine--greater anticholinergic effects
  7. what are the conditions TCAs treat
    depression, migraine prophylasxis, neuropathic pain, OCD, enuresis, panic disorder, sleep disorders, ADHD
  8. what drugs have least se /worst se
    nest--nortriptyline lease sedation, anticholinergic, orthostatic worse amitrypitline, clomipramine, imipramine
  9. where do tcas work in body
    • serotonin reuptake inhibition
    • ne reuptake inhibition
    • anticholinergic effects
    • alpha 1 blockade
    • histamine blockade
  10. what is general dosing strategy for TCAs
    • start with 50 mg and increase by 25-50 mg q 3 days (not nortiriptilyine)
    • most 100-300 mg except nortriptyline 50-150
  11. what are adverse effects of TCAs
    • anticholinergic effects,
    • antihistamine effects
    • alpha 1 adrenergic blockade
    • sexual side effects
    • cardiac conduction delays--arrhythmias in od
    • decreased seizure threshold
    • toxic in OD--do not use in acutely suicidal pateitns
  12. what are SSRIs
    • fluoxetine 20-60
    • paroxetine 20-50
    • sertraline 50-100
    • fluvoxamine 100-300
    • citalopram 20-60
    • excitalopram 10-20
    • relatively safe in OD, relatively safe in pt with CV dz
  13. what are uses for SSRIs
    • depression
    • social phobia'
    • panic disorder
    • ocd
    • bulimia nervosa
    • PTSD
    • PMDD
  14. what are SSRIs adverse effects
    • GI--NVD
    • sexual side effects
    • headache
    • insomnia
    • fatigue
    • agitation
    • akathesia and dystonic reactions--5ht can reduce DA levels
  15. what are specific things for SSRIs
    • most likely to cause sedation--paroxetine, fluvoxamine
    • paroxetine--mild anticholinergic effects
    • fluoxetine--higher rates of ax and nervousness
    • sertraline-more diarrhea
  16. what are SSRI withdrawal effects
    • onst in 24-72 hours and last up to 7-14 days
    • shock-like sensations---parathesias, shockline thinling in figners/toes
    • GI compliants
    • dizziness,
    • flu like symptoms
    • sleep disturbances
  17. what is serotonin syndrom
    • several serotnergic drugs combiend
    • often involves MAOIs as on the drugs
    • other serotonergic drugs implicatied
    • SSRIS TCAs serotonin releasing agents, destromethorphan, meperidine
    • SYMPTOMS-- altered metnal status--confusion, agitation ; autonomic dysfunction--diaphoresis, tachycardia, BP changes, fever
    • neruomuscular abnormalities--clonus
    • Allow 2 weeks between MAOI and other antidpressent admin--5 weeks for fluoxetine
  18. how does trazodone work
    • MOA--potent 5ht2 receptr antagonist, relatively weak 5ht reuptake inhibition
    • most commonly used as a sedative
    • antidepressant dose 200-400mg/day
    • one of major metabolites in mcpp--non specific serotonin agonsit, anxiogenic, metabolized by CYP2d6
  19. what are adverse effects of trazodone
    sedation, cognitive slowing, dizziness, priapism
  20. how does nefazodone work
    • potent 5ht2 receptor antagonist
    • relatively weak 5ht reuptake inhibition
    • alpha 1 receptor blockade
    • 300-600 mg/day in 2 divided doses
    • preserves sleep architecture
    • limited use due to hepatic toxicity warning
  21. how does venlafaxine work and adverse effects
    • serotonin reuptake inhibition, NE reuptake inhibition, dopamine reuptake inhibition
    • usual dose 75-225
    • adverse effects --nausea, constipation, headache, dizziness, nervousness, somnolence, ry mouth, sexual dysfunction , increased BP--
  22. what is special about bupropion
    • NE and dopamine reuptake inhibtion
    • no sexual dysfunction
    • no weight gain
    • not effective for panic disorder, social phobia,
    • effective for smokin cessation and sometimes used for ADD
  23. what are adverse effects of bupropion
    • insomnia
    • anxxiety
    • dry mouth
    • tremor
    • nausea
    • skin reactions
    • increased blood pressure
    • dose related seizure risk--more common with IR formulation
  24. how does mirtazapine work
    • antagonism of presynaptic alpha 2 receptors
    • block 5ht2 and 5ht3 receptors
    • blockade histamine receptors
    • adverse effects--increased appetite, weight gain, sedation, dry mouth, constipation--dose 15-45 mg
  25. how does duloxetine work/adverse effects
    • indicated for MDD, GAD
    • NE and Serotonin reuptake inhibitor
    • metabolised by CYP 1A2 and CYP 2D6
    • Common sE-- nausea, drymouth, fatigue, insomnia, dizziness, constipation, somnolence, increased sweating, decreaed appetite, increased BP--rare--increased LFTs/hepatic failure.
    • 40-60 mg
  26. what cyp does fluvoxamine inhibit
    1a2, 2c, 2d6, 3a4
  27. what cyp does fluoxetine inhibit
    2c, 2d6, 3a4
  28. what cyp does sertraline inhibit
    2c, 2d6, 3a4
  29. what cyp does paroxetine inhibit
  30. what cyp does nefazodone inhibit
  31. what cyp does bupropion inhibit
  32. what cyp does duloxetine inhibit
  33. what drugs inhibtin cyp 1a2
  34. what drugs inhibti cyp2c
    • fluovoxamine
    • fluoxetine
    • sertrailine
  35. what drugs inhibit cyp2d6
    • fluoxetine
    • sertraline, paroxetine duloxetine
    • bupropion
    • (NOT ALOT citalopram, escitalopram, venlafaxine)
  36. what drugs inhibti 3a4
    • fluvoxamine
    • fluoxetine
    • sertraline
    • nefazodone
  37. what are symptoms of atypcial depression
    • weight gain or increased appetite
    • hypersomnia
    • heavy feeling in arms or legs
    • interpersonal rejection sensitivity
    • MAOIs greater efficacy than TCAs
    • efficacy of SSRIs relative to MAOIs unclear
  38. what is melancholic dperession
    • subtype of severe depression
    • nearly completely absence of capacity for pleausre
    • diurnal mood swings--worse in the am
    • excessive guilt and eight loss
    • unclear if ssris as effectve as TCAs in treatment
    • some datea indiate mirtazapine and venlafaxine mroe effective than SSRIs
  39. what is a relapse
    symptoms return within 4-9 months of recover
  40. what s recurrence
    symptoms return after 6 to 12 months of recover, increase risk of recurrence after multiple episodes
  41. what are the different phases of treatment
    • acute phase--goal is remission (absense of symptoms) approximately 6-12 weeks
    • CONTINUATION PHASE--goal is to prevent relapse and elminate residual symptoms, approximately 4-9 months
    • MAINTENANCE PHASE--prevent recurrence, length of treatment varies depending on history of previous episodes
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pharmacotherapy exam 3 pct of depression
pharmacotherapy of depression