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Therapeutics 05

Antidepressants Part 01

QuestionAnswer
3 major side effects of TCAs 1) Anticholinergic (peripheral/central), 2)Neurologic (sedation, seizures, anxiety), 3)Cardiovascular (orthostasis, tachy, QRS/QT changes, AV block)
Tx of anticholinergic side effects in TCAs Sugarless gum/candy, artificial saliva; Artificial tears; Central: decr dose/taper
Tx of cardiovascular side effets in TCAs Pt education about what to expect; use nortriptyline, avoid trazodone; baseline/serial ekg
Tx of neurologic side effects in TCAs Take hx; alternate agent if seizures; Anxiety - titrate slowly; Tremor - decr caffeine, beta blockers; Myclonus(leg jerking when falling asleep) - clonazepam
Other side effects of TCAs Wt gain; Incr BG; Photosensitivity; Sexual dysfunction; Cholinergic rebound (SLUD) if stopped abruptly.
SSRI side effect spectrum Early effects; Early onset, persistent effects; Later effects (weeks-months); Discontinuation symptoms; Sexual dysfunction
SSRI early side effects GI (nausea, diarrhea), Activation (anxiety), Dose-related
SSRI early onset, persistent side effects Sleep disturbances; GI (flatulence)
SSRI later effects (weeks-months) Often not attributed to teh drug (somnolece), weight gain.
SSRI discontinuation symptoms After 6 weeks of use; 24-48 hrs after D/C
SSRI discontinuation syndromes FINISH: Flu-like symptoms; Insomnia; Nausea; Imbalance; Sensory disturbances; Hyperarousal
Onset of discontinuation syndromes - for SSRIs Starts 1-2 days after d/c (1-3 weeks w/fluoxetine)
Discontinuation vs. relapse Temporal relationship is key: discontinuation=days vs. relapse=weeks.
The 2 SSRIs w/most d/c syndromes Paroxetine and venlafaxine.
Tx of d/c syndrome taper
Characteristics of sexual dysfunction -Individual variability. Affects both sexes, Dose related
Cause of sexual dysfunction Theory that NO needed for appropriate sexual function; SSRI’s are NO synthase inhibitors
Tx sexual dysfuntion Add or switch to bupropion, or switch to nefazodone.
Metabolic effects of SSRIs Hyponatremia (SIADH); May improve BG but doesn't cause hypoglycemia.
Movement Disorders assoc w/SSRIs Bruxism (teeth grinding - tx=buspirone); Tics/stuttering; Parkinsonism; Restless leg (tx=clonazepam)
Unusual effects of SSRIs Metabolic, movement disorders, sweating (tx=terazosin)
Inhibitors of TCAs Cimetidine, highly protein-bound meds
Inducers of TCAs Tobacco, phenytoin, phenobarbitol, carbamazepine, other inducers
TCA drug interactions - incr side effects Anticholinergics, sedatives (TCAs are already anticholinergic & sedating), sympathetic stimulating, cardiotoxicity
TCA drug interactions - therapeutic/toxic effects MAOIs, thyroid, methylphenidate, SSRIs
Effect of TCA + alpha-2 agonists (clonidine) decr antihypertensive effect (have competing effects - clonidine inhibits NE release while TCA inhibits reuptake of NE).
Serotonin syndrome Too much serotonin when combined w/another serotonergic agent. S/S = severe N/V, anxiety, tremulousness, palpitations.
Depression + chronic HAs = most appropriate what antiD? TCA (avoid SSRIs)
Depression + Smoking, Parkinson's = what antiD? Bupropion
Depression + Anxiety = what antiD SSRI, venlafaxine, nefazodone, TCA
what drug for Atypical Depression? SSRI, bupropion, MAOI
What antidepressant for a depressed CA pt (assuming they want to gain weight, antiemetic effect, and sedation) Mirtazepine
Why would - or wouldn't - you give TCAs to a CHF pt? Assuming the CHF pt was on a loop - an ADR is orthostasis. An ADR of TCAs is also orthostasis. = incr orthostasis
Pt w/arrythmias, ischemia + depression = what antidepressant? SSRIs, bupropion. Avoid TCAs in cardiov pts.
Depression + alzheimers = what antid NOT to give TCAs d/t anticholinergic effects
Depression + DM = what antiD? TCAs (for neuropathy) or SSRIs
Depression + insomnia = what antiD? trazadone, mirtazapine, TCAs
Created by: ryanw
 

 



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