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PHAR 191 exam 2

Grady's material

Categories of symptoms of MDD Emotional, physical, cognitive, psychotic (in severe), "atypical"
MOA of TCAs 5-HT and NE reuptake inhibition. Alpha-1, histamine-1, and muscarinic cholinergic blockade.
MOA of SNRIs 5-HT and NE reuptake inhibition.
MOA of SSRIs 5-HT reuptake inhibition
MOA of trazodone 5-HT reuptake inhibition. 5-HT2a, alpha-1, and histamine-1 blockade
MOA of bupropion DA and NE reuptake inhibition
MOA of mirtazapine Alpha-2, 5-HT2a, 5-HT2C, 5-HT3, and histamine-1 blockade
MOA of MAOIs Inhibit monoamine oxidase
Antidepressant most likely associated with sedation Trazodone, mirtazapine
Antidepressants most likely associated with sexual dysfunction TCAs, SSRIs
Antidepressants most likely associated with weight gain TCAs
Antidepressant most likely associated with hepatotoxicity Duloxetine
Antidepressant most likely associated with increased blood pressure Venlafaxine, desvenlafaxine
Antidepressant most likely associated with seizures Bupropion (CI)
First-line antidepressant options for depression SSRIs, bupropion SR/XL, mirtazapine, SNRIs
Antidepressant augmentation options Lithium, triiodthyronine, aripiprazole
Time course to therapeutic effect for antidepressants 2-4 weeks before improvement in emotional symptoms, as long as 6-8 weeks for full effects
Potential duration of therapy of antidepressants additional 4-9 months in continuation phase to prevent relapse
Symptoms of antidepressant withdrawal Sleep disturbances, anxiety, fatigue, mood changes, malaise, GI disturbances, return of depressive symptoms
Lifetime prevalence of depression 16.2%
Gender most likely to develop depression Females (2:1)
Average age of onset of depression Mid-twenties
What psychiatric comorbidities occur most frequently with depression Anxiety disorders and substance-use disorders
What causes depression? Exact cause unkown. Associated with genetics, chornic stresses, and deficiency in monoamines (NE, 5HT, DA)
Emotional symptoms of depression Sadness, anhedonia, pessimism, feeling of emptiness, irritability, anxiety, worthlessness, thoughts of death/suicidal ideation (SI)
Physical symptoms of depression Disturbed sleep, change in appetite/weight, psychomotor changes, decreased energy, fatigue, bodily aches and pain
Cognitive symptoms of depression Impaired concentration, indecisiveness, poor memory
Psychotic symptoms of depression Hallucinations, delusions
"Atypical features" symptoms of depression Reactive mood, significant increase in appetite/weight gain, hypersomnia, heavy feelings in arms or legs, sensitivity to interpersonal rejection
Define reactive mood Mood improves in response to positive events
What medical conditions might cause/contribute/exacerbate depressive symptoms Bipolar, hypothyroidism, neoplasms, anemia, infections, electrolyte disturbances, neurological disoders
What medications might cause/contribute/exacerbate depressive symptoms CNS depressants, corticosteroids, contraceptives, gonadotropin-releasing hormone agonists, interferon-alpha, interluekin-2, mefloquine, isotretinoin, propranolol, sotalol
What are the goals of treatment in depression? Resolution of depressive symptoms, return to euthmia, prevent relapse/recurrence of symptoms, prevent suicidal attempts, improve QOL, normalize functioning areas such as work/relationships, avoid/minimize ADR, reduce health care costs
Nonpharmacologic therapies available for individuals having depression Interpersonal therapy, cognitive behavioral therapy, ECT, light therapy, VNS
What antidepressants have less likelihood of causing sexual side effects? Bupropion, mirtazapine, nefazodone
Which antidepressant may cause priapism? Trazodone
Which antidepressants have a short half-life? nefazodone, venlafaxine
Which antidepressant has a long half-life? Fluoxetine
Symptoms of serotonin syndrome Confusion, restlessness, fever, abnormal muscle movements, hyper-reflexia, sweating, diarrhea, shivering
Factors to take into account when selecting an antidepressant Pt hx of response, hx of 1st degree relative response, ADR profile, drug-drug/disease interactions, psychiatric comorbidities, potential for ODing, affordability
Antidepressants with greatest reproductive safety data Fluoxetine, citalopram, TCAs
Antidepressants chosen frequently to treat geriatric depression SSRIs
Antidepressants considered intially in pediatric population SSRIs
Antidepressants with narrow therapeutic indices TCAs and MAOIs
Which drugs are SNRIs? Duloxetine, venlafaxine, desvenlafaxine
Which drug is an NDRI? Bupropion
Symptoms of GAD Excessive anxiety or worrying (>6months), restlessness, easily fatigued, poor concentration, irritability, muscle tension, insomnia, unsatisfying sleep
Role of antidepressants in treating anxiety disorders Considered first-line agents in management of chronic GAD.
Antidepressants recommended first line in the management of GAD SNRI or SSRI
MOA of benzodiazepines Enhance transmission of GABA (inhibitor NT)
MOA of buspirone 5-HT1a partial agonist-reduce presynaptic 5-HT firing
Therapeutic uses of benzodiazepines Acute treatment of GAD when short-term relief is needed, as an adjunct during initiation of antidepressant therapy, or to improve sleep
Therapeutic uses of buspirone
Abuse potential of benzodiazepines Abuse potential!
Abuse potential of buspirone No abuse potential
Onset of action of benzodiazepines Fast-acting
Onset of action of buspirone Graudal (ie 2 weeks)
Adverse effects of benzodiazepines CNS depressive effects, cognitive effects, confusion, irritability, aggression, excitement, withdrawal symptoms, rebound symptoms
Lifetime prevalence of GAD 5.7%
Gender more likely to develop anxiety Females (2:1)
Average age of onset for GAD 24-31 years
Psychiatric comorbidities that occur most frequently with anxiety disorders Depression, alcohol or substance use disorders, other co-occuring anxiety disorders
What causes anxiety? Anxiety is normal response to stressful or fearful circumstances, allowing to adapt/manage the situation.
Goals of treatment for GAD Acutely reduce severity and duration of anxiety symptoms and restore overall functioning. Long-term, achieve and maintain remission
What medical conditions can cause/contribute/exacerbate anxiety symptoms? Psychiatric, neurologic, cardiovascular, endocrine and metabolic, respiratory, carcinoid syndrome, anemias, lupus
What medications can cause/contribute/exacerbate anxiety symptoms? Anticonvulsants, antidepressants, anti-HTN, antimicrobials, antiparkinson, bronchodilator, corticosteorids, decongestants, herbals, NSAIDs, stimulants, thyroid, toxicity, abrupt withdrawal of CNS depressants
Nonpharmacologic therapies available for pt with GAD Psychoeducation, regular exercise, stress management, psychoterapy
What is recommended if 1st line for GAD fails? Switch to another SNRI or SSRI
Which symptoms of anxiety do antidepressants reduce? Psychic symptoms (worry and apprehension) with modest effect on autonomic or somatic symptoms (tremor, rapid heart rate, and/or sweating)
Onset of antianxiety effect with antidepressants 2-4 weeks
Which antidepressants are used in the management of GAD? SSRI (citalopram, escitalopram, fluoxetine, fluvoxamine, paroxetine, sertraline) SNRI (venlafaxine XR, duloxetine) TCA (imipramine)
Which symptoms of anxiety do benzos reduce? Somatic symptoms (tremor, rapid heart rate, and/or sweating)
Disadvantages of benzos lack of effectiveness in treating depression, risk for dependency and abuse, potential interdose rebound anxiety, avoid in pt with chemical dependency
Which benzos are preferred in patients having hepatic dysfunction or in the elderly? lorazepam and oxazepam
Sleep hygiene principles Regular sleep schedule, exercise frequently but not immediately before bed, avoid alcohol/stimulants in late afternoon/pm, comfortable sleeping environment (dark, quiet, free of intrusions), avoid large quantities food/liquids immediately before bed
Duration of action of eszopiclone 8 hours
Adverse effects of first line agents for insomnia residual sedation, grogginess, psychomotor impairment, anterograde amnesia, rebound insomnia with D/C
Antidepressants prescribed for insomnia Trazodone, amitriptyline, mirtazapine, nefazodone, doxepin
Gender more likely to develop insomnia Females (1.5:1)
Prevalence of chronic insomnia 10%
Medical conditions that may cause/contribute/exacerbate insomnia Pain, thyroid abnormalities, asthma, reflux
Medications that may cause/contribute/exacerbate insomnia SSRIs, steroids, stimulants, beta-agonists
Characterize insomnia Difficulty falling asleep, frequent nocturnal awakenings, early-morning awakenings, which may result in daytime impairments in concentration or performance
Transient insomnia A few days
Short-term insomnia Less than 3 weeks
Chronic insomnia >1 month
Treatment goals for insomnia restoration of normal sleep patterns, elimination of daytime sequelae, improved QOL, prevent complications/ADR from therapy
Agents recommended 1st line for insomnia? Benzodiazpine receptor agonists, zolpidem, zaleplon, eszopiclone
Duration of action of temazepam 7 hours
Duration of action of zaleplon 6 hours
Duration of action of zolpidem 7-8 hours
Advantage of eszopiclone Can be used for up to 6 months for chronic insomnia
Advantages of temazepam Well-tolerated, inexpensive
Advantages of zaleplon Short-acting, only for difficulty falling asleep
Advantage of zolpidem No effects on sleep architecture
How does Ramelteon work? Melatonin receptor agonist- good for insomnia characterized by difficulty with sleep onset
Reasons why antidepressants are unappealing option for insomnia at doses for sleep, only mirtazapine exhibits significant antidepressant activity. lack clinical study proving efficacy. frequent and unpleasant SE.
Symptoms of mania 1-week period or greater: Abnormal and persistent elevated mood, with 3 of following: grandiosity, FOI, distractible, increase activity/motor activity/agitation, excessive involvement in activities pleasurable but high-risk for serious consequence
Medications and substances that may cause/contribute/exacerbate symptoms of mania Corticosteroids, diltiazem, levodopa, oral contraceptives, zidovudine, anabolic steroids, hallucinogens, stimulants
Potential adverse effects of lithium GI upset, tremor, polyuria, polydipsia, hypothyroidism, poor concentration, rash, alopecia, worsening of psoriasis, weight gain, metallic taste, benign reversible leukocytosis; cause/worsen arrhythmias
Drug interactions of lithium Thiaizde diuretics, NSAIDs, ACEIs
Potential adverse effects of valproic acid GI upset, tremor, DW, weight gain, alopecia, change hair color/texture, hair loss, polycystic ovarian syndrome, thrombocytopenia; hepatotoxicity, pancreatitis
Drug interactions of valproic acid Anticonvulsants, TCAs, lamotrigine
Potential adverse effects of carbamazepine DW, DZ, ataxia, lethargy, confusion, GI upset, antidiuretic, hyponatremia, mild elevation in liver enyzmes; diplopia, dysarthria, leuokopenia; hepatitis, aplastic anemia, agranulocytosis
Drug interactions of carbamazepine Induce metabolism of anticonvulsants, antipsychotics, antidepressants, OCs, antiretrovirals. Clozapine. Antidepressants, macrolides, azoles, grapefruit-inhibit metabolism of carbamazepine
Baseline monitoring parameters for lithium pregnancy, ECG if >40 or cardiac disease, CBC, glucose, lipids, weight, renal function, thyroid function, electrolytes, dermatologic
Baseline monitoring parameters for valproic acid Pregnancy, drug abuse, CBC, glucose, lipids, weight, LFTs, dermatologic
Baseline monitoring parameters for carbamazepine Pregnancy, drug abuse, CBC, LFT, renal function, electrolytes, dermatologic
Routine monitoring parameters for lithium Every 6-12 months: lithium level, weight, CBC, renal function, thyroid function, electrolytes, dermatologic
Routine monitoring parameters for valproic acid CBC, glucose, lipids, weight, LFTs, dermatologic
Routine monitoring parameters for carbamazepine CBC, LFT, electrolytes, dermatologic
Estimated prevalence of schizophrenia 1%
Symptoms of schizophrenia Delusions, hallucinations, disorganized speech, grossly disorganized, catatonic behavior, negative symptoms (flat affect, alogia, avolition)
Differences between typical and atypical antipsychotics SGAs have lower risk of motor side effects, may offer greater benefits for affective, negative, and cognitive symptoms, and may prolong the time to psychotic relapse
Potential EPS Akathisia (motor and/or subjective restlessness) Dystonia (muscle spasm) Pseudoparkinsonism (akinesia, tremor, rigidity) TD (movement disorder) NMS (severe muscle rigidity, autonomic instability, altered consciousness)
Medications used to treat EPS Anticholinergic medications (benztropine, trihexyphenidyl, diphenhydramine)
Medications sometimes effective for akathisia Beta-blockers
Antipsychotics with greatest association for EPS Haloperidol, risperidone, fluphenazine
Antipsychotics with greatest association for prolactin elevation risperidone
Antipsychotics with greatest association for seizures Clozapine, thioridazine
Antipsychotics with greatest association for QTc prolongation Ziprasidone, thioridazine
Antipsychotics with greatest association for hyperglycemia Clozapine, olanzapine
Antipsychotics with greatest association for hyperlipidemia Clozapine, olanzapine
Antipsychotics with greatest association for weight gain Clozapine, olanzapine
How often should weight be checked in patients taking SGAs? Baseline, week 4, week 8, week 12, and quarterly
How often should blood pressure and glucose be checked in patients taking SGAs? Baseline, week 12, and annually
How often should lipids be checked in patients taking SGAs? Baseline, week 12, and every 5 weeks
Created by: steponmegrace



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