Antidepressants

Question 1

How do antidepressants work?

Answer 1

• Increase the amount of neurotransmitter in the synaptic cleft
  
  • Inhibition of reuptake
  • Enzymatic degredation

Question 2

Which antidepressant increases synaptic serotonin and norepinephrine?

Answer 2

Tricyclics

Question 3

Which antidepressant increases synaptic norepinephrine?

Answer 3

Tetracyclics

Question 4

Which antidepressant blocks the degredation of norepinephrine, dopamine and serotonin?

Answer 4

MAOIs

Question 5

Which antidepressant increases synaptic serotonin?

Answer 5

SSRIs

Question 6

What is an example of a dopamine-reuptake inhibitor?

Answer 6

bupropion (Wellbutrin, Zyban)

Question 7

What are the characteristics of bupropion (Wellbutrin, Zyban)?

Answer 7

• Increased risk for seizures
• Risk for emergent hypertension with concurrent nicotine patch use
• Take BP on patients using this drug

Question 8

What does monoamine oxidase do?

Answer 8

It’s responsible for metabolism of norepinephrine, serotonin, and dopamine - MAOI’s inhibit them

Question 9

What types of depression are MAOI’s used for?

Answer 9

• Atypical, non-endogenous, neurotic depression
• Depression associated with Parkinson’s
• PTSD

Question 10

What do you do as a dentist when your patient is on MAOIs?

Answer 10

• Take blood pressure before anesthesia
• Caution with epinephrine

Question 11

What are the MAOIs?

Answer 11

• isocarboxazid (Marplan)
• phenelzine (Nardil)
• selegiline (Atapryl, Eldepryl, Selpak)
• tranylcypromine (Parnate)

Question 12

What are the adverse events with MAOIs?

Answer 12

• Causes release of endogenous catecholamines
• Results in hyperadrenergic crisis
  
  • Severe hypertension, fever, arrhythmias
• Avoid tyramine containing foods

Question 13

What are the popular SSRIs?

Answer 13

• fluoxetine (Prozac, Sarafem)
• proxetine (Paxil)
• sertraline (Zoloft)

Question 14

Which SSRI’s are the biggest market sellers?

Answer 14

Paxil and Zoloft

Question 15

What is the only SSRI approved for use in children with OCD?

Answer 15

Zoloft

Question 16

What has been mandated to be put on the boxes of SSRIs?

Answer 16

• Antidepressants increase risk of suicidal thinking and behavior in children with depression and pyschiatric disorders

Question 17

What antidepressant is not FDA approved for use in children?

Answer 17

Escitalopram

Question 18

What are the known side effects of SSRIs?

Answer 18

• Agitation
• Anxiety
• Hostility
• Aggression

Question 19

When taking SSRI’s for depression, when it the highest risk for suicidal attempt?

Answer 19

Within 6 weeks of initiating drug therapy

Question 20

What are popular Serotonin/Norepinephrine Reuptake Inhibitors (SNRIs)?

Answer 20

• desvenlafaxine (Pristiq)
• duloxetine (Cymbalta)
• milnacipran (Savella)
• venlafaxine (Effexor XR)

Question 21

Which SNRI is used solely to treat fibromyalgia?

Answer 21

milnacipran (Savella)

Question 22

What are some oral complications or side effects of venlafaxine (Effexor XR)?

Answer 22

• Xerostomia
• Stomatitis
• Loss of taste
• Taste alteration
• Tongue discoloration

Question 23

What’s an example of a tetracyclic and what’s it used for?

Answer 23

maprotiline (Ludiomil)

Depression, anxiety with depression, dsythymic disorder

Question 24

What’s unique about Tricyclics?

Answer 24

Adjunctive therapy for chronic pain – exhibits analgesic properties

Question 25

How are tricyclic antidepressants adverse effects determined?

Answer 25

By their blockade on cholinergic, adrenergic and histamine transmission.

Question 26

What are some of the side effects of TCA's?

Answer 26

* Anticholinergic effects - blurred vision, xerostomia, constipation * Sympatholytic effects - postural hypotension, dizziness * Histamine antagonism - sedation

Question 27

What are the tricylics that are blockers of both norepinephrine and serotonin?

Answer 27

* **amitryptyline (Elavil)** * imipramine (Tofranil)

Question 28

What are the tricyclics that are selective norepinephrine reuptake blockers?

Answer 28

* desipramine (Norpramin) * nortriptyline (Pamelor)

Question 29

What is St. John's Wort?

Answer 29

A weed-like plant that has been used as an antidepressant, and **you cannot take with prescription antidepressants**

Question 30

What are the major active constituents in St Johns wort?

Answer 30

* hyperforin and hypericin * flavonoids and tannis

Question 31

Is St. Johns wort effective in treating depression?

Answer 31

Meta-analysis then a **Cochrane Review** shows it to be more efficacious than placebo.

Question 32

Within St. John's wort there is hypericin - what effect does this have and what cautions do you take?

Answer 32

* Induces some cytochrome P450 liver enzymes * Reduces anticoagulant effect on warfarin (increases clotting) and lowers the INR

Question 33

What's bad about St. John's wort?

Answer 33

Many drug interactions

Question 34

Do you discontinue herbs before surgery?

Answer 34

Yes - discontinue all drugs 14 days before surgery

Question 35

What are the common adverse effects of antidepressants?

Answer 35

* Orthostatic hypotension - **watch for falling in older adults** * Sedation * Dizziness * Light-headedness

Question 36

What is the drug of choice for bipolar disorder?

Answer 36

Lithium (Eskalith, Lithobid)

Question 37

How does Lithium work?

Answer 37

* Prevents release of neurotransmitters * Increases uptake of serotonin precursor tryptophan * Decreases rate of serotonin synthesis * Inhibits serotonergic and adrenergic receptor-mediated activation of cAMP and second messenger cascades

Question 38

What are some general characteristics of Lithium?

Answer 38

* Peaks in blood within 2 hours * Improvement in condition occurs over several weeks of treatment * Very low therapeutic index - monitored weekly

Question 39

What are the side effects of Lithium?

Answer 39

* Nausea, vomiting, diarrhea * Weakness, hand tremors * Polyuria, renal damage * Hypothyroidism * Sexual dysfunction

Question 40

What are the drug interactions with Lithium and what do they do?

Answer 40

* These increase the levels of Lithium in blood creating toxicity * Diurectics * NSAIDS (COX-2 especially) * Anticonvulsants * Antihypertensives

Question 41

What is contraindicated with lithium?

Answer 41

NSAIDS - they inhibit renal excretion of lithium, use _acetaminophen_ as analgesic instead