NSG 533 Module 4 Flashcards by Mr. Bobbits

When a patient has depressive symptoms, it is necessary to investigate the possibility of a medical, psychiatric, and/or drug-induced cause. You will find these exclusions also listed in DSM5. All depressed patients should have a complete physical examination, mental status examination, basic laboratory work-up and suicide risk evaluation (There is an increased risk of suicide at the beginning of the antidepressant therapy)

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Pharmacological causes of depression

Antihypertensive drugs (propranolol, methyldopa, clonidine)
Hormones (oral contraceptives, glucocorticoids)
Acne therapy (isotretinoin)

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Antidepressants are used in treatment of depression, as well as some anxiety, pain and eating disorders, but not B______ D_______.

bipolar disorder

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All antidepressants take ______ weeks to achieve their full effect. Adequate trial is necessary prior to making changes.

4-6

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Principles: Most studies find combination of pharmacotherapy + cognitive therapy more efficacious than either therapy alone. Efficacy of different antidepressants is generally comparable across and within classes.

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For patients with unipolar major depression who are initially treated with antidepressants, newer agents such as SSRIs / SNRIs rather than other antidepressants should be tried. It is critical to take into account patient specific factors such as prior response to a given class of medications, tolerability of adverse effects, comorbid conditions (eg. avoiding anticholinergics in glaucoma or BPH; avoiding bupropion in seizure disorders), etc

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There is an increased risk of suicide at the beginning of the antidepressant therapy

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Potential for withdrawal symptoms with abrupt discontinuation of antidepressant therapy.

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In patients with mild to moderate major depression who obtain little symptom relief from an initial antidepressant, switching to an antidepressant from a _______________ as first-line treatment, rather than augmenting the initial antidepressant with a second drug is recommended (After an adequate trial)

different class

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For patients who obtain little symptom relief despite repeated (eg, one to three) antidepressant switches, augmentation with a ________ medication is recommended.

second

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For patients who obtain definite symptom relief that is not satisfactory and can tolerate the initial antidepressant, we suggest augmentation as first-line treatment

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______ - Selective serotonin re-uptake inhibitor

SSRIs

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Currently most often prescribed initial drug of choice because of low side effect profile and not lethal if overdose as single agent

_________ (psych drug class)

SSRIs - Selective serotonin re-uptake inhibitor

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Nearly all SSRIs undergo hepatic oxidative (P450) metabolism with fluoxetine having an extremely long T 1/2 because of its active metabolite. In fact, the “wash out period” for fluoxetine is about ___ weeks (eg to prevent serotonin syndrome if starting a MAOI, John’s Wort, etc)

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o Fluvoxamine inhibits CYP1A2, 3A4, 2C9, 2C19

o Fluoxetine and paroxetine inhibit CYP2C9 and 2D6

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o Citalopram, escitalopram and sertraline do not block P450 enzymes

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_______ (psych drug class)

Generally well tolerated.

o May be associated with n/v, weight gain (especially paroxetine), etc.
o 30-40% of patients report loss of libido, delayed orgasm or diminished arousal
o Class effect

SSRIs

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Fluoxetine and TCAs have greatest ________________ safety

reproductive

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SNRIs block both SER-T and NE-T (re-uptake of serotonin and norepinephrine)

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examples of this drug class include venlafaxine, duloxetine, desvenlefaxine

SNRIs

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Similar indications and side effect profile to SSRIs with different MOA

SNRIs

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Higher doses of some agents (venlafaxine) may be associated with increases in DBP, but not seen with others (duloxetine).

Which psych drug class?

SNRIs

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Not only indicated in MDD, but also used in treatment of chronic pain disorders (including neuropathies and fibromyalgia), generalized anxiety, stress urinary incontinence (duloxetine), and vasomotor symptoms of menopause

SN______ (psych drug class)

SNRIs

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Because of their side effects and potential for lethal overdose (even if taken alone), _________ have essentially been replaced (ie. NOT initial therapy) by SSRIs and SNRIs as the first choice for treatment of depression. They still are used in refractory cases and for other indications (enuresis, migraine prophylaxis, neuropathies, etc).

TCAs

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Significant anticholinergic effects mnemonic "Anti-SLUD" - salivation (dry mouth), lacrimation (dry eyes/blurred vision), urination (urinary retention), defecation ( constipation). Can't see, pee, spit, or shit. ___________ (psych drug class)

TCAs

T_________ ADs (psych drug class) * Avoid in: o Patients with benign prostate hyperplasia o Patients with closed-angle glaucoma o Patients with cardiac disease o Patients with hepatic impairment o Elderly patients

TCAs

Side effects of ______ (psych drug class): * Alpha-blocking properties - orthostasis, falls * H1 blocking properties - drowsiness, sedation, weight gain * Sexual side effects * QTc prolongation * CNS depression, especially if combined with other CNS depressants (benzo's, EToH, opiates)

TCAs

Trazodone was among most commonly prescribed antidepressants before introduction of SSRIs. Use now primarily limited to insomnia Drug class? 5H_______ (psych drug class)

5HT2 antagonists

* Bupropion - Also known as norepinephrine-dopamine reuptake inhibitor (NDRI) (also used in smoking cessation) main drug class?

Unicyclic / tetracyclic antidepressants

o Blockade of 5-HT2A, 5-HT2C and 5-HT3 * receptors o Also blockade of H1 receptors and presynaptic α2-adrenoreceptors

* Mirtazapine Unicyclic / tetracyclic antidepressants

o good choice if weight loss part of clinical picture and weight gain is desired (mi________, psych med)

* Mirtazapine Unicyclic / tetracyclic antidepressants

o Significant sedative effects, weight gain, dizziness  does NOT cause sexual dysfunction mi_________ (psych med)

* Mirtazapine Unicyclic / tetracyclic antidepressants

o Reasonable 1st line option in select patients where weight gain is a concern, patients w/ ADRs from SSRIs (eg. sexual dysfunction), where smoking cessation is also a consideration, etc. b____________ (psych med)

Bupropion

o Active metabolites (including amphetamine-like compounds)... note side effects in relation to this fact and yes, this will cause a positive urine test  CNS stimulant effects, such as decreased appetite, anorexia,[weight loss], insomnia, agitation, tremor, seizures b____________ (psych med)

Bupropion

 May NOT be a good choice for monotherapy if anxiety is part of the clinical picture b___________ (psych med)

Bupropion

o Contraindications: seizure disorder; history of anorexia/bulimia; patients undergoing abrupt discontinuation of ethanol or sedatives, including benzodiazepines, barbiturates, or antiepileptic drugs --> because ______________ lowers seizure threshold!

Bupropion

o Very Low likelihood of sexual dysfunction. Sometimes used as add on therapy to offset the sexual dysfunction caused by other antidepressants or in place of other antidepressants bup___________ (psych drug class)

Bupropion

MAOI:

Mono-amine oxidase inhibitors

Used only for refractory cases of MDD ________ (psych drug class)

MAOI

* By blocking the enzyme that breaks down 5-HT, NE and DA, MAO inhibitors increase the levels of these NTs in the brain

MAOI

* This drug class (psych drug class) has several significant drug interactions, one being hypertensive crisis. o Drugs that can precipitate a hypertensive crisis include: Ephedrine, pseudoephedrine, phenylephrine

MAOI

 Washout period of 14 days necessary when switching from an ______ (AD drug class) to another antidepressant or from another antidepressant to an ______ (AD drug class) (5 week washout when switching from fluoxetine to an ______(AD drug class))

MAOI

Which psych drug class? (M____) Several significant drug interactions o Serotonin syndrome with other antidepressants, narcotic analgesics (esp. meperidine (Demerol®)), St. John’s wort, linezolid (Zyvox®)

MAOI

o Drug -food interactions precipitating hypertensive crisis  The "Wine and Cheese Reaction"

MAOI

o Drug -food interactions precipitating hypertensive crisis Aged cheeses smoked/pickled meats yeast extracts red wines italian broad beans

MAOIs

Regarding anxiety: Primary therapy should address underlying issues and should be managed accordingly (i.e. with SSRIs,SNRIs, etc.)

Citalopram, sertraline, fluvoxamine, and fluoxetine are not FDA-approved for the treatment of GAD. However, the efficacy of SSRIs in GAD appears to be a class effect, and there is uncontrolled data to support the use of all SSRIs in the pharmacotherapy of GAD.

Generally, treatment of GAD should be continued for at least one year

BZDs:

Benzodiazepines

o Most prescribed agents for the acute treatment of anxiety (and in conditions such as depression with there is an anxious component -"bridge therapy") o Efficacy is similar among the available agents

BZD - Benzodiazepines

BZ___ tapering: 25% per week reduction until 50% of dose is reached, then decrease by 1/8th every 4-7 days.  > 8 weeks of therapy: 2-3 week taper  >6 months of therapy: 4-8 week taper  > 1 year of therapy: 2-4 month slow taper

BZD - Benzodiazepines

o Use should be limited to short term (2-6 weeks) until "other therapies (SSRI, SNRI)" takes effect B__s

BZD - Benzodiazepines

Should not be used in patients with past or current substance and/or alcohol abuse or dependence

BZD - Benzodiazepines

Prefer those agents with longer half-life due to better coverage of anxiety (this is not the same in elderly patients or for insomnia)

BZD - Benzodiazepines

May paradoxically produce an increase in irritability and aggression in some individuals (particularly if short- acting drugs are given (triazolam) B________ (psych drug class)

BZD - Benzodiazepines

________ (psych drug class), shown to affect memory, can produce anterograde amnesia (i.e., a loss of memory for events occurring forward in time). Following the ingestion of a _______ (drug class), short-term memory is not affected, but long-term memory is impaired.

BZD - Benzodiazepines

Caution: patients are often prescribed _______ (psych drug class) for different reasons (muscle spasm, anxiety, insomnia, etc) by different providers. Always be aware of potential therapeutic duplications

BZD - Benzodiazepines

All BZ______ (psych drug class) are lipid soluble (easy access to the CNS) and can cause profound CNS depression, especially if combined with other CNS depressants

BZD - Benzodiazepines

o Duration of action:  Short-acting: alprazolam, triazolam

BZD - Benzodiazepines

o Duration of action:  Intermediate-acting: lorazepam, oxazepam

BZD - Benzodiazepines

o Duration of action:  Long-acting: diazepam, flurazepam, chlordiazepoxide ... The half lives of the parent compound and active metabolites are extensive (up to 100 hours)and can accumulate. AVOID in the elderly. (psych drug class)

BZD - Benzodiazepines

Anxiolytic drug, but NO sedative, hypnotic, anticonvulsant or muscle relaxant properties

Buspirone

o Comparable efficacy to benzodiazepines in the treatment of GAD, but some trials reported inconsistent findings. Considered second line overall

Buspirone

o Abrupt discontinuation of buspirone does not cause withdrawal effects as seen in BZDS

Buspirone

Slow onset of action (2-3 weeks) b_________ (psych med)

Buspirone

o lack of activity against comorbid conditions (e.g., depression, panic disorder, social phobia) is a drawback in some patients.

Buspirone

_____________________ (drug class) may be helpful in patients with physical symptoms (e.g., palpitations and other cardiovascular complaints) but are not effective for the treatment of GAD.

β-Adrenergic antagonists (e.g., propranolol)

* Basic principles for the rational treatment of ______________ are to use the lowest effective dose, use intermittent dosing (2-3 nights/wk), use short term (2-3 wk at a time), discontinue after slow taper if the patient has been taking it regularly, and use agents with short and/or intermediate half-life to minimize daytime sedation

insomnia

Dosage, pharmacokinetic properties, and risk-benefit ratio are the key factors in selecting the most appropriate medication for ____________.

insomnia

Regarding _____________: Choice of agents should be based on alleviating particular sleep problems (Eg difficulty falling asleep, decreased TST, early awakening, etc). Short-acting agents are recommended for patients with difficulty falling asleep, while intermediate-acting drugs are indicated for problems with sleep maintenance.

insomnia

o Examples of short-acting medications (duration of effect ≤8 hours) include zaleplon, zolpidem, triazolam, lorazepam, and ramelteon.  Short-acting agents taken at bedtime can result in both early-morning wakening and rebound insomnia the following night  may be beneficial if intermediate or longer acting agents result in "hangover" or excessive daytime (morning) sedation  good choice when sleep induction

o Examples of longer-acting medications include zolpidem extended release, eszopiclone, temazepam, estazolam  Used for sleep maintenance  Long-acting agents taken at bedtime can result in daytime sedation the following day leading to falls, etc

o Avoid ____________ sleep agents, especially in older people, because they cause daytime sedation and impair cognition, thereby increasing the risk of falls.

long-acting

Risks of using long-term sleep agents.  Influence of manual skills (such as driving performance) due to drowsiness, confusion, amnesia and impaired coordination  enhancement of depressant action of other drugs (in a more than additive way)

o Caution and close monitoring is needed in the administration of ___________ to older people and to patients with hepatic, renal, or pulmonary disease.

hypnotics

Treatment of insomnia in older adults requires careful attention to the role of medical, neurologic, sleep, and psychiatric comorbidities. Vulnerability to side effects increases with age, and medications for insomnia often exacerbate existing age-related impairments such as gait instability, sedation, cognitive dysfunction, urinary and bowel dysfunction, and cardiac arrhythmias. Older adults may have slower drug metabolism, and thus maximum and next-day serum concentrations will be increased.

* 5 BZDs marketed for insomnia

o Flurazepam, triazolam, temazepam, estazolam, quazepam

* 5 BZDs marketed for insomnia o Flurazepam, triazolam, temazepam, estazolam, quazepam o No respiratory depression in healthy patients, but respiratory depression in patients with COPD or obstructive sleep apnea o Note: Any BZD can be used for sleep.

* "Z Hypnotics" - Zolpidem, zaleplon, eszopiclone. Act on the BZD receptor similar to traditional benzodiazepines o no effect on sleep architecture o minimal rebound insomnia o no anti-convulsant or muscle relaxing properties (as do typical BZDs)

* "Z Hypnotics" - Act on the BZD receptor similar to traditional benzodiazepines

Zolpidem, zaleplon, eszopiclone.

* __________________ - blocks the binding of wake-promoting neuropeptides orexin A and orexin B to receptors OX1R and OX2R, which is thought to suppress wake drive. o Increased levels in women and obese patients o An increased risk for hazardous sleep-related activities such as sleep-driving; cooking and eating food, making phone calls, or having sex while asleep have also been noted

Suvorexant

* Ramelton - Ramelteon is a melatonin receptor agonist that specifically targets the MT1 and MT2 receptors in the brain, believed to be critical in the regulation of the body's sleep-wake cycle o Reduced the latency of persistent sleep with no effects on sleep architecture and no rebound insomnia or significant withdrawal symptoms o Drowsiness, dizziness, increased prolactin levels o NO ABUSE POTENTIAL or Cross tolerance with other CNS depressants(including alcohol)

* 1st generation antihistamines (eg. diphenydramine, hydroxyzine). For insomnia. o Generally safe but have anticholinergic adverse effects, such as dry mouth, blurred vision, urinary retention, and confusion in older patients

Regarding this insomnia med drug class and the Elderly. These medications, a_____________________ (drug class), are a concern and should be avoided in patients with BPH and glaucoma, among others

1st generation antihistamines (eg. diphenydramine, hydroxyzine).

Mr. Sime was recently diagnosed with depression. As you are discussing his recent paroxetine prescription, he states that he is not happy that it isn't working. He has been taking it for about 5 days. Which of the following actions is most appropriate? - Refer to provider to change paroxetine to a different antidepressant - Refer to provider to change paroxetine to add an additional antidepressant - Explain to the patient that the medication takes up to a couple of weeks to begin to take effect - Contact the pharmacy to ensure he received the medication

Explain to the patient that the medication takes up to a couple of weeks to begin to take effect This patient is likely adherent to the medication as he states it isn't working indicating that he is likely taking it. 5 days would be too soon to assess the efficacy and the provider is unlikely to change the medication or add a new one unless there are obvious adverse effects. The patient should be educated that it may take up to a couple of weeks to begin working and up to several weeks for maximum effect.

Which of the following antidepressants has the least sexual adverse effects? Venlafaxine Paroxetine Duloxetine Bupropion

Bupropion Bupropion is the least likely to cause sexual adverse effects of the antidepressants listed. Both SSRIs and SNRIs are associated with sexual dysfunction.

Which of the following antidepressants is classified as an SNRI? Venlafaxine Amitriptyline Citalopram Doxepin

Venlafaxine An SNRI is a selective norepinephrine reuptake inhibitor. Venlafaxine has activity at norepinephrine receptors, as well as serotonin receptors.

Of the following, which antidepressant tends to be most sedating? Zoloft Celexa Wellbutrin Trazodone

Trazodone Although several antidepressants can be sedating, trazodone, through its mechanism of action, can have sedative effects. It is often used off-label to help with insomnia and sleep maintenance.

Which antidepressant can be used to aid with smoking cessation? Paroxetine Bupropion Citalopram Trazodone

Bupropion Wellbutrin (bupropion) has activity at nicotinic receptors and inhibits them, which is thought to contribute to its efficacy as a smoking cessation aid.

Mr. Rist is a 55-year-old math teacher who struggles with urinary retention symptoms during the day due to a history of BPH. Which antidepressant would be most likely to contribute to this issue? Trazodone Mirtazapine Bupropion Amitriptyline

Amitriptyline Amitriptyline should be avoided in patients who have urinary retention. It is highly anticholinergic and has significant sedative properties. It is on the Beers Criteria and should be avoided in elderly patients as well.

KM is a 42-year-old female who recently stopped taking her sertraline. Which symptoms would be inconsistent with antidepressant withdrawal symptoms? Constipation Anxiety Nausea Insomnia

Constipation Nausea, dizziness, anxiety, headaches, and diarrhea are more likely to be symptoms of withdrawal from antidepressants.

Which of the following medications is an SSRI? Duloxetine Trazodone Escitalopram Buspirone

Escitalopram Venlafaxine is an SNRI but does have activity on serotonin receptors in addition to norepinephrine receptors. Trazodone is a serotonin modulator. Buspirone is an anxiolytic agent. Escitalopram is the only true SSRI.

JS is a 78-year-old female with anxiety associated with end-of-life cares. She has been taking lorazepam 0.25 mg every 6 hours by mouth as needed for anxiety. Her caregiver has tried it about 5 times in the last 3 days and they report no effect. What is the likely reason for this? Poor oral absorption Dose is too low It has to be taken with food It has to be taken regularly to work

Dose is too low Lorazepam (Ativan) should work on an as-needed basis and typically has adequate oral absorption. Taking it with food wouldn't have a significant impact and it can be taken as needed. The most likely issue preventing efficacy is that the dose is too low.

Which SSRI is most likely to cause drug interactions? Sertraline Paroxetine Fluoxetine Fluvoxamine

Fluvoxamine Fluvoxamine interacts with several CYP isoenzymes and has nonselective inhibition, leading to a high potential for drug-drug interactions.

Food containing what substance can cause problems while taking an MAOI? Thiamine Folic acid Gluten Tyramine

Tyramine Tyramine-rich foods can increase norepinephrine release, which can lead to life-threatening hypertensive crises or serotonin syndrome. Foods can be high in tyramine when they have been aged, fermented, pickled or smoked, and some red wines and beers.

Which of the following is NOT a likely symptom of serotonin syndrome? Muscle rigidity Fever Confusion Bradycardia Serotonin syndrome is more likely to cause tachycardia than bradycardia.

Bradycardia Serotonin syndrome is more likely to cause tachycardia than bradycardia.

LG is a 30-year-old female in the clinic for a routine visit. When reviewing her medication list, she adds that she started taking St. John’s Wort for her depression about two weeks ago. She is also taking fluoxetine 20 mg daily, ibuprofen 200-400 mg as needed, vitamin D3 5,000 units daily, Junel Fe 1/20 daily, and cetirizine 10 mg as needed for allergies. What are some important counseling points for LG regarding her medications? Select all that apply. - Ibuprofen use while taking an SSRI can increase the risk of GI bleed - There is an increased risk of serotonin syndrome while taking St. John’s Wort - St. John’s Wort can reduce oral contraceptive efficacy - All of the above are important counseling points

All of the above are important counseling points St. John’s Wort should not be used with other serotonergic agents as it can increase the risk of serotonin syndrome. NSAID use while taking an SSRI can increase the risk of GI bleed. St. John’s Wort can reduce the effectiveness of oral contraception.

What is the primary mechanism of action of antipsychotic medications? Block acetylcholine Block dopamine receptors Increase acetylcholine Increase norepinephrine

Block dopamine receptors The primary mechanism of most antipsychotic medications is to decrease dopamine activity and help control psychosis.

Which of the following extrapyramidal symptoms (EPS) is correctly paired with its definition? - Dystonia: lack of muscle tone and contractions - Parkinsonism: muscle rigidity and painful muscle spasms - Akathisia: restlessness with anxiety and unable to remain still - Tardive dyskinesia: a state of catatonia due to untreated seizures

Akathisia: restlessness with anxiety and unable to remain still Dystonia is prolonged muscle contraction, including painful muscle spasms. Parkinsonism symptoms look similar to Parkinson's disease, with tremors, abnormal gait, and bradykinesia. Tardive dyskinesia is abnormal facial movements but can also involve the trunk and arms.

KY is a 24-year-old male with bipolar I disorder taking lithium 600 mg twice daily. He works in construction and sometimes works long days outdoors. What are some counseling points for KY regarding his lithium? - Avoid prolonged sun exposure since lithium can lead to sunburns - Take on an empty stomach at least 2 hours before a meal - Lithium can alter thyroid function and labs should be monitored - He should avoid any salt intake as it can cause dehydration with lithium

Lithium can alter thyroid function and labs should be monitored Prolonged exposure to heat/sun can cause dehydration, which can increase lithium levels and side effects. Salt intake should remain consistent as too little or too much can affect lithium levels. Lithium should be taken with food or at the end of a meal to reduce nausea. Hypothyroidism is a possibility with the use of lithium and TSH and other thyroid labs should be monitored.

A lithium level greater than _____ mEq/L can cause what symptoms? Select the correct pairing. - 1.5 mEq/L; sedation, constipation, depression - 2.5 mEq/L; CNS depression, arrhythmia, seizures - 1 mEq/L; persistent diarrhea, confusion, sedation - 0.8 mEq/L; seizures, coma, death

2.5 mEq/L; CNS depression, arrhythmia, seizures The therapeutic range for lithium is 0.6-1.2 mEq/L (trough level). At levels above 1.5 mEq/L, lithium toxicity may manifest as ataxia, coarse hand tremor, vomiting, persistent diarrhea, confusion, and sedation.

A melatonin receptor agonist. Indicated for insomnia characterized by difficulty with sleep onset. __________ is not a controlled substance and can be a viable option for pts with a history of substance abuse.

Ramelteon

_________________: an orexin receptor antagonist. It is the first medication that turns off wakefulness mechanisms instead of stimulating pathways that induce sleepiness. _____________ is indicated for both difficulty initiating and maintaining sleep, and like BZDRAs, it is classified as a Schedule IV controlled substance.

Suvorexant

_____________ is indicated for both difficulty initiating and maintaining sleep, and like BZDRAs, it is classified as a Schedule IV controlled substance.

Suvorexant

_________________: an orexin receptor antagonist. It is the first medication that turns off wakefulness mechanisms instead of stimulating pathways that induce sleepiness.

Suvorexant

___________________: These drugs, such as diphenhydramine, are frequently used (usual doses 25-50 mg) for difficulty sleeping. Benadryl is FDA-approved for the treatment of insomnia and can be effective at reducing sleep latency and increasing sleep time. However, Benadryl produces undesirable anticholinergic effects and carry-over sedation that limits its use, especially in the elderly.

1st class antihistamines

- All antidepressants: _______ weeks to work For patients who show little improvement (eg, reduction of baseline symptoms ≤25 percent) after four to six weeks, it is reasonable to administer next-step treatment

4-6

Caution and close monitoring is needed in the administration of H___________ (psych drug class) to older people, pregnancy and to patients with hepatic, renal, or pulmonary disease (including sleep apnea)

hypnotics

Avoid long-acting sleep agents, especially in ______ people, because they cause daytime sedation and impair cognition, thereby increasing the risk of falls.

older

Examples of longer-acting medications include ____________________________. (x4)

zolpidem extended release, eszopiclone, temazepam, estazolam

Examples of short-acting medications (duration of effect ≤8 hours) include ____________________. (x5 AD hypnotics?)

zaleplon, zolpidem, triazolam, lorazepam, and ramelteon.

Short-acting sleep agents are recommended for patients with difficulty _______________, while intermediate-acting drugs are indicated for problems with sleep maintenance

falling asleep

Drug: __________ (Ambien) (non-BZD; aka Z-hypnotic) Indication: Sleep onset

Zolpidem (Ambien)

Drug: __________________ (non-BZD; aka Z-hypnotic) Indication: Sleep onset, sleep maintainence

Zolpidem ER

Drug: ________ (Sonata) (non-BZD; aka Z-hypnotic) Indication: Sleep onset

Zaleplon (Sonata)

Drug: _________ (Lunesta) (non-BZD; aka Z-hypnotic) Indication: Sleep maintenance

Eszopliclone

Drug: _________ (Rozerem) (Melatonin receptor agonist) Indication: Sleep onset

Ramelteon

__________________: (including traditional BZDs, zolpidem, zaleplon, and eszopliclone) and ramelteon are approved by the FDA for the treatment of insomnia and are first-line therapies.

BZD receptor agonists (BZDRAs) aka Z-hypnotics

_______________, a 5-HT1A partial agonist, is thought to exert its anxiolytic effects by reducing presynaptic 5-HT (serotonin) firing. Unlike BZDs, _____________________ does not have abuse potential, causes withdrawal reactions, or potentiate alcohol and sedative hypnotic effects. It has a gradual onset (2 weeks) of action and does not provide immediate anxiety relief. Data is inconsistent regarding its efficacy in chronic GAD or GAD with comorbid depression. It may be less effective in patients who have been treated previously (4 weeks to 5 years) with BZDs. _________________ is well tolerated and most common SEs include dizziness, nausea, and headache. _______________ elimination is affected significantly by drugs that inhibit (verapamil, diltizem, itraconazole, fluvoxamine) or induce (e.g., rifampin) CYP34A. _____________ may increase BP when co-administered with an MAOI.

Buspirone (Buspar)

bus____________ (psych med), a 5-HT1A partial agonist, is thought to exert its anxiolytic effects by reducing presynaptic 5-HT (serotonin) firing.

Buspirone (Buspar)

Unlike BZDs, bu_____________________ (psych med) does not have abuse potential, causes withdrawal reactions, or potentiate alcohol and sedative hypnotic effects. It has a gradual onset (2 weeks) of action and does not provide immediate anxiety relief. Data is inconsistent regarding its efficacy in chronic GAD or GAD with comorbid depression. It may be less effective in patients who have been treated previously (4 weeks to 5 years) with BZDs.

Buspirone (Buspar)

_________________ is well tolerated and most common SEs include dizziness, nausea, and headache.

Buspirone (Buspar)

b_______________ (psych med) elimination is affected significantly by drugs that inhibit (verapamil, diltizem, itraconazole, fluvoxamine) or induce (e.g., rifampin) CYP34A.

Buspirone (Buspar)

bu_____________ (psych med) may increase BP when co-administered with an MAOI.

Buspirone (Buspar)

With regards to BZDs and anxiety related disorders: Should be used only for ______ weeks until the antidepressant begins to work

2-4

Long-term use is not recommended due to concerns regarding dependence and withdrawal symptoms Which drug class? (B__s)

benzodiazepines

Because of the potential for abuse, ______________ (psych drug class) should not be used in patients with past or current substance and/or alcohol abuse or dependence

benzodiazepines

________________ inhibit the enzyme responsible for the breakdown of 5-HT (serotonin), NE, and DA. Dietary restrictions limiting the consumption of tyramine are necessary for orally available ______________ due to inhibition of MAO-A in the gut. Drinking wine or eating cheese will cause a sudden and dangerous rise in BP (hypertensive crisis).

MAOIs

Because l________ and o_________ bypass hepatic oxidation and are conjugated only, they are the preferred agents for patients with reduced hepatic function secondary to aging and disease. (two different psych meds)

lorazepam and oxazepam

All ______ (psych drug class) are on the BEERs list.

BZDs

BZD shortest half-life: ___________ and ___________

oxazepam and temazepam

BZD longest half-life: ____________ and ____________

Chlorazepate and valium

Best BZDs for the elderly are ______, ______, ______, and ______. ("ALOT")

oxazepam, lorazepam, alprazolam, temazepam ("ALOT")

Worst BZDs for patients over 65 years old (VCCC): _________, _________, _______, ________

clonazepam, chlordiazepoxide, valium, chlorazepate.

____________ is also known as norepinephrine-dopamine reuptake inhibitor (NDRI) and is used in MDD (major depressive disorder) and smoking cessation therapy.

Bupropion

Good characteristics of bup______________: Decreased appetite, less likely to lower libido than other ADs, and not sedating.

Bupropion

Bad characteristics of b________________ (psych med): Causes insomnia, nightmares, decreased appetite, anxiety, tremors, and seizures.

Bupropion

Regarding __________________ (psych med): Seizures are the most concerning AE. Because of the risk for seizures, patients with a CNS lesion, history of seizure disorder, head trauma, anorexia, or bulimia should not receive this medication.

Bupropion

Besides the possibility of being lethal in an overdose, what side effects are commonly associated with T____________ (psych drug class) now almost exclusively limits use to refractory cases and other non-depressive indications? These SEs include sedative, anticholinergic, and cardiovascular SEs.

TCAs

You need really high doses to treat depression. Which drug class?

TCAs.

________ - Blocks both 5-HT and NE. Often seen as an alternative to SSRIs.

SNRIs

At higher doses ----> Noradrenergic effects more prominent relative to serotonergic activity ----> dose dependent ’s in diastolic BP (SN__s)

SNRIs

Similar AEs to SSRIs, except more incidence of BP elevation with _________.

SNRIs

d_______________ (psych med), an SRNI: unique beneficial treatment for physical pain associated with depression.

duloxetine (Cymbalta)

___________ (psych drug class) can be lethal in an overdose.

TCAs

Don't start a patient with uncontrolled high BP on an ______.

SNRI

Common SE of ________ (psych drug class) is diarrhea, and constipation after quitting.

SSRIs

________________________: Blocks 5-HT. Currently most often prescribed initial drug of choice because of low side effect profile and not lethal if overdose as single agent.

SSRIs

_________ : an SSRI metabolized into an active metabolite norfluoxetine with a long half-life

Fluoxetine

_________________ (psych med) has to be stopped (wash-out period) 4-5 weeks before MAO inhibitors can be started

Fluoxetine

Characterized by confusion, restlessness, fever, abnormal muscle movements, hyperreflexia, sweating, diarrhea, and shivering. It may result when a serotogenic agent is added to any other serotogenic agent. MAOIs are strongly associated with severe cases of _______________. _____________ is complicated by (a) an unawareness by clinicians of the diagnosis and (b) the fact that many implicated drugs are not serotonergic in nature, such as dextromethorphan, meperidine, tramadol, linezolid, and methylene blue. Avoid by avoiding causative drug interactions.

Serotonin syndrome

In general, the dose of an antidepressant should be tapered by no more than _______% per week to minimize the risk of withdrawal symptoms.

25%

_____________________ is a good example of a problematic herbal product.

St. John's Wort

____________ syndrome: almost all ADs can produce withdrawal syndromes if DC'd abruptly or tapered too rapidly, especially ADs with shorter half-lives (e.g., venlafaxine IR, paroxetine, and fluvoxamine).

Discontinuation

Tapering and DC of ADs can be completed over __-__ months.

2-3

ADs take about __-__ weeks to feel less depressed.

2-4

All antidepressants: __-__ weeks to work

4-6

Regarding _______________: For patients who show little improvement (eg, reduction of baseline symptoms ≤25 percent) after four to six weeks, it is reasonable to administer next-step treatment

ADs

Regarding _________ (and PPIs and PDE-5s): All equally effective at equipotent dose

ADs

Regarding _____: Usual trial of 8-12 weeks at therapeutic doses before deciding whether antidepressants have sufficiently relieved symptoms

ADs

___________ is the "worst" for sedation. Never give in the morning. (mi______)

Mirtazapine

The two "worst" activators (makes patient move): b_____________, f______________ (x2 psych meds)

Bupropion, fluoxetine

____________ is the "worst" med for weight loss (causing weight loss).

Bupropion

When considering treatment, bu_________ (psych med) may be useful for both lowering alcohol cravings and preventing some of the withdrawal symptoms associated with alcohol consumption (Cherney, 2019).

buspirone

Taking St._____________ (for depression), when combined with some other antidepressants can lead to increased serotonin, or serotonin syndrome (causing high temperature, confusion, twitchiness, tachycardia, nausea, and even coma).

St. John's Wort

A______ B________ (BP med for BPH) - fairly ra[id onset (2-4 weeks) with relatively rapid symptom resolution, durable effect (years), with AUA symptom index (AUASI) improving 30-45%. No effect on prostate size or disease progression. Can cause ED. --osin medications tamsulosin silodosin alfuzosin doxazosin terazosin prazosin

Alpha Blockers

Alp_______ (drug class: PgE1 analog for ED)

Alprostadil

Var_______ (PDE51 for ED) Prolonging of QT interval with this class, especially this med.

Vardenafil

5-alpha reductase inhibitors (5ARIs): f__________ d__________ Mgmt of mod-severe BPH in patients with enlarged prostate glands. Reduce prostate size and thus outlet obstruction. ADR: decreased libido, impotence and ejaculatory disorder, breast tenderness/enlargement.

finasteride dutasteride

tad______ (can treat both ED and BPH) - don't use with nitrates

tadalafil

Mir_______ (agonist of the beta-3 adrenergic receptor) Relaxes the detrusor smooth muscle during the storage phase of the urinary bladder fill-void cycle. - it reduces irritative voiding symptoms ADRs: HA, HTN, tachycardia, constipation, nasopharyngitis

mirabegron

Bup______ lowers seizure threshold.

Bupropion

Bup______ is not a good choice for monotherapy if anxiety is part of the clinical picture.

Bupropion

Mir________ is a good choice if weight loss is part of clinical picture and weight gain is desired.

Mirtazapine

NSG 533 Module 4 Flashcards

(174 cards)