Classes of Antidepressants:
MAOIs (Monoamine Oxidase Inhibitors):
Indication for MAOIs:
"Atypical" depression & resistant depression.
(rarely used d/t SEs)
Blocks monoamine oxidase throughout the body, increasing norepi (NE), dopamine (DA), serotonin (5HT), and tyramine.
SEs of MAOIs:
HTN CRISIS (if proper diet/med restrictions not followed)
What foods to avoid when on MAOIs:
Strong aged cheese
Aged meat, liver
Non-distilled ETOH, beer, wine
Broad beans (fava beans), soy sauce, miso
*Above contains Tyramine
What drugs to avoid when on MAOIs:
Amphetamines, cocaine, methylphenidate
Sympathomimetic amines (in OTC cold meds)
CNS depression w/sedative hypnotics, ETOH
Contraindications for MAOIs:
Pts w/severe HTN, Liver Dz, Renal Dz
**Allow 2 wk "washout period" and continue dietary restrictions before starting new class of drug. ...5-6 wk washout for FLUOXETINE.
TCAs (Tricyclic Antidepressants):
Tertiary metabolizes to secondary in liver
Which is the only antidepressant drug that has a therapeutic window?
Combo of CNS NE inc d/t dec in presynaptic reuptake + postsynaptic sensitization to serotonin.
Resistant & atypical depression.
Selected pts w/chronic pain.
Death (overdose - cardiac arrhythmias)
Anticholinergic (constipation,...more 2ndary than tertiary)
Autonomic (sweating, ortho htn)
Sedation, wt gain, tremor
*TOXIC in >wks worth of therapeutic dose)
TCA affect onset:
Which TCAs have been remarketed as sleep agents?
Amitryptyline (Elavil) & Doxepin
*Elavil for some pain disorders
Caution prescribing in suicide risk pts.
Avoid ETOH & CNS depressants
Pre-existing Cardiac dz (get baseline EKG)
SSRIs (Selective Serotonin Reuptake Inhibitors):
Fluoxetine (Prozac & Sarafem - for PMS)
Paroxetine (Paxil)....more SEs
*NOT TOXIC (not lethal in overdose)
Inhibits the reuptake of Serotonin.
1st line for Major Depression... and for Anxiety Disorders (GAD, OCD, PTSD)
SSRI affect onset:
4-6 wks (he said 2-8 wks?)
H/A, N/D, sexual dysfunction (get a baseline libido)
Which SSRI is worse for SEs?
Paroxetine (Paxil) wt gain, sedation
*Has nasty "d/c syndrome"
Avoid Tramadol (chemo anti-emetic) d/t increases Serotonin = "Serotonin Syndrome".
Pts w/anxiety start on very low dose or start w/ a Benzo.
Taper off when d/c (don't need to for Prozac d/t long half-life)
Lexapro is not avail in generic, so is $$$. (not worth it, b/c does not have less SEs as promised)
Fluoxetine (Prozac) 4-6 days
Citolopram (Celexa) 35 hours
Escitalopram (Lexapro) 35 hrs
Sertraline (Zoloft) 26 hours
Paroxetine (Paxil) 21 hours
Buproprion (Wellbutrin): heterocyclic
Trazodone: heterocyclic...used as sleep aid
Nefazodone: receptor modulator
Mirtazepine: receptor modulator
Venalafaxine (Effexor): SNRI = serotonin & norepi inhibitor
Enhances NE & DA.
Avail generic in IR, SR, & XL
Activating (no sedation), wt neutral, inc libido.
Avoid w/ sz & eating disorders
What is Buproprion (Wellbutrin) remarketed as?
Zyban = smoking cessation.
5 HT reuptake/5 HT2 antagonist
SEs: Priaprism, ortho htn, sedation (so no used as a sleep aid >> non-addictive)
Similar to Trazodone
Less sedating...not used much d/t liver failure risk.
Alpha 2 adrenergic antagonist
For sedation & increase in appetite. (CA pts).
Reuptake inhibitor of 5 HT & NE (SNRI?)
For anxiety & depression
Avail in IR & XR
SEs: Nausea, dizziness, sexual inhibition, (HTN at high doses)...."d/c syndrome" if stopped suddenly
Which are the Newly released anti-depressants?
"Depression hurts, but you don't have to"
For physical symptoms of depression, GAD, DPNP (DM periperal neuropathy pain), and fibromyalgia
Dual uptake inhibitor (5 HT and NE) SNRI?
Once Daily Dosing
SEs: Nause, fatigue, dry mouth, hepatotoxicity
Transdermal Selegiline (Emsam):
For depression (for those who can't do PO)
Patch allows for high enough levels of MAO in the brain, while preserving GI MAO-A barrier which breaks down ingested tyramine (so low doses don't require diet restrictions)
6mg patch, no diet restrict; 9 & 12mg do... however, med restrictions still in effect.
SEs: rash at patch site & postural htn
Cramps, bloating, diarrhea
Tremors, myoclonus, dysarthria, incoordinat
Diaphoresis, hyperthermia, death via CVA
Manic-like symps (racing thoughts, push of speech, elevated/dysmorphic mood, confusion, hyperactivity