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Drugs for mood disorders:antidepressants
What general considerations should be taken into account before prescribing anti-depressants? (6)
prior hx of response, co-occuring disorders, concomitant of meds-drug drug interactions, concurrent illness,
3rd party coverage
, adherence concerns
What are TWO common problems in prescribing drugs?
inadequate duration (4-6 weeks), inadequate dose
When should one consider upping the dose of a drug that is working for the patient?
Once there is a 50% reduction in symptoms
What is the mechanism of action of tricyclic antidepressants?
inhibit re-uptake of NE and 5-HT
What is the mechanism of action of monoamine oxidase inhibitors?
inhibit enzyme (MOA) responsible for breakdown of NE and 5-HT
What is the mechanism of action of selective serotonin re-uptake inhibitors?
"selective" inhibition of 5-HT re-uptake
What is the mechanism of action of serotonin-noepinephrine reuptake inhibitors?
inhibit re-uptake of NE and 5-HT
what are the side effects of TCAs? (6)
anticholinergic:dry mouth, constipation, urinary hesitancy, antihistamenic: sleep inducing, orthostatic hypotention-risk of falls, cardiac conduction abnormalities
what are the drug-drug interactions of TCAs? (2)
additive effects for anticholinergics and antihypertensives
What is the overdose risk of TCAs?
the overdose risk is high
What are the drug-drug interactions of MAOIs? (5)
hypertensive interaction with foods containing tyramine, OTC decongestants, caffeine, antidepresants, meperidine/demerol
what are some of the side effects of SSRIs? (5)
nausea, insomnia, restlessness, headache, sexual dysfunction
What is serotonin syndrome? (1)
over stimulation of central and peripheral serotonin receptors
What are some of the clinical symptoms of serotonin syndrome? (3)
tachycardia, confusion, restlessness
What is the best way to prevent serotonin syndrome? (1)
prevent drug drug interactions
What should you never abruptly stop a patient's SSRI or SNRI regimen?
What are some of the drug-drug interactions of SSRIs? (1)
anything that is also metabolized by P450
What is the overdose potential of SSRIs?
What are the side effects of SNRIs? (1)
What is the overdose risk of SNRIs?
higher than SSRIs but still low
what drugs have a potential to cause depression? (7) IF PATIENT IS ON THESE DRUGS YOU MUST RULE OUT DEPRESSION PRIOR TO STARTING/INTENSIFYING TREATMENT
fat soluble beta blockers, clonidine, corticosteroids, estrogen, tamoxifen, narcotics, interferon
what is lithium used to treat and in what dose? (2) (2)
manic and depressive effects of BPD, 0.8-1.2 mEq/L for acute mania and 0.8-1.0 for maintenance
what are the side effects of lithium? (7)
fine tremor, GI upset, diarrhea, hypo-thyroidism, weight gain, rash, polyuria/dypsia
lithium has drug-drug interactions with drugs that do what FOUR things? Examples for each
drugs that decrease lithium plasma concentration (sodium, caffeine, theophylline); drugs that increase lithium plasma concentration (NSAIDS, thiazide diuretics, ACEIs); enhanced toxicity (carbamazepine, calcium channel blockers, antipsychotics)
lithium monitoring parameters? (3)
check plasma concentration: 5-6 days after initial loading dose or change in dose, when renal and or hydration levels change, if new onset change in thyroid function or suspected DDIs
when would one prescribe valproic acid?
for patients that experience rapid cyling,
what is the mechanism of valproic acid?
similar to GABA (related to inc availability)
when prescribing valproic acid what should you primarily monitor? (5)
cbc w diff, hepatic enzymes, pregnancy test, BUN/Cr
what is carbamazepine prescribed with?
what affect does carbamazepine have on the liver?
EXTENSIVELY increases liver metabolism
when you prescribe carbamazepine to a patient what side effect should you carefully monitor them for? (2)
leukopenia and rash
what foods have tyramine? (7)
aged cheese, aged and cured meats, banana peel, sauerkraut, soy sauce, draft beer, red vine
what are the side effects of MAOIs?
hypotension, dry mouth, GI, upset, urinary hesitancy, h/a, myoclonic jerks, sexual dysfunction, sleep disturbances, afternoon fatigue
what is the mechanism of action of lithium?
inhibit recycling of inositol substrates thus depleting PIP2 and reducing release of IP3 and DAG
what are the side effects of valproic acid? (8)
GI (n/v/d/anorexia), sedation, increased liver function tests, hepatitis, liver failure, rash, thrombocytopenia, hair loss
what are the DDIs of valproic acid? (2)
inc VPA plasma concentration (macrolides, INH) dec VPA plasma (carbapenem antibiotics),
what is the mechanism of action of carbamazepine?
influx of sodium ions across cell membrane
what should be monitored when a patient is one carbamazepine? (3)
cbc with platelets, liver function tests, electrolytes and pregnancy test
what are the side effects of carbamazepine? (6)
GI, hyponatremia, rash, leukopenia, hepatotoxicity, neurotoxicity
what are the DDIs of carbamazepine? (1)
with any drug hepatically metabolized
metabolism of valproic acid (1)
extensive hepatic metabolism
metabolism of carbamazepine (3)
extensive hepatic metabolism, 3A4, incuces own metabolism