CNS 2- Test 1
Where does Fetzima act in the synapse?
- SERT & NET
Why?... it is an SNRI
FETZIMA generic name?
Where does EMSAM act in the synapse?
- Monoamine Oxidase
Why?... it is a MAOI
EMSAM generic name?
Where does Lexapro act in this synapse?
Why?.... It is an SSRI
Inhibiting inositol formation and glycogen synthase kinase is associated with what drug?
Target for Esketamine?
It will inhibit the NMDA receptors
Target for Zulresso?
Positive Allosteric Modulator
Only drug approved for postpartum depression
High Ki value=
Low Ki value=
Orthostatic hypotension is due to which receptor?
The higher the Ki value for a drug in regards to the alpha-1 receptor means....
The least likely it will cause orthostatic hypotension (as compared to a drug that has a lower Ki in regards to the alpha-1 receptor)
H1 receptor antagonism will cause?
Sleepiness and drowsiness
Antimuscarinic side effects?
- blurry vision
- dry mouth
What are the targets for TCAs?
What class of drugs can be dangerous in overdose?
(They will cause major cardiovascular issues)
Fluoxetine will inhibit which enzyme?
(Since it inhibits this enzyme, it would decrease the metabolism of drugs that use the same enzyme)
St Johns Wort will...?
Induce the CYP450 enzymes, which would increase the metabolism of drugs that are also metabolized by those enzymes
This leads to decreased effectiveness of those medications
A patient has been identified as a slow acetylator, which statement is the most correct?
MAOI levels will be higher
Why?... because the MAOI would not be metabolized as quickly, so there are higher levels in the body. This could also increase a persons likelihood of causing Serotonin Syndrome
Grapefruit juice is?
A CYP3A4 inhibitor
Which one works faster, pharmacotherapy or psychotherapy?
Electro Convulsive therpay
- very effective
- very safe
- rapid onset of effect
ECT has the ability to alter __________ term memory
What are the CAM therapy options for MDD?
- St John's Wort
- Omega-3- fatty acids
What is the issue with ST Johns Wort?
The purity of the product since herbal supplements are not regulated by the FDA
St Johns Wort is...
an INDUCER of CYP450 enzymes
- increase NE, DA, and Serotonin
- Irreversible inhibition
- takes 2 weeks for MAOI to get out of your body "wash out period"
- HTN Crisis (too much NE)
- Serotonin Syndrome (too much serotonin)
One major side effect of serotonin syndrome
Which SSRI has the longest half life and would be a good choice if patients tend to forget to take their medications?
Which SSRI tends to interact with a lot of other medication due to the PK parameters?
What is the only NDRI?
**** has no effect on Serotonin
What is the number one counseling point for Bupropion?
What is the max dose of Bupropion?
450 mg per day
What is the black box warning for Nefazodone?
Because trazodone is a WEAK SRI, at low doses it mostly produces?
The sleepy effect
normally need at least 200 mg for it to be for depression
* low dose = sleep
* high dose = depression
- INDIRECTLY increasing NE and Serotonin
- blocks H-1 (antihistamine effects)
- most common side effect is SLEEP
- patient may have increased appetite
- "can be used to help elderly with appetite"
- low dose = for sleep
- high dose = antidepressant (30 mg or HIGHER)
- partial agonist at 5-HT1A
- no activity at dirty receptors
- "there can still be a possibility of sexual dysfunction"
- faster onset
- better tolerated
- "will help with the cognitive effects of depression"- since people who are depressed can have memory impairment and difficulty concentration
- "multi-modal MOA"
- TACKLES COGNITIVE EFFECTS OF DEPRESSION
- with CYP2D6:
- increase dose with inducers
- decrease dose with inhibitors
- "still counsel a patient on sexual dysfunction"
What is euthymia?
"normal" or balanced mood
- depression is dysthymia
In an acute setting you prevent ____________ of MDD
Which black box warning for antidepressants should you ALWAYS counsel your patient?
an increased risk of suicidal ideation (worsening symptoms of depression)
What is the number 1 side effect of antidepressants that decrease compliance?
Preferred first line treatment for MDD
Partial Response to first line
- ADD MEDICATION ON (you dont want to lose the progress you made)
- What is considered a partial response? --> 3 of their 5 presenting symptoms have gone away, but they still have 2 that are uncontrolled
No Response to first line
- switch medications
- this is when the patient just experiences side effects and nothing improved for the patient
If there is psychosis along with depression, you must add ____________ to therapy
What is the "safe bet" due to few to no drug drug interactions?
How long does it take to see full antidepressant effect?
This is an "adequate trial"
How long does it take to see an improvement in sadness and loss of pleasure?
How long does it take the physical symptoms to improve (sleeping better, better sleep, eating better)?
Adding a medication that will enhance the existing anti-depressant
a drug in a different class that will work a different way
TWO FDA APPROVED MEDICATIONS FOR AUGMENTATION
these are both antipsychotics
What other agent can be used for augmentation but is not FDA-approved?
Should anti-depressants be taken PRN?
NOOOOO; must be taken consistently
Treatment Resistant Depression
failing two adequate trials
What are the two drugs that are approved for TRD?
- Symbyax (olanzapine/Fluoxetine)
- Spravato (Esketamine)
Spravato is a nasal spray; & it has a VERY rapid onset of action and supposedly you can feel better within days.
- nasal spray
- non-competitive antagonist of the NMDA receptor (glutamate)
- REMS program due to the risk of abuse
- common side effects: increase BP (could be hurtful to pregnant women)
- MONTHLY DOSE
________ depressed patients should receive both acute and continuation treatment
Do all depressed patients need maintenance treatment?
No, just the people who are at the highest risk
How long should you tell a patient they will be on their medication?
_______________ is least likely to cause antidepressant discontinuation syndrome
Is antidepressant discontinuation syndrome life threatening like BZDs?
But it will normally resolve after 2 weeks
"This can also happen when you switch medication classes"
BZD for anxiety
- used for GAD, PD, and SAD
- do not use these in PTSD
- higher dose for panic disorder
- lower dose for anxiety
- used for GAD ONLY!!!!
- avoid in PD (ineffective)
it can also be used for augmentation
- 5-HT1A partial agonist
- "this drug is not well understood, but it is well tolerated"
- normally 2 to 3 times a day (due to short half life)
- maximum dose is 60 mg a day!!!! (they are in divided doses)
- this could be a compliance issue due to how often it is dosed