Anxiety & Depression

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Anxiety & Depression
2013-05-02 18:21:59
Boston College NU 420 pharmacology

Pharm Exam 3
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  1. T/F: Some adverse effects of Buspar (Buspirone)  are tolerance, dependency, CNS depression, & sedation.
    False. Buspar does not cause tolerance or dependency, and it does not have any anticonvulsive or muscle relaxant qualities that would lead to depression or sedation.
  2. What is Buspar (buspirone) indicated for?
    • Generalized anxiety disorder (mild to moderate intensity)
    • Depression w/overlay of anxiety or agitation (give with SSRI or SNRI)
    • Situational anxiety that is long-lasting
  3. Buspar contraindications?
    • Benzodiazepine withdrawal
    • Unable to adhere to multiple daily dosing
    • Serotonin syndrome risk w/MAOIs & SSRIs 
    • Panic ATTACKS (prolonged onset of 2-6weeks)
    • Anxiety ATTACKS
    • Renal or hepatic disease (severe)
  4. What is the MOA for Buspar (Buspirone)?
    • partial serotonin receptor agonist
    • (Serotonergic Anxiolytic)

    Buspirone acts as an agonist at presynaptic serotonin receptors, opens channel & permits serotonin binding (inhibits neuron firing)
  5. T/F: Buspar (Buspirone) is good for those with a history of substance abuse.
  6. T/F: Although Buspar (Buspirone) does not lead to tolerance or dependency, it has a lot of side effects, and is not well tolerated.
    False. The side effects are few and resolve with continued use. 

    Light-headedness, HA, insomnia, nausea, nervousness, & dry mouth

    RARE - akathisia & involuntary movements
  7. Why is Buspar (Buspirone) not used with panic attacks?
    A metabolite has noradrenergic (norepi) effects
  8. What type of drug is Alprazolam (Xanax)?
    short-acting anxiolytic of Benzodiazepine drug class, "gaba-ergic"

    decreases neuronal excitation by increasing the action of GABA (an inhibitory NT)
  9. T/F: Xanax (alprazolam) is likely to cause dependency.
    True. High potency & rapid action make it likely. 

    Over time, need higher dosage. Abrupt withdrawal causes anxiety/panic (so taper off).
  10. Xanax (alprazolam) is indicated for treatment of...
    anxiety and insomnia (main one)

    • Alprazolam also possesses sedative, hypnotic, skeletal muscle relaxant, anticonvulsant, and amnestic properties.
    • ·       muscle relaxant
    • ·       pre-anesthesia sedation
    • ·       prevention & tx of panic attacks
    • ·       acute agitaion
    • ·       dystonia
    • ·       emergency tx of uncontrollable seizures
    • ·       tx of RLS
  11. What do benzodiazepine drugs do?
    work on chloride ion channels of GABAA receptors. They enhance GABA neurotransmission which lengthens hyperpolarization and slows down responses.
  12. T/F: Withdrawal symptoms occur within 1-2 days after last dose of Xanax (alprazolam).

    S&S of WD: insomnia, agitation, anxiety, & rarely seizures
  13. What are contraindications for benzodiazepines? (Xanax, Serax, Klonopin)
    • Pregnancy & Lactation
    • Hepatic or Renal Disease
    • Children <6
    • Acute narrow-angle glaucoma
  14. T/F: Benzodiazepines (xanax, serax, klonopin) can be prescribed for an elderly patient.
    Yes, but remember to decrease the dose (decreased metabolism)
  15. What are the major adverse effects of Benzodiazepines (xanax, serax, klonopin)?
    • Dependence
    • CNS depression...
    • ·       excessive sedation
    • ·       cardiac or respiratory depression
    • ·       dizziness, confusion, blurred vision, hypotension
    • ·       additive effects with other CNS depressants (barbituates, alcohol, antihistamines, neuroleptics)
  16. Benzodiazepines (Xanax, Klonopin, Serax) can cause increased drug levels of
    TCAs or digitalis
  17. Labs needed to monitor for Xanax
    Liver function, CBC
  18. What drug will increase Haldol levels due to competitive metabolism?
    Buspar (buspirone)
  19. What might happen if you give Buspar (buspirone) with Trazadone?
    increased ALT
  20. In what drug class is Prozac (fluoxetine)?
  21. What is Prozac (fluoxetine) indicated for?
    • Bulimia
    • Major depression
    • Premenstrual dysphoric disorder
    • OCD
    • Panic disorder
  22. T/F: You should see results of antidepressants in less than 3 weeks.
    False. Response in <3 weeks is a placebo effect.
  23. How long does it take Prozac (fluoxetine) to reach steady state?
    ~1 month
  24. What do antidepressants have a black box warning for?
    antidepressants may increase the risk of suicide in people younger than 25

    most likely to occur in first 2 months of tx
  25. MOA for Prozac?
    • SSRI
    • NE (0), 5-HT (+++++), ACh (+), H (+), a1 (+)
  26. Metabolism of Prozac (fluoxetine)?
    Liver via cytochrome P450

    caution in elderly, liver dysfunction
  27. Half-life of Prozac (fluoxetine)?
    2-7d (longest for SSRIs)

    slow elimination distinguishes it from other antidepressants

  28. T/F: You have to taper Prozac gradually when stopping treatment, as it can result in abrupt withdrawal syndrome if stopped suddenly .
    False. Side effects of the fluoxetine discontinuation are uncommon and mild. One of the recommended strategies for the management of discontinuation syndrome with other SSRIs is to substitute fluoxetine for the original agent, in cases where tapering off the dose of the original SSRI is ineffective
  29. What pregnancy category is Prozac?
    • C (epocrates), B (ppt slide)
    • (not recommended during lactation)
  30. T/F: It is best to give Prozac before bed due to the sedation side effect.
    Fasle. It will cause insomnia, so it is best to take  it in the morning.
  31. Major contraindication for fluoxetine (Prozac)?
    MAOI - either concurrent or within 14 days
  32. What is a fatal side effect of Prozac?
    Serotonin syndrome if given with triptans, tramadol or other serotonergic agents (antidepressants, dopamine agonists, analgesics)
  33. What are some S&S of serotonin syndrome and when do you see them?
    2-72 hours after start of treatment

    hyperthermia, HTN, myoclonic jerking, tremor, agitation, ataxia, disorientation, hyperreflexia, fever, confusion, delirium, nausea, diarrhea
  34. T/F: You can start an MAOI in someone that has been off Prozac as long as it has been at ≥ 2 weeks.
    No, 5-6 weeks should elapse after discontinuing a SSRI and starting a MAOI
  35. T/F: Prozac (fluoxetine) is not associated with GI disturbances.
    False. GI disturbances are common.
  36. With Prozac, treatment usually works well at first, but as side effects develop the efficacy diminishes.
    False. Side effects come first (onset in hours to days) and therapeutic effects can take up to 4 to 6 weeks.
  37. Is Prozac (fluoxetine) indicated for mania or bipolar disorder?
    No. It can make them manic! Have to be careful because hypomania can mimic depression. 

    (S&S: hx of lots of energy, no sleep, risky behavior)
  38. T/F: You should encourage pts to take NSAIDs for pain control when on Prozac (fluoxetine), as acetaminophen is a bad option due to additive liver side effects.
    False! NSAIDs increase bleeding risk.

    Also should not take ASA, Vit E, anticoagulants...
  39. What drug class is escitalopram (Lexapro)?
    • SSRI
    • selectively inhibits serotonin reuptake
  40. With Prozac, treatment usually works well at first, but as side effects develop the efficacy diminishes.
    No. It can make them manic! Have to be careful because hypomania can mimic depression. 

    (S&S: hx of lots of energy, no sleep, risky behavior)
  41. How do you d/c escitalopram (Lexapro)?
    Titrate down slowly. ↓ by 50% for 3-4 days, then another 50% for 3/4 days.

    If develop withdrawal S&S–dizziness, lethargy, diarrhea, flulike symptoms, vertigo, tremors, tinnitus, insomnia, vivid dreams, anxiety, agitation, irritability, confusion, slowed thinking–↑ to previous dose, wait longer (1-2 weeks instead of 3-4 days).
  42. How long will abrupt withdrawal syndrome last without intervention?
    a couple of weeks
  43. T/F: Routine vital signs and lab reports are needed in SSRI treatment for healthy individuals.
    False. Need to watch electrolytes in the elderly.
  44. T/F: Since antidepressants require an adequate trial of up to maximum dosing of 8 weeks, the first prescription should be written for 8 weeks.
    False. Never give >4 weeks for the first perscription. You want to see them in 4 weeks to assess the response of the medication.
  45. T/F: SSRI's (like Prozac or Lexapro) increase the risk of thromboemboli.
    False. They increase the risk of bleeding.

    • 2x the volume of blood loss during surgery
    • 4x higher risk for blood transfusions
  46. T/F: Escitalopram (Lexapro) causes sedation.
    False. Insomnia.
  47. What antidepressant do you avoid if sexual dysfunction is a concern?

    70% of pts on Prozac develop sexual dysfunction
  48. What drug class is phenelzine (Nardil) in?

    (MAO is an enzyme that metabolize dopamine, NE, 5HT)
  49. Who should prescribe MAOIs (Nardil/phenelzine)?
    a psychiatrist

    low safety margin/potential lethal effects
  50. What dietary problems result from MAOIs?
    tyramine, phenylethylamine... ↑ HTN

    Avoid tyramine-rich foods (yeast, yogurt, cheese, fish or meat, caviar, figs, bananas, raisins, avocados, wine, soy sauce)

    Avoid foods with vasopressors too (fava beans, caffeine, chocolate, alcohol)
  51. What is the big risky side effect of MAOIs (like Nardil)?
    HTN/sympathomimetic crisis with concurrent anticholinergic, sympathomimetics, & stimulants

  52. MAOIs are first-line treatment for depression but have a long half-life.
    • No. SSRIs or SNRIs are first-line treatment. 
    • relatively SHORTER half-life
  53. Treatment for MAOI HTN crisis?
    Regitine (phentolamine)
  54. Monitor what lab test for MAOIs?
    LFTs, d/c if abnormal

    Take their BP too!
  55. Common ADRs of MAOIs
    • insomnia, anxiety, agitation (due to dopamine)
    • Anticholinergic SE (can't see, can't spit, can't pee, can't shit)
    • dizziness, HA, insomnia, restlessness, orthostatic hypotension
  56. Your patient on Nardil (phenelzine) was just diagnosed with CAD on his 60th birthday. Also, he says, "Now that I'm 60, I'm gonna do whatever I want!". What's next?
    MAOIs are contraindicated in arteriosclerotic disease or CHF, age ≥60, and in the impulsive, cognitively impaired, and those unable to follow the diet. Need to d/c, but need to taper down. Consult with psychiatrist.

    PS- it's also CI for liver or kidney disease
  57. What is the MOA of Klonopin (clonazepam)?
    binds to benzodiazepine receptors; enhances GABA effects
  58. What is clonazepam (Klonopin) indicated for and what class is it in?
    a benzodiazepine drug (gaba-ergic)

    Clonazepam (Klonopin) has anxiolytic, anticonvulsant, muscle relaxant, sedative, and hypnotic properties
  59. Does clonazepam (Klonopin) cause dependency?
    Yes. Tolerance, dependence, & withdrawal syndrome occur in 1/3 of people on clonazepam for > 4 weeks
  60. PS-APN, what is clonazepam (Klonopin) used to treat?
    • Panic disorder
    • Seizure disorder
    • Anxiety
    • Periodic leg movement
    • Neuralgia
  61. Major adverse reactions for clonazepam (Klonopin)?
    • Drowsiness and other CNS effects
    • Depression
    • "hangover effect" - long half life
    • sexual side effects
    • elevated LFTs

  62. Contraindications of clonazepam (Klonopin)?
    • contraindicated if liver disease
    • pregnancy C
    • do not drink alcohol
  63. In what drug class is oxazepam (Serax)?
    Benzodiazepine (gaba-ergic)
  64. What is an advantage of clonazepam (Klonopin)?
    long half life means daily dosing
  65. What is an advantage of Serax (oxazepam)?
    good for detox, easy on liver
  66. First-line therapy for anxiety?
  67. Regarding SSRIs, which s/s resolve first (anxiety versus depression)?
    Anxiety resolves earlier, but higher doses are needed for anxiety than for depression.
  68. When is the full therapeutic effect of SSRIs realized?
    2-4 weeks