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Anti depressants
 

Anti depressants

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Broad Over-view of classification of anti-depressants, indications & side-effects.

Broad Over-view of classification of anti-depressants, indications & side-effects.

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    Anti depressants Anti depressants Presentation Transcript

    • Anti-Depressants Dr.Harim Mohsin
    • First things first  Depression is a medical condition & not any fault of the individual concerned.  Assessment & evaluation is mandatory-Severity, etiology & risk-factors.  Treatment plan comprises of medication, psychological & social support.
    • Indications  Depression Moderate-Severe, Atypical, SAD, Depressive episode of Bipolar disorder.  Anxiety disorders GAD, Panic Disorder, Social Anxiety, Adjustment disorders, Agoraphobia, OCD, PTSD.
    • Mode of Action
    • Mode of action All antidepressants function by increasing availability of monoamines (5-HT, NA or DA) by one of the following methods:  Presynaptic inhibition of reuptake of 5-HT, NA or DA.  Antagonist activity at presynaptic inhibitory 5HT or NA receptors which enhances neurotransmitter release.  Inhibition of Monoaminase oxidase, reducing NT breakdown.  Increasing availability of NT precursors. Initial resolution of depressive symptoms takes minimum of 2-4 weeks.
    • Classification Broadly into 2 Types:  Re-uptake Inhibitors  Enzyme Inhibitors
    • Classification  Selective serotonin reuptake inhibitors (SSRIs) Monoamine oxidase inhibitors (MAOIs) – –  Serotonin-norepinephrine reuptake inhibitors (SNRIs) Irreversible Reversible   Norepinephrine reuptake inhibitors (NRIs)  Tricyclic antidepressants (TCAs)  Norepinephrine-dopamine reuptake inhibitors (NDRIs)  Serotonin antagonist and reuptake inhibitors (SARIs) Noradrenergic and specific serotonergic antidepressant (NaSSA)  Tetracyclic antidepressants (TeCAs)
    • SSRIs (Selective serotonin reuptake inhibitors) Mechanism: Increases 5HT in synaptic cleft.  Citalopram (Cipram)  Escitalopram (Cipralex, Citanew, Neolexa)  Paroxetine (Paroxin, Seroxat)  Fluoxetine (Prozac, Depex)  Fluvoxamine (Faverin)  Sertraline (Zoloft, Sert):
    • Indications  Depression  Panic Disorder with agoraphobia  Social Anxiety/ GAD/ OCD  Bulimia  PTSD
    • Side-effects         GI discomfort/ nausea Sexual dysfunction Sleep disturbance Dry mouth Tremor Headache Anxiety/ restlessness. Fatigue Caution:  Be aware of interactions-inhibitory effects on P450 & changes with alcohol, anticoagulants, MAOIs, TCA, smoking etc.
    • TCA Mechanism Mechanism:  Reuptake inhibition NA, 5HT & DA.
    • TCAs (Tricyclic antidepressants )  Amitriptyline (Tryptanol)  Clomipramine (Clomfranil)  Desipramine (Norpramin,Pertofrane)  Dosulepin (Prothiaden)  Doxepin (Doxin)  Imipramine (Tofranil, Imidol)  Nortriptyline (Sensival)
    • Indications  Depression  Nocturnal Enuresis (Amitriptyline/ Imipramine)  Phobic/Obsessional  Cataplexy States with narcolepsy
    • Side-effects        Dry mouth, Caution: Blurred vision,  Arrhythmias & ECG Sedation, changes. Monitor Orthostatic hypotension, Cardiac function, LFTs, Constipation, UCEs. urinary incontinence. Disorientation or  Should be used confusion cautiously in elderly.
    • SNRIs (Serotonin-norepinephrine reuptake inhibitors ) Mechanism: Similar to SSRI, Inhibit 5HT & NA (high doses DA) Indications: GAD, Depression.  Venlafaxine (Efexor)  Duloxetine (Oxcym DR, Hapibar, Lyta)  Levomilnacipran (Fetzima)  Tramadol (Tramal, Ultram)  Sibutramine (Meridia, Reductil) Side-effects: Similar to SSRIs & may cause HTN.
    • MAOIs (Monoamine oxidase inhibitors)   Irreversible inhibition of MAO-A (acts on NA, DA, 5HT & Tyramine) & MAO-B (acts on DA, Tyramine, Phenylethylamine, benzylamine) leading to accumulation of monoamines in Synaptic Cleft.  RIMAs: Reversible inhibition of MAO-A.
    • Indications  Depression (atypical)  Parkinson's Disease,  Migraine prophylaxis  Other disorders: panic disorder with agoraphobia, social phobia, bulimia, PTSD, borderline personality disorder, and bipolar depression.
    • MAOIs (Monoamine oxidase inhibitors) Irreversible  Isocarboxazid (Marplan)  Phenelzine (Nardil)  Selegiline (Selgin, Eklin) Reversible  Moclobemide (Aurorix, Manerix)  Pirlindole (Pirazidol)
    • MOA Inhibitors- Say No.
    • Side-Effects  Hypertensive crisis  Dizziness/ Headaches  Hepatotoxicity  Sleep disturbance  Weight gain  Sexual dysfunction  Drug Interactions Caution:  Dietary restriction (Tyramine) e.g: cheese, chocolate, wine, beans & soy products.  Serotonin Syndrome: Lifethreatening condition with somatic, autonomic & cognitive effectsTachycardia, myoclonus, tremors, altered Mental status, hyperthermia, DIC, metabolic disturbances.
    • Tetracyclic antidepressants (TeCAs) Mode: Similar to TCA without anticholinergic SE Indications: TCA with sedation. S/E- Cardiotoxicity     Mirtazapine (Remeron) Mianserin (Bolvidon, Norval, Tolvon) Amoxapine (Asendin) Maprotiline (Ludiomil) Noradrenergic and specific serotonergic antidepressant (NaSSA) Mode: α2 inhibitor (^NA/5HT), 5HT1, 5HT2 antagonist. Indications: Depression (+anxiety,wt loss) adjunct SSRI/venlafaxine to improve SxD, GI discomfort. Advantages: Low Toxicity, less sexual dysfunction & GI upset.
    • (SARIs) Serotonin antagonist and reuptake inhibitors Mode: 5HT reuptake inhibitor & antagonist. (sedation/ antihistamine) Indication: Depression (+insomnia) / Anxiety Advantage: Less antimuscranic/ cardiotoxic than TCA.  Trazodone (Deprel)  Etoperidone (Axiomin, Etonin)  Nefazodone (Serzone, Nefadar)
    • Other anti-depressants  Norepinephrine-dopamine reuptake inhibitors (NDRIs) Mode: NA/DA reuptake inhibition Indications: Depression (with marked psychomotor retardation or hypersomnia), Nicotine/stimulants dependence, ADHD. Advantage: Unusual mode of action-alerting effects, controls impulse disorders & secondary benefits as AD. S/E: Seizures & hypersensitivity.  Bupropion (Wellbutrin, Zyban)
    • Other anti-depressants  Norepinephrine reuptake inhibitors (NRIs)- Indication: Atypical Depression Reboxetine (Edronax)
    • Adjunctive treatments Itself doesn’t possess antidepressant quality but works in combination. Atypical antipsychotics  Aripiprazole (Aripip)  Olanzapine (Olanzia,Amprexa)  Quetiapine (Qusel)  Risperidone (Risperdal,Persch, Neoris)      Others Carbamazepine Lamotrigine (Lamictal) Lithium salts Triiodothyronine (T3; a thyroid hormone)
    • Alternate treatments Psychotherapy / counseling  Phytotherapy: St-John’s Wort  Exercise  Nutritional Supplements- Vitamins, minerals, O3-FA.  Adequate sleep.  Avoid Alcohol & other recreational drugs  Meditation, Acupuncture, chiropractice & yoga. 
    • Think Positive! Thank You