1 00:00:00,880 --> 00:00:04,480 All right, so today we're gonna be talking about antidepressants. Thank you everybody 2 00:00:04,519 --> 00:00:08,560 who's supporting the podcast, the really nice comments, everything, I really appreciate 3 00:00:08,640 --> 00:00:11,320 it, and thank you so much for today's sponsor, True Learn. So 4 00:00:11,400 --> 00:00:16,760 let's talk about antidepressants, SSRIs, S, NRIs, TCAs MAOIs, atypical 5 00:00:16,800 --> 00:00:20,280 antidepressants. There's a lot to know here, so I'll keep it as high 6 00:00:20,320 --> 00:00:23,879 yield as possible and throwing a bunch of nomonics to help you remember what you 7 00:00:23,960 --> 00:00:27,079 really need to know. Before we get started, let's really quickly talk about 8 00:00:27,079 --> 00:00:31,160 a couple basic fundamental concepts that will help you better understand the meds will go 9 00:00:31,199 --> 00:00:37,200 over today. Let's start with the monoimmine hypothesis. So the monomine pothesis dates 10 00:00:37,200 --> 00:00:42,399 back to the nineteen fifties, basically states that the underlying pathiophysiologic basis of depression 11 00:00:42,759 --> 00:00:47,920 is essentially a depletion in levels of serotonin or apenephrine or dopamine in the CNS. 12 00:00:48,119 --> 00:00:50,840 Now, we've learned a lot over the years and we know that's not 13 00:00:50,960 --> 00:00:54,479 all that's going on. There's definitely more to it than just a chemical imbalance. 14 00:00:54,679 --> 00:00:58,079 But understanding this basic concept, it's going to help you better understand the 15 00:00:58,119 --> 00:01:02,000 meds will go over today and their propose mechanism of action. So before we 16 00:01:02,000 --> 00:01:04,040 start with the first class of meds, let's really quickly run down this whole 17 00:01:04,040 --> 00:01:08,840 neuro transmitter exchange in the brain. So we have two neurons close together. 18 00:01:10,000 --> 00:01:14,000 One neuron is the presynaptic neuron, the other is the post synaptic neuron. 19 00:01:14,239 --> 00:01:18,760 They're separated by a teeny tiny space called a synaptic left. So the presynaptic 20 00:01:18,840 --> 00:01:21,840 neuron, it's got all the goodies depending on which type of neuron we're referring 21 00:01:21,840 --> 00:01:26,319 to, serotonergic et cetera. It's stocked with either dopamine, serotonin, neuropinephrin, 22 00:01:26,599 --> 00:01:30,840 and they're all stored in these sac like structures called vesicles. So eventually 23 00:01:30,879 --> 00:01:33,680 we have to get those neurotransmitters out of those vesicles so they can do their 24 00:01:33,719 --> 00:01:38,480 work. So what happens is an action potential zaps this presynaptic neuron, which 25 00:01:38,519 --> 00:01:42,560 causes these vesicles to open up and dump their delicious contents into that presynaptic left 26 00:01:42,560 --> 00:01:47,640 between the two neurons. At this point, those neurotransmitters dopamine, serotonin, 27 00:01:47,680 --> 00:01:51,359 et cetera. They bind to the receptors on the post synaptic neuron and then 28 00:01:51,400 --> 00:01:55,040 they work their magic. After a period of time, though the neurotransmitters that 29 00:01:55,040 --> 00:01:57,239 are still hanging out in the synaptic left not really doing much. Bodies got 30 00:01:57,239 --> 00:02:00,719 to clean them up. So some of them will just drift off in a 31 00:02:00,719 --> 00:02:05,359 process called diffusion. Other cases they'll be sucked back into that presynaptic neuron and 32 00:02:05,439 --> 00:02:08,319 potentially broken down by an enzyme not as monoamineoxidase. A lot of the meds 33 00:02:08,319 --> 00:02:14,360 will go over today impact this specific area inhibiting that clean up process. Some 34 00:02:14,479 --> 00:02:17,439 meds block the reabsorption of those neurotransmitters, allowing them to hang out in the 35 00:02:17,479 --> 00:02:23,680 synaptic left for longer. Some meds block monominoxidase, so those neuro transmitters aren't 36 00:02:23,680 --> 00:02:25,680 broken down. It can be recycled for another go. And we'll dive deeper 37 00:02:25,719 --> 00:02:30,560 into that once we break down each individual class of medication. So that's the 38 00:02:30,599 --> 00:02:32,840 basics. Now that we have that covered, we'll get started and we'll start 39 00:02:32,840 --> 00:02:38,039 with arguably the most important class of medication to know for psych and that's your 40 00:02:38,080 --> 00:02:42,199 SSRIs, our selective serotonin reuptake inhibitors. If you're going to focus on one 41 00:02:42,199 --> 00:02:46,639 class of medication for psych Let it be SSRIs. You get a question and 42 00:02:46,719 --> 00:02:49,719 it says, which is the first line med for the psychiatric disorder? And 43 00:02:49,800 --> 00:02:52,680 you can't remember which met it is? Pick an SSRI and you got to 44 00:02:52,680 --> 00:02:55,479 good chance of getting it right. So the meds in this class are cytalopram 45 00:02:55,800 --> 00:03:01,439 esketalaprem, fluoxetine, fluvoxamine, roxetine, and sertraline. It's a lot of 46 00:03:01,479 --> 00:03:06,800 weird and similar sounding meds. A lot of these antidepressants are just really difficult 47 00:03:06,800 --> 00:03:09,680 to memorize as they all sound so similar, and usually I don't recommend taking 48 00:03:09,680 --> 00:03:14,000 the time, but for SSRISE, this would be the one time where I 49 00:03:14,000 --> 00:03:16,000 would make an effort if you can, because they come up so often and 50 00:03:16,000 --> 00:03:19,639 it's good to be familiar with them, so if you do want a way 51 00:03:19,680 --> 00:03:23,199 to memorize them, I do have anemoonic. So when you think of SSRIs, 52 00:03:23,400 --> 00:03:25,280 I want you to visualize, for now on, is a snake charmer, 53 00:03:25,360 --> 00:03:29,280 those guys who play that flute that makes the snake come out of those 54 00:03:29,280 --> 00:03:32,439 little baskets. That's what you're gonna associate with SSRI medications from now on. 55 00:03:32,800 --> 00:03:36,960 Think of a snake charmer. Sitting down. He's got a parrot on his 56 00:03:37,000 --> 00:03:39,960 shoulder. Oddly enough, he's playing the flute, and the snake also known 57 00:03:40,000 --> 00:03:45,000 as a serpent, is slowly escaping the basket. Again, snake charmers sitting 58 00:03:45,000 --> 00:03:47,439 down, parad on his shoulder, playing his flute. The serpent is escaping 59 00:03:47,439 --> 00:03:52,479 the basket. So sitting down should help you remember sit talipram not the same 60 00:03:52,520 --> 00:03:55,759 spelling, but same pronunciation. Parrot should help you remember paroxetine. And the 61 00:03:55,759 --> 00:04:00,439 parad on his shoulder, by the way, is really fat because peroxetine is 62 00:04:00,479 --> 00:04:03,199 the SSRI associated with the most weight gain of all of the SSRIs. And 63 00:04:03,240 --> 00:04:08,479 he's playing as flute. Flute helps you remember fluoxetine and fluvoxamine. And then 64 00:04:08,599 --> 00:04:13,719 the escaping serpent. Remember serpent slowly escaping the basket. Escaping helps you remember 65 00:04:13,879 --> 00:04:17,600 escitelepram m. Serpent helps you remember certraline. All right, hopefully that helps 66 00:04:17,600 --> 00:04:20,839 remember snake charmer every time you hear about SSRIs. Now that we know the 67 00:04:20,879 --> 00:04:24,480 meds that are in this class, let's talk about how they work. Well. 68 00:04:24,519 --> 00:04:29,480 The name certainly helps with that. SSRI stands for selective serotonin reuptake inhibitor, 69 00:04:29,759 --> 00:04:33,920 so SSRIs selectively inhibit the reuptake of serotonin. So let's start with the 70 00:04:33,920 --> 00:04:39,800 words selective, because that's actually really important. This class of medication has relative 71 00:04:39,959 --> 00:04:44,639 little affinity for other types of receptors besides serotonin, unlike some of the other 72 00:04:44,680 --> 00:04:47,160 meds will go over today that target a bunch of other areas, often causing 73 00:04:47,199 --> 00:04:51,079 a number of unwanted side effects. The selectivity of this class, it's part 74 00:04:51,120 --> 00:04:55,839 of the reason they're so well tolerated and have a relatively benign side effect profile. 75 00:04:56,000 --> 00:05:00,319 It's also the reason they're preferred over other classes quite often. Select Ativity 76 00:05:00,399 --> 00:05:03,160 definitely important. Now, how do they inhibit the reuptake of serotonin? Why 77 00:05:03,199 --> 00:05:06,839 does this matter? But we talked about this briefly before. So SSRIs do 78 00:05:06,879 --> 00:05:13,560 this by decreasing the action of that presynaptic reuptake pump, that pre synaptic serotonin 79 00:05:13,560 --> 00:05:17,120 reuptake pump, So they essentially block the removal of serotonin from the synaptic left 80 00:05:17,480 --> 00:05:21,639 for a period of time. It's like if there was a big vacuum sucking 81 00:05:21,720 --> 00:05:26,480 up all the serotonin from the synapse. SSRIs just come in and plug that 82 00:05:26,600 --> 00:05:30,120 up, so in turn, we have more serotonin hanging around for longer and 83 00:05:30,160 --> 00:05:33,920 it was originally hypothesized that more serotonin meant improved mood, and that's how these 84 00:05:33,920 --> 00:05:38,199 meds work, and it was so simple, but in actuality, it's not 85 00:05:38,279 --> 00:05:41,399 that simple, and we later realized there's more to it than that, because 86 00:05:41,680 --> 00:05:45,800 if the effect of SSRIs were solely based on the fact that they just inhibit 87 00:05:45,839 --> 00:05:49,480 reuptake of serotonin leading to increased serotonin levels, they'd be effected from day one, 88 00:05:49,519 --> 00:05:54,680 as serotonin levels increase very rapidly after taking the first dose. But in 89 00:05:54,720 --> 00:05:59,680 actuality, the full therapeutic effect of SSRIs usually takes many weeks to manifest, 90 00:06:00,040 --> 00:06:02,759 so we know something else is going on here besides the increased serotinergic activity. 91 00:06:03,000 --> 00:06:05,480 And I don't think you need to know this for your exam, but it's 92 00:06:05,480 --> 00:06:12,800 believed SSRIs also increase production of neuroprotective proteins that can modify serotonergic receptors, and 93 00:06:12,839 --> 00:06:15,639 these added effects, which occur in the week's following initiation of the medication, 94 00:06:16,160 --> 00:06:19,800 are thought to be the reason for the delay therapeutic benefit. So for the 95 00:06:19,839 --> 00:06:25,240 exam, remember, these drugs selectively inhibit reuptake of serotonin, leading to increased 96 00:06:25,240 --> 00:06:29,040 serotonin activity in the CNS. But for real life. Realize there's more to 97 00:06:29,079 --> 00:06:30,319 it than that. All right, Now, let's talk about the indications for 98 00:06:30,399 --> 00:06:35,680 these meds next. Starting with major depressive disorder unipolar major depressive disorder, so 99 00:06:35,680 --> 00:06:41,560 when we're talking about pharmacologic therapy for treatment of depression, SSRIs are usually going 100 00:06:41,600 --> 00:06:45,000 to be your first line agents. Now, depending on the comorbidities the patient 101 00:06:45,040 --> 00:06:49,040 has, in some cases snrize atypical an adepressants and serotoninodulators that will go over 102 00:06:49,120 --> 00:06:54,439 later, they can be reasonable alternatives to ssriz for initial treatment, but in 103 00:06:54,480 --> 00:06:59,120 general most patients you're going to start with an SSRI. So some other indications 104 00:06:59,120 --> 00:07:03,360 for SSRIs are generalized anxiety disorder, panic disorder, post traumatic stress disorder, 105 00:07:03,639 --> 00:07:09,879 pre menstrual syndrome, and pre menstrual dysphoric disorder, obsessive compulsive disorder, and 106 00:07:09,920 --> 00:07:14,959 then blimia nervosa, but specifically fluoxetine, so believe me is another indication for 107 00:07:15,079 --> 00:07:18,759 SSRIs. Specifically fluoxetine though, is what you should remember as it's the only 108 00:07:18,959 --> 00:07:24,480 FDA approved med Other SSRIs can be you second line, but the only f 109 00:07:24,480 --> 00:07:28,079 first line FDA proved met for bolimia is fluoxetine. So this is such an 110 00:07:28,120 --> 00:07:30,360 easy test question. I know I got it, and you'll probably be asked 111 00:07:30,360 --> 00:07:33,639 this, so how can you remember this? I have a mnemonic. It's 112 00:07:33,680 --> 00:07:35,879 not perfect, but it's going to at least help you down narrow down the 113 00:07:35,959 --> 00:07:41,160 choices on an exam question. So, bolimia has the word bull in it, 114 00:07:41,240 --> 00:07:44,639 so a bull is a cow with horns, and then fluoxetine has the 115 00:07:44,680 --> 00:07:46,199 word ox in it, and then ox is just another type of caw with 116 00:07:46,240 --> 00:07:50,360 horns. So when you see bulimia, think of an ox as in fluoxetine, 117 00:07:50,600 --> 00:07:55,319 the other caw with horns bolimia, fluoxetine, bull and an ox. 118 00:07:55,720 --> 00:07:59,600 The only crappy part about this mneumonic is there's other meds in this class that 119 00:07:59,639 --> 00:08:03,000 have the word ox in them, peroxetine, fluvoxamine, but the rest of 120 00:08:03,000 --> 00:08:05,639 the SSRIs do not, and a lot of the other classes don't. So 121 00:08:05,680 --> 00:08:07,000 it's going to at least help you narrow it down on the answer choices. 122 00:08:07,240 --> 00:08:11,079 So they ask you what's your first line med for bulimia, be thinking of 123 00:08:11,079 --> 00:08:13,800 a bowl, then remember your other cow with horns and ox, and then 124 00:08:13,800 --> 00:08:16,399 make sure you look for a med with the word ox in it. And 125 00:08:16,439 --> 00:08:18,399 then you can narrow it down that way. So there's some other indications, 126 00:08:18,439 --> 00:08:20,680 but those are the main ones you'll likely be tested on, and that's what 127 00:08:20,720 --> 00:08:24,560 you should be aware of. Let's next move on to our adverse effects. 128 00:08:24,720 --> 00:08:28,399 So, because SSRIs are so selective, as we discussed before, mainly just 129 00:08:28,439 --> 00:08:33,279 affecting the serotonin receptor and not messing around with the other stuff like the cholinergic 130 00:08:33,320 --> 00:08:37,960 receptors exception being proxyetine. Anyways, because of the selectivity, they have a 131 00:08:39,000 --> 00:08:41,960 relatively benign side effect profile. With that being said, they still of course 132 00:08:43,000 --> 00:08:45,960 have some side effects. So which ones do you need to know for the 133 00:08:46,000 --> 00:08:48,919 exam. Let's start, of course with the black box warning, as you 134 00:08:48,960 --> 00:08:52,840 should always know any block box warning for any medication class. So SSRIs increase 135 00:08:52,919 --> 00:08:58,840 the risk of suicidal ideation in children, adolescents, and adults younger than twenty 136 00:08:58,840 --> 00:09:03,200 five years. This doesn't seem to be the case for older adults, but 137 00:09:03,279 --> 00:09:05,480 patients twenty four and under need to be aware of this black box warning. 138 00:09:05,679 --> 00:09:09,720 Now, this black box warning isn't just for SSRIs. In two thousand and 139 00:09:09,799 --> 00:09:15,919 four, the FDA issued this black box warning for all antidepressant drug classes SSRIs, 140 00:09:16,000 --> 00:09:18,919 SNRIs, TCAs, etc. So this isn't unique to SSRIs, and 141 00:09:18,960 --> 00:09:22,440 I'm not going to bring this up every single med class we go over for 142 00:09:22,440 --> 00:09:26,159 the sake of time. But just be aware of this risk with all antidepressants, 143 00:09:26,279 --> 00:09:31,519 all right. Next is QT prolongation, specifically citalopram most importantly, and 144 00:09:31,519 --> 00:09:35,639 then esctalopram. This is a very important one when it comes to QT interval 145 00:09:35,639 --> 00:09:39,240 prolongation. The biggest culprit by far is citalopram. You need to know cetalobram 146 00:09:39,360 --> 00:09:45,320 can cause QT interval prolongation. Esctalopram it's a close second. Studies are not 147 00:09:45,360 --> 00:09:48,960 as convincing. And then the other SSRIs in the class have minimal to no 148 00:09:48,039 --> 00:09:52,000 impact on QT interval. So you need to know these two, especially citalopram. 149 00:09:52,039 --> 00:09:54,440 They're going to ask you this at some point on an exam question. 150 00:09:54,879 --> 00:09:58,720 So when you see an exam question that asks which SSRI should be avoided in 151 00:09:58,720 --> 00:10:01,919 a payd with long QT syndrome, I want you to think of this sentence. 152 00:10:03,279 --> 00:10:05,159 If you long for quiet time, you need to escape the city. 153 00:10:05,320 --> 00:10:09,759 If you long for quiet time, you need to escape the city. Long 154 00:10:09,840 --> 00:10:13,399 for quiet time helps remember long QT quiet time QT long for quiet time, 155 00:10:13,759 --> 00:10:20,200 long QT escape helps remember escitalopram, and city helps you remember the most important 156 00:10:20,200 --> 00:10:22,240 of all, citalopram. So again, if you long for quiet time, 157 00:10:22,279 --> 00:10:24,600 you need to escape the city. That's going to help you remember. The 158 00:10:24,639 --> 00:10:31,480 SSRIs associated with prolongation of the QT interval citalopram and esctelepram. Sexual dysfunction is 159 00:10:31,480 --> 00:10:35,000 another one. It's one of the most common adverse effects of SSRIs. Actually, 160 00:10:35,200 --> 00:10:39,600 it's been estimated that sexual appairment and roughly fifty percent of patients treated with 161 00:10:39,720 --> 00:10:45,879 SSRIs. This occurs in both men and women and includes decreased libido, decreased 162 00:10:45,919 --> 00:10:48,759 arousal, delayed orgasm. Sometimes this will get better as the weeks go on 163 00:10:48,799 --> 00:10:52,039 if they've been taking the SSRI for a while. Sometimes you need to decrease 164 00:10:52,080 --> 00:10:54,840 the dose to kind of help with this. Sometimes you just need to change 165 00:10:54,840 --> 00:11:00,240 the metal together. In some cases though, the side effects are actually beneficial. 166 00:11:00,559 --> 00:11:05,120 For instance, SSRIs are considered first line treatment for men with premature ejaculation. 167 00:11:05,279 --> 00:11:09,480 So sexual dysfunction another big one you need to know. And then serotonin 168 00:11:09,480 --> 00:11:13,879 syndrome. It's a potentially lethal condition that usually results from an interaction between multiple 169 00:11:13,960 --> 00:11:18,559 meds that increase serotenergic neurotransmission. It's not specific to SSRIs, as this can 170 00:11:18,559 --> 00:11:20,919 be caused by pretty much all the antidepressants will go over today all of the 171 00:11:20,919 --> 00:11:26,279 serotonergic agents. But SSRIs are one of the more commonly implicated groups of meds 172 00:11:26,360 --> 00:11:30,759 leading to serotonin syndrome, probably because their frequency of being prescribed. They're so 173 00:11:30,879 --> 00:11:35,080 commonly used and they're usually associated with a more benign course though compared to other 174 00:11:35,120 --> 00:11:41,159 classes like MAOIs, which can often be fatal with serotonin syndrome. And we'll 175 00:11:41,159 --> 00:11:43,840 talk about more about that later once we get into that class. Next, 176 00:11:43,960 --> 00:11:50,679 hyponatremia, So SSRIs are also associated with SIADH and hyponatremia. The risk is 177 00:11:50,720 --> 00:11:52,440 pretty low, but you want to be careful prescribing to these patients who are 178 00:11:52,480 --> 00:11:56,720 at risk for hyponatremia, your older patients, patients taking diuretics, et cetera. 179 00:11:58,159 --> 00:12:01,399 And then finally we have weight changes, so SSRIs can be associated with 180 00:12:01,440 --> 00:12:05,600 weight gain. It's usually not a significant amount of weight, and sometimes it's 181 00:12:05,639 --> 00:12:09,399 not clear whether it was caused from the med or the weight gain was just 182 00:12:09,440 --> 00:12:13,000 the result of recovery from depression. But it is possible to see some weightain 183 00:12:13,080 --> 00:12:18,440 with the ssrise Fluoxetine usually causes the least amount of weight gain, and then 184 00:12:18,559 --> 00:12:22,080 peroxetine usually causes the most weight gain. Remember the fat parrot to help your 185 00:12:22,080 --> 00:12:26,080 remember. Peroxytine causes the most weake in of the SSRISE. Now there's other 186 00:12:26,159 --> 00:12:31,480 adverse drug reactions nausea, headache, insomnia, bleeding, but for the exam, 187 00:12:31,559 --> 00:12:33,720 the ones that went over those are the ones that are likely to be 188 00:12:33,799 --> 00:12:37,200 tested on, So focus on those all right. Next class is our SNRIs 189 00:12:37,519 --> 00:12:45,360 serotonin nor epinephrine reuptake inhibitors. This includes ben lefaccine, deuloxetine, level, 190 00:12:45,440 --> 00:12:50,200 manaciprim, milnacipran, and ben lefaccine. So there's five meds in this class, 191 00:12:50,600 --> 00:12:52,480 but if we're being real for an exam, I just focus on two, 192 00:12:52,639 --> 00:12:58,039 deloxetine and ven lafacxine. Know those really well, especially deloxetine, that's 193 00:12:58,120 --> 00:13:01,799 likely what you'll be tested on. As far as the mechanism of action, 194 00:13:01,000 --> 00:13:07,519 they block presynaptic reuptake of serotonin and nor epinephrin, so very similar to SSRIs. 195 00:13:07,919 --> 00:13:13,720 SNRIZE inhibit the reuptake of serotonin, but they also inhibit the reuptake of 196 00:13:13,759 --> 00:13:18,519 norepinephrin. They do this by binding two and inhibiting the serotonin and norepinephrin transporters 197 00:13:18,519 --> 00:13:24,679 on the serotonergic and neuadrienergic neurons. They're also technically weak inhibitors of dopamine reuptake, 198 00:13:24,720 --> 00:13:28,080 but the effect is pretty minimal and I wouldn't worry about that. Main 199 00:13:28,120 --> 00:13:31,440 effect is on serotonin and nor epi. Now you probably don't need to know 200 00:13:31,480 --> 00:13:35,759 this, but how well these meds affect nor epinephrin or serotonin really depends on 201 00:13:35,799 --> 00:13:41,639 the drug and the dose. For instance, venlofaxine at low doses is essentially 202 00:13:41,720 --> 00:13:46,759 just an SSRI It really just affects serotonin, whereas in high doses of ventlefacxine 203 00:13:46,960 --> 00:13:50,759 it has really significant effects on norepinephrin. So it's just a little extra knowledge. 204 00:13:52,200 --> 00:13:56,720 So again, with SSRIs we were really just affecting one neurotransmitter, serotonin. 205 00:13:56,919 --> 00:14:01,440 With s nrize we have effects on two serotonin and norapinephrim. So you'll 206 00:14:01,480 --> 00:14:03,919 notice a lot of overlap when comparing these two classes. A lot of their 207 00:14:03,919 --> 00:14:07,679 indications out of our drug reactions are the same, but there are some differences 208 00:14:07,759 --> 00:14:11,720 due to this new interaction with nor epi, which will go over shortly, 209 00:14:11,000 --> 00:14:15,240 so let's talk about the indication's next lot of overlap. Like I just talked 210 00:14:15,240 --> 00:14:20,080 about with SSRIs, so unipolar major depressive disorder. Just like SSRIs, SNRIs 211 00:14:20,120 --> 00:14:24,759 are obviously indicated for treatment of depression. And you might wonder if a class 212 00:14:24,799 --> 00:14:31,000 that affects both serotonin and nor epi would be more effective than SSRIs that just 213 00:14:31,039 --> 00:14:35,840 affects serotonin, And the answer is technically yes, snrize have proven to be 214 00:14:35,919 --> 00:14:41,759 a bit more efficacious than SSRIs, but the advantage is fairly small. And 215 00:14:41,840 --> 00:14:46,159 with that being said, SSRIs are still usually preferred first line for depression, 216 00:14:46,200 --> 00:14:50,320 but sentrized are reasonable alternative for initial treatment in certain patient populations, which we'll 217 00:14:50,360 --> 00:14:56,919 talk about shortly. SNRIs are also indicated in generalized anxiety disorder, post traumatic 218 00:14:56,919 --> 00:15:01,799 stress disorder, panic disorder. So there's a lot of similar when comparing snriz 219 00:15:01,879 --> 00:15:05,440 to SSRIs, But when things are the same, that's usually not what's going 220 00:15:05,480 --> 00:15:09,840 to be tested on. What's usually tested on is the unique aspects and what 221 00:15:09,960 --> 00:15:15,200 makes s NRIs different than SSRIs, and what we should really be familiar with 222 00:15:15,600 --> 00:15:20,480 is their ability to treat chronic pain syndromes like diabetic peripheral neuropathy, fibromyalogia, 223 00:15:20,600 --> 00:15:26,600 chronic muscular skeletal pain. So snriz possess analg sequalities that we did not see 224 00:15:26,679 --> 00:15:31,080 with the use of SSRIs, and this is likely due to the fact that 225 00:15:31,279 --> 00:15:35,639 SNRI is also target or P. As we discussed, this neurotransmitter likely plays 226 00:15:35,639 --> 00:15:39,240 a role in some form of pain modulation. So this is the main difference 227 00:15:39,279 --> 00:15:41,519 to know for indications as the rest are as. The rest are really just 228 00:15:41,559 --> 00:15:46,039 a repeat from SSRIs, so s nrize, in addition to treatment of depression, 229 00:15:46,080 --> 00:15:50,759 anxiety, et cetera, also have a dual purpose for treating chronic pain 230 00:15:50,799 --> 00:15:54,080 syndromes, so you need to remember that. And the s NURI you really 231 00:15:54,159 --> 00:15:58,960 need to know is douloxetine because while the other SNRIs have indications for some chronic 232 00:16:00,080 --> 00:16:06,559 pain syndromes, duloxetine actually has the largest evidence base to support nalgesic efficacy and 233 00:16:06,600 --> 00:16:10,840 it's FDA proof not only for fibromyalgia, chronic lower back pain, osteoorithritis, 234 00:16:10,879 --> 00:16:14,360 but diabetic neuropathy as well. So that's the one you really need to know, 235 00:16:14,399 --> 00:16:15,840 and that's the one they'll likely test you on the way that you're gonna 236 00:16:15,840 --> 00:16:22,960 remember that is by instead of remembering duloxetine, remember it as dual loxetine dul 237 00:16:23,240 --> 00:16:29,440 dual oxetine, as it's dual indicated for both major depression as well as chronic 238 00:16:29,480 --> 00:16:33,399 pain. Then you can also remember dual oxetine because it's a dual action agent 239 00:16:33,600 --> 00:16:37,679 that has an effect on both serotonin and norepinephrine. All right, adverse drug 240 00:16:37,759 --> 00:16:42,120 reactions next. So, just like SSRIs, s NRIZ are pretty specific, 241 00:16:42,200 --> 00:16:47,519 meaning they have little to no effect on your alpha one adrinergic receptors, your 242 00:16:47,559 --> 00:16:51,799 cholinerges, your kissamine receptors. And because of this, like SSRIs, they 243 00:16:51,799 --> 00:16:55,559 have a fairly clean side effect profile and their side effects are pretty similar to 244 00:16:55,639 --> 00:16:57,279 SSRIs, a lot of overlaps, so I'm not gonna waste your time with 245 00:16:57,360 --> 00:17:02,799 the similarities. Yes, just like SSRIs, they can cause hyponatremia, nausea, 246 00:17:03,080 --> 00:17:07,640 sexual dysfunction, serotonin syndrome, bleeding, same black box warning for increased 247 00:17:07,680 --> 00:17:11,319 suicidal ideation and young adults. Well, you should really focus on in what's 248 00:17:11,400 --> 00:17:15,559 different. So we know this class is affecting an additional neurotransmitter, nor EPI, 249 00:17:15,920 --> 00:17:18,480 So this causes new issues we didn't see with SSRIs, the main one 250 00:17:18,480 --> 00:17:23,680 to know is hypertension. So this one's unique. Snriz can cause hypertension, 251 00:17:23,920 --> 00:17:27,319 which appears to be due to their effect in neuropinephrin. So this is different 252 00:17:27,359 --> 00:17:30,599 compared to SSRIs and this is the one to focus on. Again, Remember 253 00:17:30,599 --> 00:17:34,279 focus on those unique aspects of these classes because there's so much to know. 254 00:17:34,599 --> 00:17:37,480 You don't want to waste your time with the overlap. Focus on the stuff 255 00:17:37,519 --> 00:17:42,559 that's different. All right, So quick recap. Remember snrize have dual effects. 256 00:17:42,559 --> 00:17:48,039 They target not only serotonin but norropinephrin. Remember they not only treat depression 257 00:17:48,079 --> 00:17:52,480 but also chronic pain syndromes. Deloxetine is the main one to know aka dual 258 00:17:52,519 --> 00:17:56,480 oxetine. And for ADR's focus on hypertension. Let's move on to our TCA's 259 00:17:56,559 --> 00:18:02,200 next. All right, So tricyclic anidepress or TCAs. These were developed back 260 00:18:02,200 --> 00:18:06,559 in the nineteen fifties starting with empromine, and they became first line treatment for 261 00:18:06,599 --> 00:18:10,880 close to thirty years for depression. So why did we stop using them? 262 00:18:10,920 --> 00:18:12,880 Well, it wasn't for their lack of efficacy. It's quite the opposite, 263 00:18:12,960 --> 00:18:18,480 as they wore and still are very effective in treating depression, But the same 264 00:18:18,480 --> 00:18:22,319 thing that makes them so effective, being very broad spectrum and interacting with so 265 00:18:22,319 --> 00:18:25,880 many neurotransmitter systems, it's also the same thing that makes them so dangerous, 266 00:18:25,920 --> 00:18:30,160 as they have numerous side effects and they have a very low threshold for overdose. 267 00:18:30,440 --> 00:18:33,119 So due to this, this class of meds has fallen out of favor 268 00:18:33,359 --> 00:18:37,920 and has been replaced by newer, safer classes like the SSRIs and SNRIs. 269 00:18:37,839 --> 00:18:42,119 They still do have some utilization in certain types of issues which will go over 270 00:18:42,200 --> 00:18:45,920 later, but not so much for depression anymore. All right, So what 271 00:18:45,960 --> 00:18:48,240 meds are in this class? While there's two main groups. TCAs are broken 272 00:18:48,319 --> 00:18:53,960 up into your tertiary TCAs they're known as, which include amatriptoline, chlomipramine, 273 00:18:55,039 --> 00:19:00,000 doccipin, empromine, trimipramine, and then your secondary TCAs, your secondary amens, 274 00:19:00,000 --> 00:19:04,000 which are decipromine, nor trip delene, and pro triptlene. So there's 275 00:19:04,079 --> 00:19:07,559 a lot of meds in this class, and there's not a good way to 276 00:19:07,599 --> 00:19:10,920 memorize all of them, and I strongly suggest against trying to do so, 277 00:19:10,960 --> 00:19:14,559 you're just gonna waste your time. But if you want to remember one that 278 00:19:14,599 --> 00:19:17,960 will likely be tested on. Remember Emma trip Delen. And if you're feeling 279 00:19:18,000 --> 00:19:19,920 a bit more ambitious and you want to remember a few of the high old 280 00:19:19,920 --> 00:19:25,079 meds in this class, just remember you're tripping if you're thinking about prescribing a 281 00:19:25,119 --> 00:19:29,240 TCA. You're trippin'. If you're thinking about prescribing a TCA, so trippin' 282 00:19:29,359 --> 00:19:33,759 trip space Pin. If you're thinking about prescribing a TCA, trip helps you 283 00:19:33,799 --> 00:19:38,319 remember Amma trip Delene, nor trip Delene, pro trip to line and pin 284 00:19:38,519 --> 00:19:41,799 helps remember Doc Sipin. That's all I remember from my exam, and it 285 00:19:41,839 --> 00:19:45,920 was enough for me to get the question right. So remember you're tripping if 286 00:19:45,920 --> 00:19:48,000 you're thinking about prescribing a TCA. All right, so now that we know 287 00:19:48,039 --> 00:19:51,440 the meds in this class, or at least the important ones, let's talk 288 00:19:51,440 --> 00:19:56,960 about how they work next. So TCAs inhibit serotonin and nor epinephrine reuptake. 289 00:19:56,160 --> 00:20:00,039 So you might be thinking that sounds a whole lot like how NRIs worked, 290 00:20:00,039 --> 00:20:06,200 and you're right, scent arize inhibited serotonin and orpinephrine reuptake. But the difference 291 00:20:06,480 --> 00:20:10,319 is they did this very selectively and very precisely, kind of tiptoed in. 292 00:20:10,400 --> 00:20:12,400 Did what they needed to as to not disturb other systems in the body, 293 00:20:12,720 --> 00:20:17,240 which is why they had a very clean side effect profile. TCA's, on 294 00:20:17,279 --> 00:20:19,200 the other hand, they come in like a wrecking ball, not only affecting 295 00:20:19,279 --> 00:20:26,200 the intended targets serotonin and norepi, but also affecting the muscarinic receptors, histamine 296 00:20:26,200 --> 00:20:30,319 receptors as well as others, causing a bunch of unintended side effects we did 297 00:20:30,319 --> 00:20:33,119 not see with scn ARISE. So the difference really is about the selectivity of 298 00:20:33,160 --> 00:20:38,359 this class or lack thereof. So indications for TCAs they're not really high yield. 299 00:20:38,359 --> 00:20:41,039 I wouldn't waste a whole lot of time here, as many other classes 300 00:20:41,119 --> 00:20:45,839 have replaced TCA's as first line agents, but sometimes these still do come up 301 00:20:45,880 --> 00:20:49,440 on exam's questions. So let's really quickly run down through some of the indications. 302 00:20:51,000 --> 00:20:55,119 So starting with major depressive disorder, these are not first line medser depression. 303 00:20:55,480 --> 00:20:57,119 You're not going to use a TCA for depression. This isn't going to 304 00:20:57,119 --> 00:21:00,799 be the answer on the test. Unless they specifically mentioned they have tried and 305 00:21:00,880 --> 00:21:06,440 failed multiple other classes SSRIs, S, centriize, et cetera. They may 306 00:21:06,480 --> 00:21:08,880 still be called tricyclic anidepressants, but you're generally not going to use them for 307 00:21:08,960 --> 00:21:14,680 depression unless all else fails due to their pre side effect profile. Next obsessive 308 00:21:14,680 --> 00:21:18,519 compulsive disorder, specifically clomippromine, so clomippermine can be used for the treatment of 309 00:21:18,559 --> 00:21:22,400 OCD, but SSRIs are usually going to be or not. Usually they're going 310 00:21:22,440 --> 00:21:26,160 to be first line. Clomippermine, though, is another treatment option only if 311 00:21:26,279 --> 00:21:33,400 SSRIs proved to be ineffective. Diabetic neuropathy TCAs can be used am atriptlene or 312 00:21:33,400 --> 00:21:37,920 triptlene or some common options migraine prophylaxis. Am Atriptlene is the only TCA that 313 00:21:38,039 --> 00:21:45,319 has proven efficacy for migraines insufficient data. With the other TCAs nocturnal and USIS 314 00:21:45,599 --> 00:21:49,079 aka bedwetting, you can use emippromine. It's not first lined. Desmopressin is, 315 00:21:49,079 --> 00:21:52,960 but if the child has tried and failed other treatment options including desmopressin, 316 00:21:53,319 --> 00:21:57,440 mippermine is a second line option. I used to remember I'm appeeing instead of 317 00:21:57,440 --> 00:22:00,799 emipramine to help me remember this indication, but you probably not even can be 318 00:22:00,839 --> 00:22:06,720 asked about this. And then finally, post trapetic neuralgia usually start with gabapentin 319 00:22:06,799 --> 00:22:11,079 or per gabbling as initial therapy, but TCAs are a reasonable second line option. 320 00:22:11,640 --> 00:22:14,599 I'm sure you notice a trend here. These are usually going to be 321 00:22:14,759 --> 00:22:18,559 backup options indication for TCAs, they're not really high yield. I don't think 322 00:22:18,599 --> 00:22:21,240 you should waste a lot of time memorizing them as. In general, there's 323 00:22:21,240 --> 00:22:23,960 better mets for most of these conditions. So where you should be focusing on 324 00:22:25,000 --> 00:22:27,319 when it comes to TCAs and where the questions will usually come from on the 325 00:22:27,359 --> 00:22:32,079 exam, is with their adverse effects. So TCAs, like we touched on 326 00:22:32,119 --> 00:22:34,519 before, they got some side effects and the side effects that they get tested 327 00:22:34,559 --> 00:22:37,720 on a lot. So let's talk about what you need to know and a 328 00:22:37,759 --> 00:22:41,079 little mnemonic to help you remember it. So with TCAs, I want you 329 00:22:41,119 --> 00:22:45,279 to focus on that C and TCAs to help you remember the five c'snmonic I 330 00:22:45,279 --> 00:22:49,359 came up with. So the five c's for adverse effects of TCAs stand for 331 00:22:49,599 --> 00:22:55,759 cardiac, QT, chubby convulsions, and anticholinergic. So what are these meaning. 332 00:22:55,839 --> 00:22:59,359 Let's start with the first C standing for cardiac, So all of the 333 00:22:59,400 --> 00:23:03,519 TCAs are a potentially cardiotoxic so you want to avoid this class in susceptible individuals 334 00:23:03,559 --> 00:23:10,160 with heart disease. TCAs can slow intracardiac conduction, cause various arrhythmias, orthostatic 335 00:23:10,240 --> 00:23:14,359 hypotension, and the most important cardiac adverse effect that you need to remember, 336 00:23:14,519 --> 00:23:18,640 and it's so important it gets its own C is QT QTCUTI should help your 337 00:23:18,680 --> 00:23:25,519 member QT prolongation QT QT prolongation. So this is a major concern with TCAs, 338 00:23:25,680 --> 00:23:29,279 especially when you mix these meds with other classes that can prolong the QT 339 00:23:29,400 --> 00:23:34,079 interval, like certain antimicrobials anti arrhythmic drugs. QT helps your member QT prolongation. 340 00:23:34,480 --> 00:23:41,119 Next C stands for chubby straightforward. The cyclic to antidepressants block histamine receptors, 341 00:23:41,319 --> 00:23:45,279 which can cause increased appetite leading to weight gain. Next C very important 342 00:23:45,319 --> 00:23:48,759 one convulsions. All of the TCAs can lower seizure threshold. This is dose 343 00:23:48,799 --> 00:23:52,599 dependent, so the higher the dose, the greater the chance of a seizure, 344 00:23:52,880 --> 00:23:56,200 especially in overdoses, so convulsions aka seizures. And then the last C 345 00:23:56,400 --> 00:24:02,799 and one of the most important is for anticholinar dry mouth urinary retention confusion. 346 00:24:02,880 --> 00:24:06,920 All can start from this, so we touched on this before TCAs they're not 347 00:24:07,079 --> 00:24:11,279 very selective and they affect a number of neurotransmitter systems. One of those is 348 00:24:11,279 --> 00:24:18,000 your muscarinic receptors. TCAs block the muscarinic acetylcholine receptors, which causes anticholinergic effects. 349 00:24:18,200 --> 00:24:22,279 So these patients may have dry mouth, urinary retention, confusion, blurred 350 00:24:22,319 --> 00:24:26,119 vision, tachycardia, et cetera. Just remember anticholinergic for the last c all 351 00:24:26,200 --> 00:24:29,880 right, So those are your five SE's of TCAs that you need to know, 352 00:24:30,279 --> 00:24:33,400 cardiac qt, chubby convulsions, and anticholinergic. If you know those, 353 00:24:33,640 --> 00:24:37,200 you should be good for the exam. Now. One last thing to be 354 00:24:37,240 --> 00:24:41,240 aware of is the potential for overdose with TCAs. TCAs have a high potential 355 00:24:41,279 --> 00:24:45,839 for overdose, especially when we compare them to SSRIs. For instance, take 356 00:24:45,960 --> 00:24:49,759 only takes as little as ten times the daily dose of a TCA to be 357 00:24:49,880 --> 00:24:53,839 fatal. Compare this to an SSRI, where it usually takes a really large 358 00:24:53,880 --> 00:24:57,799 dose, usually greater than one hundred and fifty times the daily dose to prove 359 00:24:57,839 --> 00:25:02,039 fatal. So in a PATI overdoses on a TCA, it can lead to 360 00:25:02,079 --> 00:25:07,359 anticholinergic toxicity seizures, but most concerning it can prolong the QT interval so you 361 00:25:07,359 --> 00:25:11,759 can give them benzos to control the seizures. But the most important therapeutic intervention 362 00:25:11,920 --> 00:25:15,720 and the right answer on an exam to treat a TCA overdose is going to 363 00:25:15,759 --> 00:25:21,480 be sodium bicarb Sodium bicarbonate. You need to know this. Sodium bicarbonate is 364 00:25:21,559 --> 00:25:26,119 the standard initial therapy for a TCA overdose with hypotension arrhythmic QT prolongation. This 365 00:25:26,200 --> 00:25:30,240 is the intervention you need to know for TCA overdose. It's what they're going 366 00:25:30,319 --> 00:25:33,160 to ask you. So how can you remember this? Well? You remember 367 00:25:33,400 --> 00:25:37,680 a tricycle is a small bicycle. A tricycle is a small bicycle. Tricycle 368 00:25:37,720 --> 00:25:42,920 helps remember try cyclic and a depressant, and small bicycle helps remember sodium by 369 00:25:44,079 --> 00:25:47,880 carbonate number. If they ask you how you're going to treat a TCA overdose, 370 00:25:48,079 --> 00:25:53,119 remember sodium bicarbonate aka a tricycle is a small bicycle. So I wanted 371 00:25:53,160 --> 00:25:56,960 to quickly talk about today's sponsor, an amazing tool for PA students called true 372 00:25:57,039 --> 00:26:00,240 Learn. 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You can visit truelearn dot com to sign up, or click 381 00:26:34,319 --> 00:26:37,240 the link in the show notes and make sure to use the code cram the 382 00:26:37,319 --> 00:26:41,400 pants when signing up to save twenty percent off subscriptions of ninety days or more. 383 00:26:41,759 --> 00:26:48,279 Now back to the show. All right, let's move on to the 384 00:26:48,319 --> 00:26:52,599 monoamine oxidase inhibitors. The MAOIs so MAOIs, like TCA's, were one of 385 00:26:52,640 --> 00:26:57,119 the first drugs developed to treat depression. We discover this class really by accident. 386 00:26:57,160 --> 00:27:00,960 Back in the nineteen fifties, they were trying to develop a drug to 387 00:27:00,000 --> 00:27:06,039 treat tuberculosis, a drug called iproniazid, and during the study they found other 388 00:27:06,079 --> 00:27:11,160 potential benefits outside of its intended purpose when the patients in the study exhibited improvement 389 00:27:11,200 --> 00:27:15,119 in mood. So this med kicked off the MAOI class, and while ipronyzid 390 00:27:15,200 --> 00:27:18,880 was later removed from the market due to hepatotoxicity, it was replaced by the 391 00:27:18,880 --> 00:27:22,880 other meds will go over today. In general, MAOIs like TCAs they're rarely 392 00:27:22,960 --> 00:27:26,759 used anymore because of their side effect profile, food and drug interactions, and 393 00:27:26,839 --> 00:27:30,319 quite simply because we have better and safer options now. In general, these 394 00:27:30,359 --> 00:27:34,079 meds are really only going to be used where nothing else has worked. So 395 00:27:34,119 --> 00:27:41,240 the meds in this class are chrannelcipermine, isocarboxyzid, phenozene, and celegilline aka 396 00:27:41,359 --> 00:27:47,079 tips TIPS because the letters in those medications are tips. Just a little nomonic 397 00:27:47,079 --> 00:27:48,200 to help you remember the meds in this class. There is another one, 398 00:27:48,240 --> 00:27:52,200 meklobamide, but it's not available here in the US, so I wouldn't really 399 00:27:52,200 --> 00:27:55,519 worry about that one. So how do these drugs work? While they increase 400 00:27:55,640 --> 00:28:00,839 dopaminergic, ner adrenergic, and serotonergic neurotransmission by blocking monoamine oxidase. So I 401 00:28:00,960 --> 00:28:04,920 understand how these meds work, we first need to understand what monomine oxidase is. 402 00:28:06,319 --> 00:28:11,079 So most of the other endidepressants we discuss so far worked by decreasing reuptake 403 00:28:11,160 --> 00:28:15,319 of the neurotransmitters serotonin or epi, et cetera, which in turn left more 404 00:28:15,319 --> 00:28:18,880 of them hanging out in the synaptic left to be utilized. But MAOIs they 405 00:28:18,880 --> 00:28:22,680 work differently. So once serotonin, nor EPI or dopamine have been reabsorbed by 406 00:28:22,680 --> 00:28:27,359 those reuptake proteins, some of those neurotransmitters get packaged into vesicles waiting for the 407 00:28:27,400 --> 00:28:30,440 next go round to be released into the synaptic left. But a good portion 408 00:28:30,519 --> 00:28:34,920 of those neurotransmitters are actually broken down before they get that opportunity, and they're 409 00:28:34,960 --> 00:28:38,640 broken down by an enzyme called monoamine oxidase, and we briefly touch on this 410 00:28:38,680 --> 00:28:42,799 at the beginning. Monomine oxidase. It's a mitochondrial enzyme. It's found in 411 00:28:42,799 --> 00:28:45,680 the brain as well as a number of other organs, and one of its 412 00:28:45,759 --> 00:28:52,480 jobs is to inactivate or break down dopamine, europenephrin or serotonin once they've been 413 00:28:52,519 --> 00:28:56,799 pumped back into the pre synaptic left. So the more we inhibit monomine oxidase, 414 00:28:56,880 --> 00:29:00,319 the more neurotransmitters are available for the next go round. Now is another 415 00:29:00,359 --> 00:29:03,480 side note. There's actually two different types of monomine oxidase, monomine oxidase A 416 00:29:03,640 --> 00:29:10,279 and monoamine oxidase B. They both break down different neurotransmitter. Mono monomine oxidase 417 00:29:10,319 --> 00:29:14,720 A metabolizes more neurotransmitters than monomineoxidase B, and I wouldn't worry too much about 418 00:29:14,759 --> 00:29:18,799 that though. Just know that different meds in the MAOI class can be selective 419 00:29:18,039 --> 00:29:22,000 and that they only inhibit one type of monomine, and some are non selective, 420 00:29:22,000 --> 00:29:26,519 in which they inhibit both types of monomine. So the non selective agents 421 00:29:26,559 --> 00:29:33,559 are isocarboxyzid phenozene and chranocipromine non selective again, meaning they inhibit both MAO A 422 00:29:33,039 --> 00:29:37,599 and MAO B. And then we have celegoleine, which technically can be selective 423 00:29:37,720 --> 00:29:41,480 or non selective depending on if it's high or low dose, but for the 424 00:29:41,519 --> 00:29:45,319 sake of the exam it's best to just know it as a selective agent. 425 00:29:45,559 --> 00:29:51,720 So celegoleine at low doses around five to ten milligrams selectively inhibits only MAOB and 426 00:29:51,839 --> 00:29:55,079 due to this, it's not so effective for treatment of depression, but it 427 00:29:55,119 --> 00:29:57,880 can be used in Parkinson's disease due to its effect on dopamine. There's a 428 00:29:57,880 --> 00:30:02,640 transdermal patch for version of celegentaline that's used for depression. But in general, 429 00:30:02,680 --> 00:30:04,319 if you see this med on an exam question, it's usually going to be 430 00:30:04,519 --> 00:30:08,920 referred for its use in Parkinson's disease, so i'd really focus on that indication 431 00:30:10,079 --> 00:30:11,880 rather than for depression. All right, Next, let's talk about the indications 432 00:30:11,880 --> 00:30:15,839 for MAOIs. Is there really anything we're still using these meds for? So 433 00:30:15,880 --> 00:30:18,799 the short answer is no. For the exam and for real life, you're 434 00:30:18,839 --> 00:30:23,160 really not going to pick an maoi. These meds will only be used when 435 00:30:23,160 --> 00:30:26,839 all else has failed. And just like in TCA's it's not that these meds 436 00:30:26,839 --> 00:30:30,720 don't work. They actually work very well. They just have too damn many 437 00:30:30,799 --> 00:30:34,880 dangerous side effects. So I wouldn't really bother memorizing indications for these meds as 438 00:30:34,920 --> 00:30:38,559 it's unlikely to be tested on. So we'll just really briefly run through the 439 00:30:38,559 --> 00:30:41,960 indications. But again I wouldn't memorize these as it's not usually where you're going 440 00:30:42,000 --> 00:30:45,920 to get tested on so depression. It's not first line unit to polar depression. 441 00:30:47,000 --> 00:30:49,839 You can use an maoi, but only when the patient is unresponsive to 442 00:30:51,119 --> 00:30:56,039 several other pharmacotherapy regimens different SSRIs as, centriize, et cetera. This is 443 00:30:56,079 --> 00:31:00,480 not going to be first line. Other indications refractory cases of panic disorder, 444 00:31:00,559 --> 00:31:04,039 social anxiety disorder, bulimia. Key here with all of these conditions is again 445 00:31:04,400 --> 00:31:10,519 that MAOIs are not first line meds only for refractory cases. So probably best 446 00:31:10,559 --> 00:31:14,400 to just mentally skip the indications for MAOIs, leaving some space in your brain 447 00:31:14,440 --> 00:31:18,480 for something more important, such as the highest yield thing to know about moois 448 00:31:18,759 --> 00:31:22,039 and what you'll likely get tested on, and that's their adverse effects, So 449 00:31:22,119 --> 00:31:25,920 let's talk about that next. So, MAOIs can cause blurred vision, constipation, 450 00:31:26,079 --> 00:31:30,160 dry mouth, headache, liver enzyme elevation, orthostatic hypotension, insomnia, 451 00:31:30,240 --> 00:31:32,960 sexual dysfunction. But that's not what they're going to ask you about. They're 452 00:31:33,000 --> 00:31:36,680 going to ask you about the drug to drug interactions that can cause serotonin syndrome 453 00:31:36,839 --> 00:31:40,599 and the drug to food interactions that can cause a hypertensive crisis. That's the 454 00:31:40,680 --> 00:31:42,599 juicy stuff you need to know for exams. So let's start with probably the 455 00:31:42,640 --> 00:31:45,920 most important of all, and that is a hypertensive crisis. So if you 456 00:31:45,960 --> 00:31:49,680 take an maoi and eat some cheese, you can have a hypertensive crisis and 457 00:31:49,759 --> 00:31:53,200 potentially die. Hopefully, it's starting to become a bit more clear why we 458 00:31:53,240 --> 00:31:56,559 don't use these meds so much anymore. So let's elaborate on this a bit. 459 00:31:56,640 --> 00:32:00,039 So. Monominoxidase, as we discussed before, it's not just found in 460 00:32:00,039 --> 00:32:02,599 the brain, it's found all over the body, including the lining of the 461 00:32:02,599 --> 00:32:07,519 gut wall, and one of its jobs in the GI tract, mainly MOOA 462 00:32:07,960 --> 00:32:10,920 is to break down something called tiramine. But in a patient taking in maoi, 463 00:32:12,200 --> 00:32:15,319 as we know, this drug inhibits monomine oxidase, meaning tiamine isn't broken 464 00:32:15,359 --> 00:32:19,480 down as it should be. So out of this matter well, tiramine in 465 00:32:19,559 --> 00:32:24,240 high concentrations can increase nor epinephrine release. Nor epic can cause vasoconstriction, increased 466 00:32:24,240 --> 00:32:28,599 heart rate, and cause a rise in blood pressure, which can precipitate a 467 00:32:28,680 --> 00:32:31,799 hypertensive crisis. Long story short, MOOI is combined with foods that have a 468 00:32:31,799 --> 00:32:36,319 bunch of tiramine can cause your BP to go sky high, so you want 469 00:32:36,359 --> 00:32:38,200 to avoid that. Now, what foods have a lot of tiamine in them? 470 00:32:38,400 --> 00:32:42,359 The main ones are cheese, meat, poultry, fish, beer, 471 00:32:42,640 --> 00:32:45,400 and really any aged or fermented food. If you're a gain of thronespan, 472 00:32:45,480 --> 00:32:49,319 I have a way for you to remember which foods are high in tiamine. 473 00:32:49,519 --> 00:32:53,480 So tiamine sounds a lot like Tyrian Lanister and Tiian he liked his tiamine rich 474 00:32:53,559 --> 00:32:59,240 foods, beer and other alcohol as well as those classic medieval foods cheese, 475 00:32:59,279 --> 00:33:01,640 meats for men or spoiled food. So if you can't remember which foods are 476 00:33:01,720 --> 00:33:05,960 high in tiamine, just think what did Tyian Lanister eat and drink back in 477 00:33:06,000 --> 00:33:08,160 those medieval times? And that's your answer. At least that's how I remembered 478 00:33:08,160 --> 00:33:10,319 it, all right. Last thing, you need to know these meds can 479 00:33:10,359 --> 00:33:14,799 cause serotonin syndrome. So yes, all of the meds we went over today 480 00:33:14,839 --> 00:33:19,519 can potentially cause serotonin syndrome. So this isn't unique to MAOIs. But what 481 00:33:19,680 --> 00:33:22,559 is unique to MAOIs and why it's often tested on, is that episodes of 482 00:33:22,599 --> 00:33:29,480 serotonin syndrome involving in Maoi versus other classes are generally more severe and can potentially 483 00:33:29,559 --> 00:33:31,319 be fatal, so you really want to be careful with this class of medication. 484 00:33:31,440 --> 00:33:36,480 You never want to mix an MAOI with another serotonergic agent like an SSRI, 485 00:33:36,680 --> 00:33:38,519 s centrii, et cetera. So that's really important. And there are 486 00:33:38,599 --> 00:33:42,960 of course a lot of side effects for MAOIs, but make sure you really 487 00:33:42,960 --> 00:33:46,759 focus on your hypertensive crisis with tiramine rich foods and serotonin syndrome, that's likely 488 00:33:46,799 --> 00:33:50,279 what will be tested on. Okay, so we're almost to the end here. 489 00:33:50,319 --> 00:33:52,400 There's three other antidepressants I want to go over that don't fall into any 490 00:33:52,440 --> 00:33:55,519 of the above classes, but they come up very frequently on exams, so 491 00:33:55,640 --> 00:34:00,359 let's briefly go over them. So first one is bupropion. This is a 492 00:34:00,400 --> 00:34:06,039 really high yield meant to know. Bupropeon is considered an atypical antidepressant atypical as 493 00:34:06,119 --> 00:34:08,800 the way it works is distinct from the other classes we have gone over thus 494 00:34:08,840 --> 00:34:13,320 far, a SSRIs, at centarize, etc. What you'll find with these 495 00:34:13,320 --> 00:34:17,360 atypicals is they have some unique characteristics which can make them desirable for certain patient 496 00:34:17,360 --> 00:34:20,960 populations. You'll see what I mean in a minute. So how does this 497 00:34:21,039 --> 00:34:25,400 medication work. How's it different? Well, bupropeon inhibits presynaptic reuptake of dopamine 498 00:34:25,400 --> 00:34:30,079 and nor epinephrine, which leads to increased levels of these neurotransmitters within the synaptic 499 00:34:30,159 --> 00:34:34,440 left. Now, how is this different than the other antidepressants we've gone over 500 00:34:34,519 --> 00:34:37,840 so far. The main difference you'll notice is bupropion has little to no effect 501 00:34:37,920 --> 00:34:42,599 on serotonin. Unlike all of the other classes we have gone over so far, 502 00:34:43,079 --> 00:34:45,360 SSRIs, as, centraized, TCA's, etc. Which did have an 503 00:34:45,360 --> 00:34:50,480 impact on serotonin, bupropion does not, and its main effect is only on 504 00:34:50,519 --> 00:34:52,920 dopamine and nor epi. All Right, so there's a few other high yield 505 00:34:52,960 --> 00:34:57,840 things you need to know for bupropion, and I recommend committing these to memory 506 00:34:57,880 --> 00:35:00,360 because they really like to make exam questions on this. So luckily, everything 507 00:35:00,400 --> 00:35:05,440 you need to know about bupropion starts with the letter S at least it does 508 00:35:05,480 --> 00:35:08,400 formynomonics. So here's the four s's you need to know for this medication, 509 00:35:08,599 --> 00:35:13,599 which are seizures, smoking, skinny, and sex. You're very likely going 510 00:35:13,599 --> 00:35:15,760 to get a question on one of those, so let's break them down, 511 00:35:15,880 --> 00:35:20,000 starting with the first S that stands for seizures, So this is a very 512 00:35:20,000 --> 00:35:23,800 important thing to know. Bupropion can cause generalized seizures. The higher the dose, 513 00:35:23,920 --> 00:35:28,000 the higher the risk of a seizure. So you want to avoid using 514 00:35:28,000 --> 00:35:31,719 these in patients at risk for seizures, so patients withdrawing from alcohol, benzos, 515 00:35:31,800 --> 00:35:36,880 barbituates, et cetera. And then the highest deeled patient populations that's at 516 00:35:36,960 --> 00:35:38,440 risk for seizures. At least for the sake of an exam, the one 517 00:35:38,440 --> 00:35:43,000 that's always tested on is a patient with the history of eating disorders, so 518 00:35:43,079 --> 00:35:45,800 anorexia, bulimia. They always ask questions on this. You need to know 519 00:35:46,119 --> 00:35:51,280 you do not use bupropion in a patient that has a high risk for seizures, 520 00:35:51,519 --> 00:35:53,719 especially those patients with eating disorders. You can thank me later when you 521 00:35:53,760 --> 00:35:57,880 get this question right on your exam because they always ask it. Next S 522 00:35:57,880 --> 00:36:01,360 stands for sex, So bupropion is the antidepressant of choice if you want to 523 00:36:01,400 --> 00:36:06,079 avoid sexual side effects. So if you have a patient who's concerned about sexual 524 00:36:06,159 --> 00:36:08,599 side effects, is going to start an antidepressant, or maybe a patient who's 525 00:36:08,599 --> 00:36:14,119 already experiencing sexual side effects from SSRIs, which we know can cause that switch 526 00:36:14,159 --> 00:36:17,840 them to bupropion. There's even some studies that show benefit from adding bupropeon to 527 00:36:17,960 --> 00:36:22,039 an SSRI to help mitigate the sexual side effects experience, so you definitely need 528 00:36:22,079 --> 00:36:25,119 to know this. It'll likely be tested on. I used to remember if 529 00:36:25,199 --> 00:36:30,480 you add an M to bupropeon after the U, it made bump ropeon bump 530 00:36:30,599 --> 00:36:36,039 ropeon bump because it's the antidepressant of choice if you want to bump in grind, 531 00:36:36,239 --> 00:36:39,639 so remember it as bump ropeon instead of bupropeon to remember antidepressant of choice 532 00:36:39,679 --> 00:36:44,159 if you want to bump and grind. Next S is smoking pretty straightforward. 533 00:36:44,320 --> 00:36:47,719 Bupropeon is one of the first line pharmacotherapies that can be used to assist with 534 00:36:47,800 --> 00:36:52,559 smoking cessation. So another important S for smoking and then the last S stands 535 00:36:52,599 --> 00:36:58,159 for skinny. So bupropion, unlike some other classes, does not generally cause 536 00:36:58,199 --> 00:37:00,400 weight gain. In fact, a metal noalo is found that on average, 537 00:37:00,440 --> 00:37:06,000 patients taking bupropion actually lost around one kilogram. So if you have a patient 538 00:37:06,000 --> 00:37:08,440 who's fear full of weight game with the other classes, this is another compelling 539 00:37:08,480 --> 00:37:13,199 reason to use bupropion as it can cause weight loss. They actually have a 540 00:37:13,199 --> 00:37:17,280 weight loss medication called contrave which is just a combination of bupropion and nowtrexone. 541 00:37:17,480 --> 00:37:21,920 So if you remember those four s's four bupropion, very likely you'll get the 542 00:37:22,000 --> 00:37:25,320 question right again, seizure, sex, smoking, and skinny. Next atypical 543 00:37:25,360 --> 00:37:29,119 to know is mere tazepine. There's not a lot to know for this one. 544 00:37:29,239 --> 00:37:31,239 One major point will go over in a second. So the mechanism of 545 00:37:31,400 --> 00:37:35,800 action for meretazipine, it's kind of complex. There's a lot going on. 546 00:37:36,000 --> 00:37:37,360 I don't think you need to know all of the specifics, but the main 547 00:37:37,400 --> 00:37:43,920 thing to know is that this drug antagonizes presynaptic alpha two adrenergic receptors. That's 548 00:37:43,960 --> 00:37:50,760 really important. Antagonizes pre synaptic alpha two adreenetic receptors and post synaptics serotonin five 549 00:37:51,000 --> 00:37:53,639 H two and serotonin five HT three receptors. So I'm going to break this 550 00:37:53,679 --> 00:37:57,079 down, but for the exam again, remember if you can just remember this 551 00:37:57,119 --> 00:38:00,800 drug antagonizes alpha two receptors, probably be enough to get the question right. 552 00:38:00,840 --> 00:38:02,679 But we'll dive a little deeper for the sake of understanding. Let's first start 553 00:38:02,719 --> 00:38:07,519 with the alpha two adrenergic receptors. We didn't really talk about these receptors yet 554 00:38:07,559 --> 00:38:10,519 because most of the antidepressants didn't work on this specific area. Last, why 555 00:38:10,559 --> 00:38:15,599 this is considered an atypical antidepressant, But alpha two adrenergic receptors. They're mainly 556 00:38:15,639 --> 00:38:20,920 found in the presynaptic neuron and they work primarily through a negative feedback loop. 557 00:38:21,159 --> 00:38:23,519 For instance, when nor epi is released, some of it binds to these 558 00:38:23,519 --> 00:38:28,880 alpha two receptors, which in turn inhibits further release of neropinephrin. So this 559 00:38:28,960 --> 00:38:31,960 medication blocks these receptors so that negative feedback loop is shut off, and in 560 00:38:32,000 --> 00:38:37,559 turn we have more nor epinefrin released as well as serotonin through an additional pathway, 561 00:38:37,119 --> 00:38:42,559 so that's good. In addition, this medication also has an antagonistic effect 562 00:38:42,599 --> 00:38:47,760 on postsynaptic serotonin five HT two and serotonin five HT three receptors, so it 563 00:38:47,800 --> 00:38:55,239 basically blocks certain serotonin receptors, which sounds counterintuitive blocking serotonin receptors, but by 564 00:38:55,280 --> 00:39:00,400 blocking these two specific receptors, redirecting it away from five HT two and five 565 00:39:00,599 --> 00:39:05,480 HG three, this allows them to bind to a more useful receptor known as 566 00:39:05,519 --> 00:39:08,519 the five HT one a receptor, which has a stronger effect on depression. 567 00:39:08,599 --> 00:39:14,119 This medication also has a high affinity for histamine H one receptors, which accounts 568 00:39:14,119 --> 00:39:16,880 for some of its side effects. Again, this is a complicated mechanism. 569 00:39:16,960 --> 00:39:21,000 I don't think it's necessary to know all of this, and you probably won't 570 00:39:21,000 --> 00:39:23,480 even be asked about this on the exam, but you are likely going to 571 00:39:23,519 --> 00:39:27,519 be asked about in the main and possibly the only thing you need to know 572 00:39:27,559 --> 00:39:31,159 from mertazipine is that it stimulates appetite and causes weight gain. This is so 573 00:39:31,519 --> 00:39:35,800 high yield, I definitely got a question on it. Martazipine has a big 574 00:39:35,800 --> 00:39:39,320 impact on appetite and could cause significant weightain, up to a seven percent increase 575 00:39:39,360 --> 00:39:43,320 in body weight. This can be seen in short and long term use. 576 00:39:43,400 --> 00:39:45,199 You need to remember that it's always asked about, So how are you going 577 00:39:45,239 --> 00:39:49,400 to remember that? Well, instead of remembering mere tazipine, I want you 578 00:39:49,440 --> 00:39:53,519 to remember it as meal tazipine, meal meal, meal tazipine. Because you 579 00:39:53,519 --> 00:39:59,159 remember this can stimulate appetite, making patients finish their meals and gain weight. 580 00:40:00,000 --> 00:40:02,519 They're less important side effect to be aware of is sedation. Close to twenty 581 00:40:02,519 --> 00:40:07,039 percent of patients will have drowsiness or sedation, which is likely due to the 582 00:40:07,159 --> 00:40:10,519 drugs high affinity for histamine H one receptors. But focus on the weight gain 583 00:40:10,559 --> 00:40:14,679 as that's the most important thing to know, all right. So last ndepressent 584 00:40:14,719 --> 00:40:17,239 we're going to go over as trasidone. So trasidone is in a class of 585 00:40:17,239 --> 00:40:22,360 meds called serotonin modulators. There's a few other drugs in this class and the 586 00:40:22,440 --> 00:40:25,440 fazodone velazidone, but trazodone is the one you'll likely get tested on. So 587 00:40:25,559 --> 00:40:32,880 trasidone inhibits presynaptic serotonin reuptake and acts as an antagonist at the five HT two 588 00:40:32,920 --> 00:40:37,599 A and two C serotonin receptors. So both of these mechanisms we've gone over 589 00:40:37,639 --> 00:40:44,079 with other medications. So trasidone weekly inhibits presynaptic serotonin reuptake, so same thing 590 00:40:44,119 --> 00:40:47,239 we saw with SSRIs blocks reuptake up serotonin, so we have more serotonin hanging 591 00:40:47,239 --> 00:40:51,440 out in the synaptic left to do its thing. And then this drug also 592 00:40:51,639 --> 00:40:58,480 blocks serotonin receptors, specifically post synaptic serotonin five HT two A and five HT 593 00:40:58,679 --> 00:41:02,280 two C receptors. So We talked about this with mertazipine, basically redirecting serotonin 594 00:41:02,360 --> 00:41:07,400 away from certain receptors, causing them to bind with more useful ones. Now 595 00:41:07,480 --> 00:41:12,519 trazodone, it's a bit sloppy and it also affects alpha adrenertic receptors and histamine 596 00:41:12,599 --> 00:41:16,519 H one receptors which causes some high yield. Very often tested on side effects 597 00:41:16,559 --> 00:41:20,320 you need to know for your exam. This is another drug where the side 598 00:41:20,320 --> 00:41:23,119 effects are the most commonly tested on aspect of the drug. So first one 599 00:41:23,199 --> 00:41:29,039 is sedation. A study found that sixty one percent of patients taking traszone experience 600 00:41:29,119 --> 00:41:32,360 sedation. This is likely due to the strong effect this medication has on histamine 601 00:41:32,440 --> 00:41:37,199 H one receptors, so you'll often see this medication being used off label for 602 00:41:37,280 --> 00:41:39,320 patients with insomnia, so you need to know this. And the other side 603 00:41:39,320 --> 00:41:43,400 effect you need to know, a rare but serious one that's often tested on 604 00:41:43,559 --> 00:41:47,400 is priapism. So priapism a persistent erection. While rare, can happen with 605 00:41:47,400 --> 00:41:52,039 this medication, it's a medical emergency and while it's not common, they love 606 00:41:52,079 --> 00:41:53,960 to test on it. And it has to do with the medications effect on 607 00:41:54,000 --> 00:41:58,719 alpha adrenergic receptors. So you definitely need to know both of these side effects. 608 00:41:58,719 --> 00:42:00,119 They're likely going to be on your exist and the way that you're going 609 00:42:00,159 --> 00:42:05,039 to remember them is by instead of remembering trazodone, I want you to instead 610 00:42:05,079 --> 00:42:10,079 remember trasabone traszebone, so tras with a bunch of dizas to help you remember 611 00:42:10,119 --> 00:42:15,000 the sedation commonly experienced with this medication, and bone to help your remember priapism, 612 00:42:15,079 --> 00:42:17,920 the boner that just won't quit. So those are the two high old 613 00:42:17,920 --> 00:42:21,760 things you need to know for this medication, and that's why you'll likely be 614 00:42:21,800 --> 00:42:24,480 tested on. Remember trasabone and you should be good. All right, So 615 00:42:24,519 --> 00:42:28,559 that was your antidepressants. It's a lot, but stick to the unique, 616 00:42:28,639 --> 00:42:30,760 high old stuff. Remember the namonics we went over, and you'll likely be 617 00:42:30,840 --> 00:42:36,079 Okay. Let's do five quick questions to see what you retained. Question one. 618 00:42:36,440 --> 00:42:39,599 A sixty seven year old male presents the office today complaining of persistent low 619 00:42:39,679 --> 00:42:45,119 mood and hedonia and feelings of hopelessness that have been affecting his daily life for 620 00:42:45,159 --> 00:42:49,159 the past several months. Additionally, he reports tingling and burning pain in both 621 00:42:49,199 --> 00:42:52,800 of his feet over the past few years. And is seeking medication to alleviate. 622 00:42:52,840 --> 00:42:57,280 This patient has a history of type two diabetes, hyperlipidemia, and diabetic 623 00:42:57,320 --> 00:43:01,679 neuropathy. His current medications include glomepera and resove a statin. Patient was diagnosed 624 00:43:01,719 --> 00:43:07,119 with depression and the decision is made to initiate pharmacotherapy. Which of the following 625 00:43:07,239 --> 00:43:13,599 choices would be most appropriate for the patient mentioned above A meritazepine, B bupropion, 626 00:43:14,079 --> 00:43:22,800 C duloxetine, D S catalopram or E fluvoxamine. So that is going 627 00:43:22,840 --> 00:43:28,119 to be C duloxetine. So we have a bunch of different medications that could 628 00:43:28,159 --> 00:43:31,679 all potentially treat this patient's depression. But the question also mentions this patient has 629 00:43:31,840 --> 00:43:37,880 untreated diabetic neuropathy evident by the tingling and burning pain in his feet, in 630 00:43:37,920 --> 00:43:40,679 which he is also seeking treatment, And there's only one medication listed here that 631 00:43:40,719 --> 00:43:45,920 can treat both his depression and neuropathic pain, and that's duloxetine. Duloxetine, 632 00:43:45,960 --> 00:43:50,599 as we know, is an SNRI. It's often preferred in patients with comorbid 633 00:43:50,639 --> 00:43:54,480 depression and chronic pain conditions such as diabetic neuropathy. So remember, instead of 634 00:43:54,559 --> 00:44:00,920 duloxetine. Remember dual oxetine for the dual indication for both depression and chronic pain 635 00:44:00,280 --> 00:44:05,280 making and an appropriate choice in this patient. Question two, the decision is 636 00:44:05,280 --> 00:44:08,719 made to initiate antidepressant therapy and a twenty eight year old female with a recent 637 00:44:08,760 --> 00:44:15,480 diagnosis of major depressive disorder. Past medical history includes hypertension, hyperlipidemia, and 638 00:44:15,559 --> 00:44:20,599 coeliac disease. She states her friend found great success with cytalopram and was wondering 639 00:44:20,639 --> 00:44:23,480 if she could try this medication. Upon reviewing her past medical records, you 640 00:44:23,519 --> 00:44:29,119 find a family history of unexplained syncope and sudden cardiac arrest. What should be 641 00:44:29,199 --> 00:44:36,920 ruled out before starting this patient on citalopram. So that is going to be 642 00:44:37,000 --> 00:44:40,840 QT prolongation. So ctalopram is an SSRI and one of the biggest concerns with 643 00:44:40,880 --> 00:44:45,159 this medication is QT prolongation. You want to avoid this medication in patients with 644 00:44:45,239 --> 00:44:51,039 congenital long QT syndrome or any other risk factors for prolonged QT syndrome. So 645 00:44:51,079 --> 00:44:53,960 you have a patient with the family history of unexplained syncope sudden cardiac arrest. 646 00:44:54,320 --> 00:44:59,440 Patient definitely needs a work up to ensure she doesn't have congenital long QT syndrome 647 00:44:59,599 --> 00:45:04,199 given her family history. Remember the main ssrise where QT prolongation is a concern 648 00:45:04,440 --> 00:45:08,199 cetalopram first and foremost and esctalopram. And if you remember the sentence, if 649 00:45:08,239 --> 00:45:12,280 you long for quiet time, you need to escape the city, You'll never 650 00:45:12,320 --> 00:45:15,599 forget the SSRIs that carry the risk for QT prolongation. Long for quiet time, 651 00:45:15,679 --> 00:45:21,880 long QT escape esketealopram city, cetalopram. Question three. A thirty two 652 00:45:21,960 --> 00:45:23,960 year old male with the history of depression has been treated with searchulene for the 653 00:45:23,960 --> 00:45:29,559 past six months. He initially showed improvement in his mood, but developed bothersome 654 00:45:29,719 --> 00:45:35,280 sexual side effects, including decreased libido and difficulty achieving and maintaining erection. In 655 00:45:35,320 --> 00:45:37,559 response to these side effects, you decide to decrease the SSR I dose, 656 00:45:37,800 --> 00:45:43,639 but the sexual side effects persist. Which medication would be most appropriate to replace 657 00:45:43,679 --> 00:45:51,760 cetralene in this patient A citalopram, B bupropion, C fluoxetine, D peroxetine 658 00:45:51,880 --> 00:46:00,840 or e venlefaccine, So that's B bupropion, so bupropion and atypical antidepressant. 659 00:46:00,880 --> 00:46:04,280 As we discussed before, does not have the sexual side effects that we see 660 00:46:04,320 --> 00:46:08,719 in ssrise and is very commonly the antidepressant of choice for a patient experiencing sexual 661 00:46:08,760 --> 00:46:15,000 side effects. So remember bump ropeon instead of bupropeon, as it's the antidepressant 662 00:46:15,000 --> 00:46:17,280 of choice if you want to bump and grind. All the other choices are 663 00:46:17,320 --> 00:46:22,800 either ssrise or snrise, which all carry the risk of sexual side effects. 664 00:46:22,000 --> 00:46:25,079 Question four. A fifty eight year old male is spending a night out with 665 00:46:25,159 --> 00:46:30,400 friends celebrating a recent promotion. He is enjoying a few beers as well as 666 00:46:30,400 --> 00:46:35,840 some appetizers of age cheese cured meats when he begins to experience headache, nausea, 667 00:46:35,880 --> 00:46:38,440 and chest pain. Paramedics were called to the scene and his blood pressure 668 00:46:38,480 --> 00:46:42,960 is reported to be one eight four over one twenty two. He reports he 669 00:46:43,039 --> 00:46:46,320 was recently started on a new medication for his refractory depression, but does not 670 00:46:46,360 --> 00:46:52,000 recall the name. Which of the following antidepressants is He most likely taking a 671 00:46:52,360 --> 00:47:00,719 certralene, B mertazepine, C fluvoxamine, D phenylzene or E S catalopram, 672 00:47:00,800 --> 00:47:05,039 So that is going to be D fenelzine, So we know this is a 673 00:47:05,119 --> 00:47:07,960 hypertensive crisis. We know this was caused by an maoi due to the high 674 00:47:07,960 --> 00:47:12,639 amounts of tiramine he consumed, beer, cheese, etc. So all we 675 00:47:12,679 --> 00:47:15,559 have to figure out at this point is which one of these is an maoi. 676 00:47:15,639 --> 00:47:17,159 So even if you can't remember the names of all of the MAOIs, 677 00:47:17,199 --> 00:47:21,760 which I don't blame you. If you can at least remember the mnemonics tips, 678 00:47:21,800 --> 00:47:24,400 tips, you can narrow it down so we know all of the MAOIs 679 00:47:24,440 --> 00:47:29,159 at least here in the US. Start with the letters tips, so that 680 00:47:29,239 --> 00:47:31,079 narrows it down to just two meds in these answers. So you have a 681 00:47:31,079 --> 00:47:35,519 fifty percent chance of getting it righteous by using this mnemonic And if you can 682 00:47:35,559 --> 00:47:39,000 remember that Serchralene is an SSRI from the Serpent Snake Charmer pneumonic, you know 683 00:47:39,119 --> 00:47:44,480 all that's left is fenolzine and maoi And that's the correct answer for this question. 684 00:47:44,800 --> 00:47:47,400 Final question number five. A thirty eight year old female presents to the 685 00:47:47,400 --> 00:47:52,239 office to follow up on her recent diagnosis of depression. At the last visit, 686 00:47:52,280 --> 00:47:54,559 the decision was made to start psychotherapy, but she finds this to be 687 00:47:54,599 --> 00:47:59,679 ineffective and is seeking medication to improve her mood. She's not currently taking any 688 00:47:59,679 --> 00:48:04,679 personscryption medication, denies a family history of depression, and has no other medical 689 00:48:04,679 --> 00:48:07,559 conditions. This will be her first time taking an antidepressant, and her only 690 00:48:07,639 --> 00:48:12,119 concern is the potential for weight gain, as she has struggled with her weight 691 00:48:12,159 --> 00:48:15,320 in the past. Which medication listed below would be most appropriate to start in 692 00:48:15,360 --> 00:48:23,760 this patient A isocarboxyzid, B doxipin, c amatryptylene, D fluoxetine, or 693 00:48:23,840 --> 00:48:30,960 E peroxetine, So that's going to be D fluoxetine. So we have a 694 00:48:31,000 --> 00:48:36,960 patient with no medical conditions who's going to start pharmacotherapy for depression. She hasn't 695 00:48:36,960 --> 00:48:39,119 tried any mets. We know we start with our first line medications, and 696 00:48:39,159 --> 00:48:44,360 we know TCAs and MAOIs are never first line treatments for depression. So right 697 00:48:44,400 --> 00:48:47,320 off the bat, you can eliminate isocarboxyxid and maoi, and you can eliminate 698 00:48:47,400 --> 00:48:52,960 doxipin and amatriptlene, which are TCAs. So what we're left with is fluoxetine 699 00:48:52,000 --> 00:48:57,159 and peroxetine. Both of these are SSRIs. So which one is the right 700 00:48:57,199 --> 00:49:00,360 answer? Well, technically, either one of these would be a probe to 701 00:49:00,400 --> 00:49:05,599 treat her depression. But she mentioned she's concerned about wekain and we know peroxetine 702 00:49:05,639 --> 00:49:08,760 is the SSRI associated with the most weight gain, remember our fat parrot, 703 00:49:09,000 --> 00:49:13,880 And since this is a concern of hers, fluoxetine would be the most appropriate 704 00:49:13,960 --> 00:49:15,760 choice in this patient. All right, So that is your antidepressants. I 705 00:49:15,760 --> 00:49:19,559 hope that was helpful. Thank you so much for listening, and good luck 706 00:49:19,599 --> 00:49:20,039 in school.