WEBVTT 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.