A+ NR546 EXAM QUESTIONS AND ANSWERS LATEST UPDATE
Alpha-1 adrenergic effects
Orthostatic hypotension
Anticholinergic effects
Dry mouth
Blurred vision
Urinary retention
Constipation
Histamine effects
Weight gain
Sedation
MAOIs
first developed, LAST CHOICE medication class for depression due to the many
potential, serious side effects
-specific dietary restrictions, Foods that contain tyramine should be avoided (Red wine,
Sauerkraut, Cheese, Soy, Smoked meats)
-block enzymes responsible for the breakdown of 5-HT, NE, and DA
• two primary forms of the MAO enzyme: MAO-A and MAO-B
• both located in the brain, MAO-A also in gut
Drugs:
-phenelzine (Nardil) - duration 14 days
-selegiline (Emsam) - MAOI-B - duration 14 days
-tranylcypromine (Parnate) -duration 14-30 days
-isocarboxazid (Marplan) - duration 14 days
Side effects:
-Confusion
-Dizziness
-Insomnia
-Sedation
,-Vivid dreams
Pearls:
-high risk for hypertensive crisis if tyramine is ingested
-Do not prescribe any serotonergic agents within 2 weeks of MAOI discontinuation due
to an increased risk of serotonin syndrome
-Wait at least 5 half-lives after discontinuing a serotonergic medication before initiating
an MAIO
MAO-A
breaks down 5-HT, DA, NE, and tyramine
-used to treat depression and anxiety
"A" is for antidepressant or anxiolytic
MAO-B
responsible for the breakdown of dopamine, phenylethylamine, and tyramine
-used to treat Parkinson's disease; however, high-dose selegiline (Emsam) may be
used to treat anxiety or depression
Foods to avoid when taking MAOIs
Tyramine is present in many aged or preserved foods including aged cheeses, tap and
nonpasteurized beers, aged or smoked meat or fish, sauerkraut, kimchee, soy products,
and tofu.
Adjunct treatment for depression
Antipsychotic medications are sometimes prescribed at low doses as adjunctive
medications for severe depression
Newer tx for resistant depression: esketamine (Spravato)
nasal spray for the treatment of major depressive disorder (MDD) with acute suicidal
ideation or behavior
-reaches peak onset in the body in between 20-40 minutes
-risk of adverse outcomes due to sedation and dissociation
*must be administered in a supervised healthcare setting
Newer tx for resistant depression: Ketamine clinics
,Ketamine is an N-methyl-D-aspartate (NMDA) receptor inhibitor, results in the
downstream release of glutamate
-high doses, ketamine may cause psychotic symptoms, in low doses, it has a rapid
effect on depression
-Ketamine clinics have provided intravenous ketamine for treatment-resistant unipolar
and bipolar depression
*required frequent dosing, inconvenient, expensive
Newer tx for resistant depression: dextromethorphan/quinidine (Nuedexta)
Researchers are investigating, related to NMDA
-currently approved by the FDA for the treatment of pseudobulbar affect
*combines dextromethorphan and quinidine as an oral treatment
considered when selecting an antidepressant medication
Client preference
Prior treatment response
Anticipated adverse effects
Comorbidities
Half-life and interactions
Cost
Antidepressants: Initiating Medication
Start clients on a single drug for 4-8 weeks to assess efficacy. Start with the lowest
recommended dose to reduce side effects. If a medication is not achieving efficacy:
-Increase the dose gradually to the efficacious dose range.
-Switch to a different drug within the same class after an adequate trial which includes
higher dosing and a minimum of eight weeks of trial.
-Switch to a drug in a different class after an adequate trial which includes higher dosing
and a minimum of eight weeks of trial.
-Add a second medication as an adjunct.
Antidepressants: Discontinuing Medications
Don't suddenly stop or omit doses due to risk of discontinuation syndrome
-Paroxetine highest risk due to serotonin transporter inhibition and anticholinergic
rebound
, -If a treatment course has lasted 8 weeks, discontinuation over 1-2 weeks is safe. Once
symptoms are in remission, continue treatment for 4-9 months to reduce the risk of
relapse
Antidepressants Important Prescribing Considerations: Black Box Warning
Suicide Risk with Antidepressant Drugs
-Clients with depression may consider or attempt suicide
-risk for suicide may increase at the start of treatment
-Antidepressant-induced suicide is more prevalent in children, adolescents, and adults
younger than 25 years.
Antidepressants Important Prescribing Considerations: Drug-Drug Interactions
Most antidepressant medications have serious drug-drug interactions. Carefully review
the client's history and current prescriptions before selecting a medication.
Antidepressants Important Prescribing Considerations: Serotonin Syndrome
potentially life-threatening condition reported with the use of serotonergic
antidepressants
-especially when they are used concomitantly with other serotonergic drugs (such as
triptans, tricyclic antidepressants, fentanyl, lithium, tramadol, tryptophan, buspirone, and
St. John's Wort), and with drugs that impair serotonin metabolism (particularly MAOIs)
S/S
-mental status changes (e.g., agitation, hallucinations, delirium, and coma)
-autonomic instability (e.g., tachycardia, labile blood pressure, dizziness, diaphoresis,
flushing, hyperthermia)
-neuromuscular symptoms (e.g., tremor, rigidity, myoclonus, hyperreflexia,
incoordination)
-seizures, and/or gastrointestinal symptoms (e.g., nausea, vomiting, diarrhea)
If such symptoms occur, clients should discontinue serotonergic agents and initiate
treatment of symptoms.
Clients should be educated about the signs and symptoms of serotonin syndrome and
Alpha-1 adrenergic effects
Orthostatic hypotension
Anticholinergic effects
Dry mouth
Blurred vision
Urinary retention
Constipation
Histamine effects
Weight gain
Sedation
MAOIs
first developed, LAST CHOICE medication class for depression due to the many
potential, serious side effects
-specific dietary restrictions, Foods that contain tyramine should be avoided (Red wine,
Sauerkraut, Cheese, Soy, Smoked meats)
-block enzymes responsible for the breakdown of 5-HT, NE, and DA
• two primary forms of the MAO enzyme: MAO-A and MAO-B
• both located in the brain, MAO-A also in gut
Drugs:
-phenelzine (Nardil) - duration 14 days
-selegiline (Emsam) - MAOI-B - duration 14 days
-tranylcypromine (Parnate) -duration 14-30 days
-isocarboxazid (Marplan) - duration 14 days
Side effects:
-Confusion
-Dizziness
-Insomnia
-Sedation
,-Vivid dreams
Pearls:
-high risk for hypertensive crisis if tyramine is ingested
-Do not prescribe any serotonergic agents within 2 weeks of MAOI discontinuation due
to an increased risk of serotonin syndrome
-Wait at least 5 half-lives after discontinuing a serotonergic medication before initiating
an MAIO
MAO-A
breaks down 5-HT, DA, NE, and tyramine
-used to treat depression and anxiety
"A" is for antidepressant or anxiolytic
MAO-B
responsible for the breakdown of dopamine, phenylethylamine, and tyramine
-used to treat Parkinson's disease; however, high-dose selegiline (Emsam) may be
used to treat anxiety or depression
Foods to avoid when taking MAOIs
Tyramine is present in many aged or preserved foods including aged cheeses, tap and
nonpasteurized beers, aged or smoked meat or fish, sauerkraut, kimchee, soy products,
and tofu.
Adjunct treatment for depression
Antipsychotic medications are sometimes prescribed at low doses as adjunctive
medications for severe depression
Newer tx for resistant depression: esketamine (Spravato)
nasal spray for the treatment of major depressive disorder (MDD) with acute suicidal
ideation or behavior
-reaches peak onset in the body in between 20-40 minutes
-risk of adverse outcomes due to sedation and dissociation
*must be administered in a supervised healthcare setting
Newer tx for resistant depression: Ketamine clinics
,Ketamine is an N-methyl-D-aspartate (NMDA) receptor inhibitor, results in the
downstream release of glutamate
-high doses, ketamine may cause psychotic symptoms, in low doses, it has a rapid
effect on depression
-Ketamine clinics have provided intravenous ketamine for treatment-resistant unipolar
and bipolar depression
*required frequent dosing, inconvenient, expensive
Newer tx for resistant depression: dextromethorphan/quinidine (Nuedexta)
Researchers are investigating, related to NMDA
-currently approved by the FDA for the treatment of pseudobulbar affect
*combines dextromethorphan and quinidine as an oral treatment
considered when selecting an antidepressant medication
Client preference
Prior treatment response
Anticipated adverse effects
Comorbidities
Half-life and interactions
Cost
Antidepressants: Initiating Medication
Start clients on a single drug for 4-8 weeks to assess efficacy. Start with the lowest
recommended dose to reduce side effects. If a medication is not achieving efficacy:
-Increase the dose gradually to the efficacious dose range.
-Switch to a different drug within the same class after an adequate trial which includes
higher dosing and a minimum of eight weeks of trial.
-Switch to a drug in a different class after an adequate trial which includes higher dosing
and a minimum of eight weeks of trial.
-Add a second medication as an adjunct.
Antidepressants: Discontinuing Medications
Don't suddenly stop or omit doses due to risk of discontinuation syndrome
-Paroxetine highest risk due to serotonin transporter inhibition and anticholinergic
rebound
, -If a treatment course has lasted 8 weeks, discontinuation over 1-2 weeks is safe. Once
symptoms are in remission, continue treatment for 4-9 months to reduce the risk of
relapse
Antidepressants Important Prescribing Considerations: Black Box Warning
Suicide Risk with Antidepressant Drugs
-Clients with depression may consider or attempt suicide
-risk for suicide may increase at the start of treatment
-Antidepressant-induced suicide is more prevalent in children, adolescents, and adults
younger than 25 years.
Antidepressants Important Prescribing Considerations: Drug-Drug Interactions
Most antidepressant medications have serious drug-drug interactions. Carefully review
the client's history and current prescriptions before selecting a medication.
Antidepressants Important Prescribing Considerations: Serotonin Syndrome
potentially life-threatening condition reported with the use of serotonergic
antidepressants
-especially when they are used concomitantly with other serotonergic drugs (such as
triptans, tricyclic antidepressants, fentanyl, lithium, tramadol, tryptophan, buspirone, and
St. John's Wort), and with drugs that impair serotonin metabolism (particularly MAOIs)
S/S
-mental status changes (e.g., agitation, hallucinations, delirium, and coma)
-autonomic instability (e.g., tachycardia, labile blood pressure, dizziness, diaphoresis,
flushing, hyperthermia)
-neuromuscular symptoms (e.g., tremor, rigidity, myoclonus, hyperreflexia,
incoordination)
-seizures, and/or gastrointestinal symptoms (e.g., nausea, vomiting, diarrhea)
If such symptoms occur, clients should discontinue serotonergic agents and initiate
treatment of symptoms.
Clients should be educated about the signs and symptoms of serotonin syndrome and
