antidepressants
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DRUGS USED IN AFFECTIVE DISORDERS
Department of Pharmacology NEIGRIHMS, Shillong
Introduction
What are affective Disorders?
1. Mania
2. Depression • Reactive• Endogenous or Major Depression• Depressive syndromes – Unipolar or Bipolar
Bipolar Disorder - imageBipolar Disorder - image
Bipolar Disorder - image
Drugs used in Mania – Mood Drugs used in Mania – Mood StabilizersStabilizers
Lithium CarbonateLithium Carbonate Alternative Drugs:Alternative Drugs:
– CarbamazepineCarbamazepine– Sodium ValproateSodium Valproate– LamotrigineLamotrigine– TopiramateTopiramate– Atypical anyipsychotics – Olanzapine, risperidoneAtypical anyipsychotics – Olanzapine, risperidone
Lithium Carbonate – Pharmacological Lithium Carbonate – Pharmacological actions actions
CNS:CNS:– No discernible psychotropic effect in normal No discernible psychotropic effect in normal
individualsindividuals– Similarly, no effect on Manic-depressive Similarly, no effect on Manic-depressive
patientspatients– On prolonged administration – acts as mood On prolonged administration – acts as mood
stabilizerstabilizer– Suppresses the episodes af attackSuppresses the episodes af attack
Effect of Lithium Salts in Mania:
Lithium Carbonate – Mechanism of Lithium Carbonate – Mechanism of actionaction
1.1. Effect on Electrolyte and ion transport:Effect on Electrolyte and ion transport:– Li is the lightest of the alkali metal atomsLi is the lightest of the alkali metal atoms– Na+ and K+ are important in this familyNa+ and K+ are important in this family– Li distributes evenly in extracellular and intracellular fluids Li distributes evenly in extracellular and intracellular fluids
(contrast to Na+ and K+)(contrast to Na+ and K+)– Build up a small concentration gradient across cell Build up a small concentration gradient across cell
membranemembrane– But, cannot be transported via Na+/K+ ATPase But, cannot be transported via Na+/K+ ATPase – Interfere with transuducer mechanism of cell membraneInterfere with transuducer mechanism of cell membrane
Lithium Carbonate – Mechanism Lithium Carbonate – Mechanism of actionof action
2.2. Effects on 2Effects on 2ndnd Messenger Messenger– IPIP33 and DAG are important 2 and DAG are important 2ndnd messenger for alpha and messenger for alpha and
Muscarinic transmissionMuscarinic transmission– Lithium inhibits several enzymes in the normal recycling of Lithium inhibits several enzymes in the normal recycling of
PhosphoinositidePhosphoinositide– These include IPThese include IP22 to IP to IP11 and IP to Inositol and IP to Inositol– These leads to depletion of PIPThese leads to depletion of PIP22, the membrane precursor , the membrane precursor
of IPof IP33 and DAG and DAG– Ultimate effect may be in G-protein receptors – may Ultimate effect may be in G-protein receptors – may
uncouple receptors from G-protein uncouple receptors from G-protein
Lithium Carbonate, Mechanism – Lithium Carbonate, Mechanism – contd.contd.
Lithium Carbonate, Mechanism – Lithium Carbonate, Mechanism – contd.contd.
3.3. Neurotransmitters:Neurotransmitters:– Enhances the action of SerotoninEnhances the action of Serotonin– Decrease the noradrenaline and dopamine Decrease the noradrenaline and dopamine
turnover – antimanic actionturnover – antimanic action– Augment synthesis of AcetylcholineAugment synthesis of Acetylcholine
Lithium Carbonate - PharmacokineticsLithium Carbonate - Pharmacokinetics
•Initial Dose is 600 mg/day and gradually increased (600 to 1200 mg/day
Well absorbed orally, but slowlyWell absorbed orally, but slowly Not metabolized and not protein boundNot metabolized and not protein bound Attains uniform distribution in total body Attains uniform distribution in total body
waterwater Apparent Vd – 0.8L/kg at steady state Apparent Vd – 0.8L/kg at steady state
Lithium, Pharmacokinetics – Lithium, Pharmacokinetics – contd.contd.
Li is actively reabsorbed from proximal tubule in the Li is actively reabsorbed from proximal tubule in the kidney similar to Na+kidney similar to Na+
When Na+ is restricted larger portion of Na+ is When Na+ is restricted larger portion of Na+ is reabsorbed - similar is in case of Lireabsorbed - similar is in case of Li
Initially rapid excretion, then slower in later phase.Initially rapid excretion, then slower in later phase. T1/2 is 16 to 30 HrsT1/2 is 16 to 30 Hrs Clearance is 20% of creatinineClearance is 20% of creatinine Steady state is attained in 5-7 daysSteady state is attained in 5-7 days Available as 300 and 400 mg tabletsAvailable as 300 and 400 mg tablets
Lithium – Monitoring of TreatmentLithium – Monitoring of Treatment
Individual variation in the rate of excretionIndividual variation in the rate of excretion Narrow margin of safetyNarrow margin of safety Done 5 days after the start of treatmentDone 5 days after the start of treatment Measurement is done 12 Hrs after the last doseMeasurement is done 12 Hrs after the last dose If no therapeutic improvement, chnge the doseIf no therapeutic improvement, chnge the dose New dose = desired plasma level/present levelNew dose = desired plasma level/present level Monitor the new dose level after 5 days againMonitor the new dose level after 5 days again If steady state (0.5 to 0.8 mEq/L – increase the If steady state (0.5 to 0.8 mEq/L – increase the
interval of monitoringinterval of monitoring
Lithium – Adverse EffectsLithium – Adverse Effects
1.1. CNS:CNS: – Tremor is frequentTremor is frequent– Coarse tremor, giddiness, ataxia, motor incoordination, nystagmus Coarse tremor, giddiness, ataxia, motor incoordination, nystagmus
etc. – delirium, comaetc. – delirium, coma– Occurs mainly when plasma level is high (2mEq/L)Occurs mainly when plasma level is high (2mEq/L)– Treat with propranolol, atenolol etc.Treat with propranolol, atenolol etc.– If required – Osmotic diuretics for Li excretionIf required – Osmotic diuretics for Li excretion
2.2. Renal: Polyuria and PolydipsiaRenal: Polyuria and Polydipsia– Loss of ability of collecting tubules to conserve water by influence Loss of ability of collecting tubules to conserve water by influence
of ADH (G protein)of ADH (G protein)– Excessive free water clearanceExcessive free water clearance– Nephrogenic Diabetes InsipidusNephrogenic Diabetes Insipidus
Lithium, Adverse Effects – contd.Lithium, Adverse Effects – contd.
3.3. Cardiac Effects:Cardiac Effects: Sick-sinus syndrome – Sick-sinus syndrome – contraindicated – flattening of T wavecontraindicated – flattening of T wave
4.4. Thyroid Function:Thyroid Function: Decrease in thyroid Decrease in thyroid Function – goitre (G protein)Function – goitre (G protein)
5.5. Pregnancy Pregnancy – contraindicated– contraindicated– Foetal goitre, congenital abnormalities (cardiac) Foetal goitre, congenital abnormalities (cardiac)
Lithium – Drug InteractionsLithium – Drug Interactions
Diuretics: Renal clearance of Lithium is reduced Diuretics: Renal clearance of Lithium is reduced by 25% with Diuretic e.g. furosemide, Thiazidesby 25% with Diuretic e.g. furosemide, Thiazides
NSAIDS: Renal clearance of Lithium is reduced NSAIDS: Renal clearance of Lithium is reduced by 25%by 25%
All Neuroleptics, except clozapine – increased All Neuroleptics, except clozapine – increased EPSEPS
Insulin and oral hypoglycaemics: enhance Insulin and oral hypoglycaemics: enhance hypoglycaemiahypoglycaemia
Antimanic – Other Drugs
Carbamazepine:– Prolong remission– Relapse with Li+ therapy and rapid cycling of
Mood – Li + CBZ
Sodium Valproate:– Ist line in acute mania– Lithium resistance cases– Lithium + Valproate – resistance to monotherapy
Antimanic Drugs - contd.
Lamotrigine:– Not for acute cases but Bipolar disorders– Used as monotherapy as well as with Lithium
Atypical antipsychotics:– 1st line in acute mania in combination with BZD
except patient requiring parenteral therapy– Olanzapine in maintenance therapy and
prophylaxis
ANTIDEPRESSANTSANTID
EPRESSANTS
Drugs which can Elevate Mood (Mood Elevators)
ANTIDEPRESSANTS
1. MAO inhibitors:– Irreversible: Isocarboxazid, Iproniazid, Phenelzine and Tranylcypromine– Reversible: Moclobemide and Clorgyline
2. Tricyclic antidepressants (TCAs) NA and 5 HT reuptake inhibitors – Imipramine, Amitryptiline, Doxepin,
Dothiepin and Clomipramine NA reuptake inhibitors – Desimipramine, Nortryptyline, Amoxapine
3. Selective Serotonin reuptake inhibitors: – Fluoxetine, Fluvoxamine, Sertraline and Citalopram
4. Atypical antidepressants:– Trazodone, Mianserin, Mirtazapine, Venlafaxine, Duloxetine, Bupropion and
Tianeptine
Causes of Depression and Mechanism of antidepressants
The Monoamine Theory: Adrenaline, Noradrenaline, Dopamine and 5-HT
are neurotransmitters (Biogenic amines) Called Noradrenergic, Serotonergic or
Dopaminergic etc. neurones Normally NA and 5 HT are in adequate numbers
at post synaptic region In DEPRESSION – Deficiency of NA or 5 HT or
BOTH
Mechanism of antidepressants – contd.
Drugs act by increasing the local availability of NA or 5 HT
MAO Inhibitors: MAO is a Mitochondrial Enzyme involved in Oxidative deamination of these amines MAO-A: Peripheral nerve endings, Intestine and
Placenta (5-HT and NA) MAO-B: Brain and in Platelets and Mainly
Serotonergic (Phenylalanine) Selective MAO-A inhibitors (RIMA) have
antidepressant property
Mechanism of antidepressants – contd.
TCAs:– NA, 5 HT and Dopamine are present in Nerve endings– Normally, there are reuptake mechanism and termination of
action– TCAs inhibit reuptake and make more monoamines
available for action
SSRIs: – Serotonins also reuptaken by Nerve terminals– SSRIs inhibit the reuptake mechanism and make more 5
HT available for action
Mechanism of Antidepressants
MAO inhibitors
Drugs: Irreversible: Isocarboxazid, Iproniazid, Phenelzine and Tranylcypromine, Reversible: Moclobemide and Clorgyline
Not popular now except irreversible selective MAO-A inhibitors:– Strict dietary restrictions– Irreversible action– Drug-drug interactions– Safer drugs are available now
Major drawbacks:– Manic state or hypertensive crisis– Cheese reactions– Other drug interactions
MAO inhibitors (Drawbacks) – contd.
Drug Interactions:– Ephedrine (drugs of cold and cough): hypertensive reaction– Reserpine, guanethidine: excitement and rise in BP– Levodopa: excitement and rise in BP (delayed degradation
of NA and DA)– Antiparkinsonian anticholinergics: Hallucinations and
symptoms of atropine poisoning– MAOI and SSRI: Serotonin Syndrome (Mental confusion,
hallucinations, sweating, hyperthermia, twitching of muscle, clonus and convulsion)
MAO inhibitors – contd.
Moclobomide: Advantages– Reversible action (1-2 days after stoppage)– Potentiation of pressor response to dietary
amines is weak– Dietary restriction not required– Lack of anticholinergic, sedative,, cognitive and
CVS adverse effects– Used in elderly patients and with heart diseases– Mild to moderate depression - alternative to TCAs
Tricyclic Antidepressants - Imipramine
NA and 5 HT reuptake inhibitors – Imipramine, Amitryptiline, Doxepin, Dothiepin and Clomipramine; NA reuptake inhibitors – Desimipramine, Nortryptyline, Amoxapine
Analogue of CPZ Inhibit NET and SERT Interacts with variety of receptors – alpha, H1,
5HT1, 5HT2 and D2
Imipramine – contd.
Early effects – sedation, no other CNS effect After 2-4 wks:
– Elevation of mood, more communicative– REM sleep suppressed and no night awakening– More sedative ones are for agitated and anxiety
patients (amitriptyline, doxepin)– Withdrawn patients – less sedative Imipramine,
Nortriptyline– Induce seizure (Clomipramine, bupropion)
Imipramine - Mechanism of action
Inhibit uptake of Biogenic amines – NA and 5-HT No inhibition of DA uptake except Bupropion Cocaine and amphetamines are inhibitors of DA
uptake – strong CNS stimulant May facilitate DA transmission in forebrain –
elevation of MOOD Reuptake inhibition causes – increase amines in
synaptic cleft Inhibition of DA – stimulant action Inhibition of NA and 5-HT – antidepressant action
Imipramine - Mechanism of action – contd.
But, antidepressant action starts after few weeks, whereas blockade starts immediately
Inhibition of uptake is an early step but cascade of events that follow are important
Initially, auto receptors - α2 and 5-HT1 are activated by excess of NA/5HT – negative feed back
Limiting of synaptic availability of NA - homeostasis On repeated exposure – α2 receptor response diminishes -
desensitization of these pre-synaptic receptors Adaptive changes – in number and sensitivity of pre and
postsynaptic pre-synaptic production and release of NA - normal or more
No reuptake and no negative feed back
Imipramine – Pharmacological actions
ANS: Dry mouth, blurring of vision, constipation and urinary hesitancy
CVS: Tachycardia – – NA and anticholinergic action– Postural hypotension– ECG – T wave suppression– Arrhythmia
Effect of Antidepressants
Deficient Drive of MOOD to - Normal Rhythmic Drive on Prolonged Treatment
Imipramine - Pharmacokinetics
Good oral absorption but undergo 1st pass effect – variable bioavailablity
Highly bound to plasma protein and high Vd Metabolized in Liver: Active metaboites: Imipramine
– desipramine and amitriptyline – nortriptyline Excreted via urine, t1/2 – 16 to 24 Hrs One daily dose – because of active metabolites Therapeutic window phenomenon: Optimal effect at
50-200 ng/ml Doses to be individualized and titrated
Imipramine – Adverse effects
1. Anticholinergic effects: Dry mouth, bad taste, constipaton, urinary retention etc.
2. Dysphoric state or mania - suicide3. CVS:
Postural hypotension – older patient and overdose Arrhythmia – with IHD
4. Weight gain – not with bupropion and SSRI5. Seizure – in children6. Sedation, mental confusion etc. – more with
amitriptyline7. Sweating and fine tremor
Imipramine – Drug Interactions
1. TCAs and Sympathomimetics (Cough and cold)
2. TCAs and MAO inhibitors – Hypertensive crisis
3. TCAs and SSRIs – SSRIs inhibit metabolism of TCAs
4. Anticholinergic property – delay absorption of other drugs
Imipramine - Drawbacks
Low safety margin Anticholinergic, CVS and neurological side
effects Therapeutic lag (2-4 wks) Variable patient response
SELECTIVE SEROTONIN REUPTAKE INHIBITORS
Drugs: Fluoxetine, Fluvoxamine, Sertraline and Citalopram
Similar antidepressant action Relatively safe and better patient acceptability Some patients not responding to TCAs may respond
with SSRIs Because of absence of psychomotor and cognitive
impairment - Preferred in prophylaxis of recurrent depression
SELECTIVE SEROTONIN REUPTAKE INHIBITORS
Relative advantages:– No sedation, so no
cognitive or psychomotor function interference
– No anicholinergic effects– No alpha-blocking action,
so no postural hypotension and suits for elderly
– No seizure induction– No arrhythmia
Drawbacks:– Nausea is common– Interfere with ejaculation– Insomnia, dyskinesia,
headache and diarrhoea– Impairment of platelet
function – epistaxis– Serotonin Syndrome:
Mental confusion, hallucinations, sweating, hyperthermia, twitching of muscle, clonus and convulsion.
SELECTIVE SEROTONIN REUPTAKE INHIBITORS
Fluoxetine:– Prototype of SSRIs– Slow action and not used for rapid effects– Longest acting – 2 days, t1/2 = 2 days– Used in depression and OCDs in adult and
children
SSRIs – Pharmacokinetic comparison
Dose
mg/day
Drug interaction
Half life Steady state
(Days)
Fluoxetine 5-20 high 2-4 days 30-60
Sertraline 50 low 26 Hrs 7-14
Paroxetime 20 high 20 Hrs 10-14
Citalopram 20-40 low 35 Hrs 7
Typical Antidepressants
1. Trazodone: Weak 5-HT uptake block, α – block, 5-HT2 antagonist No anticholinergic action No arrhythmia No seizure ADRs: Priapism, Postural Hypotension
2. Venlafaxine: SNRI (Serotonin and NA uptake inhibitor) Fast in action No cholinergic, adrenergic and histaminic interference Raising of BP
Atypical Antidepressants – contd.
3. Mirtazapine: NaSSA action (Noradrenaergic and specific serotonergic
antidepressant) – enhancement of NA release and specific 5-HT1 receptor action
Blockade of 5-HT2 and 5-HT3 No anticholinergic or antidopaminergic action
4. Bupropion: Inhibitor of DA and NA uptake (NDRI) Non-sedative but excitant property Used in depression and cessation of smoking Seizure may precipitated
Antidepressants - Uses
1. Endogenous Major Depression: Aim: Relieve symptoms of depression and restore Normal social
Behavior 1st choice – SSRI (atypical ones also may be considered) TCAs – in non-responsive cases
(TCAs have to be used in severe depression in adults) MAO –A inhibitors in mild and moderate cases Maintenance – by TCAs (Imipramine 100 mg) Combined with Lithium in Bipolar disorder Newer ones are not recommended in children – suicide chance
Antidepressants (Uses) – contd.
2. Obsessive Compulsive Disorder (OCD) and Phobic states:
(SSRIs are useful)– Compulsive eating in Bulimia– Body dysmorphic disorder– Compulsive buying– Kleptomania
3. Anxiety Disorders: BZD4. Neuropathic pain: Imipramine, Amitriptyline – post herpetic neuralgia5. Attention Deficit Hyperactivity Disorder: TCAs6. Enuresis 7. Migraine: Amitryptiline as prophylactic
Antianxiety Drugs
What is anxiety?
Anxiety is a normal reaction to stress It helps one deal with a tense situation in the
office, study harder for an exam, keep focused on an important speech
In general, it helps one cope But when anxiety becomes an excessive,
irrational dread of everyday situations, it has become a disabling disorder
Antianxiety Drugs – contd.
Five major types of anxiety disorders are:– Generalized Anxiety Disorder (GAD)– Obsessive-Compulsive Disorder (OCD)– Panic Disorder– Post-Traumatic Stress Disorder (PTSD)– Social Phobia (or Social Anxiety Disorder)
GAD: – Excessive, exaggerated anxiety and worry about everyday life
events with no obvious reasons for worry– always expect disaster and can't stop worrying about health,
money, family, work, or school– interferes with daily functioning, including work, school, social
activities, and relationships.
Antianxiety Drugs – contd.
What are the Drugs?
Benzodiazepines: Alprazolam, Diazepam, Chlordiazepoxide, Oxazepam and Lorazepam
Older Drugs: Barbiturates, Chloral hydrate and Meprobamate
Azapirones: Buspirone, Gepirone and Isapirone Others: Propranolol, Imipramine Fluoxetine and
Zolpidem etc.
Antianxiety Drugs – BZDs
High potency BZDs are useful Slow and Long duration of action Relieve anxiety at low doses – no generalized CNS depression Prescribed for short period – especially for alcohol and drug
abuse persons Less cognitive impairment At low dose – CVS and Respiratory side effects are less Withdrawal syndrome – tapering of Doses Clonazepam - social phobia and GAD Lorazepam - panic disorder Alprazolam - panic disorder and GAD Diazepam – acute panic state and organic disease anxiety
Antianxiety Drugs – Buspirone
No marked sedation and euphoria No direct effect on GABA or BZD receptors No physical dependence or tolerance No muscle relaxant, no anticonvulsant or no
extra pyramidal effects No functional and cognitive impairment No cross tolerance to other anxiolytics and
little abuse potential
Buspirone – contd.
Partial agonist action on presynaptic auto receptor 5-HT1A – reduces serotonergic activity in dorsal raphe
Antagonist of certain 5-HT1A post synaptic receptors Weak D2 action but no antipsychotic effect Adaptive changes after chronic treatment – reduction
in 5-HT2 receptors in cortex Given orally, absorbed rapidly – high 1st pass
metabolism, active metabolite – urine and faeces Dose: 5-15 mg dose
Antianxiety Drugs - Propranolol
Reduces symptoms of anxiety Symptoms: Sympathetic overactivity –
palpitation, tachycardia, rise in BP, sweating, tremor, GIT hurrying etc
No action on psychological symptoms – fear, tension etc.
Useful in examination fear, public appearance etc.
Pharmacotherapy of Anxiety
Anxiety is a Physiological phenomenon Start medication only when marked impairment of performance Start with a BZD according to the type of disorder at smallest
dose possible Doses are found out by titrating with the symptoms Usually start with ½ or 2/3rd of the normal dose at bed time If required the rest of the doses be given at day time Simultaneously treat the primary cause – hypertension, Peptic
ulcer etc. SSRIs and Buspirone may be used in severe cases but not in
acute cases
Pharmacotherapy of Anxiety – contd.
Beta-blockers may be given as adjuncts Withdraw anxiolytics, if required in tapering doses Lifelong therapy may be required for some patients
but avoid short acting drugs for long therapy Monitor for Drug interactions In GAD – counseling, mental relaxations and
Behavioural therapy Avoid:
– Excess of Cola or Coffee (stimulants)– Combination of alcohol, antihistamines, anticholinergics
Thank you / Khublei
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