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CC Nov 2015 Tricyclic antidepressants (TCA)

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echoecho's version from 2015-12-01 14:00

Section

Question Answer
TCAs were initially developed in the 1950s from existing __________?antihistamines
TCAs have a 3 ring chemical structure; differences in side groups are responsible for variations in activity ______ the reuptake of various neurotransmitters?blocking
List the following actions in common between the TCAs?1) inhibition of serotonin and norepinephrine reuptake in neural synapses 2) anticholinergic properties (dry mouth, constipation, dizziness, blurry vision) 3) blockade of alpha-adrenergic receptors 4) blockade of cardiac myocyte fast sodium channels
TCAs are well absorbed ____?orally
TCAs undergo significant first-pass metabolism in the ____?liver
TCAs have a _____ (large vs. small) volume of distribution?large
The half-life of TCAs is long, generally > ____ hours?24
After conjugation in the liver, TCAs are mostly excreted ____ (renally vs. hepatically)?renally
List 5 TCAs?1) amitriptyline 2) desipramine 3) doxepin 4) imipramine 5) nortriptyline
Regarding side effects of TCAs, rank the 5 TCAs from highest symptoms to lowest symptoms of anticholinergic symptoms?amitriptyline (4+) doxepin (3+) imipramine (3+) nortriptyline (2+) desipramine (1+)
Regarding side effects of TCAs, rank the 5 TCAs from highest symptoms to lowest symptoms of sedation?amitriptyline (4+) doxepin (4+) imipramine (3+) desipramine (2+) nortriptyline (2+)
Regarding side effects of TCAs, rank the 5 TCAs from highest symptoms to lowest symptoms of orthostatic hypotension?imipramine (4+) amitriptyline (3+) desipramine (2+) doxepin (2+) nortriptyline (1+)
Regarding side effects of TCAs, rank the 5 TCAs from highest symptoms to lowest symptoms of sexual side effects?all 5 TCAs are (3+)
Regarding side effects of TCAs, rank the 5 TCAs from highest symptoms to lowest symptoms of GI upset?desipramine, doxepine, imipramine don't have. However amitriptyline and imipramine are both (1+)
Regarding side effects of TCAs, rank the 5 TCAs from highest symptoms to lowest symptoms of cardiac arrhythmia?amitriptyline, imipramine both are (3+). Desipramine, doxepin, and nortriptyline are all (2+)
Regarding side effects of TCAs, rank the 5 TCAs from highest symptoms to lowest symptoms of agitation/insomnia? desipramine (1+), the rest do not have any
Regarding side effects of TCAs, rank the 5 TCAs from highest symptoms to lowest symptoms of weight gain?amitrypline, doxepin, imipramine are all (4+), desipramine and nortriptyline both are (1+)
Summarize the above side effects of TCAs as to the best TCA given the side effects?nortriptyline has the best side effect profile. Desipramine is a close second but it has agitation and insomnia.
*** A 2009 Cochrane review concluded that _____ - _____ TCAs were more effective than placebo in reducing symptoms of depression at 4 weeks and 8 weeks?low-dose
*** Using low dose TCAs has a benefit of what?minimizing side effects
A 2012 Cochrane review of amitriptyline (Elavil) concluded that it was efficacious in the treatment of depression but was associated with more side effects than placebo, list these side effects?vision problems, constipation, sedation
A 2012 Cochrane review regarding citalopram (Celexa) compared to TCAs, was there a difference in efficacy between the two medications? why did patients stop TCAs more?1) no 2) due to side effects
In addition to depression, which TCAs are used for diabetic neuropathic pain?amitriptyline, desipramine (Norpramin)
In addition to depression, which TCAs are used for postherpetic neuralgia?amitriptyline, nortriptyline (Pamelor)
In addition to depression, which TCAs are used for migraine headache prophylaxis?amitriptyline
In addition to depression, which TCAs are used for for anxiety and insomnia?doxepin (Sinequan)
In addition to depression, which TCAs are used for chronic pain?imipramine (Tofranil)
Why do patients prefer SSRIs to TCAs?due to fewer anticholinergic side effects
List the medications that TCAs interact with?1) benzodiazepines 2) clonidine 3) hydralazine 4) diuretics 5) phenytoin 6) propranolol 7) alcohol
TCAs also have a ______ (wider vs. narrower) therapeutic index than SSRIs?narrower
True or false, TCAs are one of the most common causes of fatal and nonfatal poisonings in the world?true
TCAs are best avoided in susceptible patients with heart disease, why?they are potentially cardiotoxic (heart rate variability, various arrhythmias, slowed intracardic conduction)
*** In a prospective cohort study of almost 15,000 adults without a known hx of cardiovascular disease, the use of TCAs was associated with ______ (increased vs. decreased) risk of cardiovascular events (CVA, CAD, death)? Was this seen in SSRIs?1) increased 2) no
The above study found a nonsignificant association between TCAs and _____ events?CHD
Did TCAs increase the risk of recurrent stroke?yes
*** SUMMARY = low dose TCAs are effective for what disease?depression
*** SUMMARY = In a Cochrane review, TCAs were as effective as what SSRI but side effects were greater?citalopram (Celexa)
*** SUMMARY = TCAs have a _____ (narrower vs. wider) therapeutic window?narrower
*** SUMMARY = are TCAs cardiotoxic?yes
*** TCAs are useful for treatment of what other disorders?postherpetic neuralgia, diabetic neuropathic pain, chronic pain
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