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Update on New Psychiatric Medications

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Update on New Psychiatric Medications Update on Newer Psychiatric Medications Teresa (Tess) Judge-Ellis DNP, FNP-BC, PMHNP-BC, FAANP Associate Lecturer, Fitzgerald Health Education Associates, North Andover, MA Clinical practice, FNP/PMHNP Winfield Community Clinic, Winfield, IA PMHNP Meadowlark Psychiatric Services, North Liberty, IA Clinical Associate Professor, University of Iowa College of Nursing, Iowa City, IA Fitzgerald Health Education Associates 1 Disclosure • No real or potential conflict of interest to disclose. • No off-label, experimental or investigational use of drugs or devices will be presented. Fitzgerald Health Education Associates 2 Objectives • Upon completion of the learning activity the participant will be able to: – Recognize clinical scenarios when newer and second line medications should be considered in the management of major depressive disorder (MDD). Fitzgerald Health Education Associates 3 1 Objectives (continued) • Upon completion of the learning activity the participant…: (cont.) – Identify the mechanism of action of newer medication for the treatment of MDD. – Describe the mechanism of action of newer agents for insomnia. Fitzgerald Health Education Associates 4 Major Depressive Disorder SIG E CAPS + Mood DSM-5 criteria • Sleep • Concentration • Interest* • Appetite • Guilt • Psychomotor • Energy • Suicidal thoughts *Gateway symptoms • + mood* • One must be present + 4 other symptoms present for 2 weeks • Not due to other psychiatric or medical condition or substance use disorder Fitzgerald Health Education Associates 5 Psychotropic Options for Major Depressive Disorder Fitzgerald Health Education Associates 6 2 Generic Selective Serotonin Reuptake Inhibitors (SSRI) • The first-line medications for most mood disorders – Citalopram (Celexa®) – Escitalopram (Lexapro®) – Fluoxetine (Prozac®) – Fluvoxamine (Luvox®) – Paroxetine (Paxil®) – Sertraline (Zoloft®) Fitzgerald Health Education Associates 7 Serotonin Norepinephrine Reuptake Inhibitors (SNRI) Generic SNRI Branded SNRI • Venlafaxine • Desvenlafaxine (Effexor®) (Pristiq®) • Duloxetine • Levomilnacipran (Cymbalta®) (Fetzima®) Fitzgerald Health Education Associates 8 Other Antidepressants Generic Trade/Branded • Norepinephrine- •Serotonin modulator dopamine reuptake and stimulator inhibitor −Vortioxetine (Trintellix®) –Bupropion (Wellbutrin®) •Serotonin partial •Noradrenergic and agonist/reuptake specific serotonergic inhibitor antidepressant −Vilazodone (Viibryd®) –Mirtazapine (Remeron®) Fitzgerald Health Education Associates 9 3 Newer Antidepressants Vilazodone (Viibryd®) Vortioxetine (Trintellix®) Levomilnacipran (Fetzima®) Fitzgerald Health Education Associates 10 What do they have in common? Serotonin Adverse effects and cautions Attributed to increased serotonergic activity Fitzgerald Health Education Associates 11 Adverse Effects and Precaution Common to all SSRI/SNRI • Abnormal bleeding – Caution about increased risk of bleeding with patients on NSAIDs, aspirin, warfarin and other anticoagulants • Activation of mania/hypomania – As with all antidepressants Fitzgerald Health Education Associates 12 4 Adverse Effects and Precaution Common to all SSRI/SNRI (continued) • Hyponatremia – Especially with elderly patients and those on diuretics • Angle closure glaucoma risk in patients with anatomically narrow angles due to pupillary dilation Fitzgerald Health Education Associates 13 Adverse Effects and Precaution Common to all SSRI/SNRI (continued) • Contraindicated due to risk of serotonin syndrome – With MAOI use and within 14 days of stopping an MAOI – In patients being treated with linezolid or intravenous methylene blue Fitzgerald Health Education Associates 14 Adverse Effects and Precaution Common to all SSRI/SNRI (continued) • Boxed warning for an increase risk of suicidal thinking and behavior (suicidality) in children, adolescents and young adults (age 18−24 years) with MDD and other psychiatric disorders. • Pregnancy category C • Breastfeeding risk: Acceptable for SSRIs Fitzgerald Health Education Associates 15 5 Adverse Effects and Precaution Serotonin Syndrome • What is it? – Over activation of the central and peripheral serotonin receptors due to high level of serotonin • Incidence is unknown. – Uncommon with low dose SSRI or SNRI and occasional use of a triptan • A diagnosis of exclusion Fitzgerald Health Education Associates 16 Risk of Serotonin Syndrome (continued) • Caution with concomitant use of other serotonergic drugs – Examples: Triptans, TCAs, fentanyl, lithium, tramadol, tryptophan, buspirone, St John’s Wort, antidepressants, MAOIs, SGAs, phentermine • Alerts – Chronic pain, migraine history, depression or anxiety, end-stage renal disease Fitzgerald Health Education Associates 17 Serotonin Syndrome • Signs and symptoms – Alteration in mental status – Neuromuscular abnormalities – Autonomic hyperactivity Fitzgerald Health Education Associates 18 6 Spectrum of Clinical Findings in Serotonin Syndrome Boyer E and Shannon M. N Engl J Med 2005;352:1112-1120 Fitzgerald Health Education Associates 19 Findings in a Patient with Moderately Severe Serotonin Syndrome Boyer E and Shannon M. N Engl J Med;352:1112-1120 Fitzgerald Health Education Associates 20 Intervention in Serotonin Syndrome • Mildly ill – Hyperreflexia, tremor, afebrile • Supportive care • Removal of precipitating drugs • Benzodiazepines – Source: Boyer E and Shannon M. N Engl J Med 2005;352:1112-1120. Fitzgerald Health Education Associates 21 7 Intervention in Serotonin Syndrome (continued) • Moderately ill – Aforementioned findings, fever, cardiorespiratory abnormalities • Aggressive correction of cardiorespiratory and thermal abnormalities • Administration of 5-HT2A antagonists such as cyproheptadine (Periactin®) with a dose range=12−32 mg/24h so that up to 95% of serotonin receptor sites are occupied – Source: Boyer E and Shannon M. N Engl J Med;352:1112-1120. Fitzgerald Health Education Associates 22 Vilazodone (Viibryd®) • Indication – For the treatment of major depressive disorder in adults age ≥18 years • Mechanism of action – Increases CNS serotonergic activity • SSRI • Partial 5-HT1A receptor agonist • Cost=$140 per month Fitzgerald Health Education Associates 23 Vilazodone (Viibryd®) (continued) • How supplied – 10 mg, 20 mg, and 40 mg tablets • Recommended daily dose – Start with an initial dose of 10 mg once daily with food for 7 days – Then increase to 20 mg once daily with food – Increase up to 40 mg once daily with food after a minimum of 7 days between doses Fitzgerald Health Education Associates 24 8 Vilazodone (Viibryd®) (continued) • Take with food – Taking on an empty stomach can decrease availability by 50−60% Fitzgerald Health Education Associates 25 Vilazodone (Viibryd®) Adverse Effects • Most common adverse effects – Diarrhea, nausea, vomiting – Insomnia – Headache, dizziness • No reported weight gain in clinical trials • Minimal reported sexual adverse reactions Fitzgerald Health Education Associates 26 Vilazodone (Viibryd®) Niche Comorbid depression and anxiety Weight gain worriers Sexual adverse effect concerns Fitzgerald Health Education Associates 27 9 Case Example • Mr. R., a 25-year-old graduate student, recently moved to your town to begin graduate studies. He has a history of major depressive disorder and generalized anxiety disorder. His anxiety is worse and he is feeling depressed. His current medication is sertraline 100 mg. PHQ-9=16; GAD-7=12 Fitzgerald Health Education Associates 28 Case Example (continued) • You increase his sertraline to 150 mg and recommend counseling. • He returns in 2 months with continued mild depression (PHQ- 9=14; GAD-7=12) and worsening anxiety symptoms of rumination, muscle tension and occasional difficulty with middle insomnia. Fitzgerald Health Education Associates 29 Case Example (continued) • He is also unhappy with the sexual adverse effects, specifically difficult and delayed orgasm, that he attributes to the sertraline. • You start vilazodone 10 mg daily with breakfast and reduce the sertraline to 100 mg. Fitzgerald Health Education Associates 30 10 Case Example (continued) • During week 2 you reduce the sertraline to 50 mg daily and increase vilazodone to 20 mg daily. • During week 3 the sertraline was discontinued and the vilazodone was increased to 40 mg daily. Fitzgerald Health Education Associates 31 Case Example (continued) • Mr. R. tolerated this transition well. After a month his depression had improved (PHQ-9=10) and his anxiety symptoms were improved (GAD-7=7). • While he still has some delay to orgasm, this is much improved and he opts to continue on vilazodone (Viibryd®) 40 mg. Fitzgerald Health Education Associates 32 Vortioxetine (Trintellix®) • Indication – For treatment of major depressive disorder in adults age ≥18 years • Cost – About $240/month Fitzgerald Health Education Associates 33 11 Vortioxetine (Trintellix®) September, 2013 • What is it? – “Multi-modal” antidepressant or a “serotonin modulator and stimulator” • Selective serotonin reuptake inhibitor (SSRI) • Serotonin receptor agonist (5-HT1A) • Partial agonist (5-HT1B) • Antagonist (5-HT3A, 5HT7, 5-HT1D) Fitzgerald Health Education Associates 34 Vortioxetine (Trintellix®) (continued) • How supplied – 5 mg, 10 mg, 15 mg, and 20 mg tablets • Recommended daily dose – 10 mg starting dose without regards to meals • If 10 mg is tolerated, dosage can be increased to 20 mg/day. • Consider 5 mg/day for those unable to tolerate higher doses Fitzgerald Health Education Associates 35 Vortioxetine (Trintellix®) (continued) • Elderly study – 155 adults age
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