NURS 660 COMPREHENSIVE EXAM UPDATED QUESTIONS
AND SOLUTIONS RATED A+
✔✔Escitalopram major drug interactions - ✔✔-Tramadol increases the risk of seizures
in patients taking an antidepressant
-Can cause a fatal "serotonin syndrome" when combined with MAOIs, so do not use
with MAOIs or for at least 14 days after MAOIs are stopped
-Do not start an MAOI for at least 5 half-lives (5 to 7 days for most drugs) after
discontinuing escitalopram
-Could theoretically cause weakness, hyperreflexia, and incoordination when combined
with sumatriptan or possibly other triptans, requiring careful monitoring of patient
-Possible increased risk of bleeding, especially when combined with anticoagulants
(e.g., warfarin, NSAIDs)
NSAIDs may impair effectiveness of SSRIs
-Few known adverse drug interactions
✔✔Escitalopram lab tests - ✔✔none in healthy individuals
✔✔Escitalopram neurotransmitters and mechanism of action - ✔✔-Boosts
neurotransmitter serotonin
-Blocks serotonin reuptake pump (serotonin transporter)
-Desensitizes serotonin receptors, especially serotonin 1A autoreceptors
-Presumably increases serotonergic neurotransmission
✔✔Escitalopram pregnancy risks - ✔✔-Not generally recommended for use during
pregnancy, especially during first trimester
-Nonetheless, continuous treatment during pregnancy may be necessary and has not
been proven to be harmful to the fetus
-Neonates exposed to SSRIs or SNRIs late in the third trimester have developed
complications requiring prolonged hospitalization, respiratory support, and tube feeding;
reported symptoms are consistent with either a direct toxic effect of SSRIs and SNRIs
or, possibly, a drug discontinuation syndrome, and include respiratory distress,
cyanosis, apnea, seizures, temperature instability, feeding difficulty, vomiting,
hypoglycemia, hypotonia, hypertonia, hyperreflexia, tremor, jitteriness, irritability, and
constant crying
✔✔Sertraline (Zoloft) Major side effects SSRI
*Sertraline also has some ability to block dopamine reuptake pump (dopamine
transporter), which could increase dopamine neurotransmission and contribute to its
therapeutic actions - ✔✔-Sexual dysfunction (dose-dependent; men: delayed
ejaculation, erectile dysfunction; men and women: decreased sexual desire,
anorgasmia)
-Gastrointestinal (decreased appetite, nausea, diarrhea, constipation, dry mouth)
-Mostly CNS (insomnia but also sedation, agitation, tremors, headache, dizziness)
,Note: patients with diagnosed or undiagnosed bipolar or psychotic disorders may be
more vulnerable to CNS-activating actions of SSRIs
-Autonomic (sweating)
-Bruising and rare bleeding
Rare hyponatremia (mostly in elderly patients and generally reversible on
discontinuation of sertraline)
Rare hypotension
SIADH (syndrome of inappropriate antidiuretic hormone secretion)
✔✔Sertraline Major Adverse Reactions - ✔✔-Rare seizures
-Rare induction of mania
-Rare activation of suicidal ideation and behavior (suicidality) (short-term studies did not
show an increase in the risk of suicidality with antidepressants compared to placebo
beyond age 24)
✔✔Sertraline lab tests - ✔✔none for healthy individuals
✔✔Sertraline Major drug interactions - ✔✔-Tramadol increases the risk of seizures in
patients taking an antidepressant
-Can increase TCA levels; use with caution with TCAs or when switching from a TCA to
sertraline
-Can cause a fatal "serotonin syndrome" when combined with MAOIs, so do not use
with MAOIs or for at least 14 days after MAOIs are stopped,Do not start an MAOI for at
least 5 half-lives (5 to 7 days for most drugs) after discontinuing sertraline
-May displace highly protein bound drugs (e.g., warfarin)
-Can rarely cause weakness, hyperreflexia, and incoordination when combined with
sumatriptan or possibly with other triptans, requiring careful monitoring of patient
-Possible increased risk of bleeding, especially when combined with anticoagulants
(e.g., warfarin, NSAIDs)
-NSAIDs may impair effectiveness of SSRIs
- Via CYP450 2D6 inhibition, sertraline could theoretically interfere with the analgesic
actions of codeine, and increase the plasma levels of some beta blockers and of
atomoxetine
-Via CYP450 2D6 inhibition sertraline could theoretically increase concentrations of
thioridazine and cause dangerous cardiac arrhythmias
-Via CYP450 3A4 inhibition, sertraline may increase the levels of alprazolam, buspirone,
and triazolam
-Via CYP450 3A4 inhibition, sertraline could theoretically increase concentrations of
certain cholesterol lowering HMG CoA reductase inhibitors, especially simvastatin,
atorvastatin, and lovastatin, but not pravastatin or fluvastatin, which would increase the
risk of rhabdomyolysis; thus, coadministration of sertraline with certain ----HMG CoA
reductase inhibitors should proceed with caution
-Via CYP450 3A4 inhibition, sertraline could theoretically increase the concentrations of
pimozide, and cause QTc prolongation and dangerous cardiac arrhythmias
-Via CYP450 3A4 inhibition, sertraline could theoretically increase the concen
,✔✔Sertraline neurotransmitters and moa - ✔✔-Boosts neurotransmitter serotonin
-Blocks serotonin reuptake pump (serotonin transporter)
-Desensitizes serotonin receptors, especially serotonin 1A receptors
-Presumably increases serotonergic neurotransmission
-Sertraline also has some ability to block dopamine reuptake pump (dopamine
transporter), which could increase dopamine neurotransmission and contribute to its
therapeutic actions
✔✔Sertraline pregnancy risks - ✔✔Not generally recommended for use during
pregnancy, especially during first trimester
Nonetheless, continuous treatment during pregnancy may be necessary and has not
been proven to be harmful to the fetus
At delivery there may be more bleeding in the mother and transient irritability or
sedation in the newborn
Must weigh the risk of treatment (first trimester fetal development, third trimester
newborn delivery) to the child against the risk of no treatment (recurrence of depression,
maternal health, infant bonding) to the mother and child
For many patients this may mean continuing treatment during pregnancy
Exposure to SSRIs early in pregnancy may be associated with increased risk of septal
heart defects (absolute risk is small)
SSRI use beyond the 20th week of pregnancy may be associated with increased risk of
pulmonary hypertension in newborns, although this is not proven
Exposure to SSRIs late in pregnancy may be associated with increased risk of
gestational hypertension and preeclampsia
Neonates exposed to SSRIs or SNRIs late in the third trimester have developed
complications requiring prolonged hospitalization, respiratory support, and tube feeding;
reported symptoms are consistent with either a direct toxic effect of SSRIs and SNRIs
or, possibly, a drug discontinuation syndrome, and include respiratory distress,
cyanosis, apnea, seizures, temperature instability, feeding difficulty, vomiting,
hypoglycemia, hypotonia, hypertonia, hyperreflexia, tremor, jitteriness, irritability, and
constant crying
✔✔Duloxetine (Cymbalta) Major Side Effects SNRI
commonly prescribed for: Major depressive disorder
•Generalized anxiety disorder
•Fibromyalgia
•Diabetic peripheral neuropathic pain (PDN) - ✔✔Orthostatic hypotension and syncope
usually within the first week of use, constipation, dry mouth, sweating, diarrhea, fatigue,
loss of appetite, nausea, weight loss, hypertension, headache, asthenia (abnormal
physical weakness or lack of energy), dizziness, insomnia, somnolence
*Try magnesium for constipation
✔✔Duloxetine (Cymbalta) Major Adverse Reactions - ✔✔Serotonin syndrome
•Hepatotoxicity
•Rare activation of mania, depression, or suicidal ideation
, •Rare worsening of coexisting seizure disorders
✔✔Duloxetine Major Drug Interactions - ✔✔CYP2D6 inhibitors (duloxetine, paroxetine,
fluoxetine, bupropion) cimetidine, and valproic acid can increase drug concentration
•Concomitant use of potent CYP1A2 inhibitors (fluvoxamine, cimetidine, quinolone
antimicrobials [eg, ciprofloxacin, enoxacin]) should be avoided
•Serotonin release by platelets is important for maintaining hemostasis. Combined use
of SSRIs or SNRIs (such as duloxetine) and NSAIDs, and/or drugs that affect
anticoagulation has been associated with an increased risk of bleeding
•CYP2D6 and 1A2 enzyme inducers, such as rifamycin, nicotine, phenobarbital, can
lower levels
•May cause serotonin syndrome when used within 14 days of MAO inhibitors
•May increase risk of cardiotoxicity and arrhythmia when used with tricyclic
antidepressants vccccccccccccc
✔✔Duloxetine lab tests - ✔✔check blood pressure at baseline and when increasing
dose
*Not recommended for patients with severe renal function impairment (creatinine
clearance less than 30mL/min) or end-stage renal disease
*Not recommended for patients with hepatic function impairment
✔✔Duloxetine neurotransmitters and moa - ✔✔-Blocks serotonin and noradrenergic
reuptake pumps, increasing their levels within hours, but antidepressant effects take
weeks. ------Effect is more likely related to adaptive changes in serotonin and
norepinephrine receptors systems
•Weakly blocks dopamine reuptake pump (dopamine transporter)
✔✔Duloxetine pregnancy risk - ✔✔-Category C. =Generally not recommended for the
treatment of headache or neuropathic pain during pregnancy. Neonates exposed to
duloxetine or other SNRIs or SSRIs late in the third trimester have developed
complications necessitating extended hospitalizations, respiratory support, and tube
feeding. Respiratory distress, cyanosis, apnea, seizures, temperature instability, feeding
difficulty, vomiting, hypoglycemia, hypotonia, hyperreflexia, tremor, jitteriness, irritability,
and constant crying consistent with a toxic effect of the drug or drug discontinuation
syndrome have been reported
✔✔Paroxetine (Paxil) Major Side effects SSRI
Commonly Prescribed for
Major depressive disorder (paroxetine and paroxetine CR)
Obsessive-compulsive disorder (OCD)
Panic disorder (paroxetine and paroxetine CR)
Social anxiety disorder (social phobia) (paroxetine and paroxetine CR)
Posttraumatic stress disorder (PTSD)
Generalized anxiety disorder (GAD)
Premenstrual dysphoric disorder (PMDD) (paroxetine CR)
AND SOLUTIONS RATED A+
✔✔Escitalopram major drug interactions - ✔✔-Tramadol increases the risk of seizures
in patients taking an antidepressant
-Can cause a fatal "serotonin syndrome" when combined with MAOIs, so do not use
with MAOIs or for at least 14 days after MAOIs are stopped
-Do not start an MAOI for at least 5 half-lives (5 to 7 days for most drugs) after
discontinuing escitalopram
-Could theoretically cause weakness, hyperreflexia, and incoordination when combined
with sumatriptan or possibly other triptans, requiring careful monitoring of patient
-Possible increased risk of bleeding, especially when combined with anticoagulants
(e.g., warfarin, NSAIDs)
NSAIDs may impair effectiveness of SSRIs
-Few known adverse drug interactions
✔✔Escitalopram lab tests - ✔✔none in healthy individuals
✔✔Escitalopram neurotransmitters and mechanism of action - ✔✔-Boosts
neurotransmitter serotonin
-Blocks serotonin reuptake pump (serotonin transporter)
-Desensitizes serotonin receptors, especially serotonin 1A autoreceptors
-Presumably increases serotonergic neurotransmission
✔✔Escitalopram pregnancy risks - ✔✔-Not generally recommended for use during
pregnancy, especially during first trimester
-Nonetheless, continuous treatment during pregnancy may be necessary and has not
been proven to be harmful to the fetus
-Neonates exposed to SSRIs or SNRIs late in the third trimester have developed
complications requiring prolonged hospitalization, respiratory support, and tube feeding;
reported symptoms are consistent with either a direct toxic effect of SSRIs and SNRIs
or, possibly, a drug discontinuation syndrome, and include respiratory distress,
cyanosis, apnea, seizures, temperature instability, feeding difficulty, vomiting,
hypoglycemia, hypotonia, hypertonia, hyperreflexia, tremor, jitteriness, irritability, and
constant crying
✔✔Sertraline (Zoloft) Major side effects SSRI
*Sertraline also has some ability to block dopamine reuptake pump (dopamine
transporter), which could increase dopamine neurotransmission and contribute to its
therapeutic actions - ✔✔-Sexual dysfunction (dose-dependent; men: delayed
ejaculation, erectile dysfunction; men and women: decreased sexual desire,
anorgasmia)
-Gastrointestinal (decreased appetite, nausea, diarrhea, constipation, dry mouth)
-Mostly CNS (insomnia but also sedation, agitation, tremors, headache, dizziness)
,Note: patients with diagnosed or undiagnosed bipolar or psychotic disorders may be
more vulnerable to CNS-activating actions of SSRIs
-Autonomic (sweating)
-Bruising and rare bleeding
Rare hyponatremia (mostly in elderly patients and generally reversible on
discontinuation of sertraline)
Rare hypotension
SIADH (syndrome of inappropriate antidiuretic hormone secretion)
✔✔Sertraline Major Adverse Reactions - ✔✔-Rare seizures
-Rare induction of mania
-Rare activation of suicidal ideation and behavior (suicidality) (short-term studies did not
show an increase in the risk of suicidality with antidepressants compared to placebo
beyond age 24)
✔✔Sertraline lab tests - ✔✔none for healthy individuals
✔✔Sertraline Major drug interactions - ✔✔-Tramadol increases the risk of seizures in
patients taking an antidepressant
-Can increase TCA levels; use with caution with TCAs or when switching from a TCA to
sertraline
-Can cause a fatal "serotonin syndrome" when combined with MAOIs, so do not use
with MAOIs or for at least 14 days after MAOIs are stopped,Do not start an MAOI for at
least 5 half-lives (5 to 7 days for most drugs) after discontinuing sertraline
-May displace highly protein bound drugs (e.g., warfarin)
-Can rarely cause weakness, hyperreflexia, and incoordination when combined with
sumatriptan or possibly with other triptans, requiring careful monitoring of patient
-Possible increased risk of bleeding, especially when combined with anticoagulants
(e.g., warfarin, NSAIDs)
-NSAIDs may impair effectiveness of SSRIs
- Via CYP450 2D6 inhibition, sertraline could theoretically interfere with the analgesic
actions of codeine, and increase the plasma levels of some beta blockers and of
atomoxetine
-Via CYP450 2D6 inhibition sertraline could theoretically increase concentrations of
thioridazine and cause dangerous cardiac arrhythmias
-Via CYP450 3A4 inhibition, sertraline may increase the levels of alprazolam, buspirone,
and triazolam
-Via CYP450 3A4 inhibition, sertraline could theoretically increase concentrations of
certain cholesterol lowering HMG CoA reductase inhibitors, especially simvastatin,
atorvastatin, and lovastatin, but not pravastatin or fluvastatin, which would increase the
risk of rhabdomyolysis; thus, coadministration of sertraline with certain ----HMG CoA
reductase inhibitors should proceed with caution
-Via CYP450 3A4 inhibition, sertraline could theoretically increase the concentrations of
pimozide, and cause QTc prolongation and dangerous cardiac arrhythmias
-Via CYP450 3A4 inhibition, sertraline could theoretically increase the concen
,✔✔Sertraline neurotransmitters and moa - ✔✔-Boosts neurotransmitter serotonin
-Blocks serotonin reuptake pump (serotonin transporter)
-Desensitizes serotonin receptors, especially serotonin 1A receptors
-Presumably increases serotonergic neurotransmission
-Sertraline also has some ability to block dopamine reuptake pump (dopamine
transporter), which could increase dopamine neurotransmission and contribute to its
therapeutic actions
✔✔Sertraline pregnancy risks - ✔✔Not generally recommended for use during
pregnancy, especially during first trimester
Nonetheless, continuous treatment during pregnancy may be necessary and has not
been proven to be harmful to the fetus
At delivery there may be more bleeding in the mother and transient irritability or
sedation in the newborn
Must weigh the risk of treatment (first trimester fetal development, third trimester
newborn delivery) to the child against the risk of no treatment (recurrence of depression,
maternal health, infant bonding) to the mother and child
For many patients this may mean continuing treatment during pregnancy
Exposure to SSRIs early in pregnancy may be associated with increased risk of septal
heart defects (absolute risk is small)
SSRI use beyond the 20th week of pregnancy may be associated with increased risk of
pulmonary hypertension in newborns, although this is not proven
Exposure to SSRIs late in pregnancy may be associated with increased risk of
gestational hypertension and preeclampsia
Neonates exposed to SSRIs or SNRIs late in the third trimester have developed
complications requiring prolonged hospitalization, respiratory support, and tube feeding;
reported symptoms are consistent with either a direct toxic effect of SSRIs and SNRIs
or, possibly, a drug discontinuation syndrome, and include respiratory distress,
cyanosis, apnea, seizures, temperature instability, feeding difficulty, vomiting,
hypoglycemia, hypotonia, hypertonia, hyperreflexia, tremor, jitteriness, irritability, and
constant crying
✔✔Duloxetine (Cymbalta) Major Side Effects SNRI
commonly prescribed for: Major depressive disorder
•Generalized anxiety disorder
•Fibromyalgia
•Diabetic peripheral neuropathic pain (PDN) - ✔✔Orthostatic hypotension and syncope
usually within the first week of use, constipation, dry mouth, sweating, diarrhea, fatigue,
loss of appetite, nausea, weight loss, hypertension, headache, asthenia (abnormal
physical weakness or lack of energy), dizziness, insomnia, somnolence
*Try magnesium for constipation
✔✔Duloxetine (Cymbalta) Major Adverse Reactions - ✔✔Serotonin syndrome
•Hepatotoxicity
•Rare activation of mania, depression, or suicidal ideation
, •Rare worsening of coexisting seizure disorders
✔✔Duloxetine Major Drug Interactions - ✔✔CYP2D6 inhibitors (duloxetine, paroxetine,
fluoxetine, bupropion) cimetidine, and valproic acid can increase drug concentration
•Concomitant use of potent CYP1A2 inhibitors (fluvoxamine, cimetidine, quinolone
antimicrobials [eg, ciprofloxacin, enoxacin]) should be avoided
•Serotonin release by platelets is important for maintaining hemostasis. Combined use
of SSRIs or SNRIs (such as duloxetine) and NSAIDs, and/or drugs that affect
anticoagulation has been associated with an increased risk of bleeding
•CYP2D6 and 1A2 enzyme inducers, such as rifamycin, nicotine, phenobarbital, can
lower levels
•May cause serotonin syndrome when used within 14 days of MAO inhibitors
•May increase risk of cardiotoxicity and arrhythmia when used with tricyclic
antidepressants vccccccccccccc
✔✔Duloxetine lab tests - ✔✔check blood pressure at baseline and when increasing
dose
*Not recommended for patients with severe renal function impairment (creatinine
clearance less than 30mL/min) or end-stage renal disease
*Not recommended for patients with hepatic function impairment
✔✔Duloxetine neurotransmitters and moa - ✔✔-Blocks serotonin and noradrenergic
reuptake pumps, increasing their levels within hours, but antidepressant effects take
weeks. ------Effect is more likely related to adaptive changes in serotonin and
norepinephrine receptors systems
•Weakly blocks dopamine reuptake pump (dopamine transporter)
✔✔Duloxetine pregnancy risk - ✔✔-Category C. =Generally not recommended for the
treatment of headache or neuropathic pain during pregnancy. Neonates exposed to
duloxetine or other SNRIs or SSRIs late in the third trimester have developed
complications necessitating extended hospitalizations, respiratory support, and tube
feeding. Respiratory distress, cyanosis, apnea, seizures, temperature instability, feeding
difficulty, vomiting, hypoglycemia, hypotonia, hyperreflexia, tremor, jitteriness, irritability,
and constant crying consistent with a toxic effect of the drug or drug discontinuation
syndrome have been reported
✔✔Paroxetine (Paxil) Major Side effects SSRI
Commonly Prescribed for
Major depressive disorder (paroxetine and paroxetine CR)
Obsessive-compulsive disorder (OCD)
Panic disorder (paroxetine and paroxetine CR)
Social anxiety disorder (social phobia) (paroxetine and paroxetine CR)
Posttraumatic stress disorder (PTSD)
Generalized anxiety disorder (GAD)
Premenstrual dysphoric disorder (PMDD) (paroxetine CR)
