Clin Pharm/ alzheimer/anxiety/MDD

• Clinical examination: The clinical diagnosis of AD is usually made during the mild stage of the disease, using the above-listed signs.
• Lumbar puncture: levels of tau and phosphorylated tau in the cerebrospinal fluid are often elevated in AD, whereas amyloid levels are usually low; at present, however, routine measurement of CSF tau and amyloid is not recommended except in research settings.
• Imaging studies: Imaging studies are particularly important for ruling out potentially treatable causes of progressive cognitive decline, such as chronic subdural hematoma or normal-pressure hydrocephalus.
• Management

  
  

  Galantamine (razadyne)- 12mg

  • is used to treat mild to moderate dementia (memory loss and mental changes) that is a sign of Alzheimer's disease.

  • Galantamine will not cure Alzheimer's disease, and it will not stop the disease from getting worse.

  
• Rivastigmine (exelon cap. 1.5mg/ patch 4.6mg/24hrs.)

  • is a medication used to manage and treat neurodegenerative disease, specifically dementia, in patients with Alzheimer’s and Parkinson’s disease.

  • It is in the cholinesterase inhibitor class of drugs.
• Donepezil (aricept) 5mg

  • is a medication that treats symptoms of Alzheimer's disease like memory loss and confusion.

  • This medication works by improving your attention, memory, and ability to engage in your daily activities.

  • The brand name of this medication is Aricept®.
• Lecanemab (Leqembi) 200mg/2ml (100mg/1ml)

  • Lecanemab is an FDA-approved immunotherapy to treat early Alzheimer’s.

  • It targets the protein beta-amyloid to help reduce amyloid plaques, one of the hallmark brain changes in Alzheimer’s.

  • Approved by the FDA last July 6, 2023.

  • This is the first disease-modifying

  therapy approved for the treatment of Alzheimer’s disease in the United States.
• Adacanumab

  • a novel disease-modifying anti-amyloid-beta (Aβ) human monoclonal antibody specifically targeted to the pathophysiology of Alzheimer's disease (AD).

  • It was granted for treating AD in June 2021 by the United States Food and Drug Administration.
• Memantine (abixa) 10mg/20mg

  Memantine works by blocking the effects of a chemical called glutamate. Glutamate sends messages between nerve cells in the brain.

  Nerve cells damaged by Alzheimer's disease make too much glutamate which can cause more damage. Memantine protects nerve cells by blocking the effects of too much glutamate.

  The class of drug is called NMDA antagonist.
• First-line treatment

  • SSRIs (fluoxetine, sertraline, paroxetine, escitalopram, and citalopram) are an effective treatment for all anxiety disorders and are considered first-line treatments.
•  SNRI

  • Serotonin and norepinephrine reuptake inhibitors (SNRIs) are a class of medications that are effective in treating depression. SNRIs are also sometimes used to treat other conditions, such as anxiety disorders and long-term (chronic) pain, especially nerve pain.
  •  (venlafaxine and duloxetine) are considered as effective as SSRIs and are considered first-line treatment, particularly for generalized anxiety disorder (GAD).
• Duloxetine (cymbalta) 30mg antidepressants

  • Duloxetine is a medication used to manage major depressive disorder (MDD), generalized anxiety disorder (GAD), fibromyalgia, diabetic peripheral neuropathy, and chronic musculoskeletal pain. 
  • Off-label uses for duloxetine include chemotherapy-induced peripheral neuropathy and stress urinary incontinence.

  
• Tricyclic antidepressants

  • Tricyclic antidepressants (TCAs) constitute a class of medications used to manage and treat major depressive disorder (MDD). 
  • These medications function by inhibiting the reuptake of neurotransmitters, such as serotonin and norepinephrine, which can modulate mood, attention, and pain in individuals.
• Amitriptyline (tripgen) 25mg

  • This medication is used to treat mental/mood problems such as depression. It may help improve mood and feelings of well-being.

  
• Benzodiazepine

  • Benzodiazepines are depressants that produce sedation and hypnosis, relieve anxiety and muscle spasms, and reduce seizures. The most common benzodiazepines are the prescription drugs Valium®, Xanax®, Halcion®, Ativan®, and Klonopin®

  
• Fluoxetine (prodin) 20mg

  • Fluoxetine is used to treat depression, panic attacks, obsessive-compulsive disorder, a certain eating disorder (bulimia), and a severe form of premenstrual syndrome (premenstrual dysphoric disorder).
  • This medication may improve your mood, sleep, appetite, and energy level and may help restore your interest in daily tasks.

  
• Escitalopram (lexapro) 10mg

  •  Escitalopram is used to treat depression and generalized anxiety disorder (GAD). 

  
• Venlafaxine (maxine) 75mg

  • Venlafaxine is from a group of antidepressants called serotonin and noradrenaline reuptake inhibitors, or SNRIs. It is thought to work by increasing the levels of mood-enhancing chemicals called serotonin and noradrenaline in the brain. 
  • It's used to treat depression and sometimes anxiety and panic attacks.

  
• Buspirone

  • Buspirone is a mild tranquilizer that is slow-acting as compared to benzodiazepines and takes about 2 weeks to start working. 
  • It has the advantage of being less sedating and not being addicting with minimal withdrawal effects. It works for GAD.
• Psychological interventions include cognitive therapy, which focuses on changing negative thoughts and behaviors, and behavioral therapy, which involves learning new coping skills and strategies.
• Cognitive Behavior Therapy (CBT) - A type of psychotherapy that helps individuals identify and change negative patterns of thinking and behavior associated with mental health disorders such as depression and anxiety.
• Complementary and alternative treatments

  • Passionflower: Generally considered safe when taken as directed, but some studies have found it can cause drowsiness, dizziness, and confusion.
  • Kava: Some studies showed kava was helpful for anxiety reduction, and others did not.
  • Valerian: Generally well-tolerated, with a few case reports of people developing liver problems when taking preparations containing valerian.
  • Theanine: Preliminary evidence shows that theanine may make some people feel calmer, but limited evidence shows that it helps treat anxiety.
• Counseling

  • A standard way of treating anxiety is psychological counseling. This can include cognitive behavioral therapy (CBT), psychotherapy, or a combination of therapies.
  • CBT is a type of psychotherapy that aims to recognize and change harmful thought patterns that form the foundation of anxious and troublesome feelings.
• Diagnostic tests

  Physical examination

  • Your doctor may do a physical exam and ask questions about your health. In some cases, depression may be linked to an underlying physical health problem.

  
• Psychological evaluation

  ● A psychological evaluation, which is always performed by a licensed psychologist, can be used to diagnose a variety of mental health conditions or illnesses that impact memory, thought processes, and behaviors
• Assessment of Intellectual Functioning (IQ)

  ● An assessment of intellectual functioning, or IQ test, measures a person’s cognitive abilities and provides a score that is intended to serve as a measure of an individual's intellectual abilities and potential.

  ● There are two primary measures to test a person’s IQ: intelligence tests and neuropsychological assessment.
• Behavioral assessment

  ● A behavioral assessment is used to assess a wide variety of behaviors and emotions.

  ● It's particularly useful when it is unclear what might be causing problematic behaviors or symptoms.
• Clinical interview

  ● A clinical interview is a tool that helps psychologists make an accurate diagnosis of a variety of mental illnesses.

  ● There are two common types: structured clinical interviews and clinical diagnostic interviews.
• Personality assessment

  ● A personality assessment will allow your psychologist to learn about the genetic, environmental, and social components of your personality so they can figure out the best way to treat you.
• Management

  Selective serotonin reuptake inhibitors (SSRIs)

  • Doctors often start by prescribing an SSRI. These drugs are considered safer and generally cause fewer bothersome side effects than other types of antidepressants.

  • SSRIs include citalopram (Celexa), escitalopram (Lexapro), fluoxetine (Prozac), paroxetine (Paxil, Pexeva), sertraline (Zoloft) and vilazodone (Viibryd).
• MOA of SSRI

  ● SSRIs block the reabsorption (reuptake) of serotonin into neurons.

  ● This makes more serotonin available to improve the transmission of messages between neurons. SSRIs are called selective because they mainly affect serotonin, not other neurotransmitters.

  ● After carrying a message, serotonin is usually reabsorbed by the nerve cells (known as “reuptake”).

  ● SSRIs work by blocking (“inhibiting”) reuptake, meaning more serotonin is available to pass further messages between nearby nerve cells.

  
• 1. Serotonin-norepinephrine reuptake inhibitors (SNRIs)
  2. The SNRIs proposed mechanism of action is inhibition of both serotonin and norepinephrine reuptake, but the degree of norepinephrine blockade varies between agents and only occurs with higher doses for venlafaxine (150 mg daily or more).

  2. Examples of SNRIs include duloxetine (Cymbalta), venlafaxine (Effexor XR), desvenlafaxine (Pristiq, Khedezla), and levomilnacipran (Fetzima).

  
• Atypical antidepressants

  • These medications don't fit neatly into any of the other antidepressant categories.

  • They include bupropion (Wellbutrin XL, Wellbutrin SR, Aplenzin, Forfivo XL), mirtazapine (Remeron), nefazodone, trazodone and vortioxetine (Trintellix).
• Tricyclic antidepressants

  ● Tricyclic antidepressants (TCAs) constitute a class of medications used to manage and treat major depressive disorder (MDD).

  ● These medications function by inhibiting the reuptake of neurotransmitters, such as serotonin and norepinephrine, which can modulate mood, attention, and pain in individuals.
• TCA antidepressant MOA

  ● These medications function by inhibiting serotonin and norepinephrine reuptake within the presynaptic terminals, resulting in elevated concentrations of these neurotransmitters within the synaptic cleft.

  
• MAOi

  ● MAOIs — such as tranylcypromine (Parnate), phenelzine (Nardil), and isocarboxazid (Marplan) — may be prescribed, typically when other drugs haven't worked, because they can have serious side effects.

  ● Selegiline (Emsam), a newer MAOI that sticks on the skin as a patch, may cause fewer side effects than other MAOIs do.

  ● These medications can't be combined with SSRIs.

  
• MAOi MOA

  ● An enzyme called monoamine oxidase is involved in removing the neurotransmitters norepinephrine, serotonin, and dopamine from the brain.

  ● MAOIs prevent this from happening, which makes more of these brain chemicals available to effect changes in both cells and circuits that have been impacted by depression.

  
• Antidepressants suicidal risk

  ● Most antidepressants are generally safe, but the Food and Drug Administration (FDA) requires all antidepressants to carry a black box warning, the strictest warning for prescriptions.

  ● In some cases, children, teenagers, and young adults under age 25 may have an increase in suicidal thoughts or behavior when taking antidepressants, especially in the first few weeks after starting or when the dose is changed.

  
• Psychotherapy

  ● Psychotherapy is a general term for treating depression by talking about your condition and related issues with a mental health professional.

  ● Psychotherapy is also known as talk therapy or psychological therapy.