Raquel S. Mateus, PharmD candidate

Depression causes distressing symptom that affect how patients feel, handle daily activities, and think.

Depression can take several forms. To receive a diagnosis of depression, patients must have symptoms (TABLE 1

 By discussing symptoms, treatment options, and adverse effects, pharmacists can help patients adhere to their treatment regimen.

Some forms of depression develop under unique circumstances. For example, women may experience major depression during pregnancy or after delivery (postpartum depression). Seasonal affective disorder usually occurs in fall and winter and typically goes away during the spring and summer. Psychotic depression occurs when a person has severe depression plus some form of psychosis, such as delusions or hallucinations.

Initial treatment includes medications (TABLE 2

), psychotherapy, or both. Brain stimulation therapy is usually reserved for patients who do not respond to multiple treatments (treatment-resistant depression).

Medications used to treat depression include bupropion, a norepinephrine and dopamine reuptake inhibitor, and mirtazapine, an α2 blocker.

Counsel patients that they may not notice positive changes from the antidepressant for 2 to 4 weeks.

 Also, monitor patients closely during the first 6 to 8 weeks, and increase the dose or switch therapies in patients who do not improve.

Although many antidepressants have similar effects, a few have some

unique properties or adverse effects. These include the following:

Paroxetine has anticholinergic properties, so avoid prescribing to elderly patients.

Fluoxetine and sertraline have active metabolites that can cause hepatic impairment. Both may cause restlessness or tremors.

Citalopram can cause QTc prolongation, requiring caution in patients with electrolyte imbalances.

Mirtazapine can increase appetite and weight gain.

Monoamine oxidase inhibitors should not be taken with fermented or preserved foods, as they may cause hypertensive crisis.

First-line therapy with antidepressants does not work for some patients. If it is necessary to switch therapy, tapering prevents serotonin syndrome and withdrawal symptoms. Cross-tapering gradually decreases the dose of the first antidepressant as the new antidepressant is initiated and titrated up over 1 to 2 weeks. A direct switch is when the prescriber stops an antidepressant and starts a new one This is usually possible between drugs of the same class.

Pharmacists should mention additional ways patients can reduce the symptoms of depression. Remind patients to be active and exercise, avoid alcohol and nonprescription drugs, set realistic goals for themselves, and spend time with family and friends.

 Finally, pharmacists should advise patients to take their antidepressants at the same time every day for maximum benefit.

National Institute of Mental Health at www.nimh.nih.gov

National Suicide Prevention Lifeline: Call 1-800-273-TALK (8255)

 is a PharmD candidate at the University of Connecticut School of Pharmacy in Storrs.

MalhiGS, Bassett D, Boyce P, et al. Royal Australian and New Zealand College of Psychiatrists clinical practice guidelines for mood disorders. 

. 2015;49(12):1087-1206. doi:10.1177/0004867415617657

National Institute of Mental Health. Depression. National Institutes of Health. Updated February 2018. Accessed January 6, 2021. https://www.nimh.nih.gov/health/topics/depression/index.shtml

American Psychological Association. APA guideline for the treatment of depression. February 16, 2019. Accessed January 13, 2021. https://www.apa.org/depression-guideline/guideline.pdf

American Psychiatry Association. Treating major depressive disorder. October 2010. Accessed January 13, 2021. https://psychiatryonline.org/pb/assets/raw/sitewide/practice_guidelines/guidelines/mdd-guide.pdf

Choudhry N, Fischer MA, Hoge E, et al. The pursuit of happiness: management of depression in the elderly a review for the practicing physician. Semantic Scholar. 2008. Accessed January 27, 2021. https://www.semanticscholar.org/paper/The-Pursuit-of-Happiness%3A-Management-of-Depression-Choudhry-Fischer/8a7212d4a3f3051fb4fb1425317c7436a3c8802c

Paxil. Prescribing information. GlaxoSmithKline; 2011. Accessed January 13, 2021. https://www.accessdata.fda.gov/drugsatfda_docs/label/2012/020031s067,020710s031.pdf

Zoloft. Prescribing information. Pfizer; 2016.Accessed January 13, 2021. https://www.accessdata.fda.gov/drugsatfda_docs/label/2016/019839S74S86S87_20990S35S44S45lbl.pdf

Prozac. Prescribing information. Eli Lilly and Company; 2017. Accessed January 13, 2021. https://www.accessdata.fda.gov/drugsatfda_docs/label/2017/018936s108lbl.pdf

Celexa. Prescribing information. Forest Pharmaceuticals, Inc; 2011.Accessed January 13, 2021. https://www.accessdata.fda.gov/drugsatfda_docs/label/2012/020822s042,021046s019lbl.pdf

Wellbutrin.Prescribing information. GlaxoSmithKline; 2017. Accessed January 13, 2021. https://www.accessdata.fda.gov/drugsatfda_docs/label/2017/018644s052lbl.pdf

Remeron.Prescribing information. Schering Corporation; 2007. Accessed January 27, 2021. https://www.accessdata.fda.gov/drugsatfda_docs/label/2010/020415s023s024.pdf

Keks N, Hope J, Keogh S. Switching and stopping antidepressants. 

. 2016;39(3):76-83. doi:10.18773/austprescr.2016.039

American Psychiatric Association What is depression? October 2020. Accessed January 5, 2021. https://www.psychiatry.org/patients-families/depression/what-is-depression

National Network of Depression Centers. Resource links. Accessed January 7, 2021.https://nndc.org/resource-links/

Articles

Discuss symptoms, treatment options, and adverse effects to help those who suffer adhere to their medication regimens.

Talking to Patients With Depression Is Essential

A migraine is a recurrent neurological condition characterized by headache attacks that present as unilateral, throbbing pain. Migraine attacks are the leading cause of disability in individuals younger than 50 years  and predominantly affect women. The FDA has not approved any medication that treats both acute and preventative treatment of migraine.

Most oral treatments for migraine prevention, such as β blockers, antiepileptic drugs, and tricyclic antidepressants. have noteworthy adverse effect profiles and need daily administration.

 Because of these factors, more than 80% of patients stop taking their prophylactic medications within 1 year.

The neuropeptide calcitonin gene-related peptide (CGRP) plays a central role in the underlying pathology of migraine. CGRP is the prominent neurotransmitter that precipitates a migraine and increases during an attack.

 Rimegepant is a CGRP antagonist that is only FDA-approved for acute migraine treatment.

 Due to the lack of prophylactic migraine medications, investigators compared the efficacy of rimegepant with that of placebo for migraine prevention.

At the start of the trial, the investigators randomized adults with at least a 1-year history of migraine to oral rimegepant 75 mg or placebo every other day for 12 weeks. They used an interactive web response system.

The study found that rimegepant was superior to placebo at change in the mean number of migraine days per month. Rimegepant reduced moderate or severe migraine days per month and total migraine days per month over placebo. As a result, the CGRP receptor antagonists may provide a targeted novel approach to migraine prevention.

Findings from the study also showed a favorable safety and tolerability profile with rimegepant. Reasons individuals could benefit using rimegepant include a low adverse effect profile, oral administration, and a short half-life of 11 hours.

The investigators concluded that use of rimegepant for acute and preventive treatment of migraine might reduce the overall burden of illness associated with the condition. This idea merits further investigation, they said.

 is a 2021 PharmD Candidate at the University of Connecticut in Storrs.

Croop R, Lipton RB, Kudrow D, et al. Oral rimegepant for preventive treatment of migraine: a phase 2/3, randomised, double-blind, placebo-controlled trial. 

 2021 Jan 2;397(10268):51-60. doi: 10.1016/S0140-6736(20)32544-7

Bucklan J, Ahmed Z. CGRP Antagonists for Decreasing Migraine Frequency: A Primer. Consult QD. Published August 3, 2020. Accessed January 12, 2021. 

https://consultqd.clevelandclinic.org/cgrp-antagonists-for-decreasing-migraine-frequency-a-primer/

Durham PL, Vause CV. Calcitonin gene-related peptide (CGRP) receptor antagonists in the treatment of migraine. CNS Drugs. 2010 Jul;24(7):539-48. doi: 10.2165/11534920-000000000-00000

Migraine attacks are the leading cause of disability in individuals younger than 50 years  and predominantly affect women.

Study Examines Rimegepant for the Use of Migraine Prevention

Patients with neurologic conditions present to the emergency department (ED) daily. The diagnosis and management of such conditions can be more complex when patients are at the extremes of age.

Emergency Medicine Clinics of North America

 discusses clinical pearls useful to clinicians who treat patients with neurologic conditions.

Investigators highlighted 4 emergency conditions in the pediatric population: acute ischemic stroke (AIS), intracranial hemorrhage, fever and altered mental status (AMS), and seizures.

Pediatric stroke is rare, and children younger than 5 years are the most likely to experience AIS. Children with AIS can also present with AMS, fever, or seizure. The management of pediatric stroke requires administering weight-based tPA.

In intracranial hemorrhage, many principles of adult care are the same in pediatric patients. However, guidelines are less clear about target blood pressure in the pediatric population. In cases of cerebral edema or impending herniation, administration of either mannitol or hypertonic saline are equally acceptable.

When a pediatric patient presents with AMS, pharmacists and other health care providers should consider acute disseminated encephalomyelitis (ADEM) and anti—N-methyl-D-aspartate receptor encephalitis (NMDAR). Both ADEM and anti-NMDAR encephalitis require early initiation of steroids and empiric treatment for bacterial and viral meningitis.

In pediatric patients, seizures can take many forms, such as neonatal seizures and nonconvulsive status epilepticus. Neonatal seizures can present with mouthing (touching hands and objects to the lips or placing them in the mouth), horizontal eye deviation, blinking, or single limb extension. First-line treatment is phenobarbital 20 mg/kg.

Nonconvulsive status epilepticus is associated with higher mortality, longer pediatric ICU stays, and increased long-term disability. Treatment includes a trial of a short-acting antiepileptic medications and close observation.

The researchers also focused on 4 neurologic conditions in the elderly: AIS, AMS, Parkinson disease, and meningitis.

Some atypical AIS presentations in the elderly include dizziness, falls, headache, nausea, vomiting, difficulty walking, seizure, and urinary incontinence. Advanced age alone is not a contraindication for IV tPA within 3 hours. Around 25% of older adults in the ED have some form of AMS. The Delirium Triage Screen is a valid tool to diagnose delirium, another form of cognitive impairment.

Parkinson disease is a neurodegenerative disorder affecting 1% of the population above the age of 60 years. Acute worsening in Parkinson disease is usually due to a medication change, infection, or missed subdural hemorrhage.

In bacterial meningitis, the elderly present with atypical symptoms and are less likely to have a fever, neck stiffness, rash, or leukocytosis. Empiric antibiotics should include vancomycin and a third-generation cephalosporin.

 is a 2021 PharmD candidate at the University of Connecticut in Storrs.

Khoujah D, Cobb MJ. Neurologic Emergencies at the Extremes of Age. 

. 2021;39(1):47-65. doi:10.1016/j.emc.2020.09.003

Kwong LH, Ercumen A, Pickering AJ, Unicomb L, Davis J, Luby SP. Hand- and Object-Mouthing of Rural Bangladeshi Children 3-18 Months Old. 

. 2016;13(6):563. Published 2016 Jun 4. doi:10.3390/ijerph13060563

The diagnosis and management of neurologic conditions can be more complex when patients are at the extremes of age.

Study Examines Neurologic Emergencies at the Extremes of Age

Parkinson disease (PD) is 1 of the fastest growing neurological disorders in the world. The number of patients with PD doubled to over 6 million, from 1990 to 2015. Due to aging, this number is estimated to be more than 12 million by 2040.

Studies have shown that patients with PD admitted to the hospital experience longer hospital stays and increased mortality than age matched control groups. One risk factor resulting in deterioration during hospital admission is the incorrect timing of levodopa administration,

which is defined as administering levodopa more than 60 minutes before or after the scheduled administration time or failure to administer an ordered dose.

Another risk factor was incorrect prescription administration of antidopaminergic drugs.

 Most antidopaminergic drugs are antipsychotics used to treat delirium, such as haloperidol, olanzapine, risperidone, and aripiprazole.

These findings show that involving hospital pharmacists in the decision-making process of PD patient’s medication management has room for improvement.

A national Spanish study was conducted using surveys to analyze hospital pharmacists’ perspectives on identifying key issues in the pharmacy management of inpatients with PD.  The information collected included medication compliance, reconciliation, protocols, contraindicated medications, and areas for improvement.

Results from the survey identified weaknesses such as pharmacy services closing at certain times, low variety of antiparkinsonian drugs, delay in antiparkinsonian drug administration, and lack of flexibility in administration times. Within the survey, participants highly ranked 2 improvement needs: designing specific protocols for patients with PD; and implementing concrete actions to optimize PD pharmacotherapy.

The participants detected improvement opportunities and proposed recommendations to enhance the safety of patients with PD. Protocols for antiparkinsonian drug interchange, administration timing and nothing by mouth (NPO) status, medication reconciliation, and handling nausea/vomiting or psychotic symptoms were the main improvement areas.

This study shows that hospital pharmacists should be actively involved in the management of PD patients to decrease longer hospital stays and mortality.

Lertxundi Etxebarria U, Palacios-Zabalza I, Ibarrondo I, Domingo-Echaburu S, Hernandez R, Isla A, Solinis M. Pharmacotherapeutic management of Parkinson's disease inpatients: how about asking hospital pharmacists? 

. 2020 Dec 22:ejhpharm-2020-002461. doi: 10.1136/ejhpharm-2020-002461. Epub ahead of print. 

Martinez-Ramirez D, Giugni JC, Little CS, Chapman JP, Ahmed B, Monari E, Wagle Shukla A, Hess CW, Okun MS. Missing dosages and neuroleptic usage may prolong length of stay in hospitalized Parkinson's disease patients. 

. 2015 Apr 17;10(4):e0124356. doi: 10.1371/journal.pone.0124356. 

Ebersbach G, Ip CW, Klebe S, Koschel J, Lorenzl S, Schrader C, Winkler C, Franke C. Management of delirium in Parkinson's disease. 

. 2019 Jul;126(7):905-912. doi: 10.1007/s00702-019-01980-7.  

Studies have shown that patients with Parkinson disease admitted to the hospital experience longer hospital stays and increased mortality than age matched control groups.