barcode in c# windows application Tricyclic Antidepressants in Microsoft Office

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Tricyclic Antidepressants
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Soon after the rst successes with MAO inhibitors, a new class of tricyclic compounds appeared The rst was imipramine (Tofranil),
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soon followed by amitriptyline (Elavil) and then by desipramine (Norpramin) and nortriptyline (Pamelor) Another important dibenzazepine derivative is carbamazepine (Tegretol), which is widely used in the control of seizures but has also found a place in the treatment of lancinating neuropathic and myelopathic pain and possibly of depression and mood instability Subsequently, a number of additional antidepressant drugs were introduced Included here are variants of the conventional tricyclic drugs (amoxapine, protriptyline, trimipramine, doxepin), tetracyclics (maprotiline), bicyclics (zimeldine), and others (trazodone, bupropion) A full account of these drugs, which will not be attempted here, can be found in the monographs of Hollister and of Pirodsky and Cohn The mode of action of these agents is not fully understood, but there is evidence that they block the reuptake of amine neurotransmitters, both norepinephrine and serotonin Blocking this amine pump mechanism (called the presynaptic plasma transporter), which ordinarily terminates synaptic transmission, permits the persistence of neurotransmitter substances in the synaptic cleft and does no more than support the hypothesis that endogenous depression is associated with a de ciency of noradrenergic or serotoninergic transmission The tricyclic antidepressants and the serotoninergic drugs discussed in the next section, are presently the most effective drugs for the treatment of patients with depressive illnesses, the former being particularly useful for those with anergic depressions associated with hyposomnia, early morning awakening, and decreased appetite and libido The side effects of the tricyclic drugs are less frequent and far less serious than those of the MAO inhibitors The tricyclic (dibenzazepine) compounds are potent anticholinergic agents, which accounts for their most prominent and serious side effects orthostatic hypotension and urinary bladder weakness They may also occasionally produce CNS excitation leading to insomnia, agitation, and restlessness but usually these effects are readily controlled by small doses of benzodiazepines given concurrently or in the evenings Rarely, they may cause ataxia and blood dyscrasias As indicated earlier, the tricyclic drugs should not be given with an MAO inhibitor; serious reactions have occurred when small doses of imipramine were given to patients who had discontinued the MAO in the previous days or week It must be repeated that both the MAO inhibitors and the tricyclic antidepressants are dangerous drugs when taken in excess Tricyclic compounds are a frequent cause of accidental poisoning and a favored suicidal instrument of depressed patients It is common for the intoxicated patient to have taken several drugs, in which case chemical analyses of the blood and urine are particularly helpful in determining the drugs involved and in sorting out therapeutic and toxic concentrations Mortality from overdose is mostly due to cardiac disturbances, particularly tachyarrhythmias and impaired conduction (atrioventricular block) Treatment consists of gastric aspiration and instillation of activated charcoal and the addition of physostigmine to reverse serious arrhythmias; the short duration of action of physostigmine requires that frequent doses be given Dialysis is of no value because of the low plasma concentrations of the drug
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are being developed at a rapid pace They act presumably by inhibiting the reuptake of serotonin and to a lesser extent of norepinephrine, somewhat like the effect of a tricyclic antidepressant This results in a potentiation of the actions of these neurotransmitters Because they do not bind as avidly as tricyclic drugs to the muscarinic and adrenergic receptors in the brain, they produce fewer side effects, but some patients complain of anxiety or insomnia when they are rst introduced As with the tricyclic agents, the concomitant administration of MAO inhibitors is hazardous There should be a period of at least 1 week between the administration of these two classes of drugs to allow for the washout of the last agent used Of the several related drugs such as venlafaxine (Effexor), nefazodone (Serzone), citalopram (Celexa), and bupropion (Wellbutrin), each has a novel structure that is not analogous to that of the other categories of antidepressants They are believed to act similarly to the SSRI class by inhibiting the reuptake of serotonin and norepinephrine These newer drugs share most of the side effects of the SSRI drugs, including the danger of concomitant MAO inhibitor administration The symptoms of a serotonin syndrome that results from excessive intake or from the concurrent use of MAO inhibitors include confusion, restlessness, myoclonus, shivering, and diaphoresis, as summarized by Sternbach The risk of seizures related to the taking of certain of these medications has been much discussed For the most part, the risk is quite small but there is little information to guide their use in known epileptics Several studies suggest that the frequency of convulsions may increase in such patients Buprioprion has been particularly associated with seizures in about 05 percent of patients treated at higher dose levels (over 400 mg per day) and this drug should not be used in individuals with a history of seizures The SSRI drugs are well tolerated, may be effective in a shorter time than the tricyclic agents, and are very popular at the moment, but their long-term therapeutic usefulness in comparison with their predecessors remains to be determined (see review of Richelson) Fluoxetine has also been used with bene t in a group of autistic children (page 890) Constipation, dry mouth, and reduced sexual potency are to be expected to some, but varying degrees Hyponatremia is a rare complication
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