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35 Cards in this Set
- Front
- Back
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what is considered generalized anxiety disorder (GAD)? |
excess worry or anxiety about multiple things
need 3/5 of the following for over 1/2 the day for @ least 6 months; restless, edgy, keyed up tires easily trouble concentrating irritability inc muscle tension trouble sleeping (insomnia, restless) |
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what are some causes of anxiety? |
alterations in autonomic fxn (cause tachycardia, sweating, inc BP) |
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Diff btwn anxiety & panic attack? |
anxiety- worry, may have impending worry about panic attack that precipitates it
panic attack- somatic symptoms of tachycardia, dsypnea, sweating, palpitations, etc, usually lasting 20-30 minutes, peak at 10 mins (severe anxiety) |
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what are the roles of GABA a receptor? GABA b receptor? |
GABAa= fast inhibitory transmissions, mediates rapid mood changes, benzos specifically act on GABA a. increases Cl- influx--> hyperpolarization= INHIBITION |
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with GAD, you have palpitations, tremors, tachycardia, and HTN during severe anxiety or a panic attack. What can you give to tx a panic attack (short term GAD tx)? What can you give to treat the somatic effects? |
panic attack: Benzodiazepines *cause sedation, hangover, possible addiction
somatic effects: beta blockers |
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What can you give to tx a panic attack or short term GAD tx if you want to avoid the sedative effects of benzodiazepines? |
Buspirone
(not usually used in cases resistant to benzos, usually doesn't work either) |
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what is the long term tx for anxiety (GAD)? |
antidepressants: SSRI/SNRI always 1st line
+ Cognitive behavioral therapy |
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which SSRI/SNRI are FDA approved?
Why are these not used to tx panic attacks? |
venlafaxine (SNRI)
*take up to 10- 12 wks for full effects (combine w/ BZD, Beta-blockers, anticonvulsants initially)
(Duloxetine (SNRI) also used freq) |
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General SEs of SSRI/SNRIs? |
GI distress sexual disturbance jitteriness sleep disturbance weight gain sedation |
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T/F NEVER start or stop SSRI/SNRIs rapidly (need to taper) |
TRUE! start low to minimize exacerbation of anxiety (& watch for suicide ideation esp in kids)
taper off slowly to prevent discontinuation-related effects |
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SSRIs have the least amount of SEs. What are the 2 main SEs? |
sexual dysfunction & teeth grinding
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which SNRI should not be used in a pt w/ BPH bc it causes urinary retention & liver effects? |
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Which SNRI can increase BP at higher doses? |
Venlafaxine (effexor) |
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name the short acting (3-8 hrs), intermediate acting (10-20 hrs), and long acting (1-3 days) benzodiazepines (BZD) |
short acting- oxazepam (serax) lorazepam (ativan)
clonazepam (klonopin) alprazolam (xanax)
diazepam (valium) |
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What are benzodiazepines used for? |
reduce Anxiety & aggression (sedative & hypnotic effects anticonvulsant (status epilepticus) muscle relaxant (anesthesia adjunct) (reduces post-synaptic reflexes) alcohol detoxification (used in the HOSPITAL under supervision ONLY!) |
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Benefits of Benzos |
effective rapid onset of action usually well tolerated can be used PRN (not preferred) can decrease anxiety caused by high dose anti-depressives |
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what are some SE of benzos |
sedation (& hangover effect) motor & cognitive impairment interaction w/ alcohol (any CNS depressant) Addictive (abuse potential) Discontinuation difficulties (Withdrawal sx) Not effective for comorbid depression CNS depression- difficulty concentrating, coma, drowsiness |
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when you want to take a pt off of benzos, what do you do to minimize withdrawal symptoms? |
taper dose over weeks- months substitute for longer-acting
*ALWAYS use caution when adjusting dose! |
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what is the MOA of benzos |
active drug undergoes phase 1 metabolism by CYP450 (CYP3A4 & CYP2C19) system (CYP450 Inducers)--> active metabolite desmethyldiazepam--> bind adjacent site to GABA receptor--> Inc GABA binding--> Inc Cl- influx--> inhibits formation of action potential
*very lipophilic & undergoes redistribution (inc potency & duration of SEs (delayed toxicity) d/t redistrib) |
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what causes the hangover effect in benzos
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desmethyldiazepam is the active metabolite which hangs around |
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which 2 benzodiazepine is indicated for elderly patients? *also preferred in post-menopause & pts w hepatic disease
Why? |
oxazepam & lorazepam
because they do NOT form active metabolite desmethyldiazepam, they undergo extrahepatic conjugation & excreted---> short acting, no excessive CNS depression, or hangover |
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Which benzodiazepine is the most lipophilic/longest acting--> longest period of hangover, dizziness, sedation
*Also most likely to OD on, esp in combo w alcohol or opiods |
diazepam |
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What are the ONLY 2 Benzos indicated for tx of panic attacks?
(acute relief of panic symptoms) |
alprazolam &
(both intermediate acting) |
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benzos have a high addiction possibility. do not give for over how many weeks? |
no more than 4-6 weeks |
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If a patient on benzos presents w/ bradycardia, respiratory depression, CNS depression & hypothermia, ALWAYS suspect OD on benzos.
What can you give via IV to reverse these effects? |
flumanzenil (ramazicon)
*competitive antagonist for benzo receptor--> displaces benzo & reverses effects
*short acting, need multiple administrations |
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Benzos should not be used in what pts? |
avoid during pregnancy (not absolute CI)
1st trimester use--> birth defects- cleft lip, floppy baby syndrome (fetal hypotonia) 3rd trimester use--> fetal CNS & respiratory depression & neonatal withdrawal
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what substances are absolutely CONTRAINDICATED when taking benzos, bc they can lead to respiratory depression, coma, & death |
alcohol, TCA, opioids |
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what meds should you NOT be taking when on benzos bc they will decr the metabolism & lead to accumulation--> toxicity/ OD--> death?
Why? |
CYP3A4 (CYP450) Inhibitors: macrolides: erythromycin & clarithromycin nefadozone azole antifungal: ketoconazole, itraconozole grapefruit juice
benzos are metabolized by CYP34A and CYP2C19 (CYP450 inducers)--> inhibitors cause toxicity |
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T or F combo therapy of benzos w/ SSRIs/SNRIs (anti-depressants) is preferred for acute anxiety tx |
TRUE
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Q: 58 yr old woman arrives at physician's office complaining of moderate anxiety. What medication will tx her anxiety w/ a minimum of unwanted side effects? |
A: Buspirone |
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what is anxiety DOC for pregnancy & lactation?
What are the benefits of this drug? Downfall? |
buspirone
Benefit: NO sedation* (CNS, resp, etc), no abuse potential, doesn't intensify effects of other CNS depressants
Disadvantage: slower onset anxioltyic effects, minor psychomotor impairment
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What is the MOA buspirone?
What drugs inc metabolism? decr metabolism? |
partial 5HT1a agonist
*metabolized by CYP3A4 (CYP450 Inducer)
Rifampin (inducer)--> dec plasma levels (inc metabolism--> reduce effects)
Erythromycin & ketoconazole (inhibitors)--> inc plasma levels (dec metabolism--> toxicity) |
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what benzo can be used to facilitate sleep but is NOT a preferred tx for insomnia?
Why? |
triazolam
risk of potentiating respiratory depression!
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DOC for short-term tx of insomnia? |
benzodiazepine receptor agonists: zolpidem
*fast onset of action & short duration (4-6 hrs)
(NOT triazolam or ANY benzos*****) |
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T/F Zolpidem & Zaleplon (benzodiazepine receptor agonists) have NO anxiolytic, muscle relaxant, or anticonvulsant EFFECTS. |
TRUE
(also no significant hangover effects) |
