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67 Cards in this Set

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Which Benzo agents are most often prescribed for GAD?
alprazolam (Xanax, Xanax XR, Niravam) and lorazepam (Ativan).
Primary anxiety disorders are divided into six major classes:
genaralized anxiety disorder (GAD)
acute distress disorder
panic disorder
phobic disorder
obsessive compulsive disorder (OCD)
post traumatic stress disorder (PTSD)
What are the fist line choices for GAD?

Which for acute stabilization and which for long term treatment?
the benzodiazepines, buspirone, and three antidepressants: venlafaxine, paroxetine, and escitalopram.

Benzo's for stabilizing
Buspirone, Venlafaxine, Paroxetine, and Escitalopram for the others.
What is the first choice drug for anxiety?
Benzoidiazepines
What is the onset of Benzo therapy and what is a likely AE that results?

When will the AE subside?

What is the margin of safety?
Will see effects almost immediately. Teach the patient about the psychomotor slowing that is likely to occur and tell them it should subside in 7-10 days.

high
Do Benzoidiazepenes have a risk of physical dependence?
yes
What three advantages does Buspirone have over Benzo's in tx of GAD?
1.It does not cause sedation
2. has no abuse potential,
3.does not intensify the effects of CNS depressants.
What is Buspirones major disadvantage?
o Buspirone’s major disadvantage is that anxiolytic effects develop slowly: initial responses take 1 week to appear, and several more weeks must pass before responses peak. Because therapeutic effects are delayed, buspirone is not suitable for as-needed (PRN) use or for patients who need immediate relief.
What are the AE of Buspirone?
Buspirone is generally well tolerated. The most common reactions are dizziness, nausea, headache, nervousness, lightheadedness, and excitement.
What are the P450 inhibitors associated with Buspirone?
grapefruit juice, erythromycin, and ketoconazole.
Which antidepressants are approved for tx of GAD?
venlafaxine (Effexor XR) atypical, first approved

paroxetine (Paxil) SSRI

escitalopram (Lexapro) SSRI

*the SSRI's are as effective as Benzo's but are not tolerated as well.
What indication are benzo's and SSRI's used for?
Benzo's for GAD

SSRI's for all anxiety disorders
Which drugs for anxiety are suitable for long term tx?
All but the benzo's pretty much

• With buspirone, venlafaxine, paroxetine, and escitalopram, anxiolytic effects are delayed. Accordingly, these drugs are best suited for long-term management—not rapid relief.
What effect do Benzo's have on psychomotor control and wakefulness?
Benzodiazepines are CNS depressants and hence can cause sedation and psychomotor slowing. In addition, they can intensify CNS depression caused by other drugs.
Should a HCP be wary of patients with alcohol problems in prescribing Benzo's?
•Benzodiazepines have some potential for abuse, and hence should be used with caution in patients known to abuse alcohol or other psychoactive drugs.
Benzo's should be tapered off gradually because of their frequency in causing physical dependence at what rate should they be tapered off?
over several months
What are the characteristics of someone experiencing a panic attack?
recurrent panic attacks, characterized by palpitations, pounding heart, chest pain, derealization or depersonalization, and fear of dying or going crazy.
Many patients with a panic disorder also experience _____?
agoraphobia
What is the first line drug for panic disorder?
SSRI's

all three major classes of antidepressants (SSRI's, TCA's, MAOI's) respond well but SSRI's are favored because they are more easily tolerated.
How long does it take for antidepressants to take full effect?
With all three, full benefits take 6 to 12 weeks to develop
What role do SSRI's serve in treatment of panic disorder?
• SSRIs are first-line drugs and decrease the frequency and intensity of panic attacks, anticipatory anxiety, and avoidance behavior; and they work regardless of whether the patient has depression.
What are the S/S of OCD?
persistent obsessions and compulsions that cause marked distress, consume at least 1 hour a day, and Social anxiety disorder, formerly known as social phobia, is characterized by an intense, irrational fear of being scrutinized by others, or of doing something that is embarrassing or humiliating.
Difference between an obsession and compulsion?
obsession: a recurrent, persistent thought, impulse, or mental image that is unwanted

compulsion:a ritualized behavior or mental act that the patient is driven to perform in response to his or her obsessions. In the patient’s mind, carrying out the compulsion is essential to prevent some horrible event from occurring
What are the first line drug's for OCD tx?

What drugs are approved for treatment (5)?
SSRI's

four SSRIs and one TCA (clomipramine). All five enhance serotonergic transmission. The SSRIs are safer and better tolerated than clomipramine and hence are preferred (same with panic disorders)

all take several months to reach full effect.
What are the S/S of social anxiety disorder (social phobia)?
characterized by an intense, irrational fear of being scrutinized by others or of doing something that is embarrassing or humiliating.
What is the first line drug for tx of Social anxiety?

Why are Benzo's used in place of them at times?
• The SSRIs are first-line drugs for most patients with social anxiety disorder.
• Benzodiazepines (eg, clonazepam [Klonopin], alprazolam [Xanax]) are an option for some patients. These drugs are well tolerated, and their benefits are immediate, unlike those of the SSRIs.
When social anxiety disorder is limited to fear of specific situations, and when those situations arise infrequently what kind of tx is usually recommended?
PRN with Benzo's as opposed to long term with SSRI's
What drug is commonly used for preemptive performance anxiety?
• Propranolol (Inderal) and other beta blockers 1-2 hours prior
According to the Insititute of Medicine there is no recognized effective drug tx for PTSD although what two SSRI's are approved by FDA ?
paroxetine (Paxil) and sertraline (Zoloft)
In order to avoid serious reactions to IV injections of benzos, what procedures should you follow?
Inject slowly
Avoid arterial injection and extravasation
Use direct access; close to vein as possible
Dilute according to manufacturer
Have resuscitation equipment available (hypotension, respiratory and cardiac arrest potential)
According to the Controlled Substance Act, which schedule do the benzos fall under?
Schedule IV
Barbiturates: Schedule II or III
When are benzodiazepines contraindicated?
During pregnancy (Category D or X)
For pts with sleep apnea
Use with caution in pts with suicidal tendencies
Use with caution in pts with a hx of substance abuse (sedative-hypnotic abuse)
The elderly
In which patients should benzos be used with caution?
Those with pulmonary dz (COPD)
Alcoholics
Pts taking other CNS depressants
Those with liver problems
Pts with porphyria (< metabolism of porphyrin – a nitrogen containing compound); can cause neuro sxs, skin lesions, hemolytic anemia
What would you teach a patient who will be receiving benzos?
Tell pts about possible CNS depression
Avoid hazardous activities (driving or use of hazardous equipment) if daytime sedation is significant.
Warn pts about complex sleep-related behaviors. Must notify HCP.
Warn pts about possible paradoxical reactions: rage, excitement, heightened anxiety. (Notify HCP),
Avoid pregnancy (fetal injury esp 1st trimester)
Avoid P450 drugs (warfarin, phenytoin, OCPs)
Why is BuSpar a safer drug than Xanax or barbiturates?
Does not enhance alcohol, barbiturates, or other general CNS depressants
Devoid of hypnotic, muscle relaxant and anticonvulsant effects
Used for anxiety only (use first; short term – less than 1 year)
Little abuse potential
Well tolerated
A patient is prescribed eszopiclone (Lunesta) for treatment of insomnia. The nurse should teach the patient that the most common adverse effect is:
bitter aftertaste.
A 24-year-old female patient is prescribed triazolam (Halcion) for
short-term management of insomnia at home. Which statement
made by the patient indicates an understanding of teaching related
to this medication?
Use of oral benzodiazepines does not cause respiratory depression unless used with opioids, barbiturates, or alcohol. Patients taking benzodiazepines should be warned to abstain from alcohol. Chance of addiction is low.

Use in pregnancy and lactation is not advised.
The nurse in the emergency department (ED) administers progressive doses of flumazenil (Romazicon) to a patient who has overdosed on a benzodiazepine and alcohol. A nursing priority in this situation is:
Monitoring breathing
What are the three major groups of sedative hypnotics?
barbiturates, benzodiazepines, and benzodiazepine-like drugs
What are the three major groups of sedative-hypnotics?
barbiturates (eg, secobarbital), benzodiazepines (eg, diazepam), and benzodiazepine-like drugs (eg, zolpidem).
What are the first choice drugs for anxiety and insomnia?
Benzodiazepines are drugs of first choice for anxiety and insomnia.
Benzodiazepines are preferred to barbiturates and other general CNS depressants because ...
• they are much safer, have a low abuse potential, cause less tolerance and dependence, and don’t induce drug-metabolizing enzymes.
How do benzo's cause AE and their therapeutic response?
• All beneficial effects of benzodiazepines and most adverse effects result from depressant actions in the CNS. With increasing dosage, effects progress from sedation to hypnosis to stupor.
How is the withdrawal of Benzo's
mild, except with individuals who have undergone prolonged high dose therapy.

these withdrawal symptoms can be minimized if the drug is withdrawn over weeks or even months if need be.
Benzo's cause minimal respiratory depression when used alone. When taken in combination with what does this effect potentiate?
other CNS depressants

opiods, barbituates, alcohol
Benzo's are metabolized but there effect remains long after the parent drug has been completley metabolized. Why?
The metabolites of the drug are still pharmacologically active.
Benzo's have essentially the same effect so selection is based upon what?
differences in time course
The principal indications for Benzo's are?
The principal indications for benzodiazepines are anxiety, insomnia, and seizure disorders
What are the principal AE's of Benzo's
• The principal adverse effects of benzodiazepines are daytime sedation and anterograde amnesia.
•Patients taking benzodiazepines to promote sleep may carry out sleep driving and other complex behaviors, and then have no memory of the episode,

What is this usually due to?
excessive dosing
Tolerance and physical dependence are possible with Benzo's but the reaction is condition is usually _____
mild
What is used to treat a Benzodiazepene overdose?
Flumazenil, a benzodiazepine receptor antagonist
What Benzo like drugs are used for sedation and what is their mechanism?
• Like the benzodiazepines, the benzodiazepine-like drugs—zaleplon [Sonata], eszopiclone [Lunesta], and zolpidem [Ambien, Tovalt]—produce their effects by enhancing the actions of GABA.
What types of drugs are the DOC for insomnia?
• Benzodiazepines and the benzodiazepine-like drugs (zolpidem, zaleplon, eszopiclone)
What is the most widely used hypnotic and when should it be used?
• Zolpidem is the most widely used hypnotic. It should be used for short-term therapy.

• Zolpidem has a side effect profile like that of the benzodiazepines. Daytime drowsiness and dizziness are most common, and these occur in only 1% to 2% of patients.
What is the indication of Zaleplon (Sonata) the first of a newly approved type of drug for sedation (the pyrazalopyrimidines)
The drug is approved only for short-term management of insomnia, but prolonged use does not appear to cause tolerance.
What is the benefit associated with Sonata and what are its drawbacks?
does not produce next-day sedation or a “hangover” feeling.

Zaleplon has a very rapid onset and short duration of action and hence is good for helping patients fall asleep but not for maintaining sleep

approved for short term use only like zolpidem.
What indication does Eszopiclone (Lunesta) fit?
• Eszopiclone (Lunesta) is approved for treating insomnia, with no limitation on how long it can be used
Besides having no limit to its length of use what is another prominent benefit and AE of Eszopiclone (Lunesta)?
It is generally well tolerated and but it has a bitter aftertaste.
What is the indication for Ramelteon (Rozerem)?

What is its mechanism of action?
• The drug is approved for treating chronic insomnia characterized by difficulty with sleep onset

activation of receptors for melatonin
Is Ramelteon approved for long term use for tx of insomnia (remember its chronic)?

Is Ramelteon a controlled substance?
• Long-term use is permitted. Of the major drugs for insomnia, ramelteon is the only one not regulated as a controlled substance.
What is the prevalence of tolerance and physical dependence with use of barbituates?
some not all develop tolerance

if used long a physical dependence will occur in anyone and if disonctinued withdrawal symptoms will occur.
Acute intoxication with barbituates is a medical _______?
emergency
Acute overdose produces a classic triad of symptoms?
respiratory depression, coma, and pinpoint pupils
When the cause of insomnia is a known medical disorder the primary therapy should be directed at the underlying illness.
With this in mind how should hypnotics be prescribed?
hypnotics should be employed only as adjuncts. For example, if pain is the reason for lack of sleep, analgesics should be prescribed.
Drug therapy of transient insomnia should be how long?
2-3 weeks short term
What are the first choice drugs for treating transient insomnia?

Is non drug therapy approved?
Transient insomnia can be treated with prescription drugs, nonprescription drugs, and alternative medicines. Among the prescription drugs, benzodiazepines and the benzodiazepine-like drugs (zolpidem, zaleplon, and eszopiclone) are drugs of first choice.