Anxiety Flashcards
What are the psychological and somatic symptoms of anxiety?
Psychological:
Feelings of apprehension, fear, tension, panic
Outbursts of hostility, insomnia
Circling thoughts, inability to concentrate, easily distracted, lapses of memory
Somatic: Cardiovascular - palpitations, brady/tachycardia, hypertension Respiratory - rapid shallow breathing GI - diarrhoea dysphagia Musculoskeletal - agitation , tremor
What is the 1st, 2nd and 3rd drug treatment for generalised anxiety? If non-pharmacological treatments not working/wanted.
- Selective serotonin reuptake inhibitor (SSRI) e.g. sertraline, paroxetine, or escitalopram
- A selective serotonin-noradrenaline reuptake inhibitor (SNRI), e.g. duloxetine or venlafaxine possible alternative
- Pregabalin can be offered if SSRIs or SNRIs are contraindicated or not tolerated
What is the drug treatment option for moderate/severe short term or crisis anxiety?
Benzodiazepines e.g
- Alprazolam (Xanax) not prescribable in primary care on the NHS.
- Chlordiazepoxide hydrochloride (Librium)
- Diazepam
- Oxazepam
What happens in a benzodiazepine overdose? (6)
- Drowsiness
- Ataxia (Lack of voluntary coordination of muscle movement)
- Dysarthia (difficulty speaking)
- Nystagmus (involuntary eye movement/dancing eyes)
- Respiratory depression
- Coma
Name the benzodiazepine antidote?
Flumazenil - benzodiazepine antagonist
Cautionary advise with bezodiazepine use?
- Not for prolonged use and should not be abruptly stopped
2. Driving and skilled tasks - due to drowsiness which may persist to the next day
Mechanism of action of benzodiazepines?
Benzodiazepines enhance the effect of the neurotransmitter gamma-aminobutyric acid (GABA) at the GABAA receptor, resulting in sedative, hypnotic (sleep-inducing), anxiolytic (anti-anxiety), anticonvulsant, and muscle relaxant properties.
What can Chlordiazepoxide hydrochloride be used for in addition to anxiety?
Treatment of alcohol withdrawal in moderate and in severe dependence
Chlordiazepoxide hydrochloride dose for short term use in anxiety?
10mg TDS increased if needed to 60-100mg daily.
Elderly & debilitated patients 5mg TDS increased to 30-50mg if needed in divided doses.
Chlordiazepoxide hydrochloride dose for alcohol withdrawal?
Moderate dependence: 10-30mg QDS - dose to be gradually reduced over 5-7 days
Severe: 10-50mg QDS & 10-40mg PRN during first 2 days. then reduce over 5-7 days.
Max dose 250mg daily
Chlordiazepoxide use is not recommended for…? (3)
Chlordiazepoxide is not recommended;
- for long term use (i.e. longer than 4 weeks),
- mild anxiety
- children.
What is the diazepam dose for anxiety?
2mg TDS then increased if necessary to 15-30mg daily in divided doses.
Elderly & debilitated patients:
1mg TDS and increased if necessary to 7.5-15mg
What is the diazepam dose for insomnia associated with anxiety?
5-15mg daily at night
What is the diazepam dose for severe acute anxiety/acute panic attack/acute alcohol withdrawal?
IM injection or slow intravenous injection:
10mg then 10mg after at least 4 hours if needed. intravenous injection at a rate of not more than 5mg/min
Diazepam rectal formulation is not licensed for use in which age group?
children under 1 years
Which warning labels does Diazepam have?
- This medication may make you sleepy. if this happens do not drive or use tools or machines. do not drink alcohol.
- This medicine makes you sleepy. if you still feel sleepy the next day, do not drive or use tools or machines. do drink alcohol.
What is the Oxazepam dose for short term anxiety?
15-30mg TDS-QDS
Elderly/Debilitated patients - 10-20mg TDS-QDS
Which 4 groups of patients should benzodiazepines be used in caution or not at all?
- Elderly - reduced dose as they are more susceptible to adverse effects
- Significant respiratory impairment
- Neuromuscular disease
- Liver failure - as they precipitate hepatic encephalopathy
Are benzodiazepines suitable for use in:
- Renal impairment
- Hepatic impairment
- Pregnancy
- Breastfeeding
- Dose adjustments - start with small doses in severe impairment
- Can precipitate coma. If treatment necessary - use one with a short half-life such as temazepam or oxazepam. Or use lorazepam as it depends less on the liver for elmination. Avoid in severe impairment
- Avoid regualr use in pregnancy - use only if clear indication and need such as seizure control. Risk of neonatal withdrawal symptoms.
- Avoid if possible - present in breast feeding
What are the signs of abrupt withdrawal of benzodiazepines? (9)
Severe (3)
Headache Muscle pain Exreme anxiety Tension Nervousnes Sweating Confusion and Irritability Depression Diarrhoea.
Severe cases: feeling of unreality being separated from the body hypersensitivity to light numbness and tingling sensation of extremities
Common side effects of benzodiazepines? (5)
Side effects are usually dose dependent
Fatigue Sedation Dizziness Headache Vertigo
What CD class is diazepam and Oxazepam?
CD4 -1
What drug class does buspirone hydrochloride belong to?
Serotonin receptor agonists
buspirone hydrochloride is used for anxiety short term. What is the dose?
When should dose be adjusted?
5mg 2-3 times a day increased if necessary to 45mg daily.
Dose should be reduced to 2.5mg BD daily if taken with potent inhibitors of CYP34A.
