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Pharm III > Anxiety and Insomnia > Flashcards

Anxiety and Insomnia Flashcards

1
Q

What are first line meds for generalized anxiety disorder?

A 
Duloxetine
Escitalopram
Paroxetine
Sertraline
Venlaxfaxine XR
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2
Q

What is duloxetine also good in treating?

A

Neuropathy
Fibromyalgia
Other pain issues

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3
Q

When should paroxetine be avoided?

A

Pregnant pts

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4
Q

Initial dose of duloxetine- GAD

A

30 or 60 mg/day

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5
Q

Initial dose of escitalopram- GAD

A

10 mg/day

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6
Q

Initial dose of paroxetine- GAD

A

20 mg/day

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7
Q

Initial dose of sertraline- GAD

A

50 mg/day

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8
Q

Initial dose of venlafaxine- GAD

A

37.5 or 75 mg/day

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9
Q

1st line tx in panic d/o

A

SSRIs are preferred

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10
Q

When should BZDs be used in panic d/o?

A

When tx is urgent for pt to function and no hx of substance abuse
Short-term for 2-4 weeks until SSRI kicks in

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11
Q

How long should therapy be continued if there is an adequate response to panic d/o?

A

12-24 mos

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12
Q

Initial dose of citalopram for panic d/o

A

10 mg/day

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13
Q

Initial dose of escitalopram for panic d/o

A

5 mg/day

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14
Q

Initial dose of fluoxetine for panic d/o

A

5 mg/day

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15
Q

Initial dose of paroxetine for panic d/o

A

10 mg/day

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16
Q

Initial dose of sertraline for panic d/o

A

25 mg/day

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17
Q

Tapering of benzos in panic d/o

A

If prescribed over an extended period of time, should be tapered over 2-4 mos at rates no higher than 10% of the dose per week

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18
Q

When to evaluate med effectiveness in panic d/o

A

Acute phase- every 1-2 wks when starting a new med
Every 2-4 wks to adjust drug dosages
Every 2 mos after dose is stabilized and sx have decreased
Frequency of appointments should increase when drug is discontinued

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19
Q

First line meds for social anxiety d/o

A 
Generalized
SSRIs
SNRIs (venlafaxine)
Nongeneralized
BBs
Benzos
-Achieve effect within 30-60 mins
-Used on PRN basis
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20
Q

Initial duration of meds in social anxiety d/o

A

12 wks

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21
Q

If good response, how long should the meds be continued for social anxiety d/o

A

12 mos

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22
Q

First line meds for PTSD

A

SSRIs or venlafaxine
Acute: sertraline or paroxetine
Long-term: Sertraline (52 wks)

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23
Q

Initial dose for citalopram in social anxiety d/o

A

20 mg/day

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24
Q

Initial dose for escitalopram in social anxiety d/o

A

5 mg/day

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25
Q

Initial dose of paroxetine in social anxiety d/o

A

12.5 mg/day

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26
Q

Initial dose of sertraline in social anxiety d/o

A

25-50 mg/day

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27
Q

Initial dose of venlafaxine in social anxiety d/o

A

75 mg/day

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28
Q

What are the FDA approved SSRIs for PTSD?

A

Sertraline

Paroxetine

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29
Q

How long of a trial do you give SSRIs in PTSD?

A

4-6 wks

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30
Q

Partial response to SSRIs in PTSD

A

Maximize dose or augment based on residual sx

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31
Q

Nonresponse to SSRIs in PTSD after 4-6 wks

A

Switch to second SSRI or venlafaxine

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32
Q

Still nonresponse after med switch in PTSD

A

Switch to third SSRI, venlafaxine, mirtazapine, or TCA

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33
Q

Respond to meds in PTSD

A

Continue for at least a year

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34
Q

What to give for residual sleep difficulties, nightmares- PTSD

A

Prazosin

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35
Q

What to give for residual anger- PTSD

A

Lamotrigine

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36
Q

What to give for residual intrusive thoughts- PTSD?

A

Risperidone, quetiapine

37
Q

What to give for residual hypervigilance in PTSD

A

Risperidone, quetiapine

38
Q

Initial dose of fluoxetine- PTSD

A

10 mg/day

39
Q

Initial dose of paroxetine- PTSD

A

10-20 mg/day

40
Q

Initial dose of sertraline- PTSD

A

25 mg/day

41
Q

Initial dose of venlafaxine- PTSD

A

37.5 mg/day

42
Q

Evaluation of PTSD therapeutic outcomes in acute phase

A

Pts should be seen weekly for 1 mo, then every other week

43
Q

Evaluation of PTSD therapeutic outcomes in mos 3-6

A

Monthly

44
Q

Evaluation of PTSD therapeutic outcomes in mos 6-12

A

Every 2 mos

45
Q

What to monitor for in PTSD

A

Monitor for previously identified target sx and other sx (i.e., insomnia, SI, outbursts of anger, psychosis)

46
Q

Remission in PTSD

A

70% or greater reduction in sx

47
Q

First line tx for OCD

A

SSRIs

48
Q

FDA approved drugs for OCD

A 
Clomipramine
Fluoxetine
Fluvoxamine
Paroxetine
Sertraline
49
Q

FDA approved drugs for OCD in children and adolescents

A 
Clomipramine
Fluvoxamine
Sertraline
Paroxetine
Fluoxetine
50
Q

Dosage monitoring in hepatic dz for OCD

A 
Use with caution and in lower doses
Clomipramine
Fluoxetine
Sertraline
Paroxetine
Fluvoxamine
Citalopram
51
Q

Renal dz and OCD

A

Dosage adjustment of sertraline, clomipramine not necessary

Dosage of paroxetine should be reduced in pts with severe renal impairment and upward titration should occur more slowly

52
Q

OCD and elderly

A 
Initiate tx with lower doses
-Increase doses slowly
Selection of meds based on:
-Hx of response
-Adverse effect profile
53
Q

OCD and pregnancy

A

Risk-benefit analysis should be made by practitioners when deciding to use during pregnancy

54
Q

Evaluation of outcomes in OCD

A

Monthly f/u visits are recommended for at least 3-6 mos
Medication taper can be considered after 1-2 yrs tx
-Should not be rapidly d/c-ed
-Drug dosage can be decreased by 10-25% every 1-2 mos with careful observation for symptom relapse
Some pts require lifelong meds

55
Q

Clomipramine and OCD

A

Pts >40 yoa should received pretreatment EKG
In pts with liver dz, baseline and periodic LFTs are recommended
Those who develop fever and sore throat should have leukocyte and differential WBC counts assessed to evaluate for agranulocytosis

56
Q

SSRIs with anxiety and OCD

A

Higher doses needed, but start low and go slow
-Particularly for OCD
–Clinical response may take some time
Often used in presence of comorbid MDD
Avoid bupropion
Fluoxetine
-Despite FDA approval, may not be effective for anxiety

57
Q

Venlafaxine use in anxiety d/os

A

GAD
Social phobia
Panic d/o

58
Q

Use of duloxetine in anxiety d/os

A

GAD

Panic d/o

59
Q

Clomipramine and OCD

A

1st drug approved for OCD
Highly effective
Titration usually takes 2-3 wks to avoid GI issues

60
Q

SEs of buspirone

A 
HA
Dizziness
Nausea
GI upset
Depression
Weakness
61
Q

Hydroxizine SEs

A

Dry mouth
Nausea
HA
Rash

62
Q

Initial citalopram dose in OCD

A

20 mg daily

63
Q

Initial clomipramine dose in OCD

A

25 mg/day

64
Q

Initial escitalopram dose in OCD

A

10 mg/day

65
Q

Initial fluoxetine dose for OCD

A

20 mg/day

66
Q

Initial fluvoxamine dose for OCD

A

50 mg/day

67
Q

Initial paroxetine dose for OCD

A

20 mg/day

68
Q

Initial sertraline dose for OCD

A

50 mg/day

69
Q

Pharm management of insomnia

A 
Benzodiazepine receptor agonists
Antidepressants
Ramelteon
Antihistamines
Valerian
70
Q

FDA warning of benzodiazepine receptor agonists

A

Caution regarding anaphylaxis, facial angioedema, and complex sleep behaviors

71
Q

CIs of benzodiazepine receptor agonists

A

Pregnancy

Sleep apnea

72
Q

Amitriptyline dose in insomnia

A

100-100 mg HS (up to 150 mg if concomitant depression)- non FDA approved

73
Q

Doxepin dose in insomnia

A

3-6 mg HS

74
Q

Additional information about TCAs in insomnia

A 
Anticholinergic activity
Adrenergic blockade
Cardiac conduction prolongation
Sig daytime sedation
Extreme caution in elderly
75
Q

Ramelteon for insomnia

A

For tx of sleep-onset insomnia
Dose 8 mg qhs
May be considered for long-term use (6 mos)

76
Q

SEs of ramelteon

A 
HA
Dizziness
GI upset
Somnolence
Hyperprolactinemia
77
Q

CIs of ramelteon

A

Concomitant fluvoxamine

78
Q

Ramelteon is also effective for which comorbidities?

A

COPD
Sleep apnea
Option for pts with substance abuse

79
Q

Notable warnings in suvorexant

A 
Abnl thoughts and behavior
Memory loss
Anxiety
Sleep paralysis
Temporary leg weakness (day or night)
80
Q

Antihistamines for insomnia

A

Potential option for tx of mild insomnia
Diphenhydramine and doxylamine
Tolerance to sedative effects occurs quickly
Anticholinergic SEs

81
Q

Valerian extract for insomnia

A

Alternative therapy- OTC
300-600 mg 1 hr prior to bedtime
Small studies demonstrate no benefit
Case reports of hepatotoxicity

82
Q

Melatonin

A

May be useful for jet lag and by the elderly
Jet lag dose: 0.5-2 mg preflight and higher doses (5 mg) posflight over a period of up to 4 days
Caution in pts at risk for bleeding or on anticoagulant/antiplatelet meds (including NSAIDs)

83
Q

Discontinuation of insomnia meds

A

Taper both the dose and frequency to avoid withdrawal sx, rebound insomnia
Tapering may require several weeks to mos

84
Q

Drugs that can be used for daytime sleepiness- narcolepsy

A 
Dextroamphetamine
Dextroamphetamine/amphetamine salts
Methamphetamine
Methylphenidate
Lisdexamfetamine
Modafinil
Armodafinil
Sodium oxybate
85
Q

Agents for cataplexy- narcolepsy

A 
Fluoxetine
Imipramine
Nortriptyline
Protriptyline
Venlafaxine
Sodium oxybate
86
Q

How often should pts with narcolepsy visit their provider?

A

Every 6-12 mos to evaluate efficacy and drug side effects

87
Q

Pharm options for jet lag

A

Short-acting benzo receptor agonist
Ramelteon
0.5-5.0 melatonin
Taken at target bedtime for east or west travel

88
Q

Pharm tx for OSA

A

Avoidance of CNS depressants
Avoidance of drugs that promote wt gain
Avoidance of drugs that can cause rhinopharyngeal inflammation and cough
Modafinil, armodafinil

89
Q

Pharm tx for shift work sleep d/o

A

Short-acting benzo receptor agonist
Ramelteon
Melatonin
Modafinil and armodafinil

Pharm III (8 decks)

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