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Pharmacy School 2016-17 > Anxiety and Sleep Disorders Therapeutics > Flashcards

Anxiety and Sleep Disorders Therapeutics Flashcards

1
Q

Medical Conditions with Secondary Anxiety Symptoms

A

Endocrine (thyroid or parathyroid disease, hypoglycemia, cushings)

Cardio-respiratory (angina, pulmonary embolism)

Autoimmune disorders

Neurological disorder (seizure disorder)

Substance related (nicotine, alcohol, benzos and opioids)

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2
Q

Medications which can cause anxiety

A

Stimulants, thyroid supplements, antidepressants, corticosteroids, oral contraceptives, bronchodilators, decongestants, abrupt withdrawal of CNS depressants (benzos, barbs, and alcohol)

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3
Q

Drug classes to treat anxiety

A

Antidepressants (SSRIs, SNRIs, TCAs, MAOIs)

Benzodiazepines and Z-drugs

Antihistamines, 5HT1a agonists and GABA agonists

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4
Q

Benzodiazepines by speed of onset

A

Very fast (diazepam)

Fast (Clorazepate)

Intermediate (alprazolam, chlordiazepoxide, clonazepam, lorazepam)

Slow (oxazepam)

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5
Q

Benzodiazepines by half-life

A

Short/Intermediate (alprazolam, oxazepam, lorazepam, chlordiazepoxide)

Intermediate/Long (clorazepate, diazepam)

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6
Q

Clomipramine is used for

A

OCD or panic disorder

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7
Q

GABA Agonist

A

Meprobamate

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8
Q

5HT1a receptor agonist

A

Buspirone (GAD, SAD)

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9
Q

MAOI

A

Phenelzine (SAD, Panic, PTSD, MDD)

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10
Q

GAD Criteria (DSM 5)

A

Presence of anxiety and worry for 6 months (worry when nothing is wrong or worry that is disproportionate)

With at least 3 of the following (edginess or restlessness, tiring easily/fatigued more than usual, impaired concentration, irritability, increased muscle aches or soreness, difficulty sleeping)

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11
Q

GAD

A

Generalized Anxiety Disorder

Psychic/subjective symptoms (worry, on edge, impaired concentration, concern over health)

Somatic symptoms (muscle tension, insomnia, fatigue, irritability, nausea or diarrhea, sweating, urinary frequency, palpitations, pain, GI distress)

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12
Q

GAD Comorbidity

A

90% have another psychiatric disorder

62% have lifetime MDD; 40% have dysthymia

Anxiety disorders predict greatest risk of secondary MDD

58% of patients with lifetime MDD have an anxiety disorder

Affects 6.8 million American adults (2.1%)

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13
Q

Overlapping MDD and GAD symptoms

A

Anxiety, sleep disturbance, psychomotor agitation, concentration difficulty, irritability, fatigue

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14
Q

HAM-A

A

Hamilton Anxiety Rating Scale

Good for both psychic and somatic symptoms

Pretreatment HAM-A scores of more than 18 indicate common index need for treatment

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15
Q

GADSS

A

Generalized anxiety disorder severity scale

Specific probing in domains of worry, impairment of social and work functioning

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16
Q

PSWQ

A

PENN state worry questionnaire

Measures trait-like tendency to worry excessively

Useful to test severity of pathological worry

Discriminates among anxiety disorders - higher score indicate GAD among other disorders

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17
Q

Non-pharm for GAD

A

Relaxation techniques, biofeedback to reduce arousal, cognitive therapy, behavioral therapy

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18
Q

Cognitive Behavioral Therapy

A

Talk therapy helps change thinking patterns to find ways of coping; includes relaxation techniques, problem solving and challenging distorted beliefs

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19
Q

GAD Medication Treatment

A

Benzodiazepiens (acute; most effective for somatic symptoms)

Antidepressants (long term; most effective for psychic symptoms)

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20
Q

GAD Treatment Plan

A

1st Line (CBT with or without SSRI; if partial resposne augment with buspirone, hydroxyzine, pregabalin, or benzo)

2nd line (SNRI; duloxetine or venlafaxine)

3rd line (SSRI/SNRI + SGA (risperidone, quetiapine, olanzapine))

Continue medication/therapy treatment for at least 1 year

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21
Q

SSRI Concerns/Benefits

A

Stopped abruptly SSRIs can produce discontinuation syndrome (dizziness, insomnia, flu-like symptoms, seizures)

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22
Q

SNRIs Concerns/Benefits

A

abrupt withdrawal can cause anxiety, insomnia, flu like symptoms, headache, nausea, electrical shock like symptoms down limbs and scalp

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23
Q

TCAs Concerns/Benefits

A

Potential fatal toxicity after overdose

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24
Q

MAOIs Concerns/Benefits

A

Fatal overdose potential

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25
Q

Benzodiazepines Concerns/Benefits

A

Abrupt withdrawal may cause psychosis, delirium, confusion, seizures, insomnia and agitation

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26
Q

Anticonvulsants Concerns/Benefits

A

Discontinuation symptoms and abuse have been reported

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27
Q

SAD

A

Symptoms related to social or performance (as opposed to broad in GAD) situations in which you expect scrutiny or evaluations by others

Affects 6% of adults

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28
Q

SAD Generalized vs non-generalized

A

Generalize (70% of cases), pervasive social fears and avoidance, early onset, familial, high comorbidity, more impairment, low remission, continual treatment (non-generalized is opposite)

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29
Q

SAD Treatment

A

Medication equally as effective as CBT (high effectiveness over year when used together)

CBT produces more significant results with lower rates of relapse; meds preferred if paralyzing symptoms or comorbid severe depression

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30
Q

SAD Treatment Plan

A

1st Line: SSRI
2nd Line: Different SSRI or SNRI (venlafaxine, mirtazapine); add benzo short term, augment with buspirone or beta blocker (for performance anxiety)

3rd Line (SGA - quetiapine, risperidone; MAIO - phenelzine; anticonvulsant/mood stabilizer - pregabalin, gabapentin)

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31
Q

Other treatment options for SAD

A

Combining meds (buspiron w/ SSRI or SNRI; Benzo with SSRI or SNRI; Med with CBT better than two meds)

Gabapentin is only modestly effective

Beta blockers ONLY for performance anxiety

Antipsychotics (quetiapine, risperidone) for cognitive impairment, weight gain and metabolic issues

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32
Q

PTSD Diagnostic criteria

A

History of exposure to traumatic event with attributes from each cluster:

Exposure (direct, indirect)
Intrusion (nightmares, flashbacks)
Avoidance of situations
Cognition and mood (recall problems, memory deficit)
Arousal and reactivity (irritable, aggressive, sleep disturbance)

Symptoms must last longer than 1 month, can’t be attributable to substance or co-occurring medical conditions

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33
Q

PTSD Common Reactions/Behaviors

A

Fear, helplessness, anxiety

Reliving trigger events in form of thoughts, flashbacks or dreams

Disassociation

Avoidance

Hyperarousal and exaggerated startle resposne

Occurs on a continuum with some living their entire lives in a subthreshold PTSD state

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34
Q

Common PTSD Comorbidities

A

Substance abuse, traumatic brain injury, suicide, pain, major depression, PTSD

35
Q

PTSD Treatment

A

Psychotherapy w/ or w/o medication (exposure therapy, CBT, stress inoculation, eye movement desensitization and reprocessing)

Alternative medicine therapy (CBT with pool, massage therapy, meditation, yoga, art therapy, marital/family therapy and acupuncture) –>more effective than lifelong disability

36
Q

PTSD Medication

A

First Line (SSRI or SNRI or TCA)

Mood stabilizer (Depakote, Tegretol, Gabapentin)

Antipsychotic (Olanzapine, Risperidone, Quetiapine)

Nightmares (Clonidine, Prazosin)

Sleep (Trazodone, doxepine, nefazodone, mirtazapine)

37
Q

Special PTSD Medication Considerations

A

Avoid benzos due to lack of effect on PTSD symptoms and abuse potential

Gabapentin, divalproex, augmented SSRI with atypical antipsychotic all useful in treatment-resistant cases

Avoid opiates/abusable medications

38
Q

Anticonvulsants for PTSD

A

Valproate, Carbamazepine, Lithium (good evidence)

Gabapentine, Pregabalin (modest improvement)

Tiagabine (not proven)

Lamotrigine and Topiramate (not proven)

39
Q

Atypical Antipsychotics for PTSD

A

Risperidone and Olanzapine (inherent anti-anxiety and antidepressant effects w/ 5HT2 and 5HT1A activity; high limbic activity; some effectiveness for intrusive thoughts and flashbacks; SE include weight gain, akathisia and sedation leading to high drop outs)

Quetiapine (possibly effective in treatment resistant PTSD; most useful if psychosis)

40
Q

PTSD nightmare medications

A

Clonidine and Prazosin

Alpha-adrenergic activity associated with fear and startle response

Clonidine is centrally acting alpha 2 agonist resulting in reduced sympathetic outflow from CNS; reduces severity and duration of nightmares and improves quality of sleep

Prazosin acts peripherally and centrally as an alpha-1-adrenergic blocker; low doses (1mg) helpful within 7 days

41
Q

OCPD

A

Obsessive compulsive personality disorder characterized by (must have 4):

Excessive need for perfect, preoccupation with details, excessive devotion to work, rigidity of morals or values, inability to get rid of items that no longer have value, miserly or stingy, reluctance to work with others

42
Q

OCP and OCPD Treatment

A

Psychotherapy

No medication unless physical or mental illness accompanies

43
Q

OCP

A

Obsessive compulsive personality (strong values of order, organization, cautious, obeying rules)

44
Q

OCD

A

Obsessive Compulsive Disorder

Anxiety disorder rather than a personality disorder at which you experience recurrent obsessions and compulsions

45
Q

OCD Diagnostic Criteria

A

Must have obsessions and compulsions that significantly impact daily life

Patient usually realizes these are excessive compulsions; obsessions must be intrusive and persistent and include images that cause distress; compulsions must include excessive and repetitive or ritualistic behavior

46
Q

Common OCD Obsessions

A

Germs or dirt, intruders, preoccupation with violent acts, unwanted sexual images and acts, unwanted religion thoughts, neatness or symmetry, continual thinking of certain words/sounds/images/numbers

47
Q

OCD Compulsions

A

Behaviors that patient feels they must carry out over and over

Behaviors which provide order and symmetry

Behaviors aimed at getting rid of anxiety or to stop a feared situation

Have unrealistic solutions

48
Q

OCD (vs OCPD)

A

Obsessions and compulsions known to be problematic and non-beneficial (no obsessions or compulsions)

Use tasks to reduce anxiety caused by obsessive thoughts (justify tasks as being beneficial)

Medication used for Tx (no meds for Tx)

49
Q

Borderline Personality Disorder

A

Often caused by childhood sexual trauma

Verbal abuse by mothers increases likelihood

50
Q

Antisocial Personality Disorder

A

Environmental/parental

Lack of fathers affection or lack of boundaries in early childhood increase risk

51
Q

Anxious Personality

A

High reactivity - sensitive to light, noise, texture or other stimuli

Likely to develop anxious personalities

52
Q

OCD Non-Pharm Treatment

A

Psychotherapy (CBT; ERP - exposure and response prevention)

Relaxation

53
Q

OCD Pharm Treatment

A

Antidepressants

Step 1: Fluvoxamine or Clomipramine, or other SSRI/SNRI

Step 2: If no partial response, choose different SSRI or TCA

Step 3: SSRI/TCA + Mirtazapine or atypical antipsychotic

Step 4: SSRI + Clomipramine OR SSRI/TCA + Buspirone OR SSRI?TCA + Pindolol

54
Q

OCD Treatment for Resistant Cases

A

70% respond to CBT with or without medication

ECT not effective - consider transcranial magnetic stimulation or deep brain stimulation

Riluzole used to lower high brain glutamate levels (Memantine also does this)

N-acetylcycsteine may be used as antioxidant

55
Q

Define Panic Disorder

A

Spontaneous and unexpected occurence of panic attacks (4 or more in a 4 week period OR 1 followed by at least 1 month of fear of another attack)

Intense fear with abrupt onset of 4/13 symptoms with peak less than 10 minutes from onset

56
Q

Panic Disorder Diagnostic Symptoms

A

Palpitations, pounding heart or increased HR

Sweating

Trembling or shaking

Sense of SOB or smothering

Feeling of choking

Chest pain or discomfort

Nausea/abdominal distress

Feeling dizzy, unsteady, lightheaded or faint

Derealization or depersonalization

Fear of losing control or going crazy

Fear of dying

Numbness or tingling

Chills or hot flashes

57
Q

Panic Triggers

A

Injury, illness, conflict, use of cannabis, use of stimulants, SSRI discontinuation

58
Q

Describe panic attack

A

Patients have urge to flee or escape and have sense of impending doom

After attack they worry about next attack or going crazy, avoid situations or locations and are more passive/withdrawn

59
Q

Panic attack comorbidities

A

Alcohol use, increased suicidality

80% have some other psychiatric disorder and 50-60% have depression

Association between panic disorder and psychiatric disorders in first-degree relatives

Medical comorbidities include: IBS, migraines, COPD, asthma, mitral valve prolapse, cardiomyopathy, restless leg syndrome, epilepsy and fatigue

60
Q

Neurotransmitter targeted in panic disorder

A

Serotonin (5HT2 receptor antagonist increasing serotonergic activity)

Alpha 2 adrenergic antagonism (increases synaptic NE and 5HT)

61
Q

Panic Disorder Treatment

A

CBT is best choice

SSRIs and SNRIs | TCAs | MAIOs | Benzos

62
Q

Which antidepressant has cardiac concerns

A

Citalopram in doses greater than 40mg/day

20 is max dose

Potential interaction with cimetidine (decreasing metabolism)

TCAs also have risk of arrhythmias

63
Q

Insomnia Etiology

A

More females than males

Young adults more likely to have trouble initiating sleep, older adults staying asleep

Alcohol, stimulants, steroids and diuretics

Stress or poor sleep hygiene also factors

64
Q

Prevalence of Insomnia

A

50% of population (80% of elderly)

35% have occasional sleep disturbance with self-recovery occurring most-often

Chronic insomnia in 15% and leads to daytime impairment; later in life will increase risk for depression and anxiety; requires treatment

65
Q

Insomnia diagnostic criteria

A

Problems getting to sleep between 3-7 nights a week and taking more than 30 minutes to get to sleep those nights (present for 3 months)

Waking 3 or more times per night or waking up 30 minutes or more early

Feeling unrefreshed in the AM between 3-7 days a week with at least 7 hours of sleep

Can’t be due to another medical disorder or substance abuse

66
Q

Conditions associated with insomnia

A

Mood or anxiety disorders, delirium, dementia, eating disorders, somatoform disorders, personality disorders

Substance abuse or withdrawal

Sleep disorders (apnea, restless leg, circadian rhythm)

Jet-lag, shit work

Angina, CV problems, Parkinson’s, GERD, menopause (everything)

67
Q

Substances and medications associated with insomnia

A

Alcohol, amphetamine/stimulants, antipsychotics, anticonulsants, appetite suppressants, b-agonists, b-blockers, antidepressants, caffeine, cocaine, corticosteroids, decongestants, diuretics, hypnotics, interferon, LDOPA, modafanil, nicotine, phenytoin, thyroid

68
Q

Neurotransmitters promoting sleep

A

GABA, Melatonin (released when dark), Adenosine (may inhibit wake promoting neurons)

69
Q

Neurotransmitters promoting wakefulness

A

NE, ACh, Histamine, 5HT, DA, Orexin

70
Q

Insomnia treatment guidelines

A

First line (CBT, sleep hygiene, relaxation)

Second (short-trial antihistamine, Benzos or Z-drugs, sedating antidepressants (trazodone or doxepine; mirtazapine, paroxetine or venlafaxine if depressed))

Third (Ramelteon, sedating antipsychotic - low dose quetiapine or olanzapine; other sedating agents such as gabapentin or tiagabine)

71
Q

Herbal insomnia products

A

Valerian, cham

72
Q

OTC Melatonin

A

Minimal benefit in sleep onset

Recommended dose dropped from 6 to 0.5-2 mg

73
Q

Prescription Medications for Insomnia

A

Melatonin receptor agonists (Ramelteon; Tasimelteon - spendy and used for non-24 hour sleep-wake disorder in the blind)

Antihistamines (hydroxyzie)

Sedating antidepressants (trazodone, doxepin, mirtazapine)

Buspirone (5HT1A agonist)

74
Q

Sedative Hypnotics based on half-life

A

Short acting (Phenobarbital injection and secobarbital)

Intermediate (Amobarbital, Butabarbital)

Long acting (Mephobarbital, phenobarbital)

75
Q

Sedative Hypnotics Barbiturates

A

Addictive so use short term (except phenobarbital for seizures)

Lose effectiveness after 2 weeks and can cause seizure if stopped abruptly in seizure patients

Can cause depression, delirium, emotional disturbances, excitement/agitation, irritability, hyperactivity and stupor

Can be lethal with alcohol

Sometimes used pre-anesthetic as sedative (secobarbital and butalbital)

76
Q

Chloral Hydrate

A

GABA-A agonist

500 mg - 1 g = hypnotic
250-500 mg = sedative

Onset usually 30 minutes; half-life 7-10 hours

Used in resistant insomnia, pre-operative sedation or for post-operative pain as adjunct with opioids

77
Q

Benzodiazepines for insomnia

A

Addictive (use 5-10 days only)

GABA agonists

Avoid in elderly (65 up) or younger if comorbid cognitive conditions

Short acting, avoid in elderly (alprazolam, triazolam)

Intermediate (temazepam, lorazepam, oxazepam)

Long (diazepam, flurazepam, clonazepam)

78
Q

Z-drugs for Insomnia

A

Non-benzo sedative hypnotics

Addictive (use 10-14 days)

Zolpidem (good for onset and maintenance, intermediate acting, need at least 8 hours, no clinical difference between IR and CR formulation, Edular SL only needs 4 hours and can be used for up to 35 days)

Eszopiclone (intermediate for onset and maintenance, need at least 8 hours, metallic after-taste)

Zaleplon (quick onset for sleep onset only, need at least 4 hours, administer immediately before bed, loses effectiveness after 30 days, may result in rebound insomnia)

79
Q

Insomnia - Sedating Antipsychotics

A

Low dose Quetiapine (25-150 gm) works at H1 over D2 (not recommended for sleep aid due to akathisia, weight gain, increased triglycerides, abuse, and hepatotoxiciy)

Doxepin (used for maintenance, avoid in elderly, take on empty stomach, ACh side effects)

Mirtazapine (Low ACh, antihistamine at low dose; SEs include movement in sleep, increased appetite)

Trazodone (low ACh; SEs include priapism, hypotension and cardiac arrhythmias)

80
Q

Belsomra

A

Orexin receptor antagonist blocks orexin A and B suppressing wake drive

Promotes faster sleep onset and less waking

5-20mg qHS (10 dollars each)

Can impair daytime wakefulness and cognition, may worsen depression and become addictive; inhibits CYP3A

81
Q

General insomnia medication guidelines

A

all short term only (3-10 days)

Can cause cognitive impairment (hangover, auto accidents)

Need to be taken at proper time for effectiveness

82
Q

Zolpidem FDA warnings

A

Half-life longer in women

83
Q

FDA approved antidepressant for sleep

A

Doxepine (strong H1 blocker)

Anticholinergic, memory impairment, substantial next day sedation (SEs)

Pharmacy School 2016-17 (22 decks)

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