Anxiety Disorder Management Flashcards
Give 3 examples of benzodiazepines used for anxiety disorders
diazepam
lorazepam
temazepam
name 3 SSRIs
citalopram
fluoxetine
sertraline
Name 2 SNRIs
duloxetine
venlafaxine
what is the mechanism of action of benzodiazepines?
facilitate and enhacne binding of GABA to the GABA-A receptor in the CNS.
Name 5 useful effects of benzodiazepines
- sedation
- anterograde amnesia
- anxiolytic actions
- anticonvulsant activity
- reduction of skeletal muscle tone
when would it be useful to use a short-acting benzodiazepine and name an example.
As a hypnotic for inducing sleep but where you don’t want person to feel sedated in the morning.
e.e. temazepam
name a long-acting benzodiazepine and state when it would be useful to use it?
diazepam or lorazepam
useful as an anxiolytic with long duration of action as it prevents anxiety recurring. you can then give smaller doses to minimise sedation
abrupt cessation of benzodiazepines produces similar state to withdrawal of what other substance?
alcohol because alcohol also works on GABA-A receptors
Name some side-effects of benzodiazepams that you should warn patients of before taking them
- drowsiness (operating machinery)
- light-headedness
- confusion (particularly in the elderly)
- they can increase effects of other sedative substances such as alcohol.
- tolerance (rebound insomnia on withdrawal can perpetuate benzo use)
- dependence
Due to dependence, how long can benzodiazepines be prescribed for?
max 2-4wks
What would be the effect of a benzodiazepine overdose?
respiratory depression due to airway obstruction
what is the mechanism of action of buspirone?
unclear but partial agonist at 5-HT and alpha1-adrenoceptors and antagonist at certain dopamine receptors
what anxiety disorders would you not use buspirone?
insomnia as it has no sedative action and it is also ineffective for panic attacks
what is the first-line pharmacological treatment for generalised anxiety disorder?
SSRIs - e.g. sertraline
what is second-line pharmacological treatment for GAD?
SNRI e.g. venlafaxine
what is 3rd line pharmacological treatment for GAD?
pregabalin
what might you prescribe to help with the physical symptoms of anxiety?
beta-blocker e.g. propanolol
would you have more withdrawal problems with a drug with a short or long half life?
long half life.
You will get withdrawal symptoms for longer with a drug with a long half life
Name some aspects of sleep hygiene
- regular sleep schedule (same time bed and wake)
- relaxing bedtime routine
- avoid stimulants e.g. caffeine
- good sleep environment
- exercise during day
- get exposure to daylight
- healthy eating
Name common side effects of SSRIs
- GI upset
- changes in appetite and weight (loss or gain)
- hyponatraemia which can cause confusion in elderly
- suicidal thoughts may increase within first few weeks
- some can prolong QT interval, predisposing to arrhythmias
what is the best treatment for OCD?
psychological therapies, with CBT, to enable the person to tolerate anxiety. SSRIs can be given alongside.
what is the mechanism of action of “Z-drugs” and name 3
interact with postsynaptic GABA-A receptors but have a shorter duration of action then benzos.
e.g. zaleplon, zolpidem, zopiclone
if a person needs help getting to sleep, what drugs would be best to use?
short-acting hypnotics e.g. zolpidem
if a person wakes in teh middle of the night, what drugs would be best for them?
temazepam or zopliclone due to them being longer-acting
why should hypnotic drugs only be used for short periods of time e.g. 2wks
due to tolerance and dependence - can get rebound insomnia when drug is stopped if person is dependent
what is the antidote to benzodiazepine overdose?
flumazenil - should not be used when a mixed overdose is suspected as it may precipitate seizures and having blocked the benzodiazepine receptor means the seizure will be difficult to treat
What drugs can be used for rapid tranquilisation?
lorazepam, olanzapine or haloperidol AND promethazine
how long does oral lorazepam take to work?
allow at least 1 hour
if you give IM lorazepam for rapid tranquilisation, how long should you wait for a response?
allow 30 mins
if IM lorazepam has not worked, what 2 options could you use next?
- IM olanazpine (only after >1hr post lorazepam IM)
OR - haloperidol with promethazine OR lorazepam (only in pt with no cardiac disease)
what are risks of using benzos for rapid tranquilisation?
- loss of conscoiusness
- respiratory depression or arrest
- cardiovascular collapse
- disinhibition
what risks are there with using antipsychotics for rapid tranquilisation?
- loss of consciousness
- cardiorespiratory complications
- seizures
- akathisia
- dystonia
- dyskinesia
- neuroleptic malignant syndrome
after IM rapid tranquilisation, what should be monitored every 15 mins for at least 1 hour?
Temperature pulse BP hydration level of consciousness resp. rate
what is the MoA of tricyclic antidepressants and name 3
inhibit re-uptake of monoamine neurotransmitters by competitive inhibition of monoamine transporter proteins.
E.g. amitryptyline, imipramine, lofepramine
name some common side effects of TCAs
sedation, antimuscarinic effects (dry mouth, constipation, urinary retention, impotence), excessive sweating and tremor, reduce seizure threshold in epileptics, cardiotoxicity in overdose
what class of drug is mirtazapine and what is the MoA?
presynaptic alpha-2-adrenoceptor antagonist and
5-HT-2C receptor antagonist.
reduces negative feedback inhibition of serotonin release from raphe nucleus neurons
what class of drug is reboxetine?
selective noradrenaline reuptake inhibitor (NRI)
what class of drug are phenelzine and tranylcypromine?
irreversible monoamine oxidase A and B inhibitors (MAOIs)
what side effects should you warn patients of when starting them on MAOIs?
- postural HTN
- irritability and insomnia (as they have similar structure to amphetamine)
- acute overdose produces toxic effects after 12hrs
- avoid foods containing tyramine (cheese, yeast extracts etc.) as it can cause vasoconstriction and HTN with a throbbing headache
what should you not use MAOIs in combination with?
TCAs or SSRIs
what class of drug is moclobemide?
reversible inhibitor of monoamine oxidase A
how would you manage mild to moderate depression first-line?
psychological therapies and CBT
when should you add in drug therapy to psychological therapies in depression?
when it is prolonged/moderate/severe depression
when moving onto pharmacological therapy in depression, what is first line?
SSRIs
what is 2nd line drug use in depression?
SNRIs
3rd line drug use in depression?
combination e.g. SSRI + mirtazapine
or add lithium
When is ECT used?
in severe or treatment-resistant depression, or when you need something to work quicker than drugs
how long should you try an antidepressant for before deciding to switch?
at least 4 weeks due to delayed onset of action
