Anxiety disorders

Question 1

Name 5 classes of drugs that may be used to treat anxiety disorders and list the P drugs for each class.

Answer 1

1) Benzodiazepies (Lorazepam, Diazepam, Temazepam)
2) SSRIs and related antidepressants (Citalopram, Fluoxetine, Sertraline)
3) Serotonin and Noradrenaline reuptake inhibitors (Duloxetine, Venlafaxine)
4) Non-selective MAOIs or reversible inhibitors of monoamine oxidase A - RIMAs (Phenelzine - Non selective MAOI, Moclobemide - RIMA)
5) Busiprone

Question 2

State 2 situations when benzodiazepines might be used in anxiety.

Answer 2

1) Anxiety disorders

2) Acute behavioural control and rapid tranquillisation

Question 3

Which 2 classes of drug might be used for depressive anxiety disorders?

Answer 3

SSRIs and related antidepressants and serotonin and noradrenaline reuptake inhibitors.

Question 4

In what cases would you use non-selective MAOIs or RIMAs?

Answer 4

1) Major depression and phobic patients with hypochondriacal features.
2) Social anxiety disorder.

Question 5

What would you use Busiprone for?

Answer 5

Anxiety disorders.

Question 6

Give the 3 main clinical indications for the use of SSRIs .

Answer 6

1) First line treatment for moderate to severe depression and in mild depression if psychological treatments fail.
2) Panic disorder
3) Obsessive compulsive disorder

Question 7

Describe the basic mechanism of action for SSRIs.

Answer 7

Preferentially inhibit neuronal reuptake of serotonin from the synaptic cleft. This increases its availability for neurottransmission.

Question 8

1) How do SSRIs differ from TCAs?

2) Why are SSRIs generally preferred over TCAs?

Answer 8

1) They do not inhibit NAD uptake and cause less blockade of other receptors.
2) Because they have fewer adverse effects and are less dangerous in overdose.

Question 9

1) List 4 common side effects of SSRIs.
2) What adverse effect of SSRIs might present with confusion and reduced consciousness, particularly in the elderly?
3) What might be increased in patients on SSRIs?
4) Name an SSRI that can cause a prolonged QT interval.
5) Give 2 other side effects of SSRIs that have not been mentioned.

Answer 9

1) GI disturbance, appetite and weight disturbance, hypersensitivity reactions (skin rash).
2) Hyponatraemia.
3) Suicidal thoughts and behaviour.
4) Citalopram (may predispose to arrhythmias if causes a prolonged QT interval).
5) Increased risk of bleeding and lower seizure threshold.

Question 10

1) What might happen if SSRIs are used in high doses, in overdose or in combination with other antidepressant classes?
2) Describe this side effect.
3) What 3 things can sudden withdrawal of SSRIs cause?

Answer 10

1) Serotonin syndrome.
2) Triad of autonomic hyperactivity, altered mental state and neuromuscular excitation. Usually responds to treatment withdrawal and supportive therapy.
3) GI upset, neurological and influenza like symptoms and sleep disturbance.

Question 11

1) SSRIs should be prescribed with caution in which 2 conditions where there is a particular risk of adverse events?
2) Why should SSRIs only be prescribed by specialists in young people?
3) Why might dose reduction of SSRIs be required in patients with hepatic impairment?

Answer 11

1) Epilepsy and peptic ulcer disease.
2) They have a poor efficacy and are associated with increased risk of suicidal thoughts and self harm.
3) Because SSRIs are metabolised by the liver.

Question 12

1) Why should you not prescribe SSRIs with MAOIs?
2) What should be prescribed for patients taking SSRIs with aspirin/ NSAIDs and why?
3) What risk is increased when SSRIs are co-prescribed with anticoagulants?
4) What other types of drugs should SSRIs not be co-prescribed with?

Answer 12

1) Because they both increase synaptic serotonin levels and together may precipitate serotonin syndrome.
2) Gastroprotection due to an increased risk of GI bleeding.
3) Bleeding risk.
4) Drugs that prolong the QT interval such as antipsychotics.

Question 13

1) What might a typical starting prescription for SSRIs be?
2) What changes need to be made when prescribing SSRIs for elderly patients?
3) Why are oral drops of citalopram prescribed at lower doses to the tablets?
4) When might you consider changing the drug or dose?

Answer 13

1) Citalopram 20mg PO OD.
2) Lower starting and maximum doses are prescribed for elderly patients.
3) Because the oral drops have a higher bioavailability than the tablets.
4) If not effect has been seen at 4 weeks.

Question 14

Which SSRIs would you consider prescribing preferentially for patients with multiple comorbidities who are taking lots of other drugs and why?

Answer 14

Citalopram or Escitalopram because they appear to have fewer interactions than other SSRIs.

Question 15

List the 2 main clinical indications for use of Venlafaxine/ Mirtazapine.

Answer 15

1) Option for treatment of major depression where first line SSRIs are ineffective or not tolerated.
2) Generalised anxiety disorder (venlafaxine).

Question 16

1) What class of drug is Venlafaxine?
2) What class of drug is Mirtazipine?
3) What is the common mechanism of action of both of the above drugs?

Answer 16

1) Serotonin and NAD reuptake inhibitor (SNRI)
2) Antagonist of inhibitory pre-synaptic alpha-2 adrenoreceptors.
3) Both drugs increase availability of monoamines for transmission.

Question 17

1) How is Venlafaxine different to TCAs, making it a preferable choice?
2) How is Mirtazapine different to TCAs, making it a preferable choice?
3) What is a common adverse effect of Mirtazipine as a result of its potent antagonism of H1 receptors?

Answer 17

1) Weaker antagonist of muscarinic and histamine receptors, so fewer antimuscarinic side effects than TCAs.
2) Potent antagonist of H1 receptors, but not muscarinic receptors, so fewer antimuscarinic side effects.
3) Sedation.

Question 18

1) What are the 2 common groups of side effects of both Venlafaxine and Mirtazapine?
2) List 2 other less common but more serious adverse effects.

Answer 18

1) GI disturbance (dry mouth, nausea, diarrhoea, change in weight, constipation) and CNS effects ( headache, abnormal dreams, insomnia, confusion. convulsions).
2) Hyponatraemia and serotonin syndrome.

Question 19

1) What does Venlafaxine do that may increase the risk of arrhythmias?
2) What psychological symptom may be worsened with Venlafaxine and Mertazapine?

Answer 19

1) It can cause a prolonged QT interval.

2) Suicidal thoughts and behaviour.

Question 20

1) What can sudden withdrawal of Venlafaxine/ Mertazapine cause?
2) What risk is specific to venlafaxine compared with other antidepressants?

Answer 20

1) GI upset, neurological and influenza-like symptoms and sleep disturbance.
2) Greater risk of withdrawal effects.

Question 21

1) A dose reduction of Venlafaxine/ Mertazapine should be considered in which 2 groups of patients?
2) In what patients should Venlafaxine be used with caution (if at all)?
3) What type of drugs (examples include Venlafaxine and Mertazapine) are used that the elderly are at particular risk of adverse effects from?

Answer 21

1) Those with hepatic or renal impairment.
2) In patients with CVD associated with an increased risk of arrhythmias.
3) Centrally acting medications.

Question 22

What combinations of drugs should be avoided when using Venlafaxine/ Mertazapine and why?

Answer 22

Venlafaxine/ Mertazapine plus other antidepressants as these combinations can increase the risks of adverse effects, including Serotonin syndrome, so should in general be avoided.

Question 23

1) When is the best time to take Mertazapine and why?

2) How are Venlafaxine and Mertazapine available for administration?

Answer 23

1) At night to minimise (or benefit from) its sedative effects.
2) Only available for oral administration.

Question 24

List the 5 main clinical indications for the use of Benzodiazepines.

Answer 24

1) First line management of seizures and status epilepticus.
2) First line management of alcohol withdrawal reactions.
3) Common choice for sedation for interventional procedures if GA undesirable or unnecessary.
4) Short term treatment of severe, disabling or distressing anxiety.
5) Short term treatment of severe, disabling or distressing insomnia.

Question 25

1) What is the target of BDZs?

2) What type of receptors are these?

Answer 25

1) GABA receptor (type A)

2) GABA (A) receptor is a chloride channel that opens in response to binding by GABA.

Question 26

1) What type of neurotransmitter is GABA?
2) What does opening the chloride channel allow?
3) What do benzodiazepines facilitate and enhance?
4) What effect does this have?

Answer 26

1) The main inhibitory neurotransmitter of the brain.
2) Allows chloride to flow into the cell, making the cell more resistant to depolarisation.
3) binding of GABA to GABA (A) receptor.
4) Widespread depressant effect on synaptic transmission.

Question 27

1) Describe the clinical manifestations of the effects of benzodiazepines.
2) Name another drug that acts on GABA (A) receptors.
3) What happens when there is chronic use of drugs that antagonise GABA (A) receptors.
4) What does abrupt cessation of alcohol cause?

Answer 27

1) Reduced anxiety, sleepiness, sedation, anti convulsive effects.
2) Ethanol/ Alcohol.
3) Patients become tolerant to the presence and so larger doses are needed for the same effect.
4) The excitatory state of alcohol withdrawal.

Question 28

1) How can alcohol withdrawal be treated?
2) Give 3 predictable reactions to administration of BDZs.
3) What is there little of in BDZ overdose compared with opioid overdose?
4) What can happen with BDZ overdose that can lead to death?
5) What happens if BDZs are used repeatedly for more than a few weeks?
6) What does abrupt withdrawal of BDZs cause?

Answer 28

1) Introduction of a BDZ which can be withdrawn in a gradual and more controlled way.
2) Drowsiness, sedation and coma.
3) Relatively little cardiorespiratory depression.
4) Loss of airway reflexes that can lead to airway obstruction and death.
5) A state of dependance can develop.
6) A withdrawal reaction similar to that seen with alcohol.

Question 29

1) What group of people are more susceptible to the effects of BDZs and what should be done about this?
2) BDZs are best avoided in which 2 groups of patients?
3) Why should BDZs be avoided in liver failure?
4) Why might Lorazepam be the best choice if BDZ use is essential in patients with liver failure?

Answer 29

1) The elderly are more susceptible to the effects of BDZs so should receive a lower dose.
2) Those with respiratory impairment or neuromuscular disease (E.G. myasthenia gravis).
3) As they may precipitate hepatic encephalopathy.
4) Because it depends less on the liver for its elimination.

Question 30

1) The effects of BDZs are additive to what?
2) Concurrent use of BDZs with what may increase their effects and why?
3) Give examples of these drugs.

Answer 30

1) Other sedating drugs including alcohol and opioids.
2) Cytochrome P450 inhibitors as BDZs depend on these enzymes for elimination, so they may increase the effects of BDZs.
3) Amiodarone, Diltiazem. Macrolides, Fluconazole, Protease inhibitors.

Question 31

1) What distinguishes the different BDZs?
2) What does duration of action dictate?
3) What BDZs are used for seizures?
4) What BDZ is used for alcohol withdrawal?
5) What is Midazolam most appropriately used for?
6) What BDZ is used for insomnia and/ or anxiety?

Answer 31

1) Their duration of action.
2) How BDZs are used.
3) Lorazepam or Diazepam as they are long acting.
4) Chlordiazepoxide is the traditional choice, but diazepam is equally as acceptable. They are both long acting.
5) Sedation for interventional procedures - short acting drug allowing for rapid recovery after completion of procedure or inadvertent over sedation.
6) An intermediate acting drug such as Temazepam.

Question 32

1) What is essential following IV or high dose oral administration of BDZs?
2) What drug is a specific antagonist of BDZs?
3) When should this antagonist not be given and why?

Answer 32

1) Close monitoring of patient clinical status and vital signs.
2) Flumazenil.
3) Should NOT be given to reverse BDZ induced sedation when this forms part of a mixed or uncertain overdose as it may precipitate seizures which will be difficult to treat (as BDZ receptors will be blocked).

Question 33

Name the 2 classes of drug that might be used for acute behavioural disturbances and give examples.

Answer 33

1) Benzodiazepines (lorazepam)
2) Antipsychotic drugs for immediate control of acute behavioural disturbance (Haloperidol - typical antipsychotic/ Olanzapine - atypical antipsychotic).

Question 34

Name the 3 types of drugs used for patients with drug dependant illnesses and give examples.

Answer 34

1) Opioid substitutes - Methadone and Bupranorphine.
2) Drugs to support smoking cessation - Nicotine replacement therapy, Bupropion, Varenicline.
3) Drugs to support alcohol withdrawal - Chlordiazepoxide, Pabrinex, Thiamine (for maintenance of alcohol withdrawal = Acamprosate, Naltrexone, Disulfiram).