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BCPS > Anxiety, Insomnia, SUD > Flashcards

Anxiety, Insomnia, SUD Flashcards

1
Q

Benzodiazepine equivalents

A

Alprazolam 0.5mg
Chlordiazepoxide 25mg
Clonazepam 0.5mg
Diazepam 10mg
Lorazepam 1mg

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2
Q

Antidepressants and Anxiety

A

May be “hyperresponder” and more anxious at first. Start with low doses.

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3
Q

Buspirone

A

GAD only
Onset is weeks, cannot be used PRN

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4
Q

GAD first line SSRIs

A

Escitalopram
Paroxetine IR & CR
Sertraline

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5
Q

GAD first line SNRIs

A

Duloxetine
Venlafaxine

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6
Q

GAD second-line agent

A

buspirone

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7
Q

GAD treatment augmenttion

A

Aripiprazole
Quetiapine
Olanzapine
Risperidone

In treatment-refractory

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8
Q

Panic disorder first line

A

SSRIs and venlafaxine xR

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9
Q

Panic disorder benzos

A

effective with rapid onset

Alprazolam
Clonazepam
Diazepam
Lorazepam

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10
Q

OCD treatment of choice

A

Cognitive behavioral therapy

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11
Q

SSRIs for OCD

A

Escitalopram
Fluoextine
Fluvoxamine
Paroxetine
Sertraline

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12
Q

PTSD treatment of choice

A

Psychotherapy

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13
Q

PTSD first line pharmacotherapy

A

FDA approved - sertraline, paroxetine, venlafaxine XR

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14
Q

PTSD adjuncts

A

Prazosin - nightmares

Carbamazepine, lamotrigine, topiramate - agression, anger, depression

Aripiprazole, quetiapine, risperidone - psychotic symptoms

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15
Q

PTSD and benzos

A

VA recommends against.

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16
Q

Social anxiety disorder first line therapy

A

CBT

FDA approved - paroxetine and sertraline only

Can also try escitalopram, fluvoxamine, venlafaxine XR

Pregabalin

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17
Q

Social anxiety disorder second line

A

Benzo (alprazolam, clonazepam)
Gabapentin

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18
Q

Gold standard insomnia therapy

A

CBT-I but may not be available to all patients

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19
Q

Initial treatment duration for insomnia

A

2-4 weeks

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20
Q

Short acting benzo for insomnia

A

Triazolam

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21
Q

Intermediate acting benzo for insomnia

A

Temazepam
Estazolam

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22
Q

Long acting benzo for insomnia

A

Flurazepam
Quazepam

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23
Q

Benzo of choice for older adults with insomnia

A

temazepam

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24
Q

Eszopiclone

A

nonbenzo. GABA agonist

Take when will be in bed for at least 7-8 hours due to long half life

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25
Q

Zaleplon

A

Nonbenzo modulater GABA receptor complex

Very short half life – causes fewer problems in the morning

Indicated only for short-term tx of insomnia (5 weeks)

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26
Q

Zolpidem

A

Nonbenzo modulator of GABA receptor complex

Indicated to decrease sleep latency

CR: improve sleep maintenance, approved for chronic therapy

SL: PRN if difficulty to fall back asleep with >4 hours more of sleep remain

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27
Q

Zolpidem compared to benzos

A

-Lacks anticonvulsant action
-Lacks muscle-relaxant properties
-Lacks respiratory depressant effect

28
Q

Zolpidem dose recommendations

A

Women and older adults: 5mg (IR) or 6.25mg (CR)
Men: 5-10mg (IR) or 6.25-12.5mg (CR)

29
Q

Sedative hypnotic ADR

A

Complex behaviors while asleep (driving, eating, sex, talking on phone)

Anaphylaxis

Decreased respiratory drive

30
Q

Insomnia agents for sleep onset

A

ALL except doxepin

31
Q

Insomnia agents for sleep maintenance

A

ALL except ramelteon and zaleplon

32
Q

Insomnia agents for chronic therapy

A

Eszopiclone
Ramelteon
Zolpidem CR

33
Q

Orexin (OX1, OX2) antagonists

A

Daridorexant
Lemborexant
Suvorexant

Decrease sleep latency & promote maintenance

CI in narcolepsy

Take within 30 minutes of sleep (daridorexant, suvorexant) when you have 7 hours remaining of sleep

34
Q

Take these agents within 30 minutes of sleep

A

Daridorexant
Doxepin
Ramelteon
Suvorexant

35
Q

Guidelines recommend against

A

Both: Trazodone, diphenhydramine, melatonin, valerian

Also, tiagabine, tryptophan, BZDs, chamomile, kava kava

36
Q

Life threatening withdrawal

A

Alcohol
BZDs
Barbiturates

37
Q

Alcohol withdrawal stages

A

6-12 hr: mild (NV, anxiety, tremor, tachycardia)

12-24 hr: Hallucinations

24-48 hr: Seizures

48-72 hr: delirium tremens

38
Q

First line therapy for alcohol withdrawal

A

Benzodiazepines (cross tolerance at GABA)

FDA approved: chlordiazepoxide, diazepam, clorazepate, oxazepam

Lorazepam often used if liver issues

39
Q

Alcohol withdrawal and thiamine

A

Give to all patients to prevent Wernicke-Korsakoff

100-250mg IM/IV for 3-5 days, then 100mg PO TID x1 week, then 100mg daily

40
Q

First line for alcohol use disorder

A

Acamprosate or naltrexone

41
Q

Naltrexone for AUD

A

Reduces cravings
Use with CBT

Risk: hepatic impairment, monitor LFTs

Vivitrol is IM long acting form

42
Q

Acamprosate for AUD

A

reduces cravings

TID dosing

Reduce if CrCl 30-50

Warning: suicidal ideation

43
Q

Disulfiram for AUD

A

Reserved for patients with considerable motivation

Blocks alcohol dehydrogenase, so acetaldehyde concentrations increase = N/V, flushing, HA

Avoid with metronidazole = increased risk of encephalopathy

44
Q

Duration of opioid withdrawal

A

Short acting: 7-10 days
Long acting: ?= 14 days

45
Q

First line therapy for opioid withdrawal

A

Buprenorphine or methadone

46
Q

Lofexidine (lucemyra)

A

FDA approved for opioid withdrawal only (not long-term therapy)

Less effective than buprenorphine or methadone

Prolongs QTc

Similar to clonidine but less hypotensive

47
Q

Methadone

A

Most studied and most widely used for OUD

Preferred in pregnancy

Administered as a single daily dose at a clinic

CYP3A4 substrate

48
Q

Methadone boxed warnings

A
  1. Fatal respiratory depression (lipophilic and long half life so can still release after analgesic effect peaks)
  2. Prolonged QTc, TdP (most common if dose > 200mg). If QTc > 500, decrease or D/C methadone
49
Q

Buprenorphine

A

Partial agonist at mu opioid receptor
Antagonist at kappa receptor

Will displace opioids but only give a fraction of effect that levels out with increasing doses (“ceiling effect”) – this allows patients to feel normal without losing function

Less likely to cause respiratory depression

50
Q

Induction phase with buprenorphine

A

Start when clearly withdrawing from opioids

  1. Give 2 to 4mg of buprenorphine (or 2/0.5 or 4/1mg suboxone)
  2. If withdrawal symptoms not relieved or return at 2 hours, then repeat dose
  3. Can repeat for max of 8mg or 8/2mg on day 1
51
Q

Stabilization phase of buprenorphine

A

Occurs when
1. Patient is without withdrawal symptoms
2. Patient is not experiencing adverse effects of suboxone
3. No longer has uncontrollable cravings

Adjust dose in 2/0.5mg or 4/1mg increments

Monitor weekly

52
Q

Maintenance phase of buprenorphine

A

Administer at lowest possible dose indefinitely

53
Q

Transitioning from long acting opioid to buprenorphine

A

1.Taper to methadone 30mg/day or equivalent
2. Transition to buprenorphine
3. After 2 days of buprenorphine monotherapy, may transition to suboxone

54
Q

Sublocade

A

ER subcutaneous buprenorphine

May use AFTER induction phase

300mg x1 then1 100mg monthly

REMS/BBW due to serious harm from IV admin. Administer SC.

55
Q

Naltrexone for OUD

A

Must be off opioids for 7-10 days before starting (14 days if on methadone or buprenorphine)

Does NOT provide opioid agonism, so may be less effective in patients with severe cravings

56
Q

5 A’s of tobacco assessment

A

Ask about tobacco use
Advise to quit
Assess willingness to attempt to quit
Assist in quit attempt
Arrange for follow up

57
Q

5 R’s to quit tobacco

A

Relevance
Risks
Rewards
Roadblocks
Repetition

58
Q

Cigarettes in a pack

59
Q

Nicotine patch

A

Stop smoking before use

> 10 cigs/day: start with 21mg/day patch x6w, then 14mg/day x2w, then 7mg/day x2w

Remove every morning and replace, unless cause sleep disturbance, then remove at bedtime

Can use with gum, lozenge, inhaler, or nasal spray

60
Q

Nicotine gum

A

Chew until peppery flavor, then “park” between cheek and gum for 30 minutes or until flavor is gone

Max: 24 pieces/24 hours

At least 9 pieces used daily to increase quitting

If smoke first cig within 30 min of awakening: 4mg gum

Avoid coffee, juice ,soft drinks 15 minutes before using

61
Q

Nicotine lozenge

A

Smoke within 30 minutes of awakening: start with 4mg

Dissolve lozenge completely. Do not chew, swallow

Do not eat/drink 15 min before or after

Max 20 lozenge/24 hours

62
Q

Bupropion SR for smoking cessation

A

Start 7 days before quit date

Continue for 8 weeks or up to 6 months

Can use with nicotine patch

63
Q

Varenicline

A

Nicotine receptor partial agonist
Blocks effects of nicotine from smoking

Start 1 week before quit date (can quit up to 35 days after starting)

Continue for 12 weeks. If successful, can continue another 12 weeks

May combine with nicotine patch or bupropion

64
Q

Varenicline cautions

A

Cardiovascular disease
CrCl < 30

65
Q

Smoking cessation for pregnancy

A

Treatment of choice = nonpharmacologic

66
Q

Strong recommendations for smoking cessation

A

Varenicline > nicotine patch
Varenicline > bupropion
Varenicline + nicotine patch > varenicline alone
Varenicline > e-cigs

If pt not ready to stop, start varenicline treatment than wait for them to be ready to stop

67
Q

Conditional recs for smoking cessation

A

Comorbid psych condition: varenicline > nicotine patch

Varenicline for > 12 weeks is&raquo_space; varenicline for 6-12 weeks

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