Anxiolytics Flashcards
What is anxiety
Normal response to threatening or harmful stimul
What is pathological anxiety
Anxiety that is exhibited at inappropriate times that interferes with normal functioning
Systems involved in anxiety
Noradrenergic
Seratonergic
GABA
CCK
Way is the role of the noradrenergic system in anxiety
Locus ceruleus is the alarm center,becomes pathological when it is over active
Role of seratonergic system in anxiety
What drugs target this system?
Were is it located?
This is an inhibitory NT, concentrated in the raphe nuclei,
SSRI’s help with anxiety
Role of GABA in anxiety?
What drugs target this system
This is the major inhibitory nt in the brain.
Inhibits both serotonin and NE
Benzodiazepines act indirectly on this system
What is the role of CCK in anxiety?
Where does it act?
Acts in locus ceruleus to enhance noradrenergic activity
What drugs can induce anxiety?
Antidepressants such as SSRI’s, SNRI’s, and bupropion can cause transient anxiety.
Amantidine, dopa and its analogs
Sympathmimetics and stimulants
Way drugs cause anxiety when going through withdrawal?
Barbiturates
Benzodiazepines- especially short acting ones
Ethanol
Narcotics
Types of Anxiety disorders
General Anxiety Disorder Panic Disorders OCD PTSD Social Anxiety Disorder Specific Phobias Stage fright
Describe General anxiety disorder
This is a fear of the future.
Experience fatigue, muscle tension, or this fear on mored days than not for more than 6 months
Tx for General Anxiety Disorder
SSRI’s- venlafaxine, duloxetine, paroxetine, escitalopram
TCA
BZD- short term
Buspirone- esp if patients have- sleep apnea- h/o substance abuse, or falls
What is a Panic Attack
Sudden onset fear of death with somatic symptoms including at least 4 of the following- fear of dying, chest pain/ discomfort, chills or hot flashes, choking, shaking, and tachycardia
What is a Panic Disorder
A History of attack with 1 or more of the following after the attack- fear of another attack, concern of what will happen if another attack occurs, and agoraphobia b/c think that there are places that trigger the attack
How to Tx Panic Disorder
SSRI- DOC
BZD- clonazepam on a scheduled basis, alprazolam has withdrawal symptoms and may cause seizures (SR formula may be better)
MAO, TCA, CBT- do not mi
Describe OCD
Obsessive thoughts that are relieved by compulsive behaviors
Treating OCD
SSRI- DOC- fluoxetine, fluvoxamine, sertaline, paroxetine- could req higher dose than for depression.
TCA with a significant serotonergic component- clomipramine
CBT- Meds require accompanying CBT. more effective than meds. Dont use BZD with CBT
Describe Post Traumatic Stress Disorder
Occurs after a traumatic event
After the event the patient gets flashbacks, avoids certain beh, and is hyperarousable
What is the role of pain medication in PTSD
Treating the acute trauma and pain that occurs at the time of the event lessens the PTSD
what is the role of betablockers in preventing PTSD
Block the formation of the memories thus minimizing the rexeperience
How do you treat PTSD
SSRI,- sertaline and paroxetine
TCA, MAOI
adjunct- antipsychotics, anticonvulsants, beta blockers
BZD- similar to alcohol only make things worse
Social Anxiety Disorder
fear of embarrassment
how do you treat social anxiety disorder
SSRI, MAOI
How do you treat specific phobias
desensitization
How do you treat stage fright
small amount of beta blocker
What is the role of CBT
normally CBT and pharmacologic agents work best together.
DO NOT GIVE BZD WHILE GIVING CBT.
It is important to educate the patient
What is the role of SSRI’s in treating anxiety disorder
They work for all types of anxiety disorders
what is the role of TCA in treating anxiety disorders
TCA’s work well in panic disorders
What is the role of venlafaxine in treating anxiety disorders
Work well in GAD and panic disorders
What is the role of Bupropion in treating anxiety disorders
NONE, can inc anxiety
How and why do you use antidepressants to tx anxiety disorders
start at a low dose to avoid anxiety that comes with initial therapy.
it is Good fr patients with a history of substance abuse or concurrent depression
Benzodiazepines- MOA
increase the frequency of GABA channel opening to enhance the ability of GABA to inhibit NE and 5HT
DO benzodiazepines have a ceiling effect?
No
Benzodiazepines- AE
sedation, ataxia, anterograde amnesia, respiratory depression, paradoxical excitement, and aggression
How to differentiate between Benzodiazepine OD and an alcohol/ barbiturate OD
BZD are not assoc with a nystagmus, but alcohol and barbiturates are.
Benzodiazepine Uses
1) Short term use while waiting for SSRI to kick in
2) Long term use if there are somatic symptos
What other conditions are BZS’s used in
insomnia, akathesia, acute mania, RLS, seizures, and alcohol detox
What are the two aspects of BZD dependence
Psychological and physiological
what are the physiologic symptoms of BZD withdrawal
fatal seizures, insomnia, ataxia, tremors, anxiety, hallucinations. N/V
How are the symptoms of BZD withdrawal avoided
Make sure that you taper down the dosage
BZD- CI
concurrent alcohol or narcotic use- can be deadly
dont use during CBT
BZD- tolerance
tolerance develops to the euphoria that BZD’s can cause but not the anxilolytic effect- so be careful to examine why you are raising dose
What may happen besides withdrawal symptoms when you stop taking BZD
pt may experience a relapse or rebound which will be worse than before
What determines the absorption rate and distribution
liphollicity- the more fat soluble–> the faster it is absorbed into the CNS –> faster onset.
BZD metabolism
Generally metabolized by the liver into active products
Long Acting BZD’s- names
Diazepam
Clorazepate
Chlordizaepoxide
What are the advantages of long acting BZD’s
Less frequent dosing, less rebound between doses, less severe withdrawal
what is the metabolism of long acting BZD’s
metabolized in the liver
Short acting BZD’s-names
Lorazepam
Oxazepam
Short acting BZD’s- pros and cons
More frequent dosing, more rebound between doses, and more severe withdrawal
BUT there is less accumulation of drug in the system
Short acting BZD’s- metabolism
metabolized by glucoronidation
Short acting BZD’s preferred population
elderly and those with liver dz
Most lipohillic BZD
Least lipohillic BZD
diazepam is the most lipophillic
temazepam- least lipophillic
Flumenazil MOA
Competitive antagonist with BZD @ GABA-A receptors
Flumenazil- AE
can precipitate withdrawal in pts that are BZD dependent
Buspirone- MOA
partial presynaptic 5HT1A agonist which causes an increase in NE and 5HT activity
Buspirone- Indications
Scheduled med in GAD
good in Sleep Apnea, for pts with a h/o substance abuse, and have no prior BZD tx
Buspirone- AE
HA/N/dizziness and nervousness
overall mide SE- no rebound anxiety, no sedative effect, not associated with dependence
Busiprone- how long does it take take effect
Very slow acting
Does Busiprone interact with alcohol
NO
