Anxiolytics and Hypnotics Flashcards
Pharmacological Approaches to Anxiety
SSRI
SNRI
Benzodiazepines
Off-Lable/Other Agents
SSRI medications for anxiety
Citalopram (Celexa) Escitalopram (Lexapro) Fluoxetine (Prozac) Fluvoxamine (Luvox) Paroxetine (Paxil) Sertraline (Zoloft)
When using SSRI remember to
start low, go slow, and go all the way.
Can be activating. May need higher dosing to support and acheive antianxiety effects.
First line treatment is
SSRI
How to chose an SSRI
side effect profile, durg-drug interactions, insurance, patient preference.
SNRI medications for anxiety
Venlafaxine (Effexor) Desvenlafaxine (Pristiq) Duloxetine (Cymbalta) Vilazodone (Viibryd) Vortioxetine (Trintellix)
Benzodiazepine medications for anxiety
GABA receptor agonists Schedule IV Controlled Substances Contraindications Adverse Effects Dependence and Misuse
Benzo Guidelines
Start with long acting medications.
Use short-acting medications for as-nneded occasional anxiety
start SSRI/SNRI with benzodiazepine for 1st two weeks
consider other non-benzodiazepine medications
Short acting benzo
Midazolam (Versed)
Triazolam (Halcion)
Intermediate-acting benzo
Alprazolam (Xanax)
Lorazepam (Ativan)
Temazepam (Restoril)
Long-Acting benzo
Diazepam (Valium)
Clonazepam (Klonopin)
85% of abuse occure in
people with substance use history who take benzos
Temazepam is typically used for
sleep issues
Halcion (triazolam) is sometime used for
sleep
Xanax is FDA approved for
panic and GAD
off lable for mania psycosis and catatonia
Ativan is FDA approved for
longer half life than xanax
GAD and epilepsy
Valium is FDA approved for
sleep, anxiety, ETOH withdrawal, seizures, preop
Nice thing about ativan
better use with other medications.
Klonipin
seizures and panic diosrders
off lable, acute episode of anxity or insomnia related to bipoloar
less rebound anxiety due to long acting nature
Assess for misuse
signs of diversion of overuse pill counts urine test PMP database Controlled subtance agreement non-benzo medications
Benzodiazepine medication taper
Benzodiazepine Dosage Equivalents
Withdrawal Symptoms
Acute vs Long Term
Adjunctive Medications
Taper Schedule
Gradual and Rapid
Changing to long-acting benzodiazepine
Non-pharmacological Interventions
Acute withdrawl s/s
restlessness, agitation, tremors, shaking, diziness, SOB and sweating, heart palpitations, poor sleep, seizures, changes in appeite, bowel and bladder concerns, deleium
Long term witdrawl
worsening anxiety, greater more difficult managment of anxiety, mood changes, depression, rebound insomnia
drugs that can support benzo taper
Clonidone baclofen gababentin carbamazapine trazadone mitrazapine propanolol hydroxazine buspar
You do not want to taper in the
outpatient setting
do not want to adust dose more than
25% of total daily dose per week
Other agents to treat anxiety
Buspirone Gabapentin Quetiapine Hydroxyzine Prazosin Propanolol Pregabalin
Buspar
nice side effect, generic, may be used to as an adjunct. Can be used two to three times a day. If not working, check how they are using it.
Gabapentin
anitcunvulsant. Used off lable for anxiety, pain, nightmares
Quetiapine
off lable for anxiety, panic, sleep, PTSD, adjuct for depression. Has metabolic problems at lower doses. Less then say a zyprexa
Hydroxyzine
off lable for anxiety and sleep. Antichologeric properties so be carful in older adults
prasosin
off lable for nightmares, ptsd
propranolol
off lable for anxiety. nice for someone who has somatic symptoms
Pregabalin or lyrica
used to treat neuropatic pain. off lable for GAD but not showing good results.
Non-pharmacological approach
motivational intervering CBT Exercise Sleep reduction of stimulatn use
