Anziolytics

Question 1

Drugs potentially causing anxiety

Answer 1

BUPROPRION (do NOT use as depression option)
Nicotine
Clonidine
Albuterol
Prednisone
Amphetamines
Caffeine
Pseudoephedrine
Levothyroxine
Toxicity: anticholindergics and antihistamines, digoxin
MEDICATION WITHDRAWAL: EtOH, BDZs

Question 2

Benzodiazepines (BZDs)

Alprazolam (Xanax)
Lorazepam (Ativan)
Clonazepam (Klonopin)
Diazepam (Valium)
Oxazepam (Serax)
Temazepam (Restoril)
Chlordiazepoxide (Librium)

Answer 2

• MOA: binds to gamma subunit of GABA-A receptor in addition to GABA (facilitates inhibitory effect of GABA)
• Varying degrees of lipophilicity, higher– more likely to cross BBB, increased onset
• ADR: CNS (SEDATION; confusion, disorientation, memory impairment; ataxia, psychomotor impairment; euphoria, excitement, unpleasant feeling of loss of control; irritability, aggression), CV (respiratory depression, hypotension)
• Liver dysfunction: USE LOT- Lorazepam, Oxazepam, TRANXENE
• Elderly: USE LOT-A (Lorazepam, Oxzepam, Tranxene, Alprazolam)
• Non-adherence issues: USE Diazepam

Question 3

BDZ physical dependence

Answer 3

• Need to continue medication to avoid or relieve physical withdrawal sx (physiologic phenomenon)
• High risk due to chronic nature of disorder (may or may not be associated with abuse)
• Withdrawal: WHAT (sx: insomnia, restlessness, muscle tension, irritability); be aware of withdrawal seizures, WHEN (depends on t1/2); HOW LONG (depends on t1/2)

D/c with slow taper to help avoid withdrawal sx

Question 4

BDZ alerts

Answer 4

Elderly pts

• increased total body fat (BDZ will hang around longer)
• increased risk of AEs
• associated with falls and fractures, particularly hip fractures

Pregnancy and Lactation

• Most cat D, avoid if possible (especially alprazolam and 1st trimester)
• 1st trimester: cleft lip, palate malformations

Question 5

Buspirone (Buspar)

Answer 5

• MOA: partial agonist at 5HT-1A receptors
• Advantages: lack of dependency, less sedation, minimal Drug Drug Interactions
• Disadvantage: slow onset, dosed BID/TID, not effective for depression
• ADR: dizziness, N, HA

Question 6

Guidline

Answer 6

GAD

• First line: SSRIs (paroxetine, escitalopram), SNRIs (Venlafaxine, duloxetine), pregabalin
• Second line: buspirone
• Last line: BDZs

OCD
- First line: SSRIs

SAD
- First line: SSRIs, venlafaxine

PTSD

• SSRIs: fluoxetine, sertraline
• SNRIs: Venlafaxine