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Pamela - Naplex 2023 > Chapter 67 - Anxiety Disorder > Flashcards

Chapter 67 - Anxiety Disorder Flashcards

1
Q

The major types of anxiety disorders are:

Other disorders that have symptoms of anxiety include:

A
  • Generalized anxiety disorder (GAD)
  • Panic disorder (PD)
  • Social anxiety disorder (SAD)

Other disorders that have symptoms of anxiety include
- Obsessive compulsive disorder (OCD)
- Post traumatic stress disorder (PTSD)

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2
Q

The symptoms of occasional anxiety:

and any physical symptoms:

  • Do they resolve on their own or are chronic?
A

The symptoms of occasional anxiety:
- Fear
- Worry
and any physical symptoms:
- Tachycardia
- Palpitations
- Shortness of breath
- Stomach upset
- Chest pain
- Other pain, insomnia or fatigue
resolve once the issue is gone.

With an anxiety disorder, the symptoms are chronic, severe and cause great distress. The disorder can interfere with the ability to do well at school or work and can harm relationships.

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3
Q

SELECT DRUGS THAT CAUSE ANXIETY:

A

1- Albuterol (if used too frequently or incorrectly) (SABA)
2- Antipsychotics (aripiprazole, haloperidol)
3- Bupropion
4- Caffeine, in high doses
5- Decongestants (pseudoephedrine)
6- Illicit drugs (cocaine, LSD, methamphetamine)
7- Levothyroxine (if therapeutic overdose occurs)
8- Steroids
9- Stimulants (e.g.,amphetamine, methylphenidate)
10- Theophylline (For resp)

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4
Q

non drug ttmt

A
  • Comorbid conditions (e.g., hyperthyroidism) or medications?
  • Lifestyle changes
  • Cognitive Behavioral Therapy (CBT) provides adequate relief without the need for chronic medications.
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5
Q

Natural products

A
  • Some natural products may provide benefit in treating anxiety, but use is limited by safety issues.
  • St. John’swort, used for depression and anxiety, is a strong CYP3A4 inducer and can decrease the concentration of other medications.
    St. John’s wort causes photosensitivity and is serotonergic, which increases the risk of serotonin syndrome when used in combination with other serotonergic medications.
  • Valerian is used for anxiety and sleep, but some products may be contaminated with liver toxins; if used, liver function should be monitored.
  • Passion flower appears to be safe and is rated as “possibly effective” by the Natural Medicines Database.
  • Kava is a relaxant, but it can cause severe liver damage and is NOT recommended.
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6
Q

For how long can u use BDZ?

A

Short term

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7
Q

What are the first line ttmt for anxiety?
List the drugs
At what dose do you give them
Onset of action?

A

First-Line:
1- Selective serotonin reuptake inhibitors (SSRls)
- Escitalopram (Lexapro)
- Fluoxetine (Prozac)
- Paroxetine (Paxil, Paxil CR, Pexeva)
- Sertraline (Zoloft)

2- Serotonin and norepinephrine reuptake inhibitors (SNRls)
- Duloxetine (Cymbalta, Drizalma Sprinkle)
- Venlafaxine XR (EffexorXR)

  • Start at half the initial dose used for depression and slowly titrate to minimize anxiousness and jitteriness (common during the first couple of weeks)
  • Will not provide immediate relief; takes at least four weeks at higher doses for a noticeable effect
  • Other SSRls and SNRls may be used off-label for anxiety disorder
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8
Q

What are the 2nd line ttmt for anxiety?

A

1- Buspirone

2- Tricyclic Antidepressants
- Amitriptyline (Elavil’)
- Nortriptyline (Pamelor)
- lmipramine (Tofranil)

3- Hydroxyzine (Vistaril)

4- Pregabalin (Lyrica, Lyrica CR) (C-V)

5- Gabapentin (Neurontin)

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9
Q

Escitalopram

A

Lexapro

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10
Q

Fluoxetine

A

Prozac

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11
Q

Paroxetine

A
  • Paxil
  • Paxil CR
  • Pexeva
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12
Q

Sertraline

A

Zoloft

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13
Q

Duloxetine

A
  • Cymbalta
  • Drizalma Sprinkle
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14
Q

Venlafaxine XR

A

EffexorXR

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15
Q
  • When do u use buspirone?
  • Class?
  • Does it provide immediate relief?
A
  • 2nd line
  • Class: Anxiolytic
  • Can use in combination with antidepressants (e.g., when there is a poor response)
  • Considered a more favorable add-on medication than benzodiazepines:
    –> In elderly patients (less sedating)
    –> If there is a risk for benzodiazepine abuse
  • Does not provide immediate relief; takes 2-4 weeks for effect
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16
Q
  • When do you use TCAs?
  • List TCA drugs
A
  • Amitriptyline (Elavil’)
  • Nortriptyline (Pamelor)
  • lmipramine (Tofranil)
  • Not FDA-approved for anxiety
  • Risk of adverse effects (e.g., anticholinergic side effects) limit use
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17
Q

Hydroxyzine
- Brand
- MOA
- Is it FDA approved for anxiety?
- For how long can u use it?

A
  • Vistaril
  • Sedating antihistamine with anticholinergic activity
  • FDA-approved for anxiety but does not treat the underlying condition
  • Should not be used long-term; use only short-term, as needed, as an alternative to benzodiazepines
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18
Q

When do u use Pregabalin and Gabapentin?
- Brands
- Class
- Are they FDA approved
- onset of action?

A
  • Pregabalin (Lyrica, Lyrica CR) (C-V) (Anticonvulsant)
  • Gabapentin (Neurontin) (Anticonvulsant)
  • Not FDA-approved for anxiety but has shown benefit in patients with anxiety and neuropathic pain
  • Has immediate anxiolytic effects similar to benzodiazepines
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19
Q

When do you use propranolol?
Is it FDA approved?

A

Not FDA-approved for anxiety but can reduce symptoms of stage fright or performance anxiety others) (e.g.,tremor, tachycardia)

Dose: 10-40 mg one hour prior to an event (such as a public speech)

Can cause CNS side effects (e.g., dizziness, confusion)

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20
Q

Bupropion VS Buspirone

A

Bupropion Causes anxiety
Buspirone Treats Anxiety

21
Q

MOA of buspirone?

A

The mechanism of action of buspirone is unknown, but its effects may be due to its affinity for 5-HTlA and 5-HT2 receptors.

22
Q

Buspirone dose

Should you take it with or without food?

A

Start 7.5 mg PO BID
Can increase by 5 mg/day every 2-3 days, to a max dose of 30 mg PO BID

Take with or without food, but must be consistent

23
Q

CI with buspirone

A

Do not use with:
- MAO inhibitors (or within 14 days of discontinuation),
- linezolid
- IV methylene blue

24
Q

Warning with buspirone

A

Risk of serotonin syndrome alone or in combination with other serotonergic drugs

25
Q

SE with buspirone

A

Dizziness, drowsiness, headache, lightheadedness, nausea, excitement

26
Q
  • Does it have a high abuse risk?
  • How should you switch from BDZ to buspirone
  • In what cases should you avoid buspirone?
A

No potential for abuse, tolerance or physiological dependence

When switching from a benzodiazepine to buspirone, the benzodiazepine must be tapered off slowly

Avoid use in severe kidney or liver impairment

27
Q

DDI with buspirone

A

■ Risk of serotonin syndrome is inc when used in combination with other serotonergic drugs.

■ Avoid grapefruit and grapefruit juice, may inc buspirone levels.

■ Buspirone is a major substrate of CYP3A4.
- Decrease the dose if used in combination with moderate and strong CYP3A4 inhibitors (e.g., erythromycin, diltiazem, verapamil, itraconazole).
- An increase in the buspirone dose may be required with CYP3A4 inducers (e.g., rifampin).

28
Q

MOA of BDZ

A

BZDs enhance gamma aminobutyric acid (GABA), an inhibitory neurotransmitter.

This causes CNS depression, resulting in anxiolytic, anticonvulsant, sedative and/or muscle relaxant properties.

29
Q

BDZ: are they used for long term or short term relief?
Do they treat the underlying cause?

A

They provide fast relief of symptoms (antidepressants have a longer onset of action), but they do not treat the underlying causes of anxiety.

BZDs can be useful for short-term treatment of acute anxiety that is preventing restful sleep and disrupting life. This can be due to the recent death of a loved one, a natural disaster or another stressful situation.

30
Q

BDZ: What happens if theyre taken long term?

For how long should they be used?

What should u do if they were used for longer than that?

A

If taken long-term, patients can become addicted to BZDs and develop tolerance.

Due to the risk of dependence, they should only be used for 1- 2 weeks and then discontinued.

If used for longer periods of time, they must be tapered off slowly to prevent withdrawal symptoms.

31
Q

Beers Criteria:
(Potentially Inappropriate Medication Use in Older Adults)

BDZ and Elderly?

What SE could it cause in elderly?

A
  • BZDs are potentially inappropriate in patients > 65 years old.
  • BZDs have a high risk of confusion, dizziness and falls in the elderly, which is increased if used with other CNS depressants.
  • The elderly also have a higher risk of having a “paradoxical” reaction (hyperactivity, aggression, agitation).
  • If a BZD is used, the L-O-T drugs are preferred due to the lower risk of adverse reactions.
32
Q

When can u use BDZ for anxiety?

A

Anxiety
■ Most anxiety is due to depression; SSRls and SNRls are preferred
■ If used, consider BZD with longer half-life and less risk of abuse:
- Clonazepam
- Lorazepam
- Diazepam

(LCD tv long t1/2 no abuse)

33
Q

When can u use BDZ for Sleep?

A

Sleep
■ First-line: non-pharmacologic treatment
■ Second-line: non-BZDs hypnotics, like zolpidem (fewer safety issues than BZDs)
■ If used, consider temazepam

(tema aam bt shankher)

34
Q

When can u use BDZ for Elderly or pts with liver impairment?

A

Elderly or Patients with Liver Impairment
■ If used, consider BZDs that undergo glucuronidation; L-O-T drugs
- Lorazepam
- Oxazepam
- Temazepam)

35
Q

When can u use BDZ for Seizures?

A

Seizures
■ Injectable BZDs or diazepam rectal gel (Diastat AcuDial);
Diazepam rectal gel can be administered by a caregiver at home

36
Q

Alprazolam

A
  • Xanax
  • Xanax XR
  • Alprazolam lntensol

fast onset, often abused due to quick action

37
Q

Clonazepam

A

Klonopin

(DIFFERENT THAN Clozapine - Clozaril 2nd G ANTIPSYCHOTICS)

38
Q

Diazepam

A
  • Valium

lipophilic, fast onset, long half-life, high abuse potential

39
Q

Lorazepam

A
  • Ativan
  • Lorazepam lntensol
40
Q

Chlordiazepoxide

A

Librium

41
Q

Clorazepate

A

Tranxene-T

42
Q

Oxazepam

A
43
Q

BBW with BDZ

A

1- Use with opioids can result in sedation, respiratory depression, coma and death

2- Risks for abuse, misuse and addiction which can lead to overdose or death

3- Continued use can lead to physical dependence; abrupt discontinuation can cause withdrawal symptoms

44
Q

CI with BDZ

A
  • Acute narrow-angle glaucoma
  • Sleep apnea
  • Severe respiratory insufficiency
  • Severe liver disease (clonazepam and diazepam),
  • Myasthenia gravis (diazepam)
  • Not for use in infants <6 months of age (diazepam oral)
  • Premature infants (lorazepam parenteral products)
45
Q

Warning with BDZ

A

Physiological dependence and tolerance develop with chronic use - do not discontinue abruptly (taper off slowly)

CNS depression, anterograde amnesia, potential for abuse, safety risks in patients age 65 years and older {impaired cognition, delirium, falls/fractures), extravasation with IV use, paradoxical reactions, severe renal or hepatic impairment

46
Q

Pregnancy and BDZ

A

Pregnancy: crosses placenta; can cause birth defects and neonatal withdrawal syndrome

47
Q

Benzodiazepine Drug Interactions

A

■ Additive effects with CNS depressants (Alcohol, anticonvulsants, antihistamines, antipsychotics, opioids, mirtazapine, skeletal muscle relaxants, trazodone).

■ Diazepam, clonazepam, chlordiazepoxide and clorazepate: use cautiously with CYP3A4 inhibitors.

■ Alprazolam is contraindicated with strong CYP3A4 inhibitors (ketoconazole, itraconazole). Use caution with moderate CYP3A4 inhibitors.

■ Valproate increases the serum concentration of lorazepam.

48
Q

BUSPIRONE

A

■ The tablets are scored to easily break in half or into thirds.

■ Can cause:
o Dizziness
o Drowsiness
o Nausea

49
Q

BENZODIAZEPINES

A

■ If used regularly for> 10 days, do not stop suddenly. Taper off slowly to avoid withdrawal symptoms (e.g., anxiety, shakiness, fast heart rate, difficulty sleeping, muscle pain).

■ To reduce the risk of addiction, do not take doses more frequently or for a longer period than prescribed.

■ Can cause drowsiness.

■ Do not use with opioid medications (can cause profound sedation, respiratory depression, coma and death).

■ Do not use with alcohol (can increase risk of CNS depression).

Pamela - Naplex 2023 (32 decks)

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