CNS depressants and muscle relaxers

Question 1

Sedatives

Answer 1

• drugs that have an inhibitory effect on the CNS
• Nervousness, excitability, irritability

Question 2

Hypnotics

Answer 2

• cause sleep
• much more potent effect on CNS than sedatives
• a sedative can become a hypnotic if given in a large enough dose

Question 3

Benzodiazepines

Answer 3

• sedative-hypnotic
• anxiolytic
• depress CNS activity (sedation(
• control agitation and anxiety
• induce skeletal muscle relaxation
• induce sleep
  -treatment of acute seizure disorders
• treatment of alcohol withdrawal
• useful in providing balanced anesthesia
• used in moderate sedation

Question 4

Benxodiazepines (contradindications)

Answer 4

drug allergy
narrow-angle galucome
- pregnancy

Question 5

Benzodiazepines (adverse effects)

Answer 5

-headaches
- drowsiness
- dizziness
- cognitive impairment
-vertigo
-lethargy
- fall risk for older adults
- “hangover”effect

Question 6

Benzodiazepines (toxicity and overdose)

Answer 6

-somnolence
- confusion
-coma
-diminished reflexes
-can cauase hypotension and respiratory depression if taken with other CNS depressants
-treatment of overdose:flumazenil is antidote

Question 7

Benzodiazepines (interactions)

Answer 7

-azole antifungals, verpamil, diltiazem, protease inhibitors, macrolide antibiotics, grapefruit juice (inhibits p-450 enzymes)
- CNS depressants (alcohol, opioids)
- rifampin
- herbal interaction (kava and valerian: increases CNS depression)
- Opioids (black box warning for Benzo + Opioids)

Question 8

Kava (Herbal products)

Answer 8

-used to relieve anxiety, stress, and restlessness and to promote sleep
- may cause temporary skin discoloration (extended continued intake) and visual disturbances
- potential interactions with alcohol, barbiturates, and psychoactive drugs
- contraindicated in liver disease, alcoholism, and other conditions
- the patient should not operate heavy machinery during use

Question 9

Valerian (Herbal prodcut)

Answer 9

-used to relieve anxiety, restlessness, and sleep disorders
- may cause CNS depression, hepatotoxicity, nausea, vomiting, anorexia, restlessness, insomnia
- many interactions, including CNS depressants, MAOIs, phenytoin, warfarin and alcohol
- contraindicated in cardiac and liver disease
- patients should not operate heavy machinery during use

Question 10

Diazepam (valium)

Answer 10

• benzodiazepine
• first benzo clinically available
• antianxiety, procedural sedation, anesthesia adjunct
  -oral, injectable rectal

Question 11

Midazolam (versed)

Answer 11

• benzodiazepine
• used most commonly preoperatively and for moderate sedation
• causes amnesia, sedation, and anxiolysis
• injectable and oral (for children)

Question 12

Temazepam (Restoril)

Answer 12

-intermiedate acting benzo
- used for sleep - induces sleep within 20-40 minutes, instruct patients to take it about 1 hour prior to going to bed

Question 13

Eszopiclone (Lunestra)

Answer 13

• first hypnotic to be FDA-approved for long-term use
• provides 8 hours of sleep
• Patients should not take this medication if they will not be able to get 8 hours of sleep

Question 14

Zolpidem (Ambien)

Answer 14

• short-acting hypnotic
• lower incidence of daytime sleepiness than benzodiazepines
  Adverse Effects: somnambulation

Question 15

Ramelteon (Rozerem)

Answer 15

-strucutrally similar to the hormone melatonin
- not a controlled substance
- indicated for patients who have difficulty with sleep onset rather than sleep maintenance

Question 16

Suvorexant (Belsomra)

Answer 16

• orexin-receptor antagonist
• 12 hours half-life
• adverse effects: drowsiness, HA, dizziness, diarrhea, dry mouth, cough, increased serum cholesterol

Question 17

Barbiturates

Answer 17

-1st introduced in 1903-used to be the standard drug for insomnia and sedation
- habit forming and has a low therapeutic index
- used for seizure control, anesthesia induction, and sedation
- end in -ITAL (phenobarbital, pentobarbital, amobarbital, etc)

Question 18

Barbiturates (Contraindications)

Answer 18

-drug allergy
- pregnancy
- significant respiratory difficulties
- severe kidney or liver disease
- caution in older adults (fall risk)

Question 19

Barbiturates (drug interactions)

Answer 19

• stimulate the action of enzymes in the liver that are responsible for drug breakdown causing many drugs to be broken down more quickly
• additive effects with alcohol, antihistamines, benzos, opioids

Question 20

Pentobarbital (Nembutal and phenobarbital

Answer 20

• prototypical barbiturates
• long-acting
• prevention of seizures, rarely used as a sedative, not recommended as a hypnotic

Question 21

OTC hypnotics

Answer 21

• often contain antihistamines
• Doxylamine (Unisom) and diphenhydramine (Sominex) acetaminophen/diphenhydramine
• use with alcohol can cause respiratory depression or arrest

Question 22

Muscle Relaxants

Answer 22

• relieve pain by reducing skeletal muscle spasms
• decrease muscle spasticity for disorders such as multiple sclerosis and cerebral palsy
• can cause CNS depression

Question 23

Muscle Relaxants (Adverse effects)

Answer 23

• euphoria
  -lightheadedness
  -dizziness
• drowsiness
• fatigue
• muscle weakness

Question 24

Muscle relaxants (interactions/common names)

Answer 24

• any CNS depressants cause interaction: benzo, alcohol
• Common names:
  Baclofen (Lioresal)
  Cyclobenzaprine (Flexeril)
  Dantrolene (Dantrium)
  Metaxalone (Skelaxin(
  Tizanidine (Zanaflex)
  Carisoprodol (Soma)
  Chlorozoaxazone (Paraflex)
  Methocarbamol (Robaxin)

Question 25

Nursing Implications

Answer 25

• instruct the patient to not take other CNS depressants
• use caution while driving
• may be habit forming, rebound insomnia may continue for a few nights after discontinued
• assist with ambulation
  -monitor for adverse effects and therapeutic effects