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Therapeutics > Exam 4 lecture 5 > Flashcards

Exam 4 lecture 5 Flashcards

1
Q

What are drugs that cause anxiety

A

Albuterol
Caffeine (high dose)
Decongestant
LevotyroxineSteroids
Stimulants (ADHD meds)

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2
Q

medication overview

A

Buspirone
BZD
SSRI?SNRI
Hydroxyzine
Herbal supplements

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3
Q

Buspirone receptor? Approved for? How long to work?

A

Buspirone is a serotonin (5HT)-1a receptor agonist

Approved for generalized anxiety

May take up to 3-4 weeks for initial efficacy

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4
Q

Benzodiazepines use in anxiety? WIthdrawal effects? Warning?

A

Many tx guidelines do not support the use of BZDs in routine anxiety practice due to misuse potential for misuse. Efficacy of anxiety disorders in higher than SSRIs.

Acute withdrawals of BZDs may lead to seizures that can be life threatening

Warning for use of BZDs with other CNS depressants and OD death risk. SPecific warning for prescribing with opioids.

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5
Q

What BZDs do not have active metabolites? What does that entail?

A

Alprazolam, Lorazepam, clonazepam, oxazepam do not have active metabolite and less likely to accumulate for fall risk.

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6
Q

What BZSs have long acting active metabolite

A

Diazepam, clorazepate, chlordiazepoxide have long acting metabolites. Higher fall risk

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7
Q

Side effects of BZDs

A

Sedation
paradoxical excitement
swallowing difficulties
impairement of memory and recall
psychomotor impairement

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8
Q

How to discontinue BZDs

A

Discontinuation of BZDs require a slow taper over weeks to months. Is on beers criteria

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9
Q

What BZDs to use for BZDs

A

Is on beers criteria.

In elderly- prefer LOT
(lorazepam, oxazepam, temazepam)

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10
Q

What does hydroxizine approved for? How is it used? side effects?

A

Hydroxizine pamoate is approved for the treatment of generalized anxiety disorder.

It is taken as needed for anxiety or insomnia

Sedation and anticholinergic side effects are prominent QTc prolongation risk.

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11
Q

When to avoid hydroxizine

A

Avoid use in the elderly due to anticholinergic side effects and fall risk.

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12
Q

Use of propanolol in anxiety disodrders

A

Decreases physiological symptoms of acute anxiety (useful in performance and situational anxiety)

evaluate for history/current asthma and CV conditions

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13
Q

Natural products for anxiety and notable facts

A

Kava- may cause hepatotoxicity/liver failure

St johns wort- Used for anxiety and depression, strong 3A4 inducer so watch for drug interactions

Valerian and passionflower- avoid in pregnancy

Chamomile- avoid in ragweed allergy

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14
Q

What is the place of gabapentin and quetiapine in anxiety

A

Gapapentinoids may be considered in a patient with bipolar disorder who has anxiety symptoms or comorbid neuropathic pain

Sleep medicine does not endorse the use of quetiapine for insomnia

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15
Q

General drug therapy principles for anxiety disorders

A

SSRI/SNRI are first line for all anxiety disorders

Buspirone can also be used first line for GAD

BZDs are FDA approved to treat anxiety, but only use them if absolutely necessary

Atypical antipsychotics are not FDA approved for anxiety, but evidence suggests efficacy for treatment resistant OCD (Aripiprazole and risperidone)

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16
Q

DSM symptoms and definition of GAD

A

Excessive anxiety/worry present for atleast 6 months

Symptoms include restlessness, difficulty concentrating, irritbaility, muscle tension, sleep disturbance

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17
Q

Treatment of GAD

A

!st line maintenance treatment are the SSRI antidepressants (take 2-4 weeks for initial onset

SNRI antidepressants may be useful

BZDs- used as bridge therapy to cover time until onset of SSRI/SNRI. Must be tapered if stopping

Hydroxazine- may be useful as needed

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18
Q

DSM 5 social anxiety disorder

A

Persistent fear about social and or performance situations in which the patient fears embarassment or humiliation that is unreasonable

Specific situations may be avoided in a manner that interferes with patients normal routine. Duration of symptoms is atleast 6 months

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19
Q

Treatment of social anxiety disorder

A

SSRIs are 1st line (Paroxetine and sertraline are FDA approved)

SNRIs may be useful (Venlafaxine is FDA approved)

BB- for performance related SAD (non-generalized)

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20
Q

DSM 5 panic disorder definition

A

Panic attacks is an abrupt surge of intense fear or discomfort with atleast 4 physical and psychological symptoms, including sweating, palpitations, nausea, dizziness

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21
Q

Treatment of panic disorder

A

SSRIs are first line
SNRI (Venlafaxine) is FDA approved
BZDs should not be considered 1st line maintenance therapy unless there is inadequate response to SSRIs (Clonazepam and alprazolam are FDA approved)

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22
Q

DSM 5 OCD definition

A

Obsession- recurrent thoughts or images that are intrusive

Compulsive- Repetitive behaviors in response to obsession

23
Q

Treatment of OCD

A

SSRIs are 1st line

25-50% reduction in symptoms can be expected

Clomiprazine (TCA) is considered second line treatment

Antipsychotics are not FDA approved for OCD, may be considered augmentation therapy with SSRIs/SNRIs

24
Q

Which antipsychotics are used in augmentation therapy with SSRIs

A

Risperidone and aripiprazole

25
Q

Treatment of PTSD

A

SSRI/SNRI are 1st line

Prazosin may be helpful for sleep or nightmares

BZDs are not recommended in PTSD

Polytherapy is common in PTSD

Substance use is common

CBT and eye movement desensitization and processing

26
Q

What can result from SSRI/SNRI treatment? How to avoid this? onset of action of SSRI/SNRI? When to consider bridge therapy? Discontinuation of BZD?

A

Jitteriness syndrome can result from the use of SSRIs/SNRIs when treating anxiet disorders

Initial dose should be lower than doses used for depression to minimize jitteriness

Onset of action is 2-4 weeks

Evaluate the severity of impact on functionality by anxiety disorder before considering using “bridge therapy” with BZDs

Abrupt d/c of BZDs can be life threatening

27
Q

Non-pcol treatment of anxiety disorders? When is non drug therapy particularly useful

A

Psychotherapy and CBT

In PTSD- drug therapy may be more effective in civillian trauma (Usually a one time event) versus combat trauma, so non drug treatments are especially useful

28
Q

Disease states, medications, substances associated with insomnia

A

Anxiety
Caffeine
Modafinil
Amphetamines
B agonist
BB
Mood disorders
Bupropion
decongestant
methylphenidate

29
Q

What are sleep/wake disorders

A

-Insomnia disorders
-Breathing related sleep disorders (Obstructive sleep apnea, central sleep apnea)
-narcolepsy
-circadian sleep wake disorder (Shift work type, non 24 hr sleep wake type)
-sleep related movements in sleep
-periodic leg movements in sleep (PLMS)
-Restless leg syndrome (RLS)

30
Q

DSM 5 insomnia disorder

A

Difficulties with sleep initiation, maintenancem early morning awakening ateast 3 nights per week present for atleast 3 months

31
Q

Treatment of insomnia disorders based on sleep complaints

A

Zolpizem and eszopicclone in all 3

Sleep onset only- zaleplon, triazolam, eszopiclone, zolpidem, ramelteon

Sleep maintenance only- suvorexant, doxepin, eszopiclone, zoloidem

Both- eszopiclone, zolpidem

32
Q

Treatment of insomnia disorders

A

1st line is non-pcol
sleep hyegine principles

The Z-hypnotics (zolpidem, eszopiclone, zaleplon are the most commonly used sleep medication

33
Q

What are the Z hypnotic drugs? Dosing? metabolism? side effects? warnings?

A

Initial dose of zolpidem is lower in women and elderly- 5 mg

eszopiclone patients complain of metallic taste

3A4 substrates- metabolism is impacted by 3A4 inhibition and induction

Side effects include somnolence, dizziness, ataxia, headache

Can cause parasomnias- unusual actions while a person is sleeping

warning- Potential for abuse and has additive side effects with other CNS depressants

34
Q

BZDs use in sleep disorder? side effects?

A

BZDs can be used for insomnia

Temazepam is the BZD used for sleep

Drowsiness, dizziness, cognitive impairement, increased fall risk

35
Q

What are the melatonin receptor agonists? Side effects?

A

Ramelteon- Contraindicated with fluvoxamine

GI upset, next day somnolence, hyperprolactinemia, prolactinemia

Tasimelteon- FDA approved for non-24 hour sleep wake disorder in adults

36
Q

metabolism of melatonin receptor agonist

A

1A2 substrate- watch for 1A2 inducers and inhibitors

37
Q

Orexin receptor antagonist drugs? When to take them? contraindication? Metabolism?

A

Suvorexant-
atleast 7 hours of sleep
Contraindicated in narcolepsy- causes narcolepsy like side effects
3A4 substrate

Lemborexant- at least 7 hours to sleep
sontraindicated in narcolepsy- causes narcolepsy like side effects
3A4 substrate

Daridorexant- atleast 7 hours to sleep
contraindicated in narcolepsy- causes narcolepsy like side effects
3A4 substrate

38
Q

Place of doxepin and trazodone in sleep disorders

A

Doxepin- TCA- low doses exert effects through H1 receptor antagonism
anticholinergic side effects

Trazodone- Not FDA approved for insomnia
long half life- may see daytime hangover

39
Q

Place of mirtazapine and quetiapine in sleep disorder

A

Mirtazpine- Clinically used as sleep agent, especially in patients with depression who have difficulty sleeping

Quetiapine- low dose quetiapine is not recommended for use in insomnia unless there is a co morbid psychiatric disorder

40
Q

Place of OTC antihistamines and natural products in sleep disorders

A

Diphenhydramine/doxylamine- Not recommended by AASM
anticholinergic side effects (avoid in elderly)

Melatonin- can be considered in jet lag and patients with low melatonin levels. 1A2 substrate

German chamomile- alergic reactions in patients with daisy or ragweed allergies

41
Q

What is first line in sleep disorders

A

CBT and behavioral therapies

42
Q

symptoms of obstructive sleep apnea

A

Symptoms include excessive daytime sleepiness, snoring, pauses in breathing during sleeo, headache, irritability, sore throat

43
Q

Diagnostic testing for sleep apnea

A

Polysomnography needed if chronic medication use. Same with stroke, CVD, respiratory, mucle weakness.

44
Q

Treatment of sleep apnea

A

Sleep apnea and insomnia are usually coorbid. Treat apnea first.

weightloss (adjunctive rather than curative), smoking cessation, CNS depressants, sleep on side rather than back

If patient is overweight or obese and comes for evaluation for insomnia, consider assesing for sleep apnea prior to initiating medication.

Excessive daytime sleepiness (EDS) can be treated with modafinil or armodafinil needed to review CPAP adherence

45
Q

Describe the narcolepsy tetrad

A

-EDS0 excessive daytime sleepiness
-Cataplexy- sudden loss of muscle tone triggered by emotion
-Hallucination
-sleep paralysis

46
Q

Treatment of narcolepsy cataplexy

A

sodium oxybate (xyrem)- GHB- high sodium content

Xywave- for adults and children aged 7 or older, also approved for idiopathic hypersomnia in adults- lower sodium content

Lumryz- for adults only- ER dosage form, once nightly dosing, hoigh sodium content

47
Q

treatment of narcolepsy EDS

A

Modafinil/armodafinil- associated with possible life threatening rash
sodium oxybate

Pitosilant and solriamfetol recently FDA approved for EDS

48
Q

What kind of drug is pitosilant? CI? SE? Metabolism? Avoid use in?

A

H3 receptor antagonist/inverse agonist

Contraindicated- severe hepatic impairement

Prolongs QT interval

2D6/3A4 substrate, weak 3A4 inducer- may reduce effectiveness of oral contraceptives

Avoid use with centrally acting H1 receptor antagonist (OTC antihistamines)

49
Q

What kind of drug is soliramfetol? Indicated in? Dosing is renal impairement? Warnngs? avoid in?

A

Dopamine norepinephrine reuptake inhibitor (DNRI)

Indicated for improvement in wakefulness in adults with EDS due to narcolepsy or sleep apnea

Moderate renal impairement- start 37.5 mg, may increase to 75 mg after atleast 7 days, severe renal impairement- starting and max dose- 37.5 mg

warnings- B/P and HR increases.

avoid in unstable CV disease and arrhythmias, use caution in pts with history of psychosis or bipolar disorder- decrease dose or discontinue

50
Q

How to treat shift work sleep disorder

A

Modafinil and armodafinil are the drugs of choice taken 1 hour before the work period starts during wake time

51
Q

Restless legs syndrome drug therapy

A

Gabapentin encarbil- 1st line
Dopamine agonist (IR formulation)
Iron supplementation can be considered

52
Q

Describe gabapentin encabril

A

Prodrug of gabapentin, FDA approved for RLS

53
Q

Dopamine agonist drugs for RLS

A

Pramipexole or ropinirole

Therapeutics (38 decks)

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