hypnotics + anxiolytics Flashcards
when do anxiolytics and hypnotics have their sedating effects
anxiolytics - induce sleep when given at night
hypnotics- induce sleep when given during the day
why are anxiolytics + hypnotics reserved for short-term use
because they lead to dependence (both physical and psychological) and tolerance. It is hard to withdraw a patient if they have been taking it regularly for more than a few weeks
what is the most common class of anxiolytics + hypnotics
benzodiazepines
when would the use of benzodiazepines be indicated
- short-term relief (two to four weeks only) for severe anxiety which is disabling/severely distressing. Patient may have severe anxiety alone or with insomnia/ psychotic illness
- severe insomnia, can be disabling or causing extreme distress
Can you use benzodiazepines to treat mild anxiety
No. The use of benzodiazepines to treat short-term ‘mild’ anxiety is inappropriate.
what can happen if you abruptly withdraw a patient from benzodiazepines
may produce confusion, toxic psychosis, convulsions, or a condition resembling delirium tremens (a severe form of alcohol withdrawal)
- must withdraw benzodiazepines slowly to prevent this
how long does it take to withdraw benzodiazepines
- Short-term users of benzodiazepines (2–4 weeks only) can usually taper off within 2–4 weeks
- Long-term users should be withdrawn over a much longer period of several months or more
how long can it take for benzodiazepine withdrawal syndrome to develop
what are the symptoms of this
- can occur any time up to 3 weeks after stopping a long-acting benzodiazepine, but may occur within a day in the case of a short-acting one
symptoms of benzodiazepine withdrawal syndrome:
- insomnia, anxiety, loss of appetite and of body-weight, tremor, perspiration, tinnitus (ringing/noises in ear), and perceptual disturbances
- symptoms may be similar to original complaint + encourage further prescribing
- note some symptoms may continue for weeks or months after stopping benzodiazepines*
describe the steps to withdraw a patient from long-term use of benzodiazepines
1) transfer the patient to to an equivalent daily dose of diazepam preferably taken at night. This can be done one dose at a time, over a week
2) reduce diazepam dose gradually by 1-2 mg every 2-4 weeks. Towards the end can use smaller doses (e.g 500mcg) to reduce dose of diazepam then stop completely
* note the withdrawal process can take months to a year+.
name some long-acting and short-acting benzodiazepines
long acting: diazepam, clonazepam, clobazam, flurazepam, nitrazepam, chlordiazepoxide
short acting: oxazepam, temazepam, Loprazolam, lormetazepam, lorazepam
note Withdrawal phenomena are more common with the short-acting benzodiazepines.
which drugs should we avoid adding when a patient is taking benzodiazepines
The addition of beta-blockers, antidepressants and antipsychotics should be avoided where possible
what are hypnotics used for
insomina
note cause of the insomnia should be established and, where possible, underlying factors should be treated before use of hypnotics
which type of patients are Short-acting hypnotics preferred
- patients with sleep onset insomnia, when sedation the following day is undesirable
or - when prescribing for elderly patients
which type of patients are long-acting hypnotics preferred
- patients with poor sleep maintenance (e.g. early morning waking) that causes daytime effects
or - when an anxiolytic effect is needed during the day
or - when sedation the following day is acceptable.
what is transient insomnia
Transient insomnia: when patients normally sleep well and may be due to extraneous factors such as noise, shift work, and jet lag they are not sleeping well
how can a hypnotic be given for transient insomnia
if a hypnotic is needed, use one that is rapidly eliminated should be chosen, and only one or two doses should be given.
what is short-term insomnia
usually related to an emotional problem or serious medical illness. It may last for a few weeks and may recur
how are hypnotics given for short-term insomnia
- Intermittent use is desirable with omission of some doses. A short-acting drug is usually appropriate
- should not be given for more than three weeks (preferably only one week)
what is chronic insomnia
Psychiatric disorders such as anxiety, depression, and abuse of drugs and alcohol are common causes
- mild dependence caused by poor prescribing of hypnotics.
can hypnotics be used in chronic insomnia
no, chronic insomnia is rarely benefited by hypnotics
- the underlying psychiatric complaint should be treated, adapting the drug regimen to alleviate insomnia
which hypnotics should be avoided in elderly patients and why
- benzodiazepines
- Z-drug (Zopiclone, eszopiclone, zaleplon and zolpidem)
they should be avoided in elderly because they are at greater risk of becoming ataxic (discoordinated movements) and confused, leading to falls and injury.
which hypnotics may be used for patients during dental procedures
Diazepam or Temazepam (tempazeman is preferred to minimise any residual effect the next day)
which benzodiazepines may still have a residual effect the next day when used as hypnotics
long acting benzodiazepines such as: nitrazepam, flurazepam, diazepam
this is because they are long acting. repeated doses tend to be cumulative
which benzodiazepines have little/no hangover effect when used as hypnotics
Loprazolam, lormetazepam, and temazepam
this is because they are shorter acting.
note Withdrawal phenomena are more common with the short-acting benzodiazepines.
which benzodiazepine can be used if insomnia is associated with daytime anxiety
Diazepam
It is a long-acting benzodiazepine anxiolytic so diazepam given as a single dose at night may effectively treat both symptoms
name 2 non-benzodiazepine hypnotics (also known as Z-drug)
Zolpidem tartrate and zopiclone
- They both have a short duration of action and should not be used long-term (causes dependence)
- note zolpidem + zopiclone are non-benzodiazepine hypnotics but act on the benzodiazepine receptor*
which drug may be useful in elderly patients as a hypnotic because it has no hangover effect
Clomethiazole
- as with all hypnotics, routine administration is undesirable and dependence occurs.
which antihistamines can be used for occasional insomnia
promethazine hydrochloride, Diphenhydramine
- the sedative effect of antihistamines may diminish after a few days of continued treatment. Their prolonged duration of action can cause drowsiness the next day
which side effects are associated with antihistamines
- headache
- psychomotor impairment (disruption between mental + muscle functions. can affect how you walk/ talk/other activities*
- antimuscarinic side effects: dry mouth, blurred vision/sensitivity to light, constipation, urinary retention, hot, flushed/ dry skin
why is alcohol a poor hypnotic
- because the diuretic action interferes with sleep during the latter part of the night (frequent urination)
- Alcohol also disturbs sleep patterns, and so can worsen sleep disorders
when can melatonin be used
it is licensed for the short-term treatment of insomnia in adults over 55 years; and for the short-term treatment of jet-lag in adults
can Benzodiazepine anxiolytics be used as the only treatment for chronic anxiety
no
describe how to use for benzodiazepines during Anxiolytic benzodiazepine treatment
- should be limited to the lowest possible dose for the shortest possible time.
- Dependence is particularly likely in patients with a history of alcohol or drug abuse and in patients with marked personality disorders.
when can Beta-blockers be used during treatment of anxiety
- beta-blockers only alleviate somatic symptoms (physical manifestations of anxiety such as breathlessness, Chest pain, headache)
- this can in turn help the psychological symptoms of anxiety such as worry, fear tension. Beta-blockers do not directly act on psychological symptoms
which type of benzodiazepines are preferred in patients with hepatic impairment
short-acting benzodiazepines preferred e.g (oxazepam, temazepam, Loprazolam, lormetazepam, lorazepam)
- however greater risk of withdrawal symptoms with shorter-acting benzodiazepines
which type of benzodiazepines have the greatest risk of withdrawal symptoms
short acting benzodiazepines such as: oxazepam, temazepam, Loprazolam, lormetazepam, lorazepam
when might benzodiazepines be used in panic disorders
in patients resistant to antidepressant therapy
when might benzodiazepines be used during antidepressant therapy
may be used short-term as an adjunct at the start of antidepressant treatment to prevent the initial worsening of symptoms.
why are older drugs such as meprobamate and barbiturates are not recommended for anxiety or insomnia
they have more side-effects and interactions than benzodiazepines and are much more dangerous in overdose
why does the MHRA advice NOT to co-prescribe benzodiazepines and opioids
can produce additive CNS depressant effects, thereby increasing the risk of sedation, respiratory depression, coma, and death.
what is the Paradoxical effect that can be seen in patients taking benzodiazepines
increase in hostility and aggression may be reported by patients taking benzodiazepines. The effects range from talkativeness and excitement to aggressive and antisocial acts and anxiety
note paradoxical effect is when a drug does the opposite of what is expected
