ic15 anxiety and sleep disorders Flashcards
What is anxiety disorder
Severe, persistent anxiety and irrational fear that impairs functioning
When anxiety is out of proportion to actual danger or threat
What are the 5 anxiety disorders that can be treated by meds?
GAD
Panic disorder
Social Anxiety Disorder (SAD)
OCD
PTSD
What are the main neurotransmitters involved in GAD?
NE, Serotonin, GABA
hence drugs to treat GAD are ssri, snri, bzd
Drugs that can induce anxiety (10 points)
Pseudoephedrine
Stimulants (Increase NE, DA): Amphetamine, Bupropion
Methylxanthine: Theophylline, Caffeine
Levothyroxine: activate sympathetic NS
Corticosteroids
Antidepressants
Jitteriness side effect after initiation
Dopamine agonist eg. Levodopa
Beta agonists eg. Salbutamol
Drug withdrawal
Drug intoxication
What is panic attack
Period of intense fear
Reach peak within 10 mins, last no more than 20-30 mins
Can be expected or unexpected
Medication classes for GAD
Antidepressants
Pregabalin
Adjunctive Benzodiazepines
What are the antidepressants used for anxiety
1st: SSRI
2nd: SNRI
3rd: Clomipramine (TCA)
4th: Mirtazapine (if pt worry about sexual SE)
Why is Clomipramine 3rd line for anxiety?
Very effective, potent serotonin and norepinephrine reuptake inhibitor
But toxic, fatal on overdose, accumulates in heart muscles 40x more than serum level, promote seizures, cardiac conduction abnormalities
What drug cannot be used for anxiety?
Bupropion
Very stimulating, will worsen anxiety
Principles of antidepressant therapy in anxiety
Dosing must be LOW
Reduce transient jitteriness in initial 1-2 weeks
Maintenance dose may be HIGH
Eg. Fluoxetine 60-80 mg/day, way more than MDD Fluoxetine dose
Onset and duration of therapy for antidepressants
Onset: Takes 1-2 months for effect in “excessive worrying” symptoms
Counsel for adherence
Duration of therapy: at least 1-2 years
What is the first line Benzodiazepine and why?
Lorazepam
Most commonly used
Safe in hepatic impairment
Short duration of action (6-8hrs), hence safe in overdose
Which BZD has active metabolites?
Diazepam
Diazepam has long half life, active metabolites have even longer half lives
Drowsiness and high fall risk in elderly
Which is the last line benzodiazepine
Alprazolam
Highest potency, hence most toxic if overdose
Should not use frequently for GAD
Only for panic disorder, as adjunct to SSRI, SNRI
Counselling points for benzodiazepines
SSRI will take months to start working, you will still have anxiety attack
Lorazepam, Clonazepam will help with the attacks
Give for initial 2 weeks, then review need to continue due to tolerance dependence side effects
what drug is contraindicated with benzodiazepines?
What to do?
Opioids
Opioids also cannot give with Z-hypnotics (Q3 of post lecture)
Can cause death due to CNS depression!
Cos Z-hypnotics has similar MOA as Benzodiazepines
Switch out Benzodiazepine to another sedating agent, keep the opioid for pain relief
What are some drug drug interactions to look out for in anxiolytics (3 points)
1) CNS depression
Alcohol or other CNS depressants eg. Benzodiazepines
Separate 4-6 hours apart
Benzodiazepines (and Z-hypnotics) should not be given with Opioids
2) Anticholinergic agents
3) Serotonin syndrome
For opioids and drugs that increase serotonin eg. SSRI, SNRI, TCA, MAOi
Wash out period for Moclobemide
What are the neurotransmitters involved in sleep
GABA
Promote sleep
NE, DA, Acetylcholine, Histamine, Orexin
Promote wakefulness
What is insomnia
Inability to sleep and associated with daytime problems eg. fatigue, impaired concentration, memory
Occurs at least 3 nights a week for at least 3 months
Not caused by other disorders eg. Asthma, Pain, Itch, Obstructive Sleep Apnea
How long is transient, short term and chronic insomnia
Transient: < 1 week
Short term: < 4 weeks
Sleep hygiene
Short PRN course of hypnotics
Chronic Insomnia
> 4 weeks
Likely due to secondary underlying psychiatric or medical problems
Counselling points for sleep hygiene
Avoid caffeine, nicotine, alcohol in the evening
No heavy meal within 2hrs of bedtime
Dont drink water before sleep
Avoid noisy environment
Establish a routine for getting ready to go to bed
Avoid daytime naps
Regular exercise but avoid vigorous activities close to bedtime
What are the drugs for insomnia (7 points)
Benzodiazepines
Z-hypnotics
Antihistamine
Melatonin
Lemborexant
Trazodone
Antipsychotics (SGA)
Which patients should not use Benzodiazepines (6 points)
elderly with dementia, as BZD can cause amnesia
history of substance abuse
patients on opioids
myasthenia gravis
acute narrow angle glaucoma
history of respiratory depression
Side effects of benzodiazepines (3 points)
Sedation, Drowsiness
Amnesia
Paradoxical excitement
What are the 2 benzodiazepines indicated for insomnia?
Which is preferred and why?
Lorazepam
Shorter half life (12hrs) → Lesser hangover effects
Preferred over Diazepam
Diazepam
Very effective as cross BBB
Longer acting (T1/2 = 20 - 54hrs) → more hangover effects
Advantage of BZD over antihistamines for use in elderly
Does not cause anticholinergic effect and delirium
but should not be used in dementia patients
BZD can cause paradoxical excitement in elderly
Which patients cannot use Benzodiazepines and Z-hypnotics (5 points)
1) Acute narrow angle glaucoma
2) Respiratory depression
3) Myasthenia gravis
4) Patients with history of substance abuse
5) Patients on opioids
4 roles of benzodiazepines
1) Anxiolytic
2) Sedating
3) Muscle relaxant, hence anti-convulsant
4) Cause amnesia
What is the similarity and difference between Z-hypnotics and BZD
Both can be abused, have similar risk of dependence, should not use in myasthenia gravis, narrow angle glaucoma, history of respiratory depression.
Z-hypnotics is just for sleep, will not cause muscle relaxation like BZD
What drug is contraindicated with Z-hypnotics
Opioids (can cause CNS depression)
What are the 2 Z-hypnotics? Which is preferred?
Zolpidem and Zopiclone
Zolpidem
Useful for initiating sleep
Will not cause hangover effect
Half tablet for females, full tablet for males
Zopiclone
Useful for maintaining sleep due to longer half life
Long duration of action, hence may cause hangover effect
Side effects of Z-hypnotics
Taste disturbances, metallic taste (with Zopiclone)
Sleep walking
What H1 antihistamines are indicated for insomnia?
When are H1 antihistamines indicated
Promethazine, Hydoxyzine
for patients with history of substance abuse
Who is contraindicated from antihistamines? (2 points)
Children 2 and below should not use Promethazine
Elderly with delirium
What is Lemborexant
Indication
Orexin receptor antagonist
Orexin is a hormone that helps with alertness and appetite
For patients with history of substance abuse
What is Lemborexant for and MOA?
Who are contraindicated with use of Lemborexant (3 points)
Insomnia, orexin receptor antagonist
Narcolepsy
Narcolepsy: already have low Orexin, Lemborexant will cause paralysis
CYP3A inhibitor or inducers
Severe renal impairment
For patients with history of substance abuse, what to give for insomnia?
What cannot give?
H1 antihistamine, Lemborexant, Melatonin
-> wont cause dependence
Benzodiazepines, Z-hypnotics
What are 2 off label drugs for insomnia
Trazodone, due to H1 antagonism
Side effects: priapism
Antipsychotics eg. Quetiapine, due to H1 antagonism
