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Behavioral Health 2 > Pharm - GAD, OCD, Insomnia > Flashcards

Pharm - GAD, OCD, Insomnia Flashcards

1
Q

What are the first line agents for the tx of GAD?

A

Antidepressants: SSRI and SNRI

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2
Q

Which psychic symptoms in patients with GAD that are best treated with SSRI and SNRI?

A

Apprehension and worry

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3
Q

Which antidepressants are preferred when a patient has GAD and depression?

A
  • antidepressants are preferred over benzodiazepines

- antidepressants are effective treatments for both conditions (GAD and depression)

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4
Q

What is the time to onset of clinical effect when using antidepressants for GAD?

A
  • for an SRI, it varies by patient but averages approximately 4 weeks.
  • the initial therapeutic dose should be continued for 4-6 weeks.
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5
Q

What are the 2 meds used to augment the effects of antidepressants in the tx of GAD?

A

Anxiolytic: buspirone (Buspar®)

Anticonvulsant: pregabalin (Lyrica®, Schedule V) Not FDA approved for GAD

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6
Q

What is the time to onset of clinical effect when using buspirone or pregabalin in the treatment of GAD?

A

Buspirone should be given a trial of 4-6 weeks at the maximally tolerated dose before concluding it is ineffective.

Pregabalin minimum of 4-6 weeks at a maximally tolerated dose before concluding that it is not effective.

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7
Q

What is the drug of choice for rapid relief of acute anxiety sx?

A

Benzodiazepines are the drug of choice for rapid relief of ACUTE anxiety symptoms

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8
Q

What is the role of a benzodiazepine in the treatment of GAD when initiating an antidepressant?

A
  • can be used as either monotherapy or, more commonly, as an adjunct to antidepressant treatment
  • commonly used in GAD for acute management of anxiety and worry during the period before SSRIs or SNRIs take effect
  • counteract the initial agitation often caused by the SSRI
  • once the patient responds to the SSRI, the benzodiazepine can be tapered off gradually.
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9
Q

Which somatic symptoms in pts with GAD are best treated with benzodiazepines?

A
  • restlessness
  • increased fatiguability
  • difficulty in concentrating
  • irritability
  • muscle tension
  • sleep disturbance
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10
Q

Which autonomic symptoms in pts with GAD are best treated with benzodiazepines?

A
  • shortness of breath
  • palpitations,
  • sweating
  • dry mouth
  • dizziness
  • abdominal distress
  • they generally lead to a reduction of emotional and somatic symptoms within minutes to hours, depending on the specific medication
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11
Q

Which patients are good candidates for long-term, low-dose benzodiazepines in the tx of GAD?

A
  • patients with chronic GAD
  • who have minimal current depressive symptoms
  • who have no history of a substance use disorder
  • do not develop tolerance to their anxiolytic effects, which would require dose increase
  • experience only mild, tolerable withdrawal symptoms when the medication is tapered off
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12
Q

Which patients are poor candidates for long-term, low-dose benzodiazepines in the tx of GAD?

A
  • h/o a substance abuse disorder
  • patients who develop rapid tolerance
  • increase their doses against medical advice
  • exhibit withdrawal symptoms between doses
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13
Q

MOA of benzodiazepines (BZD)

A

Benzodiazepines exert their principal pharmacodynamic effect via central nervous system GABA receptors, potentiating the effects of endogenous GABA, the main inhibitory neurotransmitter.

**GABA receptors are membrane-bound proteins that primarily mediate neuronal excitability (seizures), rapid mood changes, clinical anxiety, sleep, memory, mood, and analgesia.

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14
Q

Which benzos are more likely to exert acute withdrawal symptoms?

A

Benzodiazepines with shorter elimination half-lives:

  • alprazolam (Xanax)
  • lorazepam (Ativan)
  • etc.
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15
Q

Which benzos are less likely to exert acute withdrawal symptoms?

A

Benzodiazepines with longer elimination half-lives

  • diazepam (Valium)
  • clonazepam (Klonopin)
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16
Q

Describe the psychomotor retardation caused by benzodiazepines

A
  • drowsiness, poor concentration, mental confusion
  • ataxia, motor coordination, muscle weakness
  • diplopia, vertigo
  • slow reaction time and impaired driving skills increasing the risk of motor vehicle crashes
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17
Q

Describe memory impairment caused by BZD

A

Anterograde amnesia: impaired episodic memory – remembering recent events, circumstances under which they occurred and the time sequence

In patients who have used more than one year – specific deficits in visual-spatial ability and sustained attention.

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18
Q

Contraindications to BZD

A

Adverse effects in PREGNANCY:

  • class D teratogen
  • can cross the placenta and cause development of dependence and withdrawal in the fetus
  • excreted in breast milk: contraindicated in breast-feeding mothers
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19
Q

Describe physiologic and psychologic dependence cause by BZD.

A
  • develops sooner (1-2 months) in patients taking high dose of high-potency agents (example is alprazolam)
  • withdrawal symptoms emerge with rapid dose reduction or abrupt discontinuation of the drug
  • psychologic: overreliance on the need for the drug, loss of self-confidence and varying degrees of drug-seeking behavior
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20
Q

What is the primary cause of withdrawal symptoms in a patient taking a BZD?

A

any abrupt or overly rapid reduction in benzodiazepine (BZD)

21
Q

Given a patient who abruptly stops a BZD, identify the withdrawal symptoms.

A

S/sx can include tremors, anxiety, perceptual disturbances, dysphoria, psychosis, and seizures.

22
Q

What is the relationship between the half-life of BZD and withdrawal symptoms?

A
  • the onset of withdrawal varies according to the half-life of the BZD involved
  • sx may be delayed up to three weeks in BZDs with long half-lives, but may appear as early as 24 to 48 hours after cessation of BZDs with short half-lives.
23
Q

Describe the the appropriate, safe withdrawal plan for benzodiazepine withdrawal from a patient.

A
  • individualize the taper
  • taper BZD slowly and gradually

One approach:

  • 10-25% reduction of the initial dose every one to two weeks until the lowest dose is reached
  • monitor the patient for symptoms of benzodiazepine withdrawal or relapse of GAD and slow the rate of dose reduction accordingly
  • early signs of withdrawal include anxiety, dysphoria, and tremor; advanced manifestations include perceptual disturbances, psychosis, and seizures.
  • if a patient has failed a previous tapering regimen, then try a slower taper over 6 months.
  • augment taper with cognitive-behavioral therapy to improve the likelihood of success.
24
Q

What is the place in therapy for mirtazapine?

A

Mirtazapine (Remeron) is a sedating antidepressant

-can be used as monotherapy or adjunctive treatment for GAD

25
Q

What is the place in therapy for hydroxyzine?

A

Hydroxyzine (Vistaril) is an antihistamine

  • it’s more sedating than BZDs and buspirone, and thus potentially useful for treating insomnia associated with GAD
  • can also be used as monotherapy in non-depressed patients who received no benefit from the SRIs and/or tolerated them poorly
26
Q

What is the place in therapy for quetiapine?

A

Quetiapine (Seroquel) is a SGA

  • can be used in the tx of resistant GAD
  • use these drugs in GAD only after safer alternatives have been exhausted
  • use adjunctively, augmenting an antidepressant or as monotherapy in patients who have had little to no response to prior drug trials
27
Q

What is the duration of the therapy for drug treatment of GAD?

A

if effective, antidepressant treatment for generalized anxiety disorder (GAD) should be continued for at least 12 months.

28
Q

What is the drug class of choice for the treatment of panic attacks?

A

SSRI are the first line agents because of their tolerability and efficacy in acute and long-term studies.

BZD are the most commonly used drugs for panic disorder BUT, are considered second-line drugs because of the risk of dependency.

29
Q

What are the BZD preferred agents for the treatment of panic attacks?

A
  • alprazolam (Xanax)

- clonazepam (Klonopin)

30
Q

Duration of therapy for the tx of panic attacks?

A

total of therapy 12 months before drug discontinuation is attempted

31
Q

What are the drugs of choice for the treatment of obsessive-compulsive disorders?

A

-cognitive-behavioral therapy (CBT) and serotonin reuptake inhibitors (SSRIs).

**SSRI: fluoxetine, paroxetine, sertraline, citalopram and escitalopram

**Tricyclic antidepressant (“old” SNRIs): clomipramine (Anafranil) inhibits the reuptake of serotonin and norepinephrine

32
Q

If a pt with OCD with has an inadequate response to first line agents, what are the alternative therapies?

A
  • providing combined treatment (SRI and CBT)
  • augmenting an SRI with an antipsychotic medication
  • switching to a different SRI
  • switching to venlafaxine
33
Q

List the benzodiazepines to treat insomnia

A 
triazolam (Halcion®) 
lorazepam (Ativan®) 
estazolam (Prosom®) 
temazepam (Restoril®)
flurazepam (Dalmane®) 
quazepam (Doral®)
34
Q

List the nonbenzodiazepines hypnotics to treat insomnia

A

zaleplon (Sonata®)
zolpidem (Ambien®)
eszopiclone (Lunesta®)

35
Q

What is the orexin receptor antagonist to treat insomnia?

A

suvorexant (Belsomra®)

36
Q

What is the melatonin receptor agonist to treat insomnia?

A

ramelteon (Rozerem®)

37
Q

What is the TCA antidepressant to treat insomnia?

A

doxepin (generic)

38
Q

What products can be used to induce sleep in a patient with sleep onset insomnia?

A
  • short-acting medication is a reasonable choice for an initial trial of pharmacologic therapy.
  • this may improve the insomnia with less residual somnolence the following morning.

Examples of short-acting medications (duration of effect ≤8 hours) include:

  • zaleplon (Sonata)
  • zolpidem (Ambien)
  • triazolam (Halcion)
  • ramelteon (Rozerem)
39
Q

What products can be used to help maintain sleep in a patient with sleep maintenance insomnia?

A

-longer-acting medication is preferable for an initial trial of pharmacologic therapy.

Examples of longer-acting medications include:

  • zolpidem (Ambien) extended release
  • eszopiclone (Lunesta)
  • temazepam (Restoril)
  • flurazepam (Dalmane)
  • estazolam (Prosom)
  • low dose doxepin
  • suvorexant (Belsomra)

*These medications may increase the risk for hangover sedation and patients must be warned about this possibility.

40
Q

If a patient awakens in the middle of night with insomnia, what is the medication and the dosage form used to help induce sleep?

A

zaleplon (Sonata) and a specific sublingual tablet form of zolpidem (Ambien)

41
Q

What must patients with middle of the night insomnia be warned of?

A

there must be at least 4 hours of time in bed remaining after administration

42
Q

What other issues must be considered when prescribing an insomnia medication?

A
  • cost
  • adverse effects
  • physical and psychological addiction with long term use
  • concurrent conditions/diseases
  • pregnancy
  • alcohol consumption
  • renal or hepatic disease
  • pulmonary disease or sleep apnea
  • nighttime decision making
  • older adults
43
Q

What ADR are common to all agents used to treat insomnia?

A
  • adverse effects associated with the nonbenzodiazepines are similar to those associated with benzodiazepines.
  • frequency and severity of nonBZD may be less as compared to BZD (possibly related to their shorter 1/2 life).
  • next morning impairment has been increasingly recognized with higher doses.
44
Q

Other ADR reported in nonBZD

A
  • unpleasant taste (eszopiclone, Lunesta) and hallucinations (zolpidem, Ambien)
  • the incidence of infection (e.g., upper respiratory, otitis media, urinary tract, conjunctivitis, others) may also be increased among patients taking a nonbenzodiazepine
45
Q

What kind of insomnia can BZD and non-BZD cause with long-term use?

A

Rebound insomnia

46
Q

What sleep-related behaviors are associated with meds used to treat insomnia?

A
  • sleep-related behaviors (e.g., sleep walking, driving, making telephone calls, eating, or having sex while not fully awake)
  • anterograde amnesia (particularly with triazolam (Halcion) or when used with alcohol)
  • aggressive behavior
  • severe allergic reaction
47
Q

What is the major drug interaction with suvorexant (Belsomra)

A
  • CYP3A4 inhibitors
  • Suvorexant has a 12-hour half-life
  • There is potential for increased toxicity when used in combination with CYP3A4 inhibitors
48
Q

How should patients be recommended to take suvorexant (Belsomra)?

A

5 mg in patients taking moderate CYP3A4 inhibitors (examples: amiodarone, diltiazem, grapefruit juice)

**It is not recommended for use in combination with strong CYP3A4 inhibitors (clarithromycin, ketoconazole)

49
Q

Effects of insomnia drugs on the elderly

A

high risk of adverse effects from hypnotic drugs including:

  • excessive sedation
  • cognitive impairment
  • delirium
  • night wandering
  • agitation
  • postoperative confusion
  • balance problems
  • impaired performance of daily activities
  • increased risk of falls

Behavioral Health 2 (11 decks)

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