Pharm: Sedatives/Hypnotics

What is a sedative?

A medication used to produce sedation before medical or diagnostic procedures.

What is a hypnotic?

A medication used for short-term management of insomnia.

What is an anxiolytic?

A medication used to treat acute anxiety or chronic anxiety disorders.

What is insomnia?

Difficulty falling asleep, staying asleep, early morning awakening, or unrefreshing sleep.

What are the three overall approaches to managing insomnia?

Cause-specific therapy, nondrug therapy, and drug therapy.

Which drugs or substances may contribute to insomnia?

Decongestants, SSRIs, diuretics, caffeine, and alcohol.

What regular schedule helps patients with insomnia?

Consistent sleep and wake times.

What should a patient do about prolonged wakefulness in bed?

Avoid remaining awake in bed for long periods.

What is the lecture's recommendation regarding naps?

Avoid daytime naps.

What exercise advice helps insomnia?

Exercise regularly, but not immediately before bedtime.

What onset is desirable in an ideal hypnotic?

Rapid onset.

What duration is desirable in an ideal hypnotic?

Enough duration to last through the night.

What daytime effect should an ideal hypnotic avoid?

Residual daytime sedation.

How should an ideal hypnotic affect normal sleep patterns?

It should not disturb them.

What tolerance or withdrawal properties should an ideal hypnotic have?

No tolerance or withdrawal.

In which patients should sedative-hypnotic drugs be avoided according to the lecture?

Patients with reduced respiratory reserve or heavy snorers.

What drug classes are used for insomnia?

Benzodiazepines, benzodiazepine receptor agonists, melatonin receptor agonists, sedating antidepressants, OTC antihistamines, and melatonin.

What is the prototype benzodiazepine for insomnia?

Triazolam (Halcion).

How does triazolam work?

Enhances the inhibitory effects of GABA by interacting with GABA receptors in the brain.

What is triazolam's therapeutic use?

Short-term treatment of insomnia.

What is triazolam's half-life characteristic?

Short half-life.

Why can triazolam cause rebound insomnia?

Its short half-life is associated with rebound insomnia.

What patient populations require avoidance or low doses of triazolam?

Avoid in pregnancy or lactation; avoid or use low doses in older adults.

What adverse effects are associated with triazolam?

Tolerance, rebound insomnia, anterograde amnesia, daytime sedation, complex sleep behaviors, dependence, withdrawal, and paradoxical reactions.

What is anterograde amnesia?

Inability to form new memories after medication administration.

What are paradoxical reactions?

Effects opposite to intended sedation, such as increased agitation or excitation.

What is tolerance?

Reduced response to a drug after repeated use.

What is physical dependence?

Physiologic adaptation that can cause withdrawal when the drug is stopped.

What is the major interaction risk when benzodiazepines are combined with other CNS depressants?

Respiratory depression.

What reversal agent is listed for benzodiazepine overdose?

Flumazenil (Romazicon).

Why should long-term high-dose benzodiazepines not be stopped abruptly?

Withdrawal may cause anxiety, insomnia, increased CNS excitability, and seizures.

How should a benzodiazepine be discontinued after long-term high-dose use?

Gradually taper the dose.

What should nurses monitor in patients receiving triazolam?

Sleep response, complex sleep behaviors, withdrawal, dependence, and other adverse effects.

What nondrug education should accompany triazolam?

Sleep hygiene and other nonpharmacologic methods; avoid long-term use.

What controlled-substance schedule applies to triazolam?

Schedule IV.

What is the prototype benzodiazepine receptor agonist or Z-drug?

Zolpidem (Ambien).

How does zolpidem work?

Acts as an agonist at the benzodiazepine receptor site on the GABA receptor.

What is zolpidem's therapeutic use?

Insomnia only.

What is zolpidem's onset and duration?

Rapid onset and short duration.

What are zolpidem's adverse effects?

Daytime drowsiness, dizziness, and sleep-related behaviors.

What is the main interaction risk of zolpidem with other CNS depressants?

Respiratory depression.

What should nurses teach patients taking zolpidem?

Avoid other CNS depressants; use short term; use nondrug sleep measures.

What controlled-substance schedule applies to zolpidem?

Schedule IV.

What is the prototype melatonin receptor agonist?

Ramelteon (Rozerem).

How does ramelteon work?

Activates melatonin receptors involved in the sleep-wake cycle.

What is ramelteon's therapeutic use?

Insomnia; long-term treatment is permitted in the lecture.

What is ramelteon's therapeutic index?

Wide therapeutic index.

Is ramelteon habit forming or controlled?

No; it is not habit forming and is not a controlled substance.

Which patients should avoid ramelteon according to the lecture?

Patients with hepatic impairment and those who are pregnant or nursing.

What are ramelteon's adverse effects?

Somnolence, dizziness, fatigue, increased prolactin, and possible sleep-driving.

What is the teaching point about ramelteon and CNS depressants?

Avoid combining them because symptoms can increase; the lecture states this does not increase respiratory depression risk.

What nonpharmacologic education is appropriate with ramelteon?

Teach sleep hygiene and other nondrug insomnia strategies.

Which sedating antidepressant is highlighted?

Trazodone (Oleptro).

How does trazodone affect sleep according to the lecture?

Decreases sleep latency and prolongs sleep duration.

When may trazodone be used for insomnia?

Especially when the patient is taking an antidepressant that causes CNS stimulation.

What adverse effects are listed for trazodone?

Daytime sedation, anticholinergic effects, weight gain, postural hypotension, and dizziness.

What nursing education is emphasized for trazodone?

Teach patients how to avoid or manage adverse effects, especially dizziness and postural hypotension.

Which OTC antihistamines are listed as sleep aids?

Diphenhydramine (Benadryl, Tylenol PM) and doxylamine (Unisom).

What is the therapeutic use of diphenhydramine and doxylamine in this lecture?

FDA-approved OTC treatment of insomnia.

What adverse effects are emphasized for OTC antihistamine sleep aids?

Daytime sedation and anticholinergic effects.

How is melatonin categorized in the lecture?

Complementary and alternative medication (CAM).

What is melatonin's main therapeutic role?

Resetting circadian rhythms in jet lag, shift work, and blind patients; evidence for insomnia is minimal.

What are melatonin's adverse effects?

Headache, dizziness, nausea, and daytime sedation.

Which drug classes can interact with melatonin?

Anticoagulants, antihypertensives, hypoglycemic medications, and CNS depressants.

When should melatonin be taken?

1–2 hours before bedtime.

What should patients taking melatonin tell their provider?

Disclose melatonin use because of potential drug interactions.

What psychological symptoms of anxiety are listed?

Tension, nervousness, sleep disturbance, and irritability.

What physiological symptoms of anxiety are listed?

Nausea and palpitations.

Which chronic anxiety disorders are listed in the lecture?

Generalized anxiety disorder, panic disorder, OCD, social anxiety disorder, and PTSD.

What characterizes generalized anxiety disorder in the lecture?

Excessive, uncontrollable worry about everyday things.

Which medication classes are used for anxiety?

Benzodiazepines, buspirone, and antidepressants.

Which benzodiazepines are listed for anxiety?

Diazepam (Valium), lorazepam (Ativan), and midazolam (Versed).

How do benzodiazepines treat acute anxiety?

Enhance GABA inhibition; they are fast acting and effective for acute anxiety.

What are the therapeutic uses of the anxiety benzodiazepines?

Short-term acute anxiety, status epilepticus, IV sedation, and alcohol withdrawal syndrome.

How do the half-lives of anxiety benzodiazepines compare with triazolam?

They have longer half-lives than triazolam according to the lecture.

Which dosage forms are listed for anxiety benzodiazepines?

Oral and IV.

What is the expected effect of oral benzodiazepines for anxiety?

Anxiolysis with minimal sedation; monitor response to the first dose.

What monitoring is needed with IV benzodiazepines?

Monitor vital signs and respirations because moderate sedation can occur, especially with other CNS depressants.

What is the prototype nonbenzodiazepine, nonbarbiturate anxiolytic?

Buspirone (Buspar).

How does buspirone work according to the lecture?

Has anxiolytic activity at serotonin receptors.

What is buspirone used for?

Anxiety only.

How quickly does buspirone work?

It takes weeks for effects to appear.

Why should buspirone not be used PRN for immediate anxiety?

Its onset is delayed by weeks.

What are buspirone's adverse effects?

Dizziness, nausea, headache, and drowsiness.

What interactions are listed for buspirone?

Ketoconazole, erythromycin, and grapefruit juice.

How does buspirone differ from benzodiazepines regarding CNS depression?

The lecture says it lacks the CNS-depressant interaction concern of benzodiazepines.

Does buspirone cause tolerance or require controlled-substance handling?

The lecture states no tolerance issues and it is not controlled.

What should nurses emphasize when teaching buspirone?

It takes weeks to work and should not be used PRN.

Which antidepressant classes are drugs of choice for chronic anxiety disorders in the lecture?

SSRIs and SNRIs.

Why are SSRIs and SNRIs not appropriate for PRN anxiety treatment?

They have a slow onset of therapeutic response.

Do SSRIs and SNRIs have abuse potential according to the lecture?

No abuse potential.

What treatment can improve antidepressant effectiveness for anxiety?

Psychotherapy or cognitive behavioral therapy (CBT).

How long is antidepressant therapy for chronic anxiety typically continued?

Prolonged treatment, similar to treatment of depression.

What can happen if SSRIs or SNRIs are abruptly discontinued?

Withdrawal symptoms.

Which type of medication is most appropriate for immediate stabilization of severe anxiety in the lecture's example?

A fast-acting benzodiazepine such as alprazolam, rather than buspirone or an antidepressant.

How do buspirone and benzodiazepines differ in onset?

Benzodiazepines act quickly; buspirone takes weeks.

How do ramelteon and triazolam differ in dependence potential?

Ramelteon is not habit forming; triazolam can cause dependence and withdrawal.

How do zolpidem and ramelteon differ in controlled-substance status?

Zolpidem is Schedule IV; ramelteon is not controlled.

Which medications in the lecture are associated with complex sleep-related behaviors?

Triazolam and zolpidem; ramelteon also lists possible sleep-driving.

Which sleep medication can increase prolactin levels?

Ramelteon.