Drug Therapy for Insomnia & Anxiety

Anxiolytics, Sedatives , Hypnotics

• Anxiolytics, sedatives: promote relaxation​

• Hypnotics: produce sleep​

• All CNS depressants with similar effects​

• Used (among other medications) to treat​

  • Anxiety​

  • Insomnia

Situational Anxiety

• Normal response to a stressful situation

• Can be helpful if it motivates towards constructive problem solving

• Examples – job interview, exams

anxiety disorders

• Severe, prolonged anxiety

• Affects activities of daily life

• Excessive/Exaggerated response

Insomnia

• Prolonged difficulty in going and/or staying asleep

• Etiology:

  • Medical

  • Neurological

  • Psychiatric

  • Environmental

  • Medications

Herbal Insomnia Tx - Kava

• Thought to increase GABA

• Adverse Rxn: ↓platelets, lymphocytes, SOB

• D-D: Benzodiazepines, antiplatelet drugs, levodopa

• Cautions: renal disease, thrombocytopenia, neutropenia ‘

• Not used in pregnancy/lactating

Herbal Insomnia Tx - Melatonin

• Influences sleep-wake cycles

• Caution: hepatic disease

• Adverse Rxn: confusion, headache, tachycardia

Herbal Insomnia Tx - Valerian

• Thought to increase GABA

• Adverse Rxn: blurred vision, cardiac issues,

• Caution: hepatic disease, pregnancy

Benzodiazepines (BZD) useful for..

• Short-term treatment

• Anxiety disorders/insomnia

• Relatively safe

• Schedule IV

• HUGE take away should NOT be abruptly stopped

• Short, immediate & long acting

Benzodiazepine onset / half life

• Medications with half-lives longer than 24 hours form active metabolites​

  • Tend to accumulate in older adults and those with impaired liver function.​

  • Therapeutic (and adverse) effects are more likely to occur after 2 to 3 days of therapy than initially.

short acting benzos that have a half life of less than 5 hours

• alprazolam

• triazolam

• oxazepam

• midazolam

• think “ATOM”

intermediate acting benzos that have a half life from 5-24 hrs

• temazepam

• lorazepam

• clonazepam

• think “TLC”

long acting benzos with a half life exceeding 24 hrs

• clorazepate, chlordiazepoxide

• diazepam

• flurazepam

• think “Clor DF”

benzos not metabolized in the liver and safe for liver failure pts

• oxazepam

• temazepam

• lorazepam

• think “Out The Liver”

PROTOTYPE: Diazepam (Valium) MOA / pharm

• Enhances the inhibitory effect of GABA

• LONG ½ life (20-100 hours)

• Can take up to 5-7 days

• Pharm: po, IV, IM, liver excretion

Diazepam (Valium) indications

Antianxiety, hypnotic & seizures

Diazepam (Valium) BBW

dont mix benzos and alcohol

Diazepam (Valium) contraindications

• Pulmonary conditions, liver disease, hx of ETOH/drug abuse in the past

• Pregnancy, glaucoma

• CAUTIONS: older patient, renal, hepatic

Diazepam (Valium) nursing considerations

• Observe for dependence, withdrawal

  • Mild withdrawal occurs in ½ of patients taking the medication for 6-12 weeks

  • Severe more likely if taken in high doses > 4 months then DC

• These medications are tapered!

Benzo Toxicity Tx

• NEVER assume

• Antidote: Flumazenil

  • IV over 15 seconds

  • Carries it own set of risks

Benzo Toxicity Clinical Signs

• respiratory depression

• inability to talk

• hallucinations

• blurry vision / nystagmus

• low blood pressure

• dizziness

• confusion

• drowsiness

• weakness

Other Common Benzo - Lorazepam (Ativan)

• Anxiety disorders, seizures (initial)

• Slow onset- intermediate to prolonged action

• IV, po, IM

Other Common Benzo - Alprazolam (Xanax)

Quicker onset, used orally to reduce anxiety & panic disorders

Other Common Benzo - Chlordiazepoxide (Librium)

• Most commonly used in alcohol withdrawal

• IM, po

• NO grapefruit juice

Other Common Benzo - Midazolam (Versed)

• Short acting, used preop, before procedures

• IM, IV, po

• BBW: Profound respiratory depression

• If given for pre procedure: considered moderate sedation, must have someone who can protect the airway, must be monitored

Other Common Benzo - Temazepam (Restoril)

Sleep aid, used in the elderly, those with liver disease

Other Common Benzo - Triazolam (Halcion)

• Rapid onset, should take while in bed

• Liver disease is a contraindication

Non Benzo Sedative Hypnotics - Eszopiclone (Lunesta)

• Approved for long-term use

• ½ life 6 hours, ↑sleep time and onset of sleep

• Should not be used in elderly

• Taken on an empty stomach, fast onset so at bedtime

Non Benzo Sedative Hypnotics - Ramelteon (Rozarem)

• Used to assist with onset of sleep

• Short ½ life

Non Benzo Sedative Hypnotics - Zaleplon (Sonata)

• Short term use

• Rapid onset of sleep, ½ life 1 hour

Non Benzo Sedative Hypnotics - Zolpidem (Ambien)

• Short term use of insomnia

• ½ life 2.5 hours

Postpartum depression

• Unipolar

• Treated with psychotherapy and antidepressants

Dysthymia depression

• Chronically depressed mood, plus 2 additional symptoms X 2 years

• Purgatory- no mild and not major depression

General Characteristics of Antidepressants

• Effective in depression

  • Differ in AR

• Take 2-4 weeks

• Given orally

  • Liver metabolism, interactions

• MOA:

  • Changes in the receptors

General Characteristics of Antidepressants indications

• Depression

• Anxiety

• Panic Disorder

• Fibromyalgia

• Neuralgia

General Characteristics of Antidepressants contraindications

• Acute Schizophrenia

• Mixed mania & depression

• Suicidal tendencies

• Severe renal, hepatic, CV disease

• Narrow angle glaucoma

• Seizures

Tricyclic Antidepressants (TCA) - Impramine

• ½ life 8-21 hr, liver

• MOC: blocks norepi, serotonin and ACh.

• Uses: 2nd line treatment

• NARROW therapeutic index (2-3)

Tricyclic Antidepressants (TCA) - Impramine adverse rxn

Anti-ACh, sedation, orthostatic BP, weight gain, cardiac dysrhythmias.

Tricyclic Antidepressants (TCA) - Impramine BBW

suicidal thoughts/ideation

Selective Serotonin Reuptake Inhibitors (SSRI) - Fluoxetine (Prozac)

• Long ½ life

• Uses: depression, OCD, bulimia, premenstrual dysphoric disorder

• Safer in older adults

Selective Serotonin Reuptake Inhibitors (SSRI) - Fluoxetine (Prozac) adverse rxn

GI, sexual, CNS stimulation

Selective Serotonin Reuptake Inhibitors (SSRI) - Fluoxetine (Prozac) caution

renal caution

Selective Serotonin Reuptake Inhibitors (SSRI) - Fluoxetine (Prozac) BBW

• suicidal ideation children/adolescents/young adults

• Serotonin Syndrome is a medical emergency

Serotonin-Norepinephrine Reuptake Inhibitors (SNRI) Venlafaxine (Effexor)

• Uses: depression, anxiety disorders

• Safe in older adults, NO use in children

• Take with food

Serotonin-Norepinephrine Reuptake Inhibitors (SNRI) Venlafaxine (Effexor) BBW

suicidal ideation

Serotonin-Norepinephrine Reuptake Inhibitors (SNRI) Venlafaxine (Effexor) caution / adverse rxn

• Caution: renal and hepatic

• Adverse Rxn: CNS, GI, GU, CV

Serotonin-Norepinephrine Reuptake Inhibitors (SNRI) other meds

• Desvenlafaxine (Pristiq)

• Duloxetine (Cymbalta)

  • Neuropathic pain

Monoamine Oxidase Inhibitors (MOI) Phenelzine (Nardil)

• 3rd line

• Mood elevation: 2-8 weeks

• Caution in older adults, NO use in children

• HUGE risk of hypertensive crisis if taken with tyramine-foods (wine, aged cheese, processed meats, beer, dried fruit, liver, sauerkraut, sourdough, soy products, yeast)

  • TREATMENT: phentolamine

Atypical Antidepressants Bupropion (Wellbutrin)

• Depression, seasonal affective disorder, smoking cessation

• Adverse Rxns: higher doses

  • Seizures, CNS effects

• BBW: increased risk of suicide, no longer used for smoking cessation

Atypical Antidepressants Mirtazapine (Remeron)

• Decreases agitation, anxiety, insomnia, migraine headaches

• Must monitor for agranulocytosis

Atypical Antidepressants Trazodone

• Used more for sleep and sedation

• Given with food

• Adverse Rxn: sedation, dizziness, edema, priapism

• Often given in tandem with other meds

Bipolar Disorder

• Characteristics alternating moods between depression or overexcitement

• Bipolar I

  • M:F, major depression with mania

• Bipolar II

  • F>M, major depression with hypomania

• There is a genetic link

• Onset 20-25 years

• Treatment:

  • Mood stabilizers & some may require neuromodulation therapy

Mood Stabilizers Lithium

• MOA: unknown

• Route: oral, effect 7-10 days

• Renal/cardiac & thyroid must be ok

• Contraindications: Pregnancy D (there is potential harm to the unborn baby if the medication is used during pregnancy, but in some cases, the benefit of using the medication may outweigh the risks)

• Narrow therapeutic index ( .5-1.2)

• Adverse Rxn: metallic taste, polyuria, polydipsia, muscle weakness, tremors, diarrhea

Aripiprazole (Abilify)

• Monotherapy for mixed bipolar

• Headache NV sedation

• BBW: compulsive/uncontrollable urges

• Children 8-17

Olanzapine (ZyPREXA)

• Monotherapy

• Dose related

• BBW: DRESS (Drug Reaction with Eosinophilia and Systemic Symptoms. It can cause rash, fever, and organ damage, and it needs immediate medical attention.)

Quetiapine (Seroquel)

• Bipolar & Schizophrenia

• Given on an empty stomach

Risperidone(Risperdal)

• Atypical antipsychotic

• IM or po

• Adolescent 10-17 Type I

• BBW: ↑ mortality in elderly with dementia related psychosis

Ziprasidone (Geodon)

Atypical antipsychotic

Psychosis

• Severe mental disorder

• Emotional

• Behavior

• Hallucinations

  • Schizophrenia- auditory

  • Delirium: tactile or visual

  • Dementia: visual

• Paranoia

• Can be acute or chronic

Schizophrenia

• Thought to be related to intrauterine event, strong genetic link

• M:F

• Clinical Domains

  • Delusions

  • Hallucinations

  • Disorganized speech

  • Grossly disorganized motor

Antipsychotics

• Reduce psychotic symptoms

• Bind to dopamine

• Can be given orally, IM, some are given as a long-acting IM

• Children present with more severe symptoms

• Classified by generation & nonphenothiazines or phenothiazines

1st Generation Antipsychotics Phenothiazine - Chlorpromazine

• Indication: excessive anxiety

• Route: po IM

• Pharm: liver, duration 4-6 hours

• Caution: renal/liver, older

1st Generation Antipsychotics Phenothiazine - Chlorpromazine adverse rxn

• Tardive dyskinesia - involves involuntary movements, such as repetitive facial grimacing, tongue protrusion, or rapid blinking

• Akathisia - feelings of restlessness and an inability to sit still

• Dystonia - involuntary muscle contractions, leading to repetitive or twisting movements and abnormal postures

• CV, Heme, drug-induced Parkinsonism

• Neuroleptic malignant syndrome

1st Generation Antipsychotics Phenothiazine - Chlorpromazine drug to drug

multiple, NO kava

1st Generation Antipsychotics Phenothiazine - Chlorpromazine nursing considerations

• Need ECG prior to administration

• Usually given with benztropine (Cogentin)

• Must keep patients in a safe environment

• Assess for fluid deficit & urinary retention – strict I&O

• Monitor CBC

• Monitor LOC

1st Generation Nonphenothiazine Haloperidol (Haldol)

• Uses: excessive anxiety

• Route: po, IM duration 4-8 hours

• Pharm: liver

• Adverse Rxn: same as Chlorpromazine

• cautions: renal, liver

1st Generation Nonphenothiazine Haloperidol (Haldol) drug to drug

↑ETOH, CNS depressants, antidepressants, antihistamines, NSAIDS, ACE inhibitors, lithium ↓Antacids, Rifampin

1st Generation Nonphenothiazine Haloperidol (Haldol) BBW

none in older adults with dementia induced psychosis; EPS (extrapyramidal symptoms. These symptoms may include muscle stiffness, tremors, and abnormal movements.) and withdrawal in infants

1st Generation Nonphenothiazine Haloperidol (Haldol) nursing consideration

• Given with full glass of water

• IM (no more than 3 ml), deep, large muscle, must be stored in a light protected vial

• Assess for sedation, tachycardia, onset of neuroleptic malignant syndrome (high fever, muscle stiffness, confusion, and other symptoms like sweating and fast heart rate. NMS can be life-threatening and requires immediate medical attention.)

2nd Generation Atypical Antipsychotics Clozapine (Clozaril)

• Route oral

• MOA: unknown

• Pharm: ½ life 12 hours, liver

• Caution: hepatic

2nd Generation Atypical Antipsychotics Clozapine (Clozaril) BBW

• risk of death in older patients w/dementia

• Risk of seizures in ↑doses

• Agranulocytosis, hyperglycemia

2nd Generation Atypical Antipsychotics Clozapine (Clozaril) contraindications

CNS depression, seizures, CV disease, acute narrow-angle glaucoma, uncontrolled DM, hx of agranulocytosis

2nd Generation Atypical Antipsychotics Clozapine (Clozaril) adverse rxns

• CV: Hypotension, tachycardia, myocarditis

• GI: constipation

• Heme: ↓neutrophils

• DM: weight gain & hyperglycemia

2nd Generation Atypical Antipsychotics Clozapine (Clozaril) nursing considerations

• Baseline CBC, blood sugar

• Must be tapered.

Olanzapine (ZyPREXA)

• Schizophrenia, mixed bipolar

• Adverse Rxn: leukopenia/neutropenia, EPS (extrapyramidal symptoms. These symptoms may include muscle stiffness, tremors, and abnormal movements.) , drowsiness, elevated LFTs

• D-D: Multiple, foods grilled meat, cabbage, broccoli, St John’s Wort

Lurasidone (Latuda)

• Schizophrenia/bipolar

• BBW: older adults w/dementia

• Adverse Rxn: same as Olanzapine

• D-D: ketoconazole, rifampin