S3 Pharm Exam 1: Anxiety Slideshow

Anti-anxiety and sedative-hypnotic drugs are

central nervous system (CNS) depressants that have similar effects

Anxiolytics

anti-anxiety drugs

Sedatives

Promote relaxation

Hypnotics

Produce sleep

Anxiolytics, sedatives and hypnotics have varying degrees of

CNS depression; therefore may also be used as anticonvulsants and anesthetics

Anxiety

Response to stress

Elevated or persistent anxiety can lead to

behavior changes and/or impaired function

There are several different classifications of anxiety disorders

Generalized Anxiety Disorder

Obsessive-Compulsive Disorder

Panic Disorder

Agoraphobia

Posttraumatic Stress Disorder

Social Anxiety Disorder

Anxiety s/s

restlessness; muscle tension; avoidance of stressful activities or events; increased time and effort required to prepare for stressful activities or events; procrastination in decision making; sleep disturbance; difficulty performing or speaking in front of others or participating in social situations; compulsive or obsessive behaviors; excessive levels of anxiety and concern

anxiety physical manifestations

palpitations; shortness of breath; choking or smothering sensation; chest pain; nausea; feelings of depersonalization; fear of dying or insanity; chills or hot flashes

anxiety medications

benzodiazepines; SSRIs; atypical anxiolytic/nonbarbiturate anxiolytic

Benzodiazepine

sedative hypnotic anxiolytics

benzodiazepines can also be used as a

premedication for medical/dental procedures to reduce anxiety

benzodiazepines can also treat

agitation, seizures, muscle spasms, and alcohol withdrawal

benzodiazepines have potential for

addiction, tolerance, and dependance

benzodiazepines are often used

short-term; can see agitation with withdrawal

SSRI antidepressants

selective serotonin reuptake inhibitors

SSRIs

first line therapy for treatment of anxiety and depression disorders; fewer side effects

Atypical anxiolytic/nonbarbiturate anxiolytic

less potential for dependance/abuse; less sedative effect

Benzodiazepine prototype

Alprazolam

Benzodiazepine suffixes

"pam"; "lam"; "oxide"

Benzodiazepines expected action

enhance effects of GABA (gamma-aminobutyric acid) in the CNS

Benzodiazepines therapeutic actions

reduce anxiety in GAD and panic disorder; alcohol withdrawal; seizures; reduce anxiety pre-op

Benzodiazepines complications

CNS depression; decreased alertness; amnesia; addiction, dependence and withdrawal

Benzodiazepines with alcohol or other CNS depressants

can cause respiratory depression

Benzodiazepine withdrawal can cause

agitation; anxiety; insomnia

Benzodiazepines must be discontinued by

tapering the dose

Benzodiazepines contraindications/precautions

Pregnancy Cat D; Schedule IV controlled substance; avoid with sleep apnea, respiratory depression or glaucoma

Benzodiazepines interactions/precautions

avoid alcohol; avoid operating machinery; caution elderly due increased fall risk; no grapefruit

Benzodiazepine nursing administration

take with food; give at night; do not chew/crush sustained-release tablets; taper when discontinued; use carefully in elderly

Benzodiazepine withdrawal symptoms

agitation; irritability; sleep disturbances; anxiety; panic attacks; tremors; headache

Alprazolam (Xanax)

caution elderly because they are more sensitive; immediate-release may be given sublingually if patient cannot swallow

Chlordiazepoxide (Librium)

commonly used to control withdrawal symptoms from acute alcoholism

Chlordiazepoxide cannot be given with

grapefruit juice, St. John's wort, kava or valerian

Grapefruit + chlordiazepoxide

decreases drug metabolism → toxicity

St. John's wort, kava or valerian + chlordiazepoxide

increase CNS depression

Lorazepam (Ativan)

benzodiazepine of first choice; provides rapid tranquilization for agitation

Lorazepam onset/duration

slow onset 5-20 min due to delayed brain penetration; intermediate-long duration

Lorazepam accumulation/elimination

little accumulation; elimination not significantly reduced by hepatic or renal disease

Benzodiazepines in elderly

always use carefully

Benzodiazepine antidote

Flumazenil

Atypical anxiolytic/nonbarbiturate prototype

Buspirone

Buspirone action

exact action uncertain; binds to serotonin and dopamine receptors

Buspirone advantage

less likely to cause dependency

Buspirone disadvantage

takes 2-4 weeks for effects

Buspirone administration

given on a scheduled basis; NOT PRN

Buspirone contraindications/precautions

Pregnancy Cat B; no pregnancy/breastfeeding; caution with liver/renal dysfunction; do not give with MAOIs

Buspirone + MAOI

hypertensive crisis

Buspirone interaction

grapefruit juice

Buspirone education

take with food; effects take 2-4 weeks; watch for suicidal ideation; not PRN

SSRI prototype for anxiety

Paroxetine

Paroxetine expected action

selectively inhibits serotonin reuptake

Paroxetine/SSRI adverse effects

insomnia; headache; sexual dysfunction; weight changes; GI bleeding; hyponatremia; bruxism

SSRI hyponatremia risk

especially with diuretic use

Serotonin syndrome

medical emergency caused by excessive serotonin activity

Serotonin syndrome symptoms

agitation; confusion; labile BP; nausea/vomiting; diarrhea; can lead to death

Serotonin syndrome onset

s/s usually occur 2-72 hr after medication initiation

Serotonin syndrome SHIVERS

Shivering; Hyperreflexia/myoclonus; Increased temperature; Vital-sign instability; Encephalopathy/altered LOC; Restlessness; Sweating

SSRI discontinuation

withdrawal potential; taper slowly

SSRI black box warning

can increase risk of suicide

SSRI contraindications/precautions

Pregnancy Cat D; contraindicated with MAOIs or TCAs

SSRI + antiplatelet/anticoagulant

monitor for bleeding

SSRI nursing administration

administer with food; take in AM; monitor liver and renal function; taper slowly; monitor suicidal ideation

Anxiety herbal supplements

Kava; melatonin; valerian

Kava claimed uses

anxiety; depression; insomnia; asthma; pain; rheumatism; muscle spasms; seizures

Kava effects

suppresses emotional excitability; may produce mild euphoria; thought to interact with GABA receptors

Melatonin

natural hormone produced by pineal gland; influences sleep-wake cycle

Melatonin uses

jet lag; insomnia

Melatonin sleep action

thought to act similarly to benzodiazepines in inducing sleep

Valerian

mainly used as a sedative-hypnotic; thought to increase GABA in the brain

Valerian should NOT be used with

other sedatives; hypnotics; alcohol; CNS depressants

General anti-anxiety medication teaching

not a cure; avoid hazardous activities; avoid alcohol; consult before OTC/herbals; take as prescribed; dependence possible; may be taken evening/night

Depression

mood/affective disorder; widespread issue and major cause of disability; associated with impaired serotonin

Depressive disorders

MDD; SAD; persistent depressive disorder; PMDD; substance-induced depressive disorder

Depression s/s

anergia; anhedonia; anxiety; sluggishness or inability to relax/sit still; eating changes; constipation; sleep disturbances; decreased sexual interest

Anergia

lack of energy

Anhedonia

loss of interest or pleasure

Eating pattern in MDD

usually anorexia

Eating pattern in persistent depressive disorder and PMDD

may have increased intake

Bowel changes with depression

usually constipation

General antidepressant characteristics

all effective at relieving depression but differ in adverse effects; usually take 2-4 weeks for symptoms to improve; administered orally

Stopping most antidepressants

can cause antidepressant discontinuation syndrome

Antidepressant discontinuation syndrome

flu-like symptoms; insomnia; nausea; imbalance; sensory disturbances; hyperarousal

Antidepressants should be discontinued by

tapering gradually over 6-8 weeks unless a severe life-threatening condition requires otherwise

5 main antidepressant groups

SSRIs; SNRIs; atypical antidepressants; TCAs; MAOIs

SSRI depression treatment

first-line treatment for depression

SSRI prototype for depression

Fluoxetine

Fluoxetine expected action

selectively blocks serotonin reuptake in the synaptic gap

Fluoxetine onset

1-3 weeks or longer before pharmacologic effects begin

Fluoxetine/SSRI complications

sexual dysfunction; CNS stimulation; weight loss followed by weight gain

SSRI sexual dysfunction

common reason patients stop the medication

SSRI contraindications

Pregnancy Cat D/increased risk of birth defects; use carefully with liver or renal disease

SSRI interactions

TCAs; MAOIs; St. John's wort; lithium; NSAIDs; anticoagulants

SSRI + NSAIDs/anticoagulants

increased bleeding risk

SNRI

serotonin-norepinephrine reuptake inhibitor

SNRI prototype

Venlafaxine

SNRI endings listed in slideshow

"pram/pran"; "ine"

SNRIs expected action

block uptake of serotonin and norepinephrine

SNRIs therapeutic actions

major depression; GAD; panic disorder; nerve pain/neuropathy

SNRI contraindications/precautions

watch for suicidal thoughts