Anti-anxiety Agents, Sedatives and Hypnotics

Question 1

Anxiolytics and Sedative Hypnotics

Answer 1

CNS depressants that have similar effects
- Produces drowsiness, sedation, possibility of respiratory depression

• Anxiolytics promote relaxation, decreased anxiety
• Sedatives/Hypnotics promote relaxation and induce sleep
• Anxiolytics used for sleeping are referred to as sedative-hypnotics
• The difference DEPENDS ON THE DOSE
• Some of these drugs, due to their CNS depressant effects, are also used as anticonvulsants and anesthetics
• Benzodiazepines are the main drug used to treat anxiety and insomnia
• Antidepressants are increasingly being used
• Barbiturates were used in the past, but due to nasty side effects and high levels of
  dependence they are no longer used

Question 2

Anxiolytics promote

Answer 2

relaxation, decreased anxiety

Question 3

Sedatives/Hypnotics promote

Answer 3

relaxation and induce sleep

Question 4

Anxiolytics used for sleeping are referred to as

Answer 4

sedative-hypnotics

Question 5

REM sleep is the MOST important for _________________ & Non REM is _______________

Answer 5

mental and emotional restoration

&

physically restorative

Question 6

true or false: there is a wide safety margin between therapeutic and toxic doses of benzodiazepines

Answer 6

true

Question 7

true or false: easy to overdose on benzodiazepines

Answer 7

Overdose not often fatal, unless combined with another CNS depressant

Question 8

Benzodiazepine

Answer 8

CNS depressant used for sedation, reduce anxiety, muscle skeletal relaxation,
anticonvulsant effects

• It does NOT SUPPRESS REM sleep

Question 9

Benzodiazepines indications

Answer 9

• Anti-anxiety
• Hypnotic
• Anticonvulsant
• Pre-op sedation (pre-surgery)
• Prevention of agitation and delirium tremens (DTs) in acute alcohol withdrawal
• Anxiety/agitation associated with depression, psychosis or mania
• Often given concurrently with anti-depressants, anti-psychotics and mood stabilizers

Question 10

Half Life of Benzodiazepines: Diazepam

Flurazepam, and Chlordiazepoxide

Answer 10

form active metabolites that have long acting half lives (greater than 24 hours) and tend to accumulate, especially in older adults or those with impaired liver function

Diazepam: Valium = 20-100 hours

Question 11

Half Life of Benzodiazepines: Alprazolam, Lorazepam, Clonazepam, Oxazepam, and Temazepam

Answer 11

immediate acting half lives of 6-24 hours which do not have active metabolites and generally do not accumulate

Lorazepam: Ativan = 10-20 hours

Question 12

Half Life of Benzodiazepines: Midazolam and Triazolam

Answer 12

short acting half lives of less than 6 hours

Question 13

why are half lives of benzodiazepines important

Answer 13

• The drugs with the shorter half life are best when a rapid response is needed and tend to be preferred as the adverse effects do not accumulate
• Benzos take 5-7 days to reach therapeutic effect, and side effects also tend to manifest at the 2-3 day mark
• These effects accumulate with chronic use and persist several days after the medication is
  discontinued

Question 14

Diazepam (Valium) used effectively in tx of?
usual dose?
max dose?

Answer 14

GAD, as a muscle relaxant, and alcohol withdrawal, IV sedation, seizures
- Usual dose is 5-60mg PO/IV, divided
- Maximum dose of 60mg per 24 hours

Question 15

Lorazepam (Ativan) used effectively to treat?
ususal dose? Max Dose?

Answer 15

GAD, agitation, alcohol withdrawal
- Usual dose is 1-6mg SL/IV, divided
- Maximum dose of 10mg per 24 hours

Question 16

Midazolam (Versed)
usual dose?
Max dose?

Answer 16

IV only for anesthesia and sedation.
IM for severe agitation
especially in ER
- Dosage of 0.07-0.08mg per kg
- Maximum dose of 5mg per 24 hours

Question 17

Clonazepam (Rivotril) used for?
usual dose?
max dose?

Answer 17

seizure disorder as an adjunct, panic disorder, agitation/anxiety, mood stabilizer
- Dosage of 0.5-2mg, divided
- Longer half life than Ativan, takes longer to have an effect and lasts longer
- Less dependency issues tha Ativan
- Maximum 20mg in 24 hours for seizure treatment, maximum is way lower for
anxiety

Question 18

Oxazepam (Serax) used for?
usual dose?
max dose?

Answer 18

Anxiety, alcohol withdrawal, still used for insomnia
- Dosage of 15-30mg, often divided
- Maximum 120mg per 24 hours

Question 19

Advantages of Benzodiazepines

Answer 19

• Therapeutic doses have little effect on consciousness
• They are relatively safe
• There are few interactions with many other drugs (except other CNS depressants)

Question 20

Disadvantages of Benzodiazepines

Answer 20

• Potentially habit forming and addictive
• Limit to TWO WEEKS of use
• DO NOT continue use after FOUR CONTINUOUS WEEKS
• Some have long half lives and can accumulate
• Memory and intellectual impairment
• Hangover
• Reduced motor coordination (driving hazard)
• Paradoxical confusion, agitation, insomnia especially with pediatric and older adult
  clients

Question 21

Adverse Effects of Benzodiazepines (CNS)

Answer 21

CNS effects:
- Diplopia (double vision)
- Tremors
- Ataxia (impaired coordination)
- Drowsiness
- Headache
- Nausea
- Vomiting

Question 22

Adverse Effects of Benzodiazepines (Autonomic effects)

Answer 22

hanges in libido, constipation, incontinence, urinary retention, hypotension, and tachycardia, nasal congestion
- Accumulations effects: confusion, hypoactivity, intellectual impairment

Question 23

Benzodiazepine Withdrawal
- Mild symptoms

Answer 23

occur with 6-12 weeks use. Includes:
- Anxiety, panic, hand tremors, sweating, restlessness, insomnia, weakness, aches and pains, blurred vision, palpitations

Question 24

Benzodiazepine Withdrawal
- Severe symptoms

Answer 24

occur when regularly taken for 4 or more months. Includes: - Irritability, agitation, nervousness, diarrhea, vomiting, sweating
- Withdrawal symptoms are caused by the abrupt removal of benzo molecules from their receptor site resulting in an acute decrease of GABA neurotransmission
- Symptoms may occur within 24 hours with short acting, 4-5 days with long acting
- To prevent withdrawal, taper the drug by 10-25% every 1-2 weeks over 4-16 weeks

Question 25

Benzodiazepine Toxicity & antidote

Answer 25

- Excessive sedation - Respiratory depression - Coma - Treatment is flumazenil (Anexate) - It is an antagonist which competes for the benzo receptors and reverses toxicity**

Question 26

Non-Benzodiazepines sedative-hypnotics

Answer 26

Chloral hydrate (Noctec) and zoplicone (Imovane)

Question 27

Non-Benzodiazepines: Chloral hydrate

Answer 27

- Oldest sedative hypnotic - Relatively safe, inexpensive and effective - Does not suppress REM sleep - Tolerance develops after about 2 weeks - Can be abused and cause physical dependence - Also used to reduce pre-operative and diagnostic testing anxiety - Dosage of 500-2000mg daily

Question 28

Non-Benzodiazepines: Zopiclone

Answer 28

- Differs structurally from benzo’s but has similar effects, binds with benzo receptors - Use for symptomatic relief of transient and short term (7-10 days) insomnia, characterized by difficulty falling and remaining asleep, and/or early morning awakenings - Delayed onset of REM sleep, DOES NOT reduce the total duration of REM periods - Metabolized via the cytochrome P450 system (the enzymes essential for the metabolism; over 60 enzymes included and 6 of these enzymes metabolize all of medications) - Several drug interactions (erythromycin can increase plasma levels. Carbamazepine and phenytoin can decrease plasma levels) - Dosage is usually 7.5mg per 24 hours (half this dose in elderly patients)

Question 29

Zopiclone considerations

Answer 29

- Should not be prescribed in quantities longer than one month - Risk of dependence - OD can be fatal - Rebound insomnia common - Taper slowly - Less side effects than other sedative hypnotics

Question 30

Non-Benzodiazepines: Antihistamines (OTC)

Answer 30

- Antihistamine with sedative and anti-emetic properties is sometimes used to treat anxiety - Primarily hydroxyzine (Atarax), but also diphenhydramine (Benedryl) and dimenhydrinate (Gravol) - It is used for anxiety, preoperative sedation, nausea, and vomiting associated with surgery or motion sickness, pruritus and urticaria associated with allergic dermatoses

Question 31

Nursing Process: Patient Teaching

Answer 31

- Use with caution in the elderly and pediatric populations - Baseline VS (including orthostatic BP) - Hypnotics: 15-30 minutes pre bedtime for maximum effectiveness - Avoid alcohol and other CNS depressants - Avoid grapefruit juice

Question 32

how soon do symptoms of benzodiazepine withdrawal occur - short acting - long acting

Answer 32

Symptoms may occur within 24 hours with short acting, 4-5 days with long acting - To prevent withdrawal, taper the drug by 10-25% every 1-2 weeks over 4-16 weeks