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Pharmacology > Anxiety > Flashcards

Flashcards in Anxiety Deck (53):
1

Anxiety

an uncomfortable feeling of vague fear or apprehension accomplished by characteristic physical sensations

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Drug induced anxiety

caffeine, methylphenidate, cocaine, nicotine, albuterol, stimulants, methamphetamine, ephedrine, pseudoephedrine, levodopa, metoclopramide, ACh, SSRIs

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Psychiatric conditions that induce anxiety

mood disorders, substance abuse, withdrawal, eating disorders, personality disorders

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Medical conditions that induce anxiety

angina, arrhythmias, anemia, electrolyte imbalances, hypoglycemia, COPD, Asthma, hypo/hyperthyroidism

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Drug withdrawal anxiety

barbiturates, benzo, narcs, EtOH, sedatives

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Types of anxiety

situational, general, panic disorder, OCD, PTSD, social phobia

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Generalized anxiety disorder

unrealistic or excessive anxiety about 2 or more life events for majority of days for more than 6 months, 2:3 m:f, onset late adolescence

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Panic disorder

1-4% lifetime prevalence, women 2-3x more likely, onset late adolescence-30s, chronic but wax and wanes, recurrent and unexpected attacks, develop and peak withing 10 mins, 20-30 mins, agorophobia common

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Obsessions

persistent ideas, thoughts, images or impulses that cause anxiety, pts attempt to ignore or suppress, pt often acknowledge the thoughts are product of mind; fear of germs, was an act performed

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Compulsions

repetitive, intentional and purposeful behaviors in response to obsessions, sense of anxiety if not allowed to perform; washing hands, ordering, counting

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PTSD

reaction of intense fear, helplessness, horror after exposure to traumatic event, persistent re-experience of the event, nightmares, flashbacks, avoidance of stimuli, acute 3 months, M:F 1:2, onset withing 3 months of event

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Social phobia

fear of social or performance situations, exposure provokes anxiety, pt recognizes as unreasonable, onset teenage years, usually continuous

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Locus coeruleus

brainstem nucleus containing 70% of noradrenergic neurons in the brain; implicated in GAD, panic, PTSD, OCD, social anxiety

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stimulation of the LC results in

a fear response and sx of anxiety

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GABA

inhibitory neurotransmitter for other neurotransmitters, GAD and panic

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Benzos

agonist that binds to the BZD receptor and enhances GABA receptor binding, GAD and panic

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Serotonin

neurons originate mostly in the raphe nucleus of brainstem and project into the cerebral cortex, limbic, and hypothalamus, GAD, panic, OCD, social anxiety

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Non pharm approaches for anxiety

psychotherapy, relaxation, situational avoidance, exss

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Pharm options

short term- BZDs, long term- buspirone, SSRIs, SNRIs, TCAs, resistant anxiety- BB, mood stabilizers

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Benzos anxiety and panic

Alprazolam (Xanax), Lorazepam (ativan), Clonazepam (klonopin), Diazepam (Valium), chlordiazepoxide (Librium), Cloazepate (Tranxene), Flurazepam (Dalmane), Oxazepam (Serax), Midazolam (Versed)

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Benzo sleep aids

temazepam (Restoril), Estazolam (Prosom), triazolam (Halcion)

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Benzo MOA

binds to benzodiazepine receptors; enhances the inhibitory effects of GABA

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Prodrugs Benzo

diazepam, chlordiazepoxide, clorazepate- T1/2 of metabolite, more than 100 hrs w/ chronic use, very long acting, avoid in elderly

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Active parent drugs Benzo

lorazepam, oxazepam, alprazolam, clonazepam, no active metabolites, short T 1/2 (except clonazepam, long T1/2)

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Benzo lipophilicity

higher fat solubility improves passage into CNS, faster onset

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Disadvantages of Benzos

tolerance, dependence, addiction, need for taper, cog impairment, only symptomatic tx

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Dosage of alprazolam (Xanax)

.5-2 mg po.iv.im 6-8 hrs, max 10 mg daily

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dosage of Clonazepam (Klonopin)

.25-1 mg po BID-TID

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Dosage of Diazepam (valium)

2-10 mg po TID-QID, max 30 mg/8hrs

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Dosage lorazepam (ativan)

.5-2mg PO/IM/IV TID-QID, max 10 mg/day

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Benzodiazpines ADRs

CNS depression, resp depression, impaired memory, impaired cog, dysphagia, tolerance/ dependence

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BZD tolerance and dependence

does not usually occur to anxiolytic effect, may occur if higher daily doses for several weeks, smaller daily doses over several months, fast onset agent being utilized, avoid by using a slower onset drug, longer acting drug

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Drug interactions of BZD

other CNS depressants, drugs that compete with or inhibit metabolism, drugs that decrease absorption, grapefruit juice

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Discontinuation of therapy of BZD

must taper slowly, example 5-10% of dose every 2 weeks, may take months to successfully and safely taper to discontinue therapy

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Prevention of withdrawal of BZD

taper doses by switching to an agent w/ a shorter T1/2 or taper a certain percentage of daily dose/week until weaned off, taper over 4-12 weeks, monitor for relapse or rebound anxiety, monitor for withdrawal

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Withdrawal symptoms

irritability, muscle aches, nausea, hyperreflexia, could lead to seizures, coma or death if untreated

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Antidote for overdose of BZD

flumazenil (Romazecon), use is controversal, seizures

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Buspirone (BuSpar) MOA

mid brain modulator, has effects on norepinephrine, serotonin, dopamine, ACh, and GABA systems

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Clinical use of Buspirone (BuSpar)

GAD, social anxiety, OCD, PTSD (adjunct only)

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Buspirone (BiSpar) advantages

non-sedating, no interactions w/ CNS depressants, including EtOH, rare side effects, little or no effect on sexual function, no dependence

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Buspirone (BuSpar)

pts, often do not feel it is effective due to slow onset and lack of buzz, may take 2-6 weeks to get full effect, multiple daily dosing, chronic med

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SSRI dosing for anxiety

often higher than seen w/ depression, still start low and titrate

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Clinical use of SSRI

depression, OCD, panic, social anxiety, PTSD, more chronic

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Clomipramine (Anafranil)

TCA, used for OCD, not well tolerated (ACh side effects, 8-12 week for benefit), combo w/ SSRIs, benefit in chronic pain, avoid in heart disease, suicidal pts

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SNRI agents

Vanlafaxine, duloxetine

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SNRIs

avoid abrupt d/c, up to 4-6 weeks for benefit, titrate to full dose, benfit for chronic pain, initiate slowly

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SNRI uses

GAD, OCD, panic (if chronic), social anxiety

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Beta blockers used for

social anxiety (PRN), PTSD

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BB

reduces peripheral sx of anxiety, Propranolol (Inderal), non-selective BB, blunts norepi and epi, can cause drowsiness, fatigue, hypotension, N/V/D

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BB propranolol dosing

10 mg PO prior to event

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Mood stabilizers

augmenting agents following tx failure w/ 1st line agents, may reduce intrusive thoughts and sx of aggression, irritability, and hyperarousal in PTSD

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Mood stabilizing agents

Carbamazepine, divalproic acid, lamotrigine, gabapentin, topiramate, pregabalin, atypical antipsychotics

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Duration of tx of mood stabilizing agents

4-6 weeks, except BZD, anxiety disorders are often life-long, may require chronic tx, decision to D/C or taper must be individualized