Anxiety and Insomnia Flashcards
(89 cards)
1
Q
What are first line meds for generalized anxiety disorder?
A
Duloxetine Escitalopram Paroxetine Sertraline Venlaxfaxine XR
2
Q
What is duloxetine also good in treating?
A
Neuropathy
Fibromyalgia
Other pain issues
3
Q
When should paroxetine be avoided?
A
Pregnant pts
4
Q
Initial dose of duloxetine- GAD
A
30 or 60 mg/day
5
Q
Initial dose of escitalopram- GAD
A
10 mg/day
6
Q
Initial dose of paroxetine- GAD
A
20 mg/day
7
Q
Initial dose of sertraline- GAD
A
50 mg/day
8
Q
Initial dose of venlafaxine- GAD
A
37.5 or 75 mg/day
9
Q
1st line tx in panic d/o
A
SSRIs are preferred
10
Q
When should BZDs be used in panic d/o?
A
When tx is urgent for pt to function and no hx of substance abuse
Short-term for 2-4 weeks until SSRI kicks in
11
Q
How long should therapy be continued if there is an adequate response to panic d/o?
A
12-24 mos
12
Q
Initial dose of citalopram for panic d/o
A
10 mg/day
13
Q
Initial dose of escitalopram for panic d/o
A
5 mg/day
14
Q
Initial dose of fluoxetine for panic d/o
A
5 mg/day
15
Q
Initial dose of paroxetine for panic d/o
A
10 mg/day
16
Q
Initial dose of sertraline for panic d/o
A
25 mg/day
17
Q
Tapering of benzos in panic d/o
A
If prescribed over an extended period of time, should be tapered over 2-4 mos at rates no higher than 10% of the dose per week
18
Q
When to evaluate med effectiveness in panic d/o
A
Acute phase- every 1-2 wks when starting a new med
Every 2-4 wks to adjust drug dosages
Every 2 mos after dose is stabilized and sx have decreased
Frequency of appointments should increase when drug is discontinued
19
Q
First line meds for social anxiety d/o
A
Generalized SSRIs SNRIs (venlafaxine) Nongeneralized BBs Benzos -Achieve effect within 30-60 mins -Used on PRN basis
20
Q
Initial duration of meds in social anxiety d/o
A
12 wks
21
Q
If good response, how long should the meds be continued for social anxiety d/o
A
12 mos
22
Q
First line meds for PTSD
A
SSRIs or venlafaxine
Acute: sertraline or paroxetine
Long-term: Sertraline (52 wks)
23
Q
Initial dose for citalopram in social anxiety d/o
A
20 mg/day
24
Q
Initial dose for escitalopram in social anxiety d/o
A
5 mg/day
25
Initial dose of paroxetine in social anxiety d/o
12.5 mg/day
26
Initial dose of sertraline in social anxiety d/o
25-50 mg/day
27
Initial dose of venlafaxine in social anxiety d/o
75 mg/day
28
What are the FDA approved SSRIs for PTSD?
Sertraline
| Paroxetine
29
How long of a trial do you give SSRIs in PTSD?
4-6 wks
30
Partial response to SSRIs in PTSD
Maximize dose or augment based on residual sx
31
Nonresponse to SSRIs in PTSD after 4-6 wks
Switch to second SSRI or venlafaxine
32
Still nonresponse after med switch in PTSD
Switch to third SSRI, venlafaxine, mirtazapine, or TCA
33
Respond to meds in PTSD
Continue for at least a year
34
What to give for residual sleep difficulties, nightmares- PTSD
Prazosin
35
What to give for residual anger- PTSD
Lamotrigine
36
What to give for residual intrusive thoughts- PTSD?
Risperidone, quetiapine
37
What to give for residual hypervigilance in PTSD
Risperidone, quetiapine
38
Initial dose of fluoxetine- PTSD
10 mg/day
39
Initial dose of paroxetine- PTSD
10-20 mg/day
40
Initial dose of sertraline- PTSD
25 mg/day
41
Initial dose of venlafaxine- PTSD
37.5 mg/day
42
Evaluation of PTSD therapeutic outcomes in acute phase
Pts should be seen weekly for 1 mo, then every other week
43
Evaluation of PTSD therapeutic outcomes in mos 3-6
Monthly
44
Evaluation of PTSD therapeutic outcomes in mos 6-12
Every 2 mos
45
What to monitor for in PTSD
Monitor for previously identified target sx and other sx (i.e., insomnia, SI, outbursts of anger, psychosis)
46
Remission in PTSD
70% or greater reduction in sx
47
First line tx for OCD
SSRIs
48
FDA approved drugs for OCD
```
Clomipramine
Fluoxetine
Fluvoxamine
Paroxetine
Sertraline
```
49
FDA approved drugs for OCD in children and adolescents
```
Clomipramine
Fluvoxamine
Sertraline
Paroxetine
Fluoxetine
```
50
Dosage monitoring in hepatic dz for OCD
```
Use with caution and in lower doses
Clomipramine
Fluoxetine
Sertraline
Paroxetine
Fluvoxamine
Citalopram
```
51
Renal dz and OCD
Dosage adjustment of sertraline, clomipramine not necessary
| Dosage of paroxetine should be reduced in pts with severe renal impairment and upward titration should occur more slowly
52
OCD and elderly
```
Initiate tx with lower doses
-Increase doses slowly
Selection of meds based on:
-Hx of response
-Adverse effect profile
```
53
OCD and pregnancy
Risk-benefit analysis should be made by practitioners when deciding to use during pregnancy
54
Evaluation of outcomes in OCD
Monthly f/u visits are recommended for at least 3-6 mos
Medication taper can be considered after 1-2 yrs tx
-Should not be rapidly d/c-ed
-Drug dosage can be decreased by 10-25% every 1-2 mos with careful observation for symptom relapse
Some pts require lifelong meds
55
Clomipramine and OCD
Pts >40 yoa should received pretreatment EKG
In pts with liver dz, baseline and periodic LFTs are recommended
Those who develop fever and sore throat should have leukocyte and differential WBC counts assessed to evaluate for agranulocytosis
56
SSRIs with anxiety and OCD
Higher doses needed, but start low and go slow
-Particularly for OCD
--Clinical response may take some time
Often used in presence of comorbid MDD
Avoid bupropion
Fluoxetine
-Despite FDA approval, may not be effective for anxiety
57
Venlafaxine use in anxiety d/os
GAD
Social phobia
Panic d/o
58
Use of duloxetine in anxiety d/os
GAD
| Panic d/o
59
Clomipramine and OCD
1st drug approved for OCD
Highly effective
Titration usually takes 2-3 wks to avoid GI issues
60
SEs of buspirone
```
HA
Dizziness
Nausea
GI upset
Depression
Weakness
```
61
Hydroxizine SEs
Dry mouth
Nausea
HA
Rash
62
Initial citalopram dose in OCD
20 mg daily
63
Initial clomipramine dose in OCD
25 mg/day
64
Initial escitalopram dose in OCD
10 mg/day
65
Initial fluoxetine dose for OCD
20 mg/day
66
Initial fluvoxamine dose for OCD
50 mg/day
67
Initial paroxetine dose for OCD
20 mg/day
68
Initial sertraline dose for OCD
50 mg/day
69
Pharm management of insomnia
```
Benzodiazepine receptor agonists
Antidepressants
Ramelteon
Antihistamines
Valerian
```
70
FDA warning of benzodiazepine receptor agonists
Caution regarding anaphylaxis, facial angioedema, and complex sleep behaviors
71
CIs of benzodiazepine receptor agonists
Pregnancy
| Sleep apnea
72
Amitriptyline dose in insomnia
100-100 mg HS (up to 150 mg if concomitant depression)- non FDA approved
73
Doxepin dose in insomnia
3-6 mg HS
74
Additional information about TCAs in insomnia
```
Anticholinergic activity
Adrenergic blockade
Cardiac conduction prolongation
Sig daytime sedation
Extreme caution in elderly
```
75
Ramelteon for insomnia
For tx of sleep-onset insomnia
Dose 8 mg qhs
May be considered for long-term use (6 mos)
76
SEs of ramelteon
```
HA
Dizziness
GI upset
Somnolence
Hyperprolactinemia
```
77
CIs of ramelteon
Concomitant fluvoxamine
78
Ramelteon is also effective for which comorbidities?
COPD
Sleep apnea
Option for pts with substance abuse
79
Notable warnings in suvorexant
```
Abnl thoughts and behavior
Memory loss
Anxiety
Sleep paralysis
Temporary leg weakness (day or night)
```
80
Antihistamines for insomnia
Potential option for tx of mild insomnia
Diphenhydramine and doxylamine
Tolerance to sedative effects occurs quickly
Anticholinergic SEs
81
Valerian extract for insomnia
Alternative therapy- OTC
300-600 mg 1 hr prior to bedtime
Small studies demonstrate no benefit
Case reports of hepatotoxicity
82
Melatonin
May be useful for jet lag and by the elderly
Jet lag dose: 0.5-2 mg preflight and higher doses (5 mg) posflight over a period of up to 4 days
Caution in pts at risk for bleeding or on anticoagulant/antiplatelet meds (including NSAIDs)
83
Discontinuation of insomnia meds
Taper both the dose and frequency to avoid withdrawal sx, rebound insomnia
Tapering may require several weeks to mos
84
Drugs that can be used for daytime sleepiness- narcolepsy
```
Dextroamphetamine
Dextroamphetamine/amphetamine salts
Methamphetamine
Methylphenidate
Lisdexamfetamine
Modafinil
Armodafinil
Sodium oxybate
```
85
Agents for cataplexy- narcolepsy
```
Fluoxetine
Imipramine
Nortriptyline
Protriptyline
Venlafaxine
Sodium oxybate
```
86
How often should pts with narcolepsy visit their provider?
Every 6-12 mos to evaluate efficacy and drug side effects
87
Pharm options for jet lag
Short-acting benzo receptor agonist
Ramelteon
0.5-5.0 melatonin
Taken at target bedtime for east or west travel
88
Pharm tx for OSA
Avoidance of CNS depressants
Avoidance of drugs that promote wt gain
Avoidance of drugs that can cause rhinopharyngeal inflammation and cough
Modafinil, armodafinil
89
Pharm tx for shift work sleep d/o
Short-acting benzo receptor agonist
Ramelteon
Melatonin
Modafinil and armodafinil
