Benzos and Z-Drugs

Question 1

Benzos general counselling

Answer 1

1. Benzodiazepines
2. Anxiety, panic disorder
3. HOW OFTEN GETTING IT DISPENSED!!!
   SLEEP HYGIENE
   - renal fn ↑ CNS effects
   - hepatic fn lower doses and C/I in severe
   - C/I in mysthenia gravis= ↑ muscle weakness, & in resp depression as can worsen.
   - Dependence= signs of it (craving, drug seeking behaviour), hx of it, tolerance
   - Withdrawal smx= suddenly stopping tx (or ↓ dose too quickly) in dependent ppl= anxiety, dysphoria, irritability, insomnia, nightmares, sweating, memory impair, hallucinations, HTN, tachycardia, psychosis, tremors and seizures.
   
   • Short-Acting benzos= alprazolam= may occur w/in few hours
   • Longer-Acting= diazepam= may take days or weeks to occur & can can last for several weeks or longer after prolonged use.
     
     • use lowest possible dose short term only
4. • Suddenly stopping can cause withdrawal smx and rebound effects
     - If you stop the medicine suddenly, you may have unpleasant effects (eg feeling anxious, difficulty sleeping). Discuss how to stop the medicine with your doctor first.
     - You may feel drowsy while taking this medication; drowsiness may persist the following day; avoid driving or operating heavy equipment until you know how you react.
     - Avoid alcohol and other medications that may cause drowsiness while taking this drug.
     - If you take this medicine regularly for more than 2–4 weeks your body may become used to it and in time, you may need a higher dose for it to continue to work.

Sleep Hygiene
- go to sleep and wake up same time each day
- avoid napping
- avoid caffeine
- avoid heavy meals and exercise before bed
- make bedroom dark, quiet, comfortable
- don’t do work/study in bed/bedroom
Relaxation techniques- relaxation techniques
- CBT
- HCPs

Question 2

Melatonin

Answer 2

1. Melatonin MT1/MT2-receptor agonist
2. Short-term use as monotherapy in primary insomnia with poor sleep quality
3. > 55 years, oral 2mg 1–2 hours before bed for up to 13 weeks. WITH FOOD!
4. • hepatic fn
     - do not use in preg or bfeeding really.
     - sleep patterns
     - sleep hygiene
     - clinical effect
     - sedation
5. Used to help you sleep.
   Take the tab 1 or 2 hours before going to bed. With food!
   LABELs: A

Take this medicine only as often and for as long as your doctor recommends.
S/Es= This medicine can cause joint pains and back pains or weakness.

Do not drink alcohol while using melatonin as it can affect the way the medicine works.

Tell dr if you feel drowsy during the daytime.

Sleep hygiene
- go to sleep and wake up same time each day
- avoid napping
- avoid caffeine
- avoid heavy meals and exercise before bed
- make bedroom dark, quiet, comfortable
- don’t do work/study in bed/bedroom
Relaxation techniques

Question 3

Suvorexant (Belsomra)

Answer 3

1. Orexin receptor antagonist
2. Tx of chronic insomnia
3. <65 years 20mg 30 minutes before bed.
   >65 years 15mg 30 minutes before bed.
   On EMPTY STOMACH
4. • C/I= narcolepsy
     - caution w/compromised resp fn
     - Avoid use w/drugs that are mod-strong inhibitors or strong induces of CYP3A4
     - assess response to tx after 7–10 days; reassess need for continuation after 3 months
     - hepatic impair= not recommended
5. Empty stomach for faster effect.
   - Only take this medication if you intend to get a full night’s rest (at least 7 hours).
   - When you take this medication, you may be drowsy or less alert the following day (or even longer). Avoid driving or operating heavy equipment for at least 9 hours after taking your tablet and possibly longer, depending on how you react.

• Tell your doctor if you develop abnormal thoughts or behaviour or a temporary inability to move or talk while you are going to sleep or waking up.
• Do not take alcohol or other medications that may cause drowsiness while taking suvorexant.
• Follow up w/dr in 7-10 days.
• You may experience= somnolence and headache
  less frequently= abnormal dreams, hallucinations, sleep paralysis, sleepwalking or suicidal ideation

Question 4

Zolpidem (Stilnox), Zopiclone (Imovane, Imrest)

Answer 4

1. non-benzodiazepine hypnotic
2. Short term tx of insomnia
3. 5-10mg immediately before bed.
   CR= 6.25-12.5mg immediately before bed.
   Zopiclone= 3.75-7.5mg nocte for up to 4 weeks.
4. C/I= mysthenia gravis & pulmonary insufficiency & alcohol intake (↑ dangerous S/Es= sleepwalking, driving while asleep)
   - psychiatric (depression, psychosis or schizophrenia, suicidal thoughts) may worsen. and combo of these tx drugs.
   - hepatic fn- hepatotoxicity
   - use lowest possible dose short term only
   - dependence, tolerance and misuse
   - withdrawal syndrome may occur on stopping, esp if high doses gradual dose reduction needed
   - controlled release tablet may provide longer sleep period
   - ↓ dose in elderly
5. • This medication is intended to make you feel sleepy, but you may be less alert or even drowsy the following day.
     - Avoid driving or operating heavy equipment for at least 8 hours (12 hours for Zopiclone) after taking your tablet and possibly longer, depending on how you react.

• Do not take alcohol or other medications that may cause drowsiness while taking zolpidem, as this may increase the risk of walking or driving while you’re asleep.
• Controlled release tablets: swallow tablets whole; do not crush or chew.

LABELs: 1a, 2, A(CR)
- diarhoea, impaired alertness next mane, amnesia, sleepwalking, driving while asleep, paradoxical smx

Zopiclone 1a, 2
- taste disturbance (bitter), dry mouth, nightmares, sleepwalking, driving while asleep, dyspepsia, anaphylaxis