Hypnotics And Anxiolytics

Question 1

Hypnotics and anxiolytics

Answer 1

-most anxiolytics are sedative and will induce sleep when given at night eg.temazepam. Most hypnotics will sedate when given in the day eg.Diazepam

-Dependence (physical and psychological) can occur which may lead to difficulty in withdrawing the drug after the patient has been taking it regularly for more than a few weeks

• therefore, use only short term and lowest possible. Dose
• Benzodiazepines are the most commonly used
• that act at the benzodiazepine receptors which are associated with GABA receptors
• Older drugs like meprobamate and barbiturates are not recommended due to their interaction, side effects and danger in overdose

Question 2

Hypnotics examples to treat insomnia

Answer 2

Examples- Temazepam,diazepam,lorazepam, nitrazepam etc.

• Establish cause of insomnia and treat underlying factors before a hypnotic is prescribed
• short acting hypnotics are proffered with patients with sleep onset insomnia when sedation is undesirable the following day or when prescribing for the elderly

Long acting hypnotics - for patients with poor sleep maintenance eg. Early waking that causes day time effects, when an anxiolytics effect is needed during the day or when sedation the following day is acceptable

Transient insomnia — May occur in people who normally sleep well eg. Sue to jet lag or noises. If hypnotics is needed, give one which is rapidly eliminated and only one or two doses should be given

• Short term insomnia - usually related to an emotional problem or serious medical illness. May last a few weeks and may recur. A hypnotic should not be given more than 3 weeks (preferable only one week). Short acting drug is usually appropriate

Question 3

ELDERLY PATIENTS

Answer 3

Benzos and a drugs should be avoided in elderly patients because the elderly are at a greater risk of becoming ataxic and confused, leading to falls and injury

Question 4

Dental patients

Answer 4

Can be given temazepam or diazepam during procedures. Temazepam is preferred when it is important to minimise any residual effects the following day

Question 5

Benzos

Answer 5

• benzos are used as hypnotics include nitrazepam and flurazepam which have prolonged action and may give rise to residual effects on the following day
• lorazepam,lormetazepam and temazepam act for a shorter time and have little or no hang over effect.Withdrawal phenomena are more common with short acting benzos
• if insomnia is associated with daytime anxiety, then the use of LA benzos anxiolytics eg.diazepam given as a single dose at night may effectively treat both symptoms

Question 6

Z drugs

Answer 6

Zolpidem and zopiclone

• zolpidem and zopiclone are non benzo hypnotics but act at the benzo receptor
• they are not licensed long term
• dependence has been reported in a small number of patients
• both have a short duration of action

Question 7

Other common hypnotics

Answer 7

• Clomethaziole - may be useful in elderly patients because they don’t cause hangover effects
• antihistamines - some antihistamines eg. Promethazine hydrochloride are on sale to public for occasional insomnia. Their prolonged duration of action can often cause drowsiness the following day. Side effects include headaches,psychomotor impairment and antimuscarinic effects
• alcohol - poor hypnotic because the diuretic action will interfere with sleep . Alcohol also disturbs sleep patterns and so can worsen sleep disorders
• Melatonin - is a pineal hormone - licensed for the short term treatment of insomnia in adults over 55 and for short term treatment of jet lag in adults

Question 8

Buspirone

Answer 8

• act at specific serotonin receptors (5ht1a)
  -used in short term anxiety
• response to treatment may take up to 2 weeks
• does not alleviate symptoms of benzo withdrawal so benzos should still be withdrawal slowly before starting buspirone

Question 9

Barbiturates

Answer 9

Only used in severe insomnia in patients that are already taking barbiturates - avoid in elderly
- long acting barbiturates (phenobarbital) has value in epilepsy but use as a sedative is unjustified

• the very short acting barbiturate (thiopental) is used in anaesthesia

-increased hostility and aggression after barbiturates and alcohol usually will indicate intoxication