ic15 anxiety and sleep disorders

Question 1

What is anxiety disorder

Answer 1

Severe, persistent anxiety and irrational fear that impairs functioning
When anxiety is out of proportion to actual danger or threat

Question 2

What are the 5 anxiety disorders that can be treated by meds?

Answer 2

GAD
Panic disorder
Social Anxiety Disorder (SAD)
OCD
PTSD

Question 3

What are the main neurotransmitters involved in GAD?

Answer 3

NE, Serotonin, GABA

hence drugs to treat GAD are ssri, snri, bzd

Question 4

Drugs that can induce anxiety (10 points)

Answer 4

Pseudoephedrine

Stimulants (Increase NE, DA): Amphetamine, Bupropion

Methylxanthine: Theophylline, Caffeine

Levothyroxine: activate sympathetic NS

Corticosteroids

Antidepressants
Jitteriness side effect after initiation

Dopamine agonist eg. Levodopa

Beta agonists eg. Salbutamol

Drug withdrawal

Drug intoxication

Question 5

What is panic attack

Answer 5

Period of intense fear
Reach peak within 10 mins, last no more than 20-30 mins
Can be expected or unexpected

Question 6

Medication classes for GAD

Answer 6

Antidepressants
Pregabalin
Adjunctive Benzodiazepines

Question 7

What are the antidepressants used for anxiety

Answer 7

1st: SSRI
2nd: SNRI
3rd: Clomipramine (TCA)
4th: Mirtazapine (if pt worry about sexual SE)

Question 8

Why is Clomipramine 3rd line for anxiety?

Answer 8

Very effective, potent serotonin and norepinephrine reuptake inhibitor
But toxic, fatal on overdose, accumulates in heart muscles 40x more than serum level, promote seizures, cardiac conduction abnormalities

Question 9

What drug cannot be used for anxiety?

Answer 9

Bupropion

Very stimulating, will worsen anxiety

Question 10

Principles of antidepressant therapy in anxiety

Answer 10

Dosing must be LOW
Reduce transient jitteriness in initial 1-2 weeks

Maintenance dose may be HIGH
Eg. Fluoxetine 60-80 mg/day, way more than MDD Fluoxetine dose

Question 11

Onset and duration of therapy for antidepressants

Answer 11

Onset: Takes 1-2 months for effect in “excessive worrying” symptoms
Counsel for adherence

Duration of therapy: at least 1-2 years

Question 12

What is the first line Benzodiazepine and why?

Answer 12

Lorazepam

Most commonly used
Safe in hepatic impairment
Short duration of action (6-8hrs), hence safe in overdose

Question 13

Which BZD has active metabolites?

Answer 13

Diazepam

Diazepam has long half life, active metabolites have even longer half lives
Drowsiness and high fall risk in elderly

Question 14

Which is the last line benzodiazepine

Answer 14

Alprazolam
Highest potency, hence most toxic if overdose
Should not use frequently for GAD
Only for panic disorder, as adjunct to SSRI, SNRI

Question 15

Counselling points for benzodiazepines

Answer 15

SSRI will take months to start working, you will still have anxiety attack
Lorazepam, Clonazepam will help with the attacks
Give for initial 2 weeks, then review need to continue due to tolerance dependence side effects

Question 16

what drug is contraindicated with benzodiazepines?

What to do?

Answer 16

Opioids
Opioids also cannot give with Z-hypnotics (Q3 of post lecture)
Can cause death due to CNS depression!
Cos Z-hypnotics has similar MOA as Benzodiazepines

Switch out Benzodiazepine to another sedating agent, keep the opioid for pain relief

Question 17

What are some drug drug interactions to look out for in anxiolytics (3 points)

Answer 17

1) CNS depression
Alcohol or other CNS depressants eg. Benzodiazepines
Separate 4-6 hours apart
Benzodiazepines (and Z-hypnotics) should not be given with Opioids

2) Anticholinergic agents

3) Serotonin syndrome
For opioids and drugs that increase serotonin eg. SSRI, SNRI, TCA, MAOi
Wash out period for Moclobemide

Question 18

What are the neurotransmitters involved in sleep

Answer 18

GABA
Promote sleep

NE, DA, Acetylcholine, Histamine, Orexin
Promote wakefulness

Question 19

What is insomnia

Answer 19

Inability to sleep and associated with daytime problems eg. fatigue, impaired concentration, memory

Occurs at least 3 nights a week for at least 3 months

Not caused by other disorders eg. Asthma, Pain, Itch, Obstructive Sleep Apnea

Question 20

How long is transient, short term and chronic insomnia

Answer 20

Transient: < 1 week

Short term: < 4 weeks
Sleep hygiene
Short PRN course of hypnotics

Chronic Insomnia
> 4 weeks
Likely due to secondary underlying psychiatric or medical problems

Question 21

Counselling points for sleep hygiene

Answer 21

Avoid caffeine, nicotine, alcohol in the evening
No heavy meal within 2hrs of bedtime
Dont drink water before sleep
Avoid noisy environment
Establish a routine for getting ready to go to bed
Avoid daytime naps
Regular exercise but avoid vigorous activities close to bedtime

Question 22

What are the drugs for insomnia (7 points)

Answer 22

Benzodiazepines
Z-hypnotics
Antihistamine
Melatonin
Lemborexant
Trazodone
Antipsychotics (SGA)

Question 23

Which patients should not use Benzodiazepines (6 points)

Answer 23

elderly with dementia, as BZD can cause amnesia

history of substance abuse

patients on opioids

myasthenia gravis

acute narrow angle glaucoma

history of respiratory depression

Question 24

Side effects of benzodiazepines (3 points)

Answer 24

Sedation, Drowsiness
Amnesia
Paradoxical excitement

Question 25

What are the 2 benzodiazepines indicated for insomnia? Which is preferred and why?

Answer 25

Lorazepam Shorter half life (12hrs) → Lesser hangover effects Preferred over Diazepam Diazepam Very effective as cross BBB Longer acting (T1/2 = 20 - 54hrs) → more hangover effects

Question 26

Advantage of BZD over antihistamines for use in elderly

Answer 26

Does not cause anticholinergic effect and delirium but should not be used in dementia patients BZD can cause paradoxical excitement in elderly

Question 27

Which patients cannot use Benzodiazepines and Z-hypnotics (5 points)

Answer 27

1) Acute narrow angle glaucoma 2) Respiratory depression 3) Myasthenia gravis 4) Patients with history of substance abuse 5) Patients on opioids

Question 28

4 roles of benzodiazepines

Answer 28

1) Anxiolytic 2) Sedating 3) Muscle relaxant, hence anti-convulsant 4) Cause amnesia

Question 29

What is the similarity and difference between Z-hypnotics and BZD

Answer 29

Both can be abused, have similar risk of dependence, should not use in myasthenia gravis, narrow angle glaucoma, history of respiratory depression. Z-hypnotics is just for sleep, will not cause muscle relaxation like BZD

Question 30

What drug is contraindicated with Z-hypnotics

Answer 30

Opioids (can cause CNS depression)

Question 31

What are the 2 Z-hypnotics? Which is preferred?

Answer 31

Zolpidem and Zopiclone Zolpidem Useful for initiating sleep Will not cause hangover effect Half tablet for females, full tablet for males Zopiclone Useful for maintaining sleep due to longer half life Long duration of action, hence may cause hangover effect

Question 32

Side effects of Z-hypnotics

Answer 32

Taste disturbances, metallic taste (with Zopiclone) Sleep walking

Question 33

What H1 antihistamines are indicated for insomnia? When are H1 antihistamines indicated

Answer 33

Promethazine, Hydoxyzine for patients with history of substance abuse

Question 34

Who is contraindicated from antihistamines? (2 points)

Answer 34

Children 2 and below should not use Promethazine Elderly with delirium

Question 35

What is Lemborexant Indication

Answer 35

Orexin receptor antagonist Orexin is a hormone that helps with alertness and appetite For patients with history of substance abuse

Question 36

What is Lemborexant for and MOA? Who are contraindicated with use of Lemborexant (3 points)

Answer 36

Insomnia, orexin receptor antagonist Narcolepsy Narcolepsy: already have low Orexin, Lemborexant will cause paralysis CYP3A inhibitor or inducers Severe renal impairment

Question 37

For patients with history of substance abuse, what to give for insomnia? What cannot give?

Answer 37

H1 antihistamine, Lemborexant, Melatonin -> wont cause dependence Benzodiazepines, Z-hypnotics

Question 38

What are 2 off label drugs for insomnia

Answer 38

Trazodone, due to H1 antagonism Side effects: priapism Antipsychotics eg. Quetiapine, due to H1 antagonism