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Drugs for Anxiety and Insomnia

Drugs for Anxiety and Insomnia. Chapter 14. OVERVIEW: Neuro System. escitalopram (Lexapro). Tri-Cyclic Antidepressant. Antidepressant / Anxiolytic. MAOIs. Benzodiazepines. lorazepam (Ativan) diazepam (Valium). GABA Antagonist. zolpidem (Ambien). A. phenytoin (Dilantin)

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Drugs for Anxiety and Insomnia

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  1. Drugs for Anxiety and Insomnia Chapter 14

  2. OVERVIEW: Neuro System escitalopram (Lexapro) Tri-Cyclic Antidepressant Antidepressant / Anxiolytic MAOIs Benzodiazepines lorazepam (Ativan) diazepam (Valium) GABA Antagonist zolpidem (Ambien) A phenytoin (Dilantin) valproic acid (Depakote) Phenytoin-Like Drugs Succinimides ethosuximide (Zarontin) phenobarbital (Luminal) Barbiturates Phenothiazines chlorpromazine (Thorazine) Non-Phenothiazines halperidol (Haldol) Opioids morphine (Infumorph) Atypical Antipsychotics risperidone (Risperdal) aspirin (ASA) Salicylates ibuprofen (Motrin) NSAIDs acetaminophen (Tylenol) Non-Opioid tramadol (Ultram) Central Acting ergotamine (Cafergot) Sumatriptan (Imitrex) Anti-Migraine Opioid Antagonists naloxone (Narcan)

  3. Major Types of Anxiety Disorders Situational anxiety Generalized anxiety disorder (GAD) Panic disorder Phobias Social anxiety Obsessive-compulsive disorder Post-traumatic stress disorder

  4. Pharmacotherapy Illustrated

  5. Common Causes of Anxiety Phobias Post-traumatic stress Generalized anxiety Obsessive-compulsive feelings Panic

  6. Nonpharmacologic Therapies to Cope with Anxiety Cognitive behavioral therapy Counseling Biofeedback techniques Meditation

  7. Anxiolytics Drugs having the ability to relieve anxiety Quite effective Used when anxiety begins to significantly affect daily activities

  8. Classes of Medications Used to Treat Anxiety and Sleep Disorders Antidepressants Benzodiazepines Barbiturates Nonbenzodiazepine/nonbarbiturate CNS depressants

  9. Treating Anxiety and Insomniawith CNS Agents • Antidepressants frequently used to treat anxiety • Two major classes • Benzodiazepines • Barbiturates • CNS depression - a continuum ranging from relaxation, to sedation, to the induction of sleep and anesthesia

  10. Sedatives and Hypnotics • CNS depressants called • sedatives due to ability to sedate or relax a patient, or • hypnotics because of their ability to induce sleep • sedative–hypnotic: calming effect at lower doses and sleep at higher doses • Most CNS depressants can cause physical and psychological dependence

  11. Monitor Client’s Condition and Provide Education Obtain vital signs, medical and drug history Discuss lifestyle and dietary habits What precipitated the feelings of anxiety?

  12. Assess Client’s Need for Antianxiety or Insomnia Drugs Assess intensity and duration of symptoms Identify precipitating factors Identify coping mechanisms Assess for sleep disorder

  13. Obtain Drug History Hypersensitivity Use of alcohol and other CNS depressants Drug abuse and dependence

  14. Use Cautiously for Certain Clients Those who are elderly Those with suicidal potential Those with impaired renal or liver function

  15. Insomnia • Acts of sleeping and waking synchronized to many different bodily functions • Insomnia sometimes associated with anxiety • Short-term or behavioral insomnia sometimes attributed to stress • Food or beverages with stimulants may disturb sleep • Long-term insomnia often caused by depression, manic disorders, chronic pain • Nonpharmacologic means should be attempted prior to drug therapy • Rebound insomnia – caused by discontinuation of long-used sedative drug • Older patients more likely to experience medication-related sleep problems

  16. Antidepressants Treat major depression and a range of anxiety conditions Primary medications to reduce symptoms of panic and anxiety: TCAs, MAOIs, and SSRIs Atypical antidepressants do not fall conveniently into the other categories Adverse reactions make antidepressants unusable for some patients

  17. Antidepressants (cont'd) Prototype drug: Escitalopram oxalate (Lexapro) Mechanism of action: increases availability of serotonin at specific postsynaptic receptor sites located within the CNS Primary use: generalized anxiety and depression Adverse effects: dizziness, nausea, insomnia, somnolennce, confusion, seizures

  18. Prototype Drug: Escitalopram oxalate (Lexapro)

  19. Escitalopram Oxalate Animation Click here to view an animation on the topic of escitalopram oxalate.

  20. Antidepressant Class Information • TCAs (partial list information/conditions): • Not for use for patients with heart attack, heart block, or arrhythmia • Potential side effects: dry mouth, blurred vision, urine retention, and hypertension • concurrent use with alcohol or other CNS depressants should be avoided

  21. Antidepressant Class Information (cont'd) • SSRIs (partial list information/conditions): • Safer than other classes • Less common sympathomimetic effects (increased heart rate and hypertension) • Fewer anticholinergic effects • can cause weight gain and sexual dysfunction

  22. Antidepressant Class Information (cont'd) • SNRIs (partial list information/conditions): • Many possible side effects: • abnormal dreams, sweating, • constipation, dry mouth, loss of appetite, weight loss, • tremor, abnormal vision, headaches, nausea and • vomiting, dizziness, and loss of sexual desire

  23. Antidepressant Class Information (cont'd) • MAOIs (partial list information/conditions): • avoid foods containing tyramine • potentiate the effects of insulin and other diabetic drugs • common adverse effects include orthostatic hypotension, headache, and diarrhea

  24. Benzodiazepines Prototype drug: lorazepam (Ativan) Mechanism of action: binds to GABA receptor-chloride channel molecule, which intensifies GABA effects Primary use: for anxiety disorders and insomnia Adverse effects: drowsiness, dizziness, respiratory depression

  25. Prototype Drug: Lorazepam (Ativan)

  26. Benzodiazepines Some treat short-term insomnia Others treat various anxiety disorders Most benzodiazepines given orally Drugs of choice for short-term treatment of insomnia caused by anxiety – greater margin of safety

  27. Benzodiazepines Bind To GABA Receptor-Chloride Channel Molecule Intensify effects of GABA Examples: Xanax, Librium, Tranxene

  28. Benzodiazepines Have a number of other important indications Seizure disorders Alcohol withdrawal Central muscle relaxation Induction agents in anesthesia

  29. Benzo’s Prototype drug: diazepam (Valium) Mechanism of action: Binds with GABA receptor-chloride channel molecules, intensifying effects of GABA Inhibits brain impulses from passing through limbic and reticular activating systems Primary use: as sedative and hypnotic Adverse effects: tolerance, respiratory depression, psychological and physical dependence

  30. Nonbenzodiazepines, Nonbarbiturate CNS depressants • Chemically unrelated to either benzodiazepines or barbiturates • Used mainly for treatment of social anxiety symptoms • Prototype:zolpidem (Ambien) • Mechanism of action: binds to GABA receptors • Primary use: as hypnotic • Adverse effects: mild nausea, dizziness, diarrhea, daytime drowsiness, amnesia, sleepwalking, ingesting carbohydrates while sleepwalking

  31. Nonbenzodiazepines, NonbarbiturateCNS depressants (cont'd) Mechanism of action: binds to GABA receptor Preserves sleep stages III and IV Offers minor effects of REM sleep OtherNonbarbiturate CNS Depressants: Buspar, Noctec, Placidyl

  32. Prototype Drug: Zolpidem (Ambien)

  33. Zolpidem Animation Click here to view an animation on the topic of zolpidem.

  34. Nonbenzodiazepine, NonbarbiturateCNS Depressants (cont'd) Assess for common side effects of CNS depression Assess neurological status, level of consciousness Monitor vital signs, observe respiratory patterns particularly during sleep Monitor patient’s intake of stimulants, such as caffeine and nicotine Monitor affect and emotional status

  35. NCLEX-RN ReviewQuestion 1 Tachypnea Astigmatism Ataxia Euphoria The nurse should assess a patient who is taking lorazepam (Ativan) for the development of which of these adverse effects?

  36. NCLEX-RN ReviewQuestion 1 – Answer Tachypnea Astigmatism Ataxia Euphoria

  37. NCLEX-RN ReviewQuestion 1 – Rationale Rationale: CNS side effects for lorazepam (Ativan) include amnesia, weakness, disorientation, ataxia, blurred vision, diplopia, nausea, and vomiting.

  38. NCLEX-RN ReviewQuestion 2 The patient sleeps in 3-hour intervals, awakes for a short time, and then falls back to sleep. The patient reports feeling less anxiety during activities of daily living. The patient reports having fewer episodes of panic attacks when stressed. The patient reports sleeping 7 hours without awakening. A patient is receiving temazepam (Restoril). Which of these responses should a nurse expect the patient to have if the medication is achieving the desired affect?

  39. NCLEX-RN ReviewQuestion 2 – Answer The patient sleeps in 3-hour intervals, awakes for a short time, and then falls back to sleep. The patient reports feeling less anxiety during activities of daily living. The patient reports having fewer episodes of panic attacks when stressed. The patient reports sleeping 7 hours without awakening.

  40. NCLEX-RN ReviewQuestion 2 – Rationale Rationale: The nurse should recognize that this medication is ordered for insomnia. Therefore, the patient should be experiencing relief from insomnia and reporting feeling rested when awakening.

  41. NCLEX-RN ReviewQuestion 3 Epinephrine Atropine Flumazenil Naloxone A 32-year-old female patient has been taking lorazepam (Ativan) for her anxiety and is brought into the emergency department after taking 30 days’ worth at one time. The antagonist used in some cases of benzodiazepine overdosage is:

  42. NCLEX-RN ReviewQuestion 3 – Answer Epinephrine Atropine Flumazenil Naloxone

  43. NCLEX-RN ReviewQuestion 3 – Rationale Rationale: Flumazenil (Romazicon) is a benzodiazepine-receptor blocker which may be used to reverse CNS depressant effects. Naloxone (Narcan) is an opioid antagonist.

  44. NCLEX-RN ReviewQuestion 4 “I will stop smoking by undergoing hypnosis.” “I will not drive immediately after I take this medication.” “I will stop the medication when I feel less anxious.” “I will take my medication with food if my stomach feels upset.” A patient has been given instructions about the newly prescribed medication alprazolam (Xanax). Which of these statements, if made by the patient, would indicate that the patient needs further instruction?

  45. NCLEX-RN ReviewQuestion 4 – Answer “I will stop smoking by undergoing hypnosis.” “I will not drive immediately after I take this medication.” “I will stop the medication when I feel less anxious.” “I will take my medication with food if my stomach feels upset.”

  46. NCLEX-RN ReviewQuestion 4 – Rationale Rationale: Benzodiazepines should not be stopped abruptly. The health care provider should decide when and how to discontinue the medication.

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