Psychopharm Anxiety Disorders

32問 • 10ヶ月前

問題一覧

Risks of Benzodiazepines

Tolerance, Dependence & Withdrawl, Sedation & Cognitive Impairment, Disinhibition or Paradoxical Reactions (irritability, aggression, and impulsive), Respiratory Depression, Addiction Potential.

Clinical Situations Where Benzos Are Relatively Contraindicated

PTSD, History of Substance Abuse, Elderly, Sleep Apnea, Pregnancy, Bipolar.

-Mechanism: Enhances GABA-A receptor activity → ↑ chloride influx → neuronal inhibition -Neurotransmitters: GABA (modulates GABAergic tone) -Side Effects: Sedation, dizziness, memory impairment, ataxia -Adverse Reactions: Dependence, withdrawal (esp. seizures), rebound anxiety -Interactions: Potentiated by other CNS depressants (alcohol, opioids); CYP3A4 substrate -Lab Tests: None routinely, but consider LFTs for long-term use -Pregnancy Risk: D – neonatal withdrawal and floppy infant syndrome

Alprazolam (Xanax) – Benzodiazepine

-Mechanism: Partial agonist at 5HT1A receptors (serotonergic); does not act on GABA -Neurotransmitters: Serotonin (modulates 5HT1A tone) -Side Effects: Dizziness, headache, nausea, nervousness -Adverse Reactions: Very few—non-sedating, no dependence, no withdrawal -Interactions: Avoid with MAOIs (risk of serotonin syndrome); metabolized by CYP3A4 -Lab Tests: None needed -Pregnancy Risk: B – generally considered safe

Buspirone (Buspar)

-Mechanism: Potentiates GABA-A receptor activity -Neurotransmitters: GABA -Side Effects: Sedation, fatigue, ataxia, confusion -Adverse Reactions: Dependence, respiratory depression (esp. with other CNS depressants) -Interactions: CYP450 (esp. CYP2C19 and CYP3A4); caution with alcohol or opioids -Lab Tests: LFTs in long-term use; caution in hepatic dysfunction -Pregnancy Risk: D – crosses placenta, risk of neonatal CNS depression

Diazepam (Valium) – Benzodiazepine

-Mechanism: Competitive antagonist at the benzodiazepine binding site on GABA-A receptors -Neurotransmitters: GABA (blocks modulatory effects of BZDs) -Side Effects: Nausea, dizziness, emotional lability -Adverse Reactions: Seizures, especially in patients chronically on BZDs or with poly-substance overdose -Interactions: Can reverse BZD sedation but not respiratory depression from other drugs -Lab Tests: Monitor vitals and seizure activity during administration -Pregnancy Risk: C

Flumazenil – BZD Antagonist

-Mechanism: Enhances GABA-A receptor activity -Neurotransmitters: GABA -Side Effects: Sedation, weakness, disorientation -Adverse Reactions: Dependence, rebound anxiety, respiratory depression -Interactions: Additive effects with alcohol, opioids; not metabolized by CYP system (safe in liver disease) -Lab Tests: None routinely; monitor respiratory status if used IV -Pregnancy Risk: D

Lorazepam (Ativan) – Benzodiazepine

-Mechanism: Blocks alpha-1 receptors in CNS and periphery → ↓ sympathetic tone -Neurotransmitters: Norepinephrine (blocks NE binding to α1 receptors) -Side Effects: Orthostatic hypotension, dizziness, headache, drowsiness -Adverse Reactions: Syncope, especially with first dose ("first-dose phenomenon") -Interactions: Additive BP-lowering effects with other antihypertensives -Lab Tests: Monitor BP, especially during dose titration -Pregnancy Risk: C

Prazosin – Alpha-1 Adrenergic Antagonist

Indications for tapering Benzos

-Taking benzos for more than 1 month -Older than 65 -Taking multiple benzos -Has cognitive disorder, TBI, or substance use

High Risk Patients for Benzos

-Pregnant -Elderly -SUD -Opioid use -COPD -PTSD/OCD

Advantages and Disadvantages of Benzos

Advantages: Rapid Onset, no latency period, wide therapetic margin Disadvantages: Adverse cognitive and motor effects, risk of tolerance/dependence, 2nd Gen antidepressants more efficacious

Name short-acting benzos and what are their potential problems they cause?

-Alpreazolam, Triazolam, Oxazepam, and Midazolam -Problems with withdrawl/dependence

Name long-acting benzos and what potential problems do they cause?

-Clorazepate, Clordiazepoxide, Diazepam, and Flurazepam -Problems with accumulation

Use of benzos in psychiatric disorders

Anxiety disorders, schizophrenic catatonia, bipolar

Use for bezos in non-psychiatric disorders

Seizures, muscle relaxants, vertigo, sedatives (procedural)

Use for benzos as rescue medications

Alcohol or benzo withdrawl and akathisia

What is the antidote for benzos?

Flumazenil

In order for benzos to work it needs?

GABA

What meds affect GABAa receptor complex?

Ativan, Alcohol, Amobarbital, Ambien

Since the GABAb receptor is not targeted by benzos, what does it affect?

Pain, Memory, and Mood

What is the function function of GABA-T?

Destroys GABA

What CVD meds treat hyperarousal in PTSD?

Beta-blockers, Alpha-1 Antagonists, Alpha-2 Agonists

5TH1A partial agonist, dosed twice daily for a max dose of 200 mg, no sexual S/E, not for PRN use, and primarily used as adjunct therapy

Buspirone

Only two meds FDA approved for PTSD

Paroxetine and Sertraline

Are preferred over benzos as monotherapies for patients with co-occurring depression or SUD

SSRIs, SNRIs, and TCAs

-1st line tx SSRI + CBT or TCA (Clomipramine) -Takes higher doses to tx

OCD

What does the Amygdala-Centered Circuit control?

Fear (panic, phobia)

What does the CSTC-Centered Circuit control?

Worry (anxious misery, apprehension, expectation, obsession)

Affects NE and Dopa causing cardiac symptoms

Locus Coeruleus

Controls fight/flight/freeze and avoidance

Periaqueductal gray

Controls respiratory response

Parabrachial nucleus

Internal fearmonger and re-experiencing trauma

Hippocampus

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