Anxiety & Sleep Drugs

Anxiety & Sleep Drugs

• Ambien (Zolpidem):
  • Indicated for insomnia.
  • A non-benzodiazepine GABAA agonist.
  • Classified as C-IV.
  • Potential for complex sleep behaviors, such as sleep driving.
  • Should be avoided in elderly patients.
• Lunesta (Eszopiclone):
  • Used for insomnia.
  • A non-benzodiazepine GABAA agonist.
  • Classified as C-IV.
  • May cause a bitter taste.
  • Has a long half-life.
• Restoril (Temazepam):
  • Indicated for insomnia.
  • A benzodiazepine that works on GABAA receptors.
  • Classified as C-IV.
  • Listed in the Beers Criteria.
  • Carries a risk of tolerance.
• Rozerem (Ramelteon):
  • Used for insomnia.
  • A melatonin receptor agonist.
  • Not a scheduled drug.
  • Should be avoided in patients with hepatic impairment.
• Belsomra (Suvorexant):
  • Indicated for insomnia.
  • An orexin receptor antagonist.
  • Classified as C-IV.
  • May cause next-day somnolence.
• Doxepin (Doxepin):
  • Used for insomnia.
  • An H1 antagonist and TCA at low doses.
  • Should be taken without food.
  • Listed in the Beers Criteria.
• Trazodone (Trazodone):
  • Used off-label for insomnia.
  • A 5-HT2 antagonist/reuptake inhibitor.
  • Sedating.
  • Potential risk of orthostasis.
  • Carries a warning for priapism.
• Mirtazapine (Mirtazapine):
  • Used off-label for insomnia.
  • An alpha-2 antagonist and H1 blocker.
  • Sedating at low doses.
  • Can cause weight gain.
• Buspar (Buspirone):
  • Indicated for anxiety.
  • A 5-HT1A partial agonist.
  • Has a delayed onset of 2–4 weeks.
  • No abuse potential.
• Vistaril (Hydroxyzine):
  • Used as needed (PRN) for anxiety.
  • An H1 antagonist.
  • Sedating.
  • Has anticholinergic side effects.
• Lyrica (Pregabalin):
  • Used off-label for anxiety.
  • Inhibits voltage-gated Ca2+ channels.
  • Classified as C-V.
  • Can cause sedation, dizziness, and weight gain.

Pain Management & Opioid Use Disorder (OUD) Drugs

Opioids & Combo Products

• Tylenol #3 (Codeine + APAP):
  • Indicated for mild to moderate pain.
  • A mu-opioid agonist.
  • Classified as C-III.
  • Requires CYP2D6 activation.
  • Has a ceiling effect.
• Vicodin (Hydrocodone + APAP):
  • Used for moderate pain.
  • A mu-opioid agonist.
  • Classified as C-II.
  • Risk of liver toxicity.
• Zohydro ER (Hydrocodone ER):
  • Indicated for severe pain.
  • A mu-opioid agonist.
  • Classified as C-II.
  • Features abuse-deterrent properties.
  • Does not contain APAP.
• Hysingla ER (Hydrocodone ER):
  • Used for severe pain.
  • A mu-opioid agonist.
  • Classified as C-II.
  • Provides 24-hour duration.
  • Features abuse-deterrent properties.
• Ultram (Tramadol):
  • Indicated for moderate pain.
  • A mu-opioid agonist and SNRI.
  • Classified as C-IV.
  • Black Box Warning for seizures and serotonin syndrome.
  • Metabolized by CYP2D6.
• Nucynta (Tapentadol):
  • Used for moderate to severe pain.
  • A mu-opioid and NRI.
  • Classified as C-II.
  • Causes less nausea.
  • Should be avoided with MAOIs.
• MS Contin (Morphine ER):
  • Indicated for severe pain.
  • A mu-opioid agonist.
  • Classified as C-II.
  • Requires renal dosing.
  • M6G is an active metabolite.
• Kadian (Morphine ER):
  • Used for severe pain.
  • A mu-opioid agonist.
  • Classified as C-II.
  • Capsules can be opened and sprinkled on applesauce.
  • Do not crush.
• OxyContin (Oxycodone ER):
  • Indicated for severe pain.
  • A mu-opioid agonist.
  • Classified as C-II.
  • A CYP3A4 substrate.
  • High abuse risk.
• Opana (Oxymorphone):
  • Used for severe pain.
  • A mu-opioid agonist.
  • Classified as C-II.
  • Black Box Warning: Alcohol increases absorption, leading to dose dumping.

Fentanyl Products

• Duragesic (Fentanyl patch):
  • Indicated for severe chronic pain.
  • A mu-opioid agonist.
  • Classified as C-II.
  • Not for opioid-naive patients.
  • Patch is applied every 72 hours.
  • Avoid heat exposure.
• Actiq (Fentanyl lozenge):
  • Used for breakthrough cancer pain.
  • A mu-opioid agonist.
  • Classified as C-II.
  • Subject to REMS.
  • Rapid onset.
  • Only for opioid-tolerant patients.

Methadone & Buprenorphine

• Dolophine (Methadone):
  • Indicated for severe pain and OUD.
  • A mu-opioid agonist and NMDA antagonist.
  • Classified as C-II.
  • Can cause QT prolongation.
  • Variable half-life.
  • Metabolized by CYP3A4.
• Subutex (Buprenorphine):
  • Used for OUD and pain.
  • A partial mu-agonist and kappa antagonist.
  • Classified as C-III.
  • Has a ceiling effect on respiratory depression.
• Suboxone (Buprenorphine/Naloxone):
  • Indicated for OUD.
  • A partial mu-agonist and antagonist.
  • Classified as C-III.
  • Naloxone discourages IV abuse.
• Sublocade (Buprenorphine ER injection):
  • Used for OUD.
  • A partial mu-agonist.
  • Classified as C-III.
  • Administered as a subcutaneous monthly injection for maintenance.
• Belbuca (Buprenorphine buccal):
  • Indicated for chronic pain.
  • A partial mu-agonist.
  • Classified as C-III.
  • Lower abuse potential.

OIC & Reversal

• Narcan (Naloxone):
  • Indicated for opioid overdose.
  • A mu-opioid antagonist.
  • Not scheduled.
  • Short half-life.
  • Repeat dosing may be needed.
• Relistor (Methylnaltrexone):
  • Used for OIC.
  • A peripheral mu-antagonist.
  • Administered subcutaneously or orally.
  • Does not reverse central analgesia.
• Movantik (Naloxegol):
  • Indicated for OIC.
  • A peripheral mu-antagonist.
  • A CYP3A4 substrate.
  • Avoid strong inhibitors.

Expanded Asthma Drug Chart

Rescue & Maintenance Inhalers

• ProAir HFA (Albuterol):
  • Rescue inhaler (SABA).
  • A beta-2 agonist.
  • Use more than twice a week indicates poor asthma control.
  • May cause tremor and tachycardia.
• Ventolin HFA (Albuterol):
  • Rescue inhaler (SABA).
  • A beta-2 agonist.
  • Interchangeable with ProAir.
• Xopenex (Levalbuterol):
  • Rescue inhaler (SABA).
  • R-isomer of albuterol.
  • Fewer side effects but more costly.
• AirSupra (Budesonide + Albuterol):
  • Rescue combination inhaler.
  • Contains an ICS and SABA.
  • For adults only.
  • Maximum of 12 puffs per day.
• Symbicort (Budesonide/Formoterol):
  • Used for SMART therapy.
  • Contains an ICS and LABA.
  • Used for both rescue and maintenance.
• Dulera (Mometasone/Formoterol):
  • Maintenance inhaler.
  • Contains an ICS and LABA.
  • Not FDA-approved for SMART; maintenance only.
• Advair (Fluticasone/Salmeterol):
  • Maintenance inhaler.
  • Contains an ICS and LABA.
  • Not for SMART, as salmeterol is too slow for rescue.
• Breo Ellipta (Fluticasone/Vilanterol):
  • Maintenance inhaler.
  • Contains an ICS and LABA.
  • Dosed once daily.
• Trelegy Ellipta (Fluticasone/Umeclidinium/Vilanterol):
  • Maintenance inhaler (Triple therapy).
  • Contains an ICS, LAMA, and LABA.
  • Dosed once daily.
  • Not for children.

Biologics for Severe Asthma

• Dupixent (Dupilumab):
  • Indicated for eosinophilic or steroid-dependent asthma.
  • An IL-4/IL-13 antagonist.
  • Also used for eczema and nasal polyps.
• Nucala (Mepolizumab):
  • Indicated for eosinophilic asthma.
  • An IL-5 antagonist.
  • Administered subcutaneously every 4 weeks.
• Fasenra (Benralizumab):
  • Indicated for eosinophilic asthma.
  • An IL-5Rα cytolytic mAb.
  • Administered subcutaneously every 4 weeks for 3 doses, then every 8 weeks.
• Cinqair (Reslizumab):
  • Indicated for eosinophilic asthma.
  • An IL-5 antagonist.
  • Administered via IV infusion only; for adults ≥18.
• Xolair (Omalizumab):
  • Indicated for allergic asthma (IgE-based).
  • An anti-IgE mAb.
  • Dosed based on IgE levels and weight, every 2–4 weeks.
• Tezspire (Tezepelumab):
  • Indicated for severe asthma (including non-eosinophilic).
  • A TSLP blocker.
  • Works across phenotypes.
  • Administered subcutaneously every 4 weeks.

Additional Asthma Therapies

• QVAR RediHaler (Beclomethasone):
  • Maintenance inhaler (ICS).
  • A corticosteroid.
  • Rinse mouth after use.
• Pulmicort Flexhaler (Budesonide):
  • Maintenance inhaler (ICS).
  • A corticosteroid.
  • Also available as nebules for children.
• Alvesco HFA (Ciclesonide):
  • Maintenance inhaler (ICS).
  • A corticosteroid.
  • A prodrug; less thrush.
• Arnuity Ellipta (Fluticasone):
  • Maintenance inhaler (ICS).
  • A corticosteroid.
  • Dosed once daily.
• Spiriva Respimat (Tiotropium):
  • Add-on LAMA.
  • A muscarinic antagonist.
  • Used if ICS + LABA is not sufficient.
• Singulair (Montelukast):
  • Indicated for allergic asthma and rhinitis.
  • A leukotriene receptor antagonist.
  • Black Box Warning: neuropsychiatric events.
• Prednisone (Prednisone):
  • Used for exacerbations.
  • An oral corticosteroid.
  • Administered in burst doses.
  • Taper if used for more than 14 days.
• Methylprednisolone (Medrol):
  • Used for exacerbations.
  • A corticosteroid.
  • Used in hospital settings or as a burst dose.
• Magnesium sulfate (IV MgSO₄):
  • Used for severe exacerbations.
  • A Ca2+ antagonist (bronchodilation).
  • Used in ER/hospital settings for status asthmaticus.
• Ipratropium (Atrovent HFA):
  • Add-on rescue medication (nebulizer).
  • A SAMA – muscarinic antagonist.
  • Added to SABA for moderate-severe exacerbations.