Module 7 CNS Study Guide PDF

Module 7 Study Guide- CNS Module 7 Unit A Anxiolytics and Sedatives/Hypnotic Drugs 1. What are the six classifications of anxiolytics? SSRIs, SNRIs, Azapirones (Buspar), Benzodiazepines, Antihistamines, and β-blockers 2. Should benzodiazepines be prescribed for daily use for anxie...

Module 7 Study Guide- CNS Module 7 Unit A Anxiolytics and Sedatives/Hypnotic Drugs 1. What are the six classifications of anxiolytics? SSRIs, SNRIs, Azapirones (Buspar), Benzodiazepines, Antihistamines, and β-blockers 2. Should benzodiazepines be prescribed for daily use for anxiety? Why or why not? No, they should not be prescribed for long-term anxiety management. They are useful for an acute event, like anticipated flight anxiety/sleep or prn for a short period. Also used for bridging to long term therapy as it usually takes 2-3 weeks for SSRIs, SNRIs, or Buspar to kick in. Benzodiazepines (Ativan, Valium, Xanax)- work to calm or sedate by raising inhibitory GABA in the brain. They should NOT be prescribed for daily use; they are very physically addictive and discontinuation leads to withdrawal, possibly inducing seizures and severe anxiety, they must be tapered down over days or weeks if used chronically.  potential for abuse due to strong and fast onset of action. 3. What could happen if benzodiazepines are abruptly stopped after chronic use? Severe withdrawal, seizures, severe anxiety 4. What other drug class must be avoided in the use of benzodiazepines? ETOH and Opioids- CNS sedation, abuse potential, also be mindful of hx of SUD, BZDs have a high rate of abuse potential BBW- BZDs, Risks from concomitant opioid use; Addiction, abuse, and misuse; Dependence and withdrawal reactions 5. Rate the onset of action of benzos with the likelihood of abuse or dependence. The faster the onset of action of BZDs, the higher the risk for abuse/dependence. Alprazolam (Xanax) has the fastest onset of action and moderate half-life, so highest risk. Ativan takes a little longer but has a shorter half-life, and Valium takes the longest and lasts the shortest duration. Klonopin is preferred for anxiety, as it has a longer half-life; lorazepam and diazepam are also used. 1  6. Discuss SSRIs as a good choice for the relief of acute anxiety. SSRIs are the go-to drugs along with SNRIs for the long-term management of anxiety disorders, but they take several weeks to take effect; BZDs are a better choice for acute anxiety. 7. List two drug-to-drug interactions with Buspirone (BuSpar)? BuSpar has several D2D interactions: MAOIs CYP450 & 3A4 inhibitors: may reduce the clearance of BuSpar AUC CYP450 &3A4 inducers: - may  AUC 8. What is the abuse potential when using hydroxyzine (Vistaril) in the treatment of anxiety? No abuse concerns, it is an antihistamine 9. Which patients should avoid the use of hydroxyzine (Vistaril)? Those with concerns for anti-cholinergic SEs: elderly, BPH, glaucoma, etc. 10. How do Beta-Blockers work to reduce anxiety related to public speaking? Propranolol (Inderal) taken an hour before the event reduces symptoms and does not cause sedation. It competitively blocks beta-1 and beta-2 adrenergic stimulation in the heart induced by epinephrine and norepinephrine. Taken before anticipated anxiety (stage fright), it will help to relieve the catecholamine-mediated autonomic symptoms without sedation. *Practice taking B Blockers on a day before the event to ensure they are tolerated 11. Who should avoid Beta-Blockers? Those with cardiac issues or already taking β-blockers, may also avoid in those who use an EpiPen, as it may hinder effectiveness or cause SEs in the case of anaphylaxis 12. List drug-to-drug interactions associated with St. John’s Wort. St John’s Wort D2D interactions- inducer of CYP3A4, CYP450/ AUC of some medications SJW; also  medications due to  P-glycoprotein: drug excretion; also interacts with medications affecting neurotransmitters (serotonin etc.): Triptans BZDs  Warfarin  Contraceptives  Digoxin 2  SSRIs intensify serotonergic effects Antibiotics 13. What are the two agents recommended in the treatment of chronic insomnia? Chronic insomnia (> 2 months) recommended treatments: Lunesta (eszopiclone), Non-BZD, agonist on BZD receptor site on GABA- preferable safety profile SEs- drowsiness, dizziness, sleep driving, CNS depression, SI, withdrawal symptoms BBW- Complex sleep behaviors, including sleepwalking and driving while not fully awake, may occur. These events can result in serious injury Rozerem (ramelteon), Melatonin agonist- Activates melatonin receptors, used for difficulty with sleep onset SEs-  testosterone, prolactin, fatigue, dizziness 14. Discuss the required patient education that must be provided regarding sleep medications. Do not take it unless you have 7-8 hours to sleep Take on an empty stomach at least 30 minutes before bedtime Drugs with long half-lives (eszopiclone) are associated with a higher risk of next-day impairment Sleepwalking, sleep driving, sleep eating, and sleep sex have been reported with zolpidem and other "Z-drugs" Do not use with other CNS depressants or alcohol 15. Which anxiolytics are considered safe in pregnancy? H1 antihistamines are considered safe and fail to demonstrate significant risk of fetal malformations. 16. Which sleep medications are considered safe in pregnancy? Benadryl, H1 antihistamines are considered safe. (Ambien) is also a category C and non- benzodiazepine and may be used as a last resort for short-term treatment. Module 7 Unit B: Antidepressants and ADHD Drugs 1. What are the five classifications of antidepressants? What is the MOA of each? SSRIs, (Paxil, Celexa, Prozac, Zoloft)- Block the reuptake of serotonin, resulting in increased levels of serotonin in the synaptic site and  activation at post-synaptic serotonin receptors SNRIs, (Effexor, Cymbalta, Pristiq)- Boost serotonin and norepinephrine TCAs, (Elavil, Anafranil, Sinequan)- Block reuptake of norepinephrine and serotonin 3 MAO Inhibitors, (Marplan, Nardil)- Increase the amount of norepinephrine and serotonin for release by inhibiting MAO-A Atypical antidepressant, Bupropion (Wellbutrin)- Boosts norepinephrine and dopamine 2. How long does it take to see an initial response with antidepressants? How long for the full effect of antidepressants? 2-3 weeks for initial effect, 4-8 weeks for full effect 3. What are the two main determinants for which antidepressant to use? Are there any others? Two main determinants- (1) concurrent conditions, (2) attributes of depression. Fatigue as part of depression- activating Rx such as fluoxetine (Prozac) or an SNRI, (Effexor, Cymbalta) Depression and anxiety- SSRIs: paroxetine (Paxil) or escitalopram (Celexa) Depression with pain- pain relief with the use of SNRI: duloxetine (Cymbalta) or a TCA (Elavil) SNRI, Duloxetine (Cymbalta), helpful with stress urinary incontinence and the treatment of diabetic neuropathy Mirtazapine (Remeron), a TCA, may be a good option for patients with weight loss, anxiety, agitation, and insomnia. *Be certain you have ruled out bipolar disorder and hypothyroidism prior to prescribing any antidepressant. 4. What is serotonin syndrome? What causes it? Serotonin Syndrome is a rare but serious complication that occurs with the use of serotonergic agents resulting from overdose or drug-to-drug interactions. It is essential to review the current medication list before prescribing serotonergic drugs. S/sx- confusion, agitation, clonus, fever, tremor, or hyperreflexia; can result in respiratory failure and death. 5. How often should a patient be seen after initial treatment with antidepressants? Why? Usually 1-4 weeks, frequently thereafter, monitor for SI, then again after the medication has time to take full effect Is the med working, not working, or somewhat working?: Adjust dose, change med, refer See after every medication change Discuss possible sexual dysfunction SEs, common reason for people to stop, *Wellbutrin has fewer sexual SEs, but is contraindicated with seizures Adolescents- on an SSRI/SNRI, or other anti-depressants-  SI risk, need to follow up one week after initiation, then every week for a month, then every other week, and then less frequently based 4 on response and any side effects. This does not mean that there must be face-to-face contact, but there does need to be frequent contact. 6. What is the BBW for antidepressants? Who is at greatest risk? BBW- Suicide risk, especially early on, may increase antidepressant-induced suicide. This applies mostly to children and adolescents