anxiolytics

Question 1

Anxiety Disorders Based on DSM-5

Answer 1

• Generalized Anxiety Disorder (GAD)
• Panic Disorder (PD)
• Social Anxiety Disorder (SAD)
• Other

Question 2

Disease Overlap mdd and anxiety

Answer 2

5HT Common Link

Question 3

Generalized Anxiety Disorder symptoms

Answer 3

• Excessive anxiety or worry
• Muscle tension
• Restlessness
• Fatigue
• Impaired Concentration
• Irritability
• Insomnia

Question 4

Panic Disorder symptoms

Answer 4

• Recurrent unprovoked panic attacks
  – Shortness of breath
  – Dizziness or faintness
  – Palpitations
  – Sweating
  – Trembling or shaking
  – Nausea
  – Dizziness
  – Paresthesias
  – Hot flashes or chills
  – Chest pain
  – Feelings of choking
  – Discomfort or fear

can lead to agoraphobia

Question 5

Social Anxiety Disorder symptoms

Answer 5

Fear or anxiety about social situations
– Concern regarding scrutiny
from others
– Concern regarding
humiliation
embarrassment
– Fear of rejection
– Concern regarding
offending others

earliest onset

Question 6

1st line tx of GAD

Answer 6

SSRI, SNRI, pregabalin

BZD short term

Question 7

1st line panic disorder

Answer 7

SSRI and SNRI

BZD short term

Question 8

SAD 1st line tx

Answer 8

SSRI

Question 9

Side Effects Important in Dentistry
(SSRI)

Answer 9

• Increased risk for
  bleeding and bruising
• Bruxism

Question 10

SSRI Drug Interaction with NSAID

Answer 10

Pharmacodynamic interactions
– SSRI – decrease platelet aggregation
* INCREASED RISK FOR BLEEDING

Question 11

SSRI Drug Interactions with Opioid Medications

Answer 11

• Pharmacokinetic interaction
• Drugs that INHIBIT CYP450 2D6
  PREVENT the metabolism of
  codeine, hydrocodone and
  oxycodone to an active medication.
• OUTCOME: pain relieving effects
  are REDUCED
• Antidepressants
  – Paroxetine (Paxil)
  – Fluoxetine (Prozac)

(codeine, hydrocodone and oxycodone)

Question 12

Pregabalin (Lyrica) and Gabapentin
(Neurontin) strucutre

Answer 12

affect GABA

Question 13

Pregabalin moa

Answer 13

affect GABA receptor, likely increase GABA but unknown

technically unknown

Question 14

Pregabalin
* FDA approved uses

Answer 14

• FDA approved uses include postherpetic neuralgia, neuropathic pain due to diabetic peripheral neuropathy and spinal cord injury, seizures, and fibromyalgi

Question 15

pregabalin first line for?

Answer 15

GAD

Question 16

pregabalin common side effects

Answer 16

Common side effects: dizziness, sedation, ataxia, blurred vision, and weight gain
] No life-threatening side effects

Question 17

pregabalin oral effects?

Answer 17

none

Question 18

pregabalin OD

Answer 18

safe

Question 19

Pregabalin interactions

Answer 19

none

Question 20

Gabapentin
* FDA approved uses?
* Used off-label ?
* Limited evidence ?

Answer 20

• FDA approved uses include postherpetic neuralgia and seizures
• Used off-label for anxiety – both scheduled and prn
• Limited evidence for use in anxiety

Question 21

gabapentin moa

Answer 21

unknown

Question 22

gabapentin common side effects?

Answer 22

• Common Side Effects
  – Dizziness, sedation and ataxia
• No life-threatening side effects

Question 23

gabapentin oral effects

Answer 23

none

Question 24

gabapentin OD

Answer 24

safe

Question 25

# gabapentin interactions

Answer 25

none

Question 26

Buspirone (Buspar) * Mechanism of Action

Answer 26

– 5-HT1A partial agonist stablize 5ht levels (increase in low areas and decrease where too high)

Question 27

Buspirone (Buspar) * Uses

Answer 27

– FDA approval for GAD (not recommend as first line therapy) – Used as adjunctive therapy with an antidepressant for treatment refractory depression

Question 28

Buspirone: *abuse/withdraw? * Onset of action ? * OD * ddi

Answer 28

* NO abuse or withdrawal potential * Onset of action 4-6 weeks * Safe in overdose situations * Low risk for drug interactions

Question 29

Buspirone Side Effects

Answer 29

* Generally well tolerated – GI complaints – Sedation – Insomnia – Agitation – Headache – Weakness – Dizziness – No serious side effects – No oral side effects

Question 30

Role of Benzodiazepines (BZD) in the Treatment of Anxiety Disorders and Other Conditions * Common Uses

Answer 30

– Panic attacks (acute treatment only - NOT panic disorder) – Anxiety (short-term treatment only) – Seizures – Insomnia – Muscle relaxant – Acute alcohol withdrawal – Acute mania – Acute agitation prn night before procedures

Question 31

BZD moa

Answer 31

binds GABA A= increases Cl | agonist

Question 32

what substances can affect GABA-A

Answer 32

Question 33

GABA agonists effects

Answer 33

* anxiolytic * sedative hypnotic * muscle relaxant * anticonvulsant * amnestic * dependency | BZDs

Question 34

GABA partial agonists effects

Answer 34

anxiolytic only

Question 35

GABA antagonists effects

Answer 35

none

Question 36

GABA partial inverse agonist effects

Answer 36

promnestic (memory enhancing) anxiogenic

Question 37

# GABA inverse agonist effect

Answer 37

promnestic anxiogenic pro-convulsant

Question 38

Midazolam (Versed) * onset * duration * use

Answer 38

Rapid Ultrashort Anesthetic

Question 39

Triazolam (Halcion) * onset * duration * use

Answer 39

Rapid Ultrashort Hypnotic

Question 40

Alprazolam (Xanax) * onset * duration * use

Answer 40

Rapid Short Anxiolytic

Question 41

Diazepam (Valium) * onset * duration * use

Answer 41

Rapid Long Anxiolytic, Muscle relaxant, ETOH withdrawal, Anticonvulsant

Question 42

Lorazepam (Ativan) * onset * duration * use

Answer 42

Intermediate Medium Anxiolytic, Hypnotic, ETOH withdrawal, Anticonvulsant

Question 43

BZD Side Effects Common

Answer 43

* Drowsiness * Sedation * Psychomotor impairment * Blurred vision * Ataxia * Daytime sedation * Impairment in memory and recall | like being drunk

Question 44

BZD Side Effects Less Common

Answer 44

* Disorientation * Aggression * Confusion * Paradoxical Excitation

Question 45

BZD oral Side Effects

Answer 45

none

Question 46

BZD with CNS depressants

Answer 46

Synergistic effect with other CNS depressants – Alcohol – TCA – Barbiturates – Pain Medication (Opioids/Opiates)

Question 47

what is depressed in BZD OD

Answer 47

CNS and respiratory depression in overdose

Question 48

BZD ddi

Answer 48

Risk for pharmacokinetic and pharmacodynamic drug interactions

Question 49

BZD tolerance

Answer 49

Tolerance develops to sedative/hypnotic effect – Tolerance does NOT develop for other uses * anticonvulsant, anxiolytic, muscle relaxant

Question 50

BZD Abuse * All benzodiazepines have the potential for? * Benzodiazepines with what property are more likely to be abused? likely agents? * Use with caution in patients with a history of? * Use with extreme caution in combination with??

Answer 50

* All benzodiazepines have the potential for abuse * Benzodiazepines with a “quick” onset of action are more likely to be abused – **alprazolam, diazepam** * Use with caution in patients with a history of substance abuse, can develop dependence * Use with extreme caution in combination with pain medications (opioids)

Question 51

Drug Interactions with BZD

Answer 51

* BZD + CNS Depressants (ex. opioid pain medication) = additive CNS depressant effects

Question 52

Propranolol (Inderal) * FDA approved uses

Answer 52

* FDA approved uses include HTN, angina pectoris, atria; fibrillation, myocardial infarction, migraine prophylaxis, essential tremor, hypertrophic subaortic stenosis, pheochromocytoma

Question 53

Propranolol (Inderal) off label use

Answer 53

Used off-label for “performance” anxiety

Question 54

Propranolol moa

Answer 54

nonselective beta- adrenergic receptor blocking agent

Question 55

Propranolol common side effects

Answer 55

* Dizziness, weakness and fatigue * No life-threatening side effects

Question 56

propranolol oral effects

Answer 56

none

Question 57

propranolol od

Answer 57

Overdose – hypotension and bradycardia

Question 58

propranolol ddi

Answer 58

High risk for drug interactions

Question 59

which BZD has a long duration

Answer 59

diazepam

Question 60

which BZD has an intermediate onset

Answer 60

lorazepam