Introduction to Clinical Pharmacology Chapter 20 Antianxiety Drugs

Introduction to Antianxiety Drugs Antianxiety drugs or anxiolytics Benzodiazepines: long-term use can result in physical dependence or psychological addiction Can be given intramuscularly, intravenous, or orally Nonbenzodiazepines: useful antianxiety drugs

Antianxiety Drugs: Actions Anxiolytic drugs: block neurotransmitter receptor sites Benzodiazepines: potentiate effects of gamma-aminobutyric acid an inhibitory neurotransmitter which decreases the neuron’s action potential and therefore neurons will not get excited; examples are alprazolam, chlordiazepoxide, lorazepam, clonazepam, clorazepate, diazepam, and oxazepam Nonbenzodiazepines: exert effect in various ways examples are: doxepin Buspirone: acts on serotonin receptors Hydroxyzine: acts on hypothalamus and brainstem reticular formation

Antianxiety Drugs: Uses Isolated episodes of intense anxiety Temporary use for those with severe functional impairment such as panic attacks Preanesthetic sedatives, muscle relaxants Convulsions or seizures Alcohol withdrawal

Antianxiety Drugs: Adverse Reactions Early reactions: mild drowsiness or sedation, lightheadedness or dizziness, and headache Other adverse body system reactions: Lethargy, apathy, fatigue Disorientation, anger, restlessness Nausea, constipation or diarrhea, dry mouth Visual disturbances

Antianxiety Drugs: Dependence Long-term use: results in physical drug dependence and tolerance and more likely can happen with benzodiazepines such as alprazolam or chlordiazepoxide among the other benzodiazepines Withdrawal symptoms may occur with as few as 4 to 6 weeks of therapy with benzodiazepines Nursing Alert Symptoms of benzodiazepine withdrawal: increased anxiety and panic, tremors, fatigue, hypersomnia and nightmares, metallic taste, concentration difficulties, headache, tinnitus, numbness in the extremities, tachycardia, hypertension, nausea, vomiting, diarrhea, fearing, sweating, muscle tension, aching and cramps, psychoses and hallucinations, agitation, memory impairment, and possible convulsions

Antianxiety Drugs: Contraindications Patients: hypersensitivity, psychoses, and acute narrow-angle glaucoma During pregnancy (category D) and labor due to floppy infant syndrome manifested by sucking difficulties, lethargy, hypotonia in the newborn Lactating women In patients in coma or shock or if vital signs of patient in acute alcoholic intoxication are low

Antianxiety Drugs: Precautions Used cautiously with elderly patients and patient-impaired: Liver function Kidney function Debilitation

Antianxiety Drugs: Interactions Interactant drug Effect of interaction Alcohol Increased risk for central nervous system (CNS) depression or convulsions Analgesics Increased risk for CNS depression Tricyclic antidepressants, antipsychotics Increased risk for sedation and respiratory depression Digoxin Increased risk for digitalis toxicity

Nursing Process: Assessment #1 Preadministration assessment Nurse obtains medical history, mental status exam, anxiety level and medication history before initiating therapy Physical assessment, physiologic manifestations of anxiety such as tenseness, extreme restlessness, or grimacing of face, inability to focus; skin would feel cool and appear pale, may find vital signs are elevated Assess and record blood pressure, pulse, respirations, and weight

Nursing Process: Assessment #2 Ongoing assessment Check blood pressure before drug administration Periodically monitor mental status and anxiety level Ask patient or family about adverse effects of drug Document general summary of patient’s outward behavior, complaints, or problems

Nursing Process: Nursing Diagnosis and Planning Nursing diagnoses Risk for Injury related to dizziness or hypotension and gait problems Impaired Comfort related to dryness in gastrointestinal (GI) tract from medications Ineffective Individual Coping related to situation causing anxiety Expected patient outcome: optimal response to drug therapy, knowledge of and compliance with prescribed therapeutic regimen, managing adverse drug reactions

Nursing Process: Implementation #1 Promoting an optimal response to therapy During initial therapy the nurse observes for adverse drug reactions The antianxiety drugs are not recommended for long-term use If used for short periods (1 to 2 weeks), tolerance, withdrawal, and dependence do not usually develop Report

Nursing Process: Implementation #2 Monitoring and managing patient needs: Risk for injury During outpatient therapy the nurse should instruct the family and patient about adverse reactions Gerontologic alert: Lorazepam and oxazepam and buspirone are safer for the geriatric patient and likely to cause less sedation therefore less risk of falling Nursing care plan- would be a priority in the care of patient receiving a benzodiazepine due to dizziness and lightheadedness

Nursing Process: Implementation #3 Monitoring and managing patient needs (cont.) Monitoring Instruction Sedation, drowsiness Intramuscular administration -done primarily in an acute state; monitored for at least 3 hours and should be kept lying down for 30 minutes to 3 hours after administration. When administered to older patient need to assure have resuscitative equipment handy in case of apnea or cardiac arrest Parenteral administration given in large muscle

Nursing Process: Implementation #4 Impaired comfort Cause Nursing interventions Administer Meals include fiber, fruits, and vegetables to aid in preventing constipation because can slow down the intestinal movement Careful with oral route due to dry mouth causing swallowing problems may advise to use hard sugarless candy to help

Nursing Process: Implementation #5 Ineffective individual coping Outpatient: the nurse observes the patient for response to therapy at time of each clinic visit Question about response to therapy; use open-ended questions Once anxiety reduced the nurse may be able to help patient identify precipitation of panic/cause of anxiety

Nursing Process: Implementation #6 Ineffective individual coping (cont.) Important to help patient understand there are health care providers who can help them gain coping skills Benzodiazepine toxicity Flumazenil-is antidote for benzodiazepine overdose or toxicity Adverse reactions to flumazenil include agitation, confusion, seizures, and, in some cases, symptoms of benzodiazepine withdrawal, relieved with administration of benzodiazepine

Nursing Process: Implementation #7 Educating the patient and family The nurse needs to evaluate the patient’s ability to assume responsibility for taking the drugs at home The nurse explains adverse effects of specific drugs and encourages the patient and family to contact primary health care provider if serious adverse effects occur

Nursing Process: Implementation #8 Educating the patient and family (cont.) Teaching plan: Take drug as directed Avoid performing hazardous tasks, alcohol Do not discontinue drugs abruptly will need to gradually decrease dosage over time Do not take OTC drugs or supplements without consulting primary health care provider Inform dentist, physicians, and health care providers of your therapy

Nursing Process: Implementation #9 Educating the patient and family (cont.) Teaching plan (cont.) If dizziness occurs when changing positions do so slowly; if severe, ask for help Eat food rich in fiber and increase fluid intake to prevent constipation Keep all appointments with primary health care provider Report any unusual changes

Nursing Process: Implementation #10 Evaluation Therapeutic effect achieved Patient reports decrease in feelings of anxiety Adverse reactions identified, reported to health care provider Verbalize importance of complying with prescribed therapeutic regimen

Question #1 Is the following statement true or false? Anxiety involves a feeling of apprehension, worry, or uneasiness that may or may not be based on reality.

Answer to Question #1 True Anxiety involves a feeling of apprehension, worry, or uneasiness that may or may not be based on reality. Anxiety is a normal feeling, yet as anxiety increases it can interfere with day-to-day functioning. Because it is a subjective feeling, patients can be asked to rate anxiety similar to rating pain.

Question #2 Is the following statement true or false? Benzodiazepines and nonbenzodiazepine anxiolytics are used to treat anxiety on a long-term basis.

Answer to Question #2 False Benzodiazepines and nonbenzodiazepine anxiolytics are used to treat anxiety on a short-term basis. Physical and psychological dependence can occur with the use of these drugs; typically, psychiatric anxiety disorders (that need long-term treatment) use antidepressants for treatment instead of benzodiazepines.

Question #3 Is the following statement true or false? Benzodiazepine doses should always be tapered and never stopped abruptly; withdrawal can occur with symptoms such as a return of anxiety, concentration problems, tremors, and sensory disturbances.

Answer to Question #3 True Benzodiazepine doses should always be tapered and never stopped abruptly; withdrawal can occur with symptoms such as a return of anxiety, concentration problems, tremors, and sensory disturbances.