1. Introduction to Clinical Pharmacology Chapter 20 Antianxiety Drugs

2. 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

3. 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

4. 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

5. 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

6. 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

7. 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

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

9. 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

10. 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

11. 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

12. 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

13. 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

14. 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

15. 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

16. 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

17. 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

18. 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

19. 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

20. 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

21. 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

22. 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

23. 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.

24. 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.

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

26. 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.

27. 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.

28. 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.