Hypnotics and anxiolytics

sedation

Most anxiolytics (sedatives) will induce sleep when given at night and most hypnotics will sedate when given during the day. Prescribing of these drugs is widespread but dependence (both physical and psychological) and tolerance occurs. This may lead to difficulty in withdrawing the drug after the patient has been taking it regularly for more than a few weeks. Hypnotics and anxiolytics should, therefore, be reserved for short courses to alleviate acute conditions after causal factors have been established. Benzodiazepines are the most commonly used anxiolytics and hypnotics; they act at benzodiazepine receptors which are associated with gamma-aminobutyric acid (GABA) receptors. Older drugs such as meprobamate and barbiturates are not recommended—they have more side-effects and interactions than benzodiazepines and are much more dangerous in overdosage.

Hypnotics

Before a hypnotic is prescribed the cause of insomnia should be established and, where possible, underlying factors should be treated. However, it should be noted that some patients have unrealistic sleep expectations, and others understate their alcohol consumption which is often the cause of insomnia.

Chloral Hydrate:

Indications: General Anesthesia Adjunct, Insomnia, and Sedation in Pediatric Patients.

Contraindications: Esophagitis, Gastritis, Peptic Ulcer, Severe Hepatic Disease, Severe Renal Disease, Acute Intermittent Porphyria, Severe Cardiovascular Disease, Substance Abuse

Dose and Administration: chloral hydrate 200 mg/5mL (4%) in a suitable vehicle with a black currant flavor. Child 1 month–1 year 30–50 mg/kg, taken well diluted with water at bedtime. 1–12 years 30–50 mg/kg (max. 1 g), taken well diluted with water at bedtime.

Anxiolytics

Benzodiazepine anxiolytics can be effective in alleviating anxiety states. Although these drugs are often prescribed to almost anyone with stress-related symptoms, unhappiness, or minor physical disease, their use in many situations is unjustified. In particular, they are not appropriate for treating depression or chronic psychosis. In bereavement, the psychological adjustment may be inhibited

by benzodiazepines. In children, anxiolytic treatment should be used only to relieve acute anxiety (and related insomnia) caused by fear (e.g. before surgery). Anxiolytic treatment should be limited to the lowest possible dose for the shortest possible time. Dependence is particularly likely in patients with a history of alcohol or drug abuse and in patients with marked personality disorders.

Benzodiazepines

Benzodiazepines are indicated for the short-term relief of severe anxiety but long-term use should be avoided. In panic disorders (with or without agoraphobia) resistant to antidepressant therapy may be used; alternatively, a benzodiazepine may be used as short-term adjunctive therapy at the start of antidepressant treatment to prevent the initial worsening of symptoms.

DIAZEPAM:

Indications: short-term use of anxiety or insomnia, the adjunct to acute alcohol withdrawal; status epilepticus, febrile convulsions, muscle spasm, peri-operative use.

Contraindications: Lactating Mother, Myasthenia Gravis, Narrow Angle Glaucoma, Pregnancy, Respiratory Depression, Severe Hepatic Disease, Sleep Apnea, Alcohol Intoxication, Depression, Pulmonary Disease, Severe Chronic Obstructive Pulmonary Disease.

Dose and Administration: By mouth, anxiety, 2 mg 3 time’s daily increased if necessary to 15–30 mg daily in divided doses; elderly (or debilitated) half adult dose. Insomnia associated with anxiety, 5–15 mg at bedtime. By intramuscular injection or slow intravenous injection (into a large vein, at a rate of not more than 5 mg/minute), for severe acute anxiety, control of acute panic attacks, and acute alcohol withdrawal, 10 mg, repeated if necessary after not less than 4 hours

ALPRAZOLAM:

Indications: Anxiety, Anxiety with Depression, Generalized Anxiety Disorder, Panic Disorder and Insomnia.

Contraindications: Lactating Mother, Narrow Angle Glaucoma, Pregnancy, Alcohol Intoxication, CNS Depression, Depression, Fainting, Seizure Disorder, Sleep Apnea, Substance Abuse, Suicidal Ideation.

Dose and Administration: 250–500 micrograms 3 times daily (elderly or debilitated 250 micrograms 2–3 times daily), increased if necessary to a total of 3 mg daily; child not recommended.

LORAZEPAM:

Indications: short-term use of anxiety or insomnia, status epilepticus, and peri­operative

Contraindications: Alcohol Intoxication, Narrow Angle Glaucoma, Pregnancy, Respiratory Depression, Sleep Apnea, Depression, Fainting, Hepatic Encephalopathy, Severe Chronic Obstructive Pulmonary Disease, Severe Hepatic Disease.

Dose and Administration: By mouth, anxiety, 1–4 mg daily in divided doses; elderly (or debilitated) half adult dose.

BROMAZEPAM:

Indications:  used to relieve anxiety, nervousness, and tension.

Contraindications: Lactating Mother, Narrow Angle Glaucoma, Pregnancy, Alcohol Intoxication, CNS Depression, Depression, Fainting, Seizure Disorder, Sleep Apnea, Substance Abuse, Suicidal Ideation.

Dose and Administration: By mouth, anxiety, 6-18 mg daily in divided doses; elderly (or debilitated) half adult dose.

 

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