Day # 79: Review Quiz -> Anxiety Part 4

Today will be our fourth review quiz for the anxiety disorder theme and our last lesson during this section. Take a few minutes and check your retention.



1) Which of the following benzodiazepines would you want to avoid in a patient with significant liver disease?

a) Oxazepam (Serax)

b) Diazepam (Valium)

c) Lorazepam (Ativan)

d)Temazepam (Restoril)



2) Which of the following side effects is not commonly associated with buspirone?

a) Restlessness/Akathisia

b) Dizziness

c) Headache

d) Sexual dysfunction

e) Nausea


3) Choose the correct order of benzodiazepines arranged from longest to shortest half-life:

a) Lorazepam (Ativan) - Diazepam (Valium) - Triazolam (Halcion) - Chlordiazepoxide (Librium)

b) Alprazolam (Xanax) - Clonazepam (Klonopin) - Diazepam (Valium) - Lorazepam (Ativan)

c) Diazepam (Valium) - Chlordiazepoxide (Librium) - Lorazepam (Ativan) - Midazolam (Versed)

d) Midazolam (Versed) - Alprazolam (Xanax) - Clonazepam (Klonopin) - Diazepam (Valium)



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ANSWERS


Question 1:

From day #75


Answer: b

Diazepam (Valium) is commonly used to treat alcohol withdrawal but would not be a preferred choice in patients with significant liver disease.


Explanation:


Metabolism of BDZs:

  • Benzodiazepines are metabolized by the liver via the cytochrome P450 system. Most are metabolized by CYP3A4.

  • In chronic alcoholics or liver disease, use BDZs that have no active metabolites. Remember these. Hint: there are a LOT of them.

  • Lorazepam (Ativan)

  • Oxazepam (Serax)

  • Temazepam (Restoril)


Question 2:

From day #76


Answer: d

Sexual side effects.


Explanation:


Common side effects of buspirone include:

  • Dizziness

  • Headache

  • Nausea -> more likely if timing of dosing is inconsistent or in relation to food.

  • Sedation -> not common but also not unusual. Risk increases at higher doses but is usually mild/moderate.

  • Restlessness/Akasthisia -> (dopamine blockade)

  • Unlike most antidepressants (SSRIs, SNRIs, TCAs, MAOIs, etc) there are little to no sexual dysfunction, weight gain, or discontinuation syndrome.



Serious side effects of buspirone include:

  • Extrapyramidal symptoms (EPS): Due to dopamine blockade, EPS symptoms are possible. Akathisia has been seen. Other EPS symptoms are very rare but have been experienced, especially in overdose.

  • Serotonin syndrome: Rare but has been seen, especially in high doses or drug reaction.

  • Abuse/Dependence: Does not cause tolerance, dependence, or withdrawal. It also does not potentiate the sedative effects of alcohol, barbiturates, and benzodiazepines (does not act on GABA receptors).

  • Overdose: Symptoms include sedation, dizziness, nausea, vomiting, and constricted pupils. No evidence for significant lethality in overdose. No deaths have been reported in monotherapy overdose.



Question 3:

From day #72


Answer: c

The only answer that is correctly arranged from longest to shortest half life is :

Diazepam (Valium) - Chlordiazepoxide (Librium) - Lorazepam (Ativan) - Midazolam (Versed)


Explanation:


•Benzodiazepines are normally divided into groups based on their half-life. Choice of BDZ is based on time to onset of action, duration of action, and method of metabolism.


Long-Acting (Half-life > 20 hours)

  • Diazepam (Valium)

  • Rapid onset with long half-life 20-80 hours.

  • Common uses: alcohol detox and muscle spasms.

  • Less commonly prescribed for anxiety due to euphoria.

  • Clonazepam (Klonopin)

  • Half-life 18-50 hours.

  • Common uses: anxiety disorders (GAD and panic disorder) and REM sleep behaviors.

  • Chlordiazepoxide (Librium)

  • Half-life 5-30 hours.

  • Common uses: alcohol detox. Easy dosing schedule.


Intermediate Acting (Half-life: 6–20 Hours)

  • Alprazolam (Xanax)

  • Rapid onset with half-life 6-27 hours.

  • Common uses: anxiety disorders (GAD and panic disorder).

  • High levels of euphoria / potential for abuse.

  • In my experience it is often prescribed by PCPs but avoided by psychiatrists.

  • Lorazepam (Ativan)

  • Relatively quick onset with half-life 10-20 hours.

  • Common uses: alcohol detox, panic attacks, agitation, and catatonia.

  • Safe in chronic alcoholics and liver disease.

  • Oxazepam (Serax)

  • Half-life 5-15 hours.

  • Common uses: alcohol detox.

  • Safe in chronic alcoholics and liver disease.

  • Temazepam (Restoril)

  • Half-life 7-11 hours.

  • Common uses: insomnia (although less commonly used now since the z-drugs were developed)

  • Safe in chronic alcoholics and liver disease.


Short Acting (Half-life: <6 Hours)

  • Midazolam (Versed)

  • Half-life 1-6 hours.

  • Common uses: acute agitation, also used in medical and surgical settings such as anesthesia induction.

  • Triazolam (Halcion)

  • Half-life 2-5 hours.

  • Common uses: insomnia (although less commonly used now since the z-drugs were developed)

  • Elevated risk of anterograde amnesia and sleep-related activities such as sleep-walking, eating, driving, etc.



CONCLUSION


Nice work. You have now finished the anxiety disorders theme. If you want to see all of the weekly quizzes you can see them here. Next theme we will cover content related to emergency psychiatry.

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