SEDATIVES

1. Kl is a 34 yo male with bipolar disease. He has been taking Lithium for 4 years. What is the therapeutic blood
level one aims for when taking this medication? What is your responsibility when the level is above or below
that range? TL is between 0.6-1.2 mEq/L. after checking dose 8-12 hrs after the last dose, if it’s too high make
sure to stop the med & assess any toxicity rxns. If too low, perhaps increase dose but has be done carefully to
make sure no toxicity occurs.

2. When educating a patient and or family about lithium, what are the signs and symptoms they should be told
to look for that may signify the Lithium level is too high? Pts need to be told to watch out for resting tremors (
as levels increase the greater the tremors are), ataxia, confusion, GI issues (diarrhea), hypo & hyper thyroidism
with long term use, diabetes insipidus (monitor sodium levels), coma, seizures, neuro dysfxn, sedation, and
interstitial nephritis.

3. Kl was recently admitted to the hospital with lithium induced diabetes insipidus. What are the s/s he was
most likely experiencing? Diabetes insipidus is an uncommon condition in which the kidneys are unable to
prevent the excretion of water therefore causing hypernatremia. These pts experience extreme thirst.

4. PY has been on lithium for 2 years and was recently started on a thiazide diuretic for HTN. Is there any
interaction between the 2 meds? If so what is the interaction? Yes there is an interaction. Thiazide diuretics
increase lithium levels increasing the risk for lithium toxicity.

5. Which class of medications work similar to naturally occurring GABA? Barbiturates, Benzodiazepines, alcohol

6. LK is to be started on lorazepam for anxiety. What should the patient be educated about? Pt should be warned
about its adverse effects which include,
a. Decreased CNS activity, sedation
b. impaired psychomotor skills, cognitive dysfunction, short-term memory impairment, low-grade coma
c. Drowsiness, loss of coordination, dizziness, headaches
d. Hypotension
e. Nausea, vomiting, dry mouth, constipation
f. Resp depression when used with other meds that can cause it

7. Which Benzodiazepine should not be given IM and why? Diazepam should not be administered IM. This drug is
no longer a good med for anxiety; it is used from muscle pain, acute seizures, alcohol withdrawal, etc. Avoid IM
because it has active metabolites that can accumulate in pts (with hepatic dysfxn). It is also the longest acting-
eratic absorption

8. Which has the longest duration with respect to clinical effects (sedation, calming, etc) alprazolam vs diazepam
vs lorazepam? Alprazolam is the shortest acting, whereas diazepam is the longest acting.

9. What is the primary role for chlordiazepoxide? It is a benzo and is primarily used for alcohol withdrawal

10. Why should benzodiazepines be avoided in one that has recently drank alcohol? Because these result in
additive CNS depression- resp dep and can lead to death- additive effects

11. What are the indications for a barbiturate? This class of meds can be used as hypnotics, sedatives,
anticonvulsants, and anesthesia for surgical procedures. These are no longer used for sleep.

12. When prescribing a non-benzodiazepine receptor agonist for sleep what are your choices?
i. Zalepion (Sonata)
ii. Zolpidem (Ambien)-short acting- not helpful for ppl w/ problems staying asleep, helps fall asleep
1. Extended Release zolpidem (ambien CR) is approved for long term therapy
 iii. Eszoplicone (Lunesta)- better for staying asleep- approved for long term therapy
1. Study of Lunesta (eszopiclone): previously recommended dose of 3 mg
a. impaired driving skills, memory, and coordination
b. can last more than 11 hours after evening dose
iv. Ramelteon (Rozerem): works by activating melatonin receptors → endogenous melatonin
induces sleepiness
1. Does not cause CNS depression
2. No potential for abuse
3. No withdrawal S/S

13. LK is in the hospital and you have bene told he has insomnia. Why does it matter if he has trouble staying
asleep vs falling asleep? To know which drug to rx him. Some drugs help falling asleep quicker but do not help in
staying asleep. I.e.- Zolpidem (Ambien). Others are better at keeping the pt asleep, i.e.- Eszolicone (Lunesta).

14. Should zolpidem be avoided in one that has sleep apnea? Why? No. Zolpidem has been shown to be effective
under these circumstances and are believed to work by consolidating the sleep pattern, thus minimizing the
instability in ventilation induced by sleep-wake transitions. A case series showed zolpidem reduced central
apneas, and the overall apnea-hypopnea index, without worsening obstructive events.

15. Who is at risk of developing respiratory depression when taking a sedative hypnotic like Zaleplon? Pts who are
currently taking opioids, pts who consume alcohol, etc.

16. What is the risk if one abruptly stops lorazepam after it has been used 3 times a day for the last 2 years?
People who wish to stop using benzodiazepines after using them regularly over a longer term will need to cut
back their use gradually over an extended period of time to reduce withdrawal effects and help ensure success
in stopping. Benzodiazepine withdrawal is characterized by sleep disturbance, irritability, increased tension and
anxiety, panic attacks, hand tremor, sweating, difficulty with concentration, confusion and cognitive difficulty,
memory problems, dry retching and nausea, weight loss, palpitations, headache, muscular pain and stiffness, a
host of perceptual changes, hallucinations, seizures, psychosis, and suicide

17. What are the signs and symptoms of a diazepam OD? Is it similar to that seen with the use of beer? An OD of a
benzo may result in the following sxs somnolence, confusion, coma, & respiratory depression. Yes it is similar to
that of beer since these receptors are near each other. That is why when used together, it causes an additive
effect

18. Why is the role of flumazenil? It is used to reverse benzodiazepine effects- benzo antagonist