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It is believed that long-term potentiation in induce drowsiness and promote sleep generic 50 mg cozaar with mastercard managing diabetes 95. This latter action is amygdala neurons establishes the memory of adverse events caused by a greater depression of central nervous system underlying anticipatory anxiety buy 50 mg cozaar mastercard diabetes symptoms urination. A few agents trusted 50 mg cozaar diabetes test in doctors office, however, exert anxiolytic effects of Anxiety Disorders without causing sedation or hypnosis. The appropriate management of anxiety disorders requires This chapter describes the pharmacologic properties of an accurate diagnosis, and treatment may involve the use of benzodiazepines, barbiturates, and other sedative-hypnotic pharmacologic agents, psychotherapy, or both. Because of their greater safety, fewer Acute Anxiety adverse effects, and the availability of an antagonist, the Acute anxiety may develop in response to various factors, benzodiazepines have largely replaced the older barbiturates such as illness, separation from loved ones, or the anticipa- for these indications. Acute anxiety is often self-limiting 186 Chapter 19 y Sedative-Hypnotic and Anxiolytic Drugs 187 and may resolve in a few weeks to a few months without venlafaxine and duloxetine (see Chapter 22), are also used drug treatment. During a panic attack, an individual may feel an Other medications, such as benzodiazepines, may also be impending sense of doom that is often accompanied by used to treat associated symptoms, such as an exaggerated sweating, tachycardia, tremor, and other visceral symptoms. Five panic attacks during the early phase of therapy, and alpra- distinct patterns of brainwave activity occur during sleep, zolam and clonazepam are benzodiazepines that have grouped into the four stages of non-rapid eye movement been particularly useful in this regard. As an individual falls asleep, the high-frequency and low- Phobic Disorders amplitude activity of the alert state gradually diminishes Phobic disorders can be grouped into specifc phobia, social during stages 1 and 2 and is replaced by the low-frequency anxiety disorder (social phobia), or agoraphobia. Phobias are and high-amplitude activity of slow-wave sleep (stages 3 conditions in which an individual is overly fearful about a and 4). A normal adult cycles through the sleep which it might be diffcult or embarrassing to cope with a stages about every 90 minutes (Box 19-1). As with panic dis- order, phobic disorders are treated with a benzodiazepine Neurologic Basis of Sleep or an antidepressant drug. Benzodiazepines provide acute The neuronal systems involved in sleep include the basal relief of symptoms and enable patients to more easily beneft forebrain nuclei and the reticular formation. Projecting from psychotherapy, whereas antidepressants are usually the from the basal forebrain to the cortex are cholinergic fbers most effective long-term drug therapy for agoraphobia and that are believed to be involved in the induction of sleep. Propranolol is useful in the prevention of The basal forebrain is the only region of the brain that is stage fright, or acute situational or performance anxiety. The reticular formation facilitates the fow of sensory infor- Obsessive-Compulsive Disorder mation from the thalamus to the cortex. Some patients with insomnia fnd it diffcult to go to sleep or to stay asleep during the night, whereas others awaken Generalized Anxiety Disorder too early in the morning. As Short-term therapy with a benzodiazepine may relieve shown in Box 19-1, the patterns of sleep stages in patients acute symptoms and provide a useful bridge to psycho- with insomnia are irregular and include longer latency to fall therapy. Buspirone, a nonsedating anxiolytic, pro- More severe insomnia caused by medical conditions whose vides a useful alternative to benzodiazepines for the treat- symptoms interfere with sleep is effectively treated with ment of chronic anxiety states, because it produces little benzodiazepines or other sedative-hypnotic drugs, such as sedation and is not associated with tolerance or dependence. As the cycles progress through the night, they become called paradoxical sleep because it is during this stage that shorter, and the amount of slow-wave sleep decreases. Elderly adults often have a similar sleep sleep and by one or more awakenings during the night. In contrast, zolpidem, zaleplon, eszopi- better restore the sleep pattern to normal. Very fast, <15 min; fast, 15-59 min; slow, 1-4 hr; very slow, 3-4 weeks; short, 1-6 hr; medium, 7-12 hr; and long, >12 hr. The newest agents, zolpidem, The sedative-hypnotic drugs include benzodiazepines, bar- zaleplon, eszopiclone, and ramelteon, have the advantages of biturates, some antihistamines, and a few nonbenzodiaz- not signifcantly affecting sleep architecture and not causing epine agents, such as zolpidem, zaleplon, eszopiclone, and as much tolerance and dependence as do the older drugs. The properties of these drugs are summarized For these reasons, zolpidem, zaleplon, eszopiclone, and in Table 19-1, and their adverse effects and drug interactions ramelteon have become the drugs of choice to treat most are listed in Table 19-2. Because the benzodiazepines have fewer adverse reactions and drug interactions and are safer in cases of overdose, they Other Sleep Disorders have largely replaced the barbiturates and other older drugs. Other sleep disorders include hypersomnia (diffculty in Nevertheless, barbiturates are still used when benzodiaze- awakening), narcolepsy (sleep attacks), enuresis (bedwet- pines are ineffective or contraindicated. The sedating anti- ting during sleep), somnambulism (sleepwalking), sleep histamines are occasionally used to treat mild insomnia and apnea (episodes of hypoventilation during sleep), and night- anxiety and have less potential for abuse than do benzodi- mares and night terrors. As the plasma concentration of a benzodiazepine drugs is largely determined by their pharmacokinetic prop- declines, the drug is redistributed from the brain to the erties and route of administration.
Because blacks have a high incidence of salt sensitivity and cigarette use cheap cozaar 50 mg on line diabetes prevention program billings mt, lifestyle modifications are an important component of treatment buy cheapest cozaar and cozaar diabetes vaccine. Controlled trials have shown that diuretics can decrease morbidity and mortality in blacks purchase 25mg cozaar free shipping diabetes insipidus nursing management. The incidence of secondary hypertension in children is much higher than in adults. Accordingly, efforts to diagnose and treat an underlying cause should be especially diligent. For children with primary hypertension, treatment is the same as for adults—although doses are lower and should be adjusted with care. Although the newer guidelines may be more lax, they do not serve as a substitute for clinical judgment. Pregnant women Drugs of choice in treating pregnant women with mild preeclampsia include labetalol and methyldopa. Magnesium sulfate is used in the prevention of seizures in severe preeclampsia or for treatment of seizures in eclampsia. Beta blockers, such as women metoprolol, appear safe for the breastfeeding infant. Caution must be taken to avoid overdiuresis when using diuretics in the older-adult population. Because cardiovascular reflexes are blunted in older adults, treatment carries a significant risk of orthostatic hypotension. Accordingly, initial doses should be low—about one-half those used for younger adults—and dosage escalation should be done slowly. Minimizing Adverse Effects Antihypertensive drugs can produce many unwanted effects, including hypotension, sedation, and sexual dysfunction. Simply put, if one drug causes effects that are objectionable, a more acceptable drug should be substituted. The best way to identify unacceptable responses is to encourage patients to report them. Adverse effects caused by exacerbation of comorbid diseases are both predictable and avoidable. Other conditions that can be aggravated by antihypertensive drugs are listed in Table 39. To help avoid drug-disease mismatches, the medical history should identify all comorbid conditions. With this information, the prescriber can choose drugs that are least likely to make the comorbid condition worse. High initial doses and rapid dosage escalation can increase the incidence and severity of adverse effects. Promoting Adherence The major cause of treatment failure in patients with chronic hypertension is lack of adherence to the prescribed regimen. In this section we consider the causes of nonadherence and discuss some solutions. Why Adherence Is Often Hard to Achieve Much of the difficulty in promoting adherence stems from the nature of hypertension itself. Hypertension is a chronic, slowly progressing disease that, through much of its course, is devoid of overt symptoms. Because symptoms are absent, it can be difficult to convince patients that they are ill and need treatment. In addition, because there are no symptoms to relieve, drugs cannot produce an obvious therapeutic response. In the absence of such a response, it can be difficult for patients to believe that their medication is doing anything useful. Because hypertension progresses very slowly, the disease tends to encourage procrastination. For most people, the adverse effects of hypertension will not become manifest for many years. Realizing this, patients may reason (incorrectly) that they can postpone therapy without significantly increasing risk. Lastly, antihypertensive drugs can cause a number of adverse effects, ranging from sedation to hypotension to impaired sexual function.
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