Sedative-Hypnotic Drugs

Which statement is true regarding the safety of benzodiazepines use?

1) it has a lower potential for abuse than other CNS depressants 2) it produces less tolerance and physical dependence than other cns depressants 3) it has fewer drug interactions than other cns depressants

A patient is prescribed zolpidem and asks how long it will take to start feeling drowsy. What is the appropriate nursing response?

30 minutes

Dosage and Administration of Benzodiazepines (Diazepam)

Diazepam can be administered orally, intramuscularly, or intravenously depending on the purpose of administration and the age of the patient. Diazepam can also be administered in the form of a rectal gel.

Dosage

Dosage and Administration of Benzodiazepines (Diazepam) Diazepam can be administered orally, intramuscularly, or intravenously depending on the purpose of administration and the age of the patient. Diazepam can also be administered in the form of a rectal gel. Dosage Anxiety PO Adults: 2-10 mg 2-4 times a day. Older adults: Initially, 1-2 mg 1-2 times a day. Children: 0.12-0.8 mg/kg/day in divided doses q6-8h. IV, IM Adults: 2-10 mg; may repeat in 3-4 hours if needed. Children: N: 0.04-0.3 mg/kg/dose q2-4h. Maximum: 0.6 mg/kg within 8-hour period.

A patient is newly prescribed a benzodiazepine, and the nurse informs the patient about the potential for daytime sedation. What does the nurse tell the patient to avoid until the drug response is established?

Driving

Interactions

Drug Interactions: Alcohol CNS depressants Herbal Interactions: Gotu kola and kava kava can further depress the respiratory system when taken with benzodiazepines-like drugs Valerian may increase CNS depression St. John's wort may decrease concentration/effect Food Interactions: None known Lab Values: None significant

Adverse Effects of Benzodiazepine-Like Drugs

Adverse effects of zolpidem are minimal. Unless high doses are taken for prolonged periods of time, zolpidem is not associated with tolerance, abuse, or dependence. Zolpidem should not be combined with alcohol or other CNS depressants. Complex sleep-related behaviors can occur, such as driving without recollection of being behind the wheel of a vehicle. Report these conditions to the health care provider immediately. Overdose of zolpidem can result in ataxia, bradycardia, diplopia, severe drowsiness, difficulty breathing, nausea, vomiting, and possible coma. Suddenly stopping zolpidem after long-term use may produce weakness, diaphoresis, vomiting, tremor, and facial flushing.

A patient is prescribed zolpidem for difficulty staying asleep. Which trade name hypnotic drug does the nurse expect to see on the patient's medication list?

Ambien CR

The four major groups of sedative-hypnotic drugs appear in the table. This lesson will focus on benzodiazepines and benzodiazepine-like drugs.

Barbiturates- Secobarbital Benzodiazepines- Diazepam, alprazolam Benzodiazepine-like drugs- Zolpidem Melatonin receptor agonists- Ramelteon

Contraindications

Contraindications: Acute narrow-angle glaucoma Respiratory depression Hepatic insufficiency Sleep apnea Myasthenia gravis Pregnancy and breastfeeding Children less than 6 months of age Cautions: Depression History of drug or alcohol abuse Renal/hepatic impairment Respiratory disease Impaired gag reflex Concurrent use of CNS depressants, psychoactive drugs, or strong CYP3A4 inhibitors or inducers.

Contraindications

Contraindications: Allergy to benzodiazepines Respiratory depression Lactation Cautions: Renal/liver impairment Depression Suicidal ideation Pregnancy/breastfeeding Children, older adults, and debilitated individuals

Which benzodiazepine is commonly ordered for the treatment of alcohol withdrawal?

DIAZEPAM

Determine Baseline Data

Assess characteristics of the sleep disturbance and length of the disturbance. Record prolonged latency, frequent awakenings, or early morning wakefulness. Assess for the presence of psychiatric illness, medical condition, use of caffeine, stimulant use, poor sleep habits, and major life stressors, which could contribute to sleep disturbances. Assess BP, pulse, RR, and oxygen saturation prior to administration. Check autonomic response (e.g., cold, clammy hands, diaphoresis). Check motor response (e.g., agitation, trembling, tension). Perform a pain assessment and assess mobility, including stiffness and swelling. Assess any history of seizure disorder (length, intensity, frequency, duration, LOC). Observe frequently for recurrence of seizure activity. Initiate seizure precautions.

Overview of Benzodiazepines

Benzodiazepines and benzodiazepine receptor agonists are the first line of treatment for anxiety and insomnia. These drugs work to depress all levels of the CNS by enhancing the action of gamma-aminobutyric acid (GABA), a major inhibitory neurotransmitter in the brain. Benzodiazepines can also be used to treat seizure disorders, muscle spasms, and alcohol withdrawal, and to induce general anesthesia. Common benzodiazepines include diazepam (Valium), lorazepam (Ativan), and alprazolam (Xanax, Xanax XR, and Niravam). Benzodiazepines may be more effective than other general CNS depressants. While benzodiazepines are believed to have a lower potential for abuse, tolerance, and dependence, these side effects are still produced by this class of drugs and caution must be used when administering these medications.

Adverse Effects of Benzodiazepines

Benzodiazepines are generally well tolerated, and serious adverse reactions are rare. Adverse effects related to CNS depression include drowsiness, lightheadedness, lack of coordination, and difficulty concentrating. Sedation may interfere with waking activities. Anterograde amnesia is more pronounced with triazolam (Halcion). Watch for complaints of forgetfulness. Sleep driving and other complex sleep-related behaviors are more prominent when benzodiazepines are combined with alcohol or other CNS depressants. If sleep driving is reported, dosing should be tapered slowly to minimize withdrawal symptoms. Other complex sleep-related behaviors include: Preparing and eating meals Making phone calls Paradoxical effects include insomnia, excitation, euphoria, heightened anxiety, and rage. If paradoxical effects occur, benzodiazepines should be discontinued. Respiratory depression is rare with oral administration and is severe with intravenous administration. The likelihood of respiratory depression increases when oral benzodiazepines are combined with other CNS depressants. Benzodiazepine use in pregnancy has been associated with an increase in congenital malformations, including cleft lip, cardiac deformities, and inguinal hernias. The FDA classifies benzodiazepines as Pregnancy Risk Category D Five. Estazolam, flurazepam, temazepam, and triazolam are in the Category X and should not be used during pregnancy or breastfeeding. Diazepam is a Schedule IV drug, so there is potential for abuse. Other adverse effects include weakness, headache, blurred vision, vertigo, nausea, vomiting, epigastric distress, and diarrhea. Rarely, benzodiazepines may cause allergic reactions, neutropenia, and jaundice.

Pharmacokinetics of Diazepam

Benzodiazepines, such as diazepam, are well absorbed from the GI tract and excreted in urine. Benzodiazepines are 98% protein bound and widely distributed. The half-life of benzodiazepines is 20-70 hours, but it can be longer in patients who are older or who have liver dysfunction. Hemodialysis has little effect on the removal of benzodiazepines from the body.

Which items will the nurse teach the patient to avoid when taking diazepam for insomnia?

Caffeinated beverages Alcohol

Interactions

Drug Interactions: Alcohol CNS depressants may increase CNS depression CYP3A4 inducers (e.g., carbamazepine, rifampin) may decrease concentration of benzodiazepines CYP3A4 inhibitors (e.g., itraconazole, ketoconazole) may increase concentration of benzodiazepines Herbal Interactions: Gotu kola and kava kava can further depress the respiratory system when taken with benzodiazepines St. John's wort may decrease concentration of benzodiazepines Valerian may increase CNS depression Food Interactions: Grapefruit products may increase concentration/effects Lab Values: None significant

Administration

For faster sleep onset, administer without food Do not break, crush, dissolve, or divide Ambien CR tablets; give whole Place Edluar sublingual tablets under tongue and allow to dissolve; do not swallow or administer with water Spray Zolpimist directly into mouth over tongue

Patient Teaching for Benzodiazepine-Like Drugs

General Teaching Teach patients not to abruptly discontinue medication after long-term use. Teach patients that use of high dosages of benzodiazepine-like drugs increases the risk of tolerance and dependence. Inform patients that Ambien CR tablets should be swallowed whole without crushing, chewing, or breaking the tablets. Diet: Teach patients to avoid alcohol and caffeine. Side Effects Teach patients that benzodiazepine-like drugs can cause decreased alertness. Teach patients about possible side effects of benzodiazepine-like drugs, including headache, dizziness, nausea, diarrhea, and muscle pain. Instruct patients to report complex sleep-related behaviors, such as driving or sleepwalking, to the health care provider.

What is an appropriate nursing response when the patient states, "I take diazepam with grapefruit juice every morning"?

Grapefruit products may increase the drug concentration and effects."

Administration

IV Administer by IV push using the port closest to the vein. Use large veins to reduce risk of thrombosis/phlebitis. Administering an IV dose of diazepam too rapidly may result in hypotension and respiratory depression. The rate should not exceed 5 mg/min for adults or 1-2 mg/min for children. Monitor respirations q5-15 minutes for 2 hours. Store at room temperature. IM Inject deeply into a large muscle to decrease pain. PO Administer with or without food. Oral concentrate may be diluted with water, juice, or carbonated beverages or may be mixed in applesauce or pudding. Tablets may be crushed. GEL Insert the rectal tip and gently push the plunger over 3 seconds. Remove the tip after 3 additional seconds. Buttocks should be held together for 3 seconds after removal.

Case Study

Mrs. Glass is a 70-year-old widow admitted to the medical surgical unit for evaluation and treatment of a wound on her left lower leg. Recently her 22-year-old grandson moved into her home. Mrs. Glass reports difficulty sleeping over the past month. She states that she has problems falling asleep and sometimes waking in the early morning hours without being able to return to sleep. Due to feeling so tired, Mrs. Glass has given up her morning walking routine.

A patient has been taking diazepam for the treatment of acute anxiety, and reports experiencing heightened anxiety after the most recent dose. What is the appropriate nursing response?

Notify the health care provider.

Interventions and Evaluation of Benzodiazepine-Like Drugs

Nurses are responsible for prioritizing care and monitoring and evaluating the effects of zolpidem. Appropriate interventions associated with the administration of zolpidem include: Assess for signs of respiratory depression (slow, irregular breathing patterns) and monitor vital signs. Monitor for confusion. Injury may result in patients receiving benzodiazepine-like drugs for the first time. Consider the use of bed alarms for older adults receiving benzodiazepine-like drugs. Monitor for residual sedation, lightheadedness, dizziness, and confusion. Evaluate sleep patterns to determine the effectiveness of zolpidem.

Patient Teaching for Benzodiazepines

Nurses must educate patients concerning the use of sedative-hypnotic drugs. Establishing expectations and discussing side effects help patients with medication compliance.

Contraindications and Interactions of Benzodiazepines

Nurses should consider the effects of benzodiazepines when planning care for patients with insomnia. Nurses have a responsibility to know drug contraindications and interactions with benzodiazepines. Health care providers should be aware of herbal interactions, as many patients use alternative therapies to treat sleep disturbances at home.

A patient is prescribed oral diazepam as needed for acute symptoms of anxiety, and asks the nurse how quickly relief will happen. How does the nurse respond?

Oral diazepam will take 30 minutes before you'll feel relief."

Cultural Considerations

Patients of different cultures may require special consideration when the nurse is providing patient education on sedative-hypnotic drugs. The nurse should consider the following: Involving the extended family in health teaching and support Using an interpreter Using written instruction (or videos) in the patient's preferred language Asking the patient about methods family members have used to promote sleep Discussing non-pharmacologic alternatives which could help with sleep

Pre-Administration Assessment for Benzodiazepines

Prior to administering benzodiazepines for insomnia, the nurse should collect baseline assessment data and identify high-risk patients.

Pre-Administration Assessment for Benzodiazepine-Like Drugs

Prior to administering zolpidem, the nurse should assess BP, pulse, respirations, mental status, and sleep patterns. When administering zolpidem, the nurse should ensure the call light is within the patient's reach and that safety measures for bed rails or alarm mattresses are observed per the facility's requirements. Encourage good sleep hygiene by providing low lighting and a quiet environment.

Side Effects

Residual CNS depression can cause wake-time sedation. Teach patients to avoid driving and other activities requiring focus and coordination while taking benzodiazepines. Teach patients about the possible development of complex sleep-related behaviors, and remind them to notify the prescriber if these occur. Educate patients concerning paradoxical reactions such as rage, excitement, and heightened anxiety. Teach patients to notify the prescriber if these occur. Caution patients about possible drug-dependency insomnia during or after benzodiazepine withdrawal. Instruct patients to avoid abrupt discontinuation of treatment. Inform women about the risk to fetuses while using benzodiazepines. Pregnancy should be avoided. Teach patients to avoid breastfeeding while taking benzodiazepines.

For which concerning side effect does the nurse closely monitor in a patient receiving an IV benzodiazepine?

Respiratory depression

Pharmacodynamics of Diazepam

Route of Administration IV Onset of Action: Immediate Peak Plasma Concentration: 8 minutes Elimination Half-Life: 20-50 hours Duration of Action: 15-60 minutes PO Onset of Action: 30 minutes Peak Plasma Concentration: 1-2 hours Elimination Half-Life: 20-60 hours Duration of Action: 12-24 hours Therapeutic Effect: Produces anxiolytic effect, elevates seizure threshold, produces skeletal muscle relaxation. Therapeutic Uses Short-term relief of anxiety Acute alcohol withdrawal Treatment of seizures (IV for termination of status epilepticus) Control of seizure activity in refractory epilepsy in patients on stable regimens (rectal gel only) Relief of acute musculoskeletal conditions Off-Label Uses Panic Disorder Spasticity in children with cerebral palsy Sedation for patients on mechanical ventilation

Introduction

Sedative-hypnotic drugs are primarily used to treat anxiety and insomnia. Benzodiazepines are the first-choice drugs for management of anxiety. Diazepam (Valium), lorazepam (Ativan), and alprazolam (Xanax) are the most commonly prescribed benzodiazepines. These drugs depress neuronal function at multiple sites in the central nervous system (CNS). Depending on dose, the effects may be sedating, hypnotic, or stupor-inducing. Benzodiazepines reduce anxiety via their effects on the limbic system. Benzodiazepines can be used as sedative-hypnotics or as anxiolytics. Doses are dependent upon the intended use for the patient's specific condition. Upon completion of this lesson, you will be able to: Discuss the effects and use of select sedative-hypnotic drugs. Determine the nursing care involved with patients receiving select sedative-hypnotic drugs.

Summary

Sedative-hypnotic drugs are primarily used to treat anxiety and insomnia. Benzodiazepines can act as sedatives or hypnotics depending on the use and dosage prescribed. Patients with a history of alcohol or drug abuse should be monitored closely due to the risk of dependence and tolerance when taking these drugs. Respiratory status should be closely monitored when administering these medications. Sedative effects can become more pronounced when they are used in combination with other CNS depressants or are administered intravenously. Patients should be educated about complex sleep-related behaviors, such as sleep driving, which can develop with the use of hypnotic medications used to treat sleep disturbances.

Overview of Sedative-Hypnotic Drugs

Sedative-hypnotic drugs are primarily used to treat anxiety and insomnia. This class of drugs causes CNS depression. Drugs administered to relieve anxiety may be referred to as antianxiety agents, anxiolytics, or tranquilizers. Drugs administered to treat insomnia may be referred to as hypnotics. Depending on the dosage prescribed and the reason for use, a single drug may be considered both an anxiolytic and a hypnotic.

Which administration technique does the nurse teach the patient taking zolpidem?

Swallow the tablet whole.

General Teaching

Teach patients to avoid alcohol and caffeine while taking benzodiazepines. Teach patients to avoid driving and activities that require mental alertness and motor coordination while taking benzodiazepines. Inform patients to take the drug with food if stomach upset occurs. Patients should be taught to swallow sustained-release formulas whole and should not crush or chew them. Teach patients to consult the prescriber prior to changing the dosage or stopping benzodiazepines. Advise patients about sleep hygiene. Discuss situational insomnia and how sleep patterns should normalize once the precipitating stressor has been eliminated.

Identify High-Risk Patients

The following patients should not be prescribed benzodiazepines: Pregnant or breastfeeding patients Patients with sleep apnea Use benzodiazepines cautiously with patients who have a history of substance abuse or suicidal tendencies

Contraindications and Interactions of Benzodiazepine-Like Drugs

There are several contraindications and interactions for zolpidem.

How are benzodiazepines and zolpidem similar in their actions?

They act as agonists on the GABA receptor-chloride channel complex.

Interventions and Evaluation of Benzodiazepines

When administering diazepam the nurse should monitor heart rate, respiratory rate, blood pressure, and mental status. Observe patients for paradoxical effects. Conduct ongoing assessments of gas exchange and assess oxygen saturation levels. Evaluate for therapeutic response as evidenced by: Decrease in intensity/frequency of seizures Calm facial expression Decreased restlessness Decreased intensity of skeletal muscle pain Therapeutic serum level: 0.5-2 mcg/mL; toxic serum level: greater than 3 mcg/mL.

Pharmacodynamics of Zolpidem

Zolpidem has a rapid onset of action. People who have difficulty falling asleep find that this medication helps them to get the rest they need. Those patients who have difficulty staying asleep find the extended-release formulation, Ambien CR, helps manage sleep throughout the night. Like benzodiazepines, zolpidem binds to the benzodiazepine receptor sites on the GABA receptor-chloride channel complex. Zolpidem, while structurally different from benzodiazepines, can prolong sleep duration, decrease awakenings, and reduce sleep latency. Zolpidem does not reduce time in rapid eye movement (REM) sleep. Patients rarely experience rebound insomnia when they stop taking zolpidem. Zolpidem does not bind with all benzodiazepine receptors. Zolpidem binds to the benzodiazepine 1 subtype of benzodiazepine receptors. Because of this it lacks the ability to produce anxiolytic, anticonvulsant, and muscle relaxant actions. Route PO Onset of Action 30 minutes Peak Plasma Concentration 1.6 hours Elimination Half-Life 1.4-4.5 hours Duration of Action 6-8 hours

Pharmacokinetics of Zolpidem

Zolpidem is administered orally and is rapidly absorbed from the GI tract. Plasma levels peak within 1.6 hours. Levels in the brain remain low. The half-life of zolpidem is 1.4-4.5 hours and can be longer in patients with liver impairment. Zolpidem is metabolized in the liver and excreted by the kidneys. Hemodialysis does not remove zolpidem.

Dosage

Zolpidem is available in four formulations: Immediate-release tablets (5- and 10-mg) sold as Ambien: Usual dose is 10 mg (or 5 mg for older adults, debilitated patients, and patients with hepatic insufficiency) Extended-release tablets (6.25- and 12.5-mg) sold as Ambien CR: usual dose is 12.5 mg (or 6.25 mg for older adults or debilitated patients) Oral spray (5 mg) sold as Zolpimist: Usual dose is 10 mg (or 5 mg for older adults, debilitated patients, and patients with hepatic insufficiency) Sublingual tablets sold as Edluar (5- and 10-mg) or Intermezzo (1.75- and 3.5-mg): Usual dose is 10 mg (or 5 mg for older adults, debilitated patients, and patients with hepatic insufficiency)

Dosage and Administration of Zolpidem

Zolpidem is available in immediate-release tablets, extended-release tablets, sublingual tablets, and an oral spray. Depending on the specific sleep disturbance and the condition of the patient, the health care provider will choose which formulation is most appropriate for the patient.

Overview of Benzodiazepine-Like Drugs

Zolpidem, zaleplon, and eszopiclone are the preferred drugs for treatment of insomnia. These drugs are not indicated for use in treatment of anxiety. These drugs work as agonists at the benzodiazepine receptor sites on the GABA receptor-chloride channel complex. The most commonly prescribed hypnotic, zolpidem, is approved for short-term treatment of insomnia. Zolpidem (Ambien, Ambien CR, Edluar, Intermezzo, Zolpimist) is taken long-term by many patients with no adverse effects.

What are the most common disorders the nurse expects to see in a patient taking a sedative-hypnotic?

anxiety and insomnia

An older adult patient has zolpidem ordered as needed for insomnia. Which historical medical diagnosis causes the nurse to question the medication order?

liver failure *zolpidem is metabolized in the liver and half-life is increased in hepatic impairment. the nurse would question the order in a pt w a history of liver failure

What contraindications does the nurse assess for prior to the administration of a benzodiazepine?

pregnancy and history of sleep apnea

An older adult patient is prescribed zolpidem in the hospital for concerns associated with difficulty falling asleep. Which nursing interventions will ensure patient safety?

use bed alarms provide call light keep side rails elevated