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Year 4 - Toxicology > Lecture 10 - Benzos > Flashcards

Lecture 10 - Benzos Flashcards

1
Q

List some GABAergic Sedative-Hypnotic Drugs

A
  • Chloral Hydrate
  • Meprobamate
  • Barbiturates
  • Benzodiazepines
  • Z-Drugs
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2
Q

BZD overdose in ____ is almost never fatal

A

isolation

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3
Q

Why are barbiturates more toxic than BZD?

A

have a more narrow therapeutic window

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4
Q

What are patient factors that predispose them to BZD overdose?

A
  • age
  • hepatic impairment
  • COPD
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5
Q

describe sedative-hypnotic symptoms

A
  • sedation, disinhibition, anxiolysis
  • hypnosis
  • anesthesia
  • medullary depression
  • coma
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6
Q

Describe the mild CNS symptoms

A

drowsiness or lethargy may appear within 30-60 mins of ingestion

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7
Q

Describe the moderate CNS symptoms

A

slurred speech, amnesia, ataxia, may appear shortly after the mild symptoms

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8
Q

Describe the severe CNS symptoms

A

stupor or coma may occur hours after large ingestions alone of sooner if polydrug overdose

*usually accompanied by: hypothermia, hyporeflexia, miosis

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9
Q

Describe the rare CNS symptoms

A

agitation, aggression with confusion may occur (more common in elderly)

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10
Q

What has the most respiratory symptoms in toxicity: barbiturates, benzos, or z drugs?

A

barbiturates

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11
Q

T or F: CNS depression always predicts respiratory depression

A

False: does not always predict it

i.e. patient in stupor or coma may have normal vital signs

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12
Q

What are risks for respiratory symptoms during toxicity?

A
  • respiratory disease
  • elderly
  • concomitant opioid use
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13
Q

What RR defines hypoventilation?

A

RR < 12 breaths/minute for adults

*if patient is apneic (breathing is suspended) or cyanotic (skin is blue), death may be imminent

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14
Q

Which drugs are CV side effects seen in toxicity: barbiturates, BZD, or Z drugs?

A

barbiturates!

*negligible CVD effects from BZD and Z-Drugs

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15
Q

What are CV effects that are produced with toxicity (specifically with barbiturates) ?

A
  • postural hypotension
  • bradycardia

*specifically in those at risk patients (elderly with pre-existing CVD)

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16
Q

Cardiovascular collapse is rare, but may occur with large combined _____ or _____ overdose.

A

alcohol or opioid

17
Q

Bullous fixed drug eruptions may occur with ______ and rarely with BZD
*idiosyncratic drug effect

A

barbiturates

18
Q

________ is common in severe overdose and may be accompanied by ____ as the poisoning progresses

A
  • hypothermia

- cyanosis

19
Q

Which benzo’s have some studies saying that they are more toxic?

A
  • alprazolam
  • flurazepam
  • temazepam
20
Q

Why do Z drugs possibly have less risk?

A

once daily dosing

i.e. lesser dispensing quantities compared to BZD

21
Q

which gender has more deaths from BZD?

A

male

22
Q

What is the unholy trinity?

A
  • BZD
  • Opioids
  • Skeletal Muscle Relaxants

*can get additive euphoric symptoms

23
Q

Describe the management of the intoxicated patient

A

Emergency and supportive measures:

  • protect airways, assist ventilation
  • treat coma
  • treat hypotension
  • treat hypothermia

Decontamination:

  • activated charcoal for poly-drug overdose (limited utility in mono-drug overdose - aspiration risk)
  • Urinary alkinization for barbiturates (esp. phenobarbital)
  • Antidotes: Flumazenil ? - it is controversial (it is a BZD receptor antagonist)
24
Q

What is Flumazenil ?

A

-competitive antagonist of BZ receptor

25
Q

What can Flumazenil reverse?

A

BZD and Z-drug induced CNS depression

26
Q

What can Flumazenil induce?

A

BZD withdrawal

27
Q

In what situation is Flumazenil ideal?

A

for BZ-naive patients with BZ only overdose

28
Q

What is the dose of Flumazenil?

A
  1. 1-0.2 mg IV over 30 seconds

- subsequent doses of 0.3mg and 0.5mg at 1 min interval up to 3mg total

29
Q

_______ is common after 1-2 hours of flumazenil ?

A

re-sedation

*common with naloxone as well

30
Q

When should we avoid using Flumazenil?

A
  • Patient is physically dependent (withdrawal situation)
  • Patient is receiving BZ for control of seizure
  • Pre-existing cardiac arrhythmia or high-risk of arrhythmia
  • Coingestion of agents causing seizures (theophylline, TCAs, etc.)
  • Increased intracranial pressure
  • Unreliable/unavailable history
31
Q

Describe the characteristics of the patient in an ideal scenario for Flumazenil

A

PURE benzodiazepine overdose in a nontolerant (BZD-naive) individual who has:

  • CNS depression
  • normal vital signs, including Saturated O2
  • normal ECG
  • otherwise normal neurologic examination
32
Q

Has long-term use of BZD been associated with cumulative toxicity or organ damage?

A

nope

33
Q

What are some common clinical consequences of chronic use of BZD?

A

Tolerance and dependence during continuous use and withdrawal after cessation of drug

34
Q

What are some strong predictors of long term BZD use?

A
  • female gender
  • older age

*role for pharmacist education and risk reduction (i.e. falls and fractures)

35
Q

What are some BZD/Z-drug use emerging issues that have yet to be unproven?

A
  • infections
  • pancreatitis
  • dementia
  • cancer
36
Q

What are some pharmacotherapy substitutions for BZD?

A
  • longer-acting BZD
  • pregabalin
  • carbamazepine
  • melatonin
  • flumazenil (patch?)
37
Q

How can we treat BZD dependency?

A
  • pharmacotherapy substitutions

- gradual dose reduction +/- behavioural or psychological interventions

38
Q

Describe a gradual dose reduction of BZD?

A

-decrease dose by 10-25% q1-2 weeks - slower taper may be needed for final 20%

39
Q

What is absolutely essential for successful discontinuation?

A

patient “buy-in”

Year 4 - Toxicology (24 decks)

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