sedative hypnotic drugs lecture
TRANSCRIPT
CNS DEPRESSANTSSEDATIVE-HYPNOTIC DRUGS
Dr. Hiwa K. Saaed, BSc, HD, MSc. PhDDepartment of Pharmacology & Toxicology
College of Pharmacy/ University of Sulaimani
2014-2015
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ANXIETY
• Unlike other mental disorders, anxiety can be both:– a normal emotion – and a psychiatric illness.
• It is a universal human emotion, and a certain amount is useful to the individual, acting as a stimulant and increasing efficiency.
• but when it becomes excessive and disproportionate to the situation, an anxiety state develops; it becomes a pathological (disabling) and needs treatment.
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ANXIETY DISORDERSIt usually involves both: • Mental features
– worry, fear, difficulty concentration, sleep problems.
• Physical symptoms – Tachycardia; muscle aches, nausea, shortness of
breath, trembling, pacing
ANXIETY CLASSIFICATION
#Primary• Generalized anxiety disorder (GAD): apprehensive and
tense for no particular reason.• Panic disorder: unexpected attacks of anxiety.• Phobic disorders: fears certain situation “agoraphobia”• Obsessive compulsive disorder: repetitive, anxiety
driven behavior or obsessive thoughts and doubts (check things more than once)
• Post-traumatic stress disorder (rape or warefare)
#Secondary due to medical causes or substances
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SEDATIVE-HYPNOTIC DRUGSThe sedative-hypnotics belong to a
chemically heterogeneous class of drug.
The most important are:• Benzodiazepines (BZs), Diazepam, • Non benzodiazepines:
buspirone, zolpidem, and Zaleplon• Barbiturates: phenobarbital, • Miscellaneous: carbamates, alcohol
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SEDATIVE-HYPNOTIC DRUGSSEDATIVE-HYPNOTIC DRUGS
SEDATIVE-HYPNOTICS
Benzodiazepines Barbiturates Miscellaneous agents
Short Ultrashort
acting acting
Intermediate Short Buspirone
acting acting Chloral hydrate
Long Long Zaleplon
acting acting Zolpidem
Ramelteon
Tasimelteon
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THE EFFECTS OF CNS DEPRESSANTS
– Sedatives cause mild depression and relaxation• Anxiolytic—drugs that relieve anxietySite of action is on the limbic system which regulates thought and mental function.
– Hypnotics induce drowsiness and encourage sleep• Amnesiac effects can cause the loss of
memorySite of action is on the midbrain and ascending RAS which maintain wakefulness.
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THE EFFECTS OF CNS DEPRESSANTS (continued)
• The same drug can cause different effects based on dose.– Low dose (sedatives—relieve anxiety and promote
relaxation)– Higher doses (hypnotics—can cause drowsiness
and promote sleep)– Even higher doses (anesthetics—can cause
anesthesia and are used for patient management during surgery)
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DOSE-DEPENDENT DEPRESSION OF CNS
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• Most S-H drugs facilitate the actions of GABA, a major inhibitory transmitter in the CNS,
• GABAA receptor activation leads to increased Cl- ion influx;
• GABAB receptor activation causes increased efflux of K+.
• Both mechanisms result in membrane hyperpolarization.
SEDATIVE HYPNOTICMECHANISMS OF ACTION
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GABAA RECEPTOR The pentapeptide structure of the GABAA receptor has binding sites for BZs and for other drugs, including Barbiturates and ethanol.
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BENZODIZEPINES
Sedative (Anxiolytics) : Alprazolam Chlordiazepoxide oxazepam Diazepam lorazepam
Hypnotics : Triazolam Diazepam Alprazolam
Lorazepam Estazolam Temazepam Flurazepam Nitrazepam Quazepam Preanesthetics : Diazepam - Midazolam Leo sternback
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DURATION OF ACTION OF BZS
• Short acting (2-8 hrs)midazolam triazolam
• Intermediate (10-20 hrs) temazepam, lorazepam, alprazolam, oxazepam, nitrazepam, estrazolam
• Long acting (1-3 days): chlordiazepoxide, diazepam, flurazepam, clonazepam, chlorazepate
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BENZODIAZEPINEMECHANISMS OF ACTION Affect neurons that have receptors for the neurotransmitter GABABZs potentiate GABA → increase frequency of Cl- ion channel opening→ causes hyperpolarization→ raise firing threshold→ and thus inhibits the formation of action potentials inhibitory effect on different sites of the brain especially motor cortex, and limbic system.
GABA—inhibitory transmitter in brain regions– Limbic system (alter mood)– RAS (cause drowsiness)– Motor cortex (relax muscles)
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PHARMACOKINETICS
Most of them are well absorbed orally.
Bzs are lipid soluble and widely distributed
Redistribution from CNS to skeletal muscles, adipose tissue.
Cross placental barrier during pregnancy and are excreted
in milk (Fetal & neonatal depression).
Highly bound to plasma protein.
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PHARMACOKINETICS
All Bzs are metabolized in the liver
Phase I: ( liver microsomal system)
Phase II: glucouronide conjugation and excreted in the urine. Many of Phase I metabolites are active: Increase
elimination half life of the parent compound , cumulative effect with multiple doses.
EXCEPT No active metabolites are formed for (LEO) Lorazepam, Estazolam, Oxazepam.
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METABOLISM
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BZs have neither antipsychotic activity nor analgesic. They don’t affect ANS
Reduction of anxiety at low dose: alprazolam, lorazepam, oxazepam, diazepam and chlordiazepoxide.
Alprazolam has anxiolytic-antidepressant effect. Diazepam is preferred in acute panic-anxiety. Chlordiazepoxide is preferred in chronic anxiety states.
Sedative and hypnotic actions at higher dose:
not all, three most commonly prescribed BZs are:– long acting flurazepam, – intermediate temazepam – short acting triazolam.
and Two non BZs: – Zolpidem & Zaleplon.
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ACTIONS AND THERAPEUTIC DOSES:
• Anterograde amnesia: short acting BZs used in premedication for endoscopic, bronchoscopic, angioplasty.
In anesthesia :
Preanesthetic medication diazepam
Induction of balanced anesthesia (Midazolam)
• Anticonvulsant: Treatment of epilepsyDiazepam – Lorazepam: Status epilepticus
Clonazepam-Clorazepate: absence , myoclonic seizures.
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ACTIONS AND THERAPEUTIC DOSES:
• To control Alcohol withdrawal symptoms:
chlordiazepoxide, chlorazepate, diazepam & oxazepam• Muscle relaxant at higher doses; diazepam is
useful in the Rx of skeletal muscle spasm• Other actions: in higher doses BZs decrease BP
and increase HR. diazepam decreases nocturnal gastric acid secretion
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ACTIONS AND THERAPEUTIC DOSES:
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INDICATIONS AND DRUG CHARACTERISTICS
• Tolerance: reduction in drug effect requiring an increase in dosage to maintain the same response.
• Chronic use leads to tolerance (cross with other S-H drugs), possibly via downregulation of BZ receptors.
• The antianxiety effects of the BZ are less subject to tolerance than sedative and hypnotic effects.
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TOLERANCETOLERANCE
DEPENDENCE• Physiological dependence: removal of the
drug evokes unpleasant symptoms, usually the opposite of the drugs effects
• Psychological dependence: the drug taker feels compelled to use the drug & suffers anxiety when separated from drug.
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WITHDRAWAL SYMPTOMSAbrupt discontinuation, particularly if high doses
used for prolong period.
1. Confusion,
2. anxiety,
3. agitation,
4. restlessness,
5. insomnia
6. tension
WD symptoms with BZs are less intense than with ethanol or barbiturates;
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ADVERSE EFFECTS OF BZS
• Drowsiness and confusion• Ataxia at high doses-precludes activities
like driving• Cognitive impairment:
↓long term recall,
↓acquisition of knowledge
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FLUMAZENIL BZS ANTAGONIST
Flumazenil: I.V only, reverses the effect of the BZs (competitive antagonist), onset is rapid, and duration is short.
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MISCELLANEOUS; NON BENZODIAZEPINES
Zolpidem and Zaleplon they:• act on BZ1 (a subtype of BZ receptor family),
• are more selective hypnotics• are not effective in chronic anxiety, seizure
disorders, or muscle relaxing.• Possibly less tolerance occur with prolong use • and lower abuse liability and dependence than
BZs. • they show no withdrawal effects, Minimal
rebound insomnia
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ZOLPIDEM AND ZALEPLON
• Rapidly absorbed, rapid onset with short duration (2-3 hrs)
• Zaleplon is very similar to zolpidem in its hypnotic action,
• but ZALEPLON causes fewer residual effect on pseudomotor and cognitive function compared with zolpidem or the BZs due to short t1/2 < 1hr
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BUSPIRONE
totally different anxiolytic from BZs, no effects on GABA systems, possible partial agonist at 5-HT1A receptors some affinity for D2 & 5-HT2A.
Indication:• Indicated for generalized anxiety disorders but
takes 1 to 2 weeks to exert anxiolytic effects.
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Buspirone lucks anticonvulsant and Muscle relaxant property of BZs and cause minimal sedation. • No additive CNS depression with other drugs.
Adverse effects:hypothermia, increase prolactin, headache, dizziness, nervousness
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BUSPIRONE
BARBITURATES
• Formerly used as sedative hypnotic replaced by BZs, because barbiturates induce:
1. tolerance,
2. drug metabolizing enzyme,
3. physical dependence
4. and very severe withdrawal symptom.
5. Flumazenil does not block the effects of barbiturates.
Bayere dicoverer of barbiturates.
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• interact with GABA receptors, the binding site is distinct from that of the BZs.
• potentiate GABA action on Cl- entry into the neuron by increase the duration of Cl- ion channel opening.
• In addition, barbiturates can block excitatory glutamate receptor (sub anesthetic dose).
• at high doses (anesthetics conc. of pentobarbital-reticular
activating system inhibition), also– open Cl- ion channels directly – and block high frequency Na+ channels).
BARBITURATES MECHANISM OF ACTION
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Duration of Action of Barbiturates
• Long acting (1-2 days) Anticonvulsant
Phenobarbital; • Short (3-8hrs) Sedative & Hypnotic Pentobarbital, secobarbital and amobarbital:• Ultrashort (20 min) I.V induction
of anesthesiaThiopental
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ADVERSE EFFECTS OF BARBITURATES
• Dose-dependent CNS depression, with nystagmus and ataxia progressing to respiratory depression, coma, and possible mortality.
• no specific antidote in overdose. • Additive CNS depression with other drugs.
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PHARMACOKINETICS
All barbiturates are weak acids, lipid soluble, absorbed
orally. distribute throughout the body
Thiopentone is highly lipid soluble (high rate of entry into
CNS- quick onset of action). Redistribute in the body from the brain to skeletal muscles-
adipose tissues. metabolized in the liver to inactive metabolites Excreted in the urine. Alkalinization increases excretion (NaHCO3) Cross the placenta ( pregnancy).04/18/2023 36
METABOLISM
• Hepatic metabolism (some to active metabolite). • Induction of Cytochrome P450 is characteristic and may
lead to drug interactions. • Because of increase heme synthesis, they are
contraindicated in porphyrias • Porphyrias: a hereditary disorder of hemoglobin
metabolism causing:
-mental disturbance,
-extreme sensitivity to light
-and excretion of dark pigments in the urine.
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WHY BENZODIZEPINES HAS REPLACED BARBITURATES?
BZS BARBITURATES They do not produce anesthesia in
high doses & patient can be aroused. These are not enzyme inducers, Very low abuse liability. Lesser distortion of normal
hypnogram. Bzs have no hyperalgesia. Bzs can be used as day time
anxiolytic. Do not effect respiratory or cvs
function. There is a specific antagonist-
Flumazenil.
Produce loss of consciousness and have low margin of safety
enzyme inducers. High abuse liability. Marked suppression of REM sleep. Hyperalgesic action. Unacceptable drowsiness is seen.
Causes respiratory and depression & hypotension.
No specific antagonist.
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MISCELLANEOUS • Antihistamines:
it has low tendency for habituation and thus is useful for patients wit anxiety who have a history of drug abuse. – hydroxyzine, – diphenhydramine – doxylamine;
• Melatonin: synthesized from 5HT, significant role in diurnal cycles and sleep-wake behavior.
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MISCELLANEOUS
• Ramelteon: melatonin receptor (MT1 and MT2) agonist with sleep promoting activities. – It has been approved for chronic insomnia and
considered free from dependence potential.
• Tasimelteon• PROPRANOLOL has efficacy in performance anxiety
and social phobias.• Tricyclicantidepressants (TCA) and SSRI• Opiod analgesics• Ethanol
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SOME OUTDATED HYPNOTICS:
• Chloral hydrate: – is a trichlorinated derivative of acetaldehyde that is
converted to the active metabolite, trichloroethanol in the body.
• Paraldehyde: – little effect on respiration and BP in therapeutic dose. – Large doses suppress all type of convulsions with
rapid onset of action. – It has strong aromatic odor and unpleasant taste.
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Thank you
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