Disinhibitory reactions to benzodiazepines: a review

Persistent Paradoxical Reaction to Midazolam despite General Anesthesia with Dexmedetomidine

Midazolam is a widely used benzodiazepine due to its rapid onset of action and relatively safe side effect profile. It is used for sedation, anxiolysis, and induction of general anesthesia. However, in <1% of instances, it may cause a paradoxical excitement: agitation, restlessness, myoclonus, stiffening of the limbs, and aggression. We report a case report in which preoperative administration of midazolam caused onset of the aforementioned symptoms that were not attenuated by general anesthesia with dexmedetomidine. This case report aims to create awareness about the rare adverse reactions of midazolam and prepare clinicians to manage these situations.

Benzodiazepine Delorazepam Induces Locomotory Hyperactivity and Alterations in Pedal Mucus Texture in the Freshwater Gastropod Planorbarius corneus

Benzodiazepines, psychotropic drugs, are ubiquitous in the aquatic environment due to over-consumption and inefficient removal by sewage treatment plants. Bioaccumulation with consequent behavioral and physiological effects has been reported in many aquatic species. However, the responses are species-specific and still poorly understood. To improve the knowledge, we exposed the freshwater snail Planorbarius corneus to 1, 5, or 10 µg/L of delorazepam, the most widely consumed benzodiazepine in Italy. Conventional behavioral tests were used to assess the effects on locomotor and feeding behavior. Histological and biochemical analyses were also performed to detect possible changes in the structure and composition of the foot mucus and glands. The results show a paradoxical response with reduced feeding activity and locomotor hyperactivity. Pedal mucus was altered in texture but not in composition, becoming particularly rich in fibrous collagen-like material, and a significant change in the protein composition was highlighted in the foot. In conclusion, exposure to delorazepam induces disinhibited behavior in Planorbarius corneus, potentially increasing the risk of predation, and an increase in mucus protein production, which, together with reduced feeding activity, would severely compromise energy resources.

Paradoxical Excitation Following Intravenous Lorazepam Administration for Alcohol Withdrawal - A Case Presentation and Literature Review

Benzodiazepines are commonly used medications which are clinically useful towards the treatment of alcohol withdrawal, seizures, anxiety disorders, among other indications. Benzodiazepine use is also known to cause the rare phenomenon of paradoxical excitation whose mechanism has many postulated theories. We report this rare presentation of paradoxical excitation with the use of lorazepam in a 50-year-old male being treated for alcohol withdrawal. We also review the underlying pathophysiology, pharmacology, and current literature as it relates to this excitation. An inability to recognize this adverse effect and to appropriately withhold the agent may adversely affect a patient's course of treatment in the inpatient setting.

Midazolam dose is associated with recurrence of paradoxical reactions during endoscopy

BACKGROUND

Midazolam is commonly used for sedation during gastrointestinal procedures. However, some patients experience paradoxical reactions characterized by excessive movement or excitement.

AIM

To investigate the rate of recurrence of paradoxical reactions to midazolam during an upper endoscopy.

METHODS

We retrospectively reviewed 122152 sedative endoscopies among a total of 58553 patients at the Seoul National University Hospital, Healthcare System Gangnam Center, from July 2013 to December 2018. Among them, 361 patients with a history of paradoxical reaction during sedative upper endoscopy were enrolled. The characteristics of patients in the recurrent and non-recurrent groups were compared via multivariable analysis using logistic regression.

RESULTS

Paradoxical reactions occurred in 0.86% (1054/122152) of endoscopies, and in 1.51% (888/58553) of patients. Among the 361 subjects with previous paradoxical reactions in sedative endoscopies, 111 (30.7%) experienced further paradoxical reactions. Univariable analysis revealed that the total midazolam dose used was higher in the recurrent group (6.74 ± 2.58 mg) than in the non-recurrent group (5.49 ± 2.04 mg; P < 0.0001). Patients were administered a lower dose of midazolam than previous doses: 1 mg less in the recurrent group and 2 mg less in the non-recurrent group. Multivariable analysis showed that the midazolam dose difference was an independent risk factor for recurrent paradoxical reaction (odds ratio: 1.213, 95%CI: 1.099-1.338, P = 0.0001).

CONCLUSION

The rate of recurrence of paradoxical reactions is significantly associated with midazolam dosage. The dose of midazolam administered to patients with previous paradoxical reactions should be less than that previously used.

Paradoxical Reactions to Midazolam in a Term Parturient After Intravenous Sedation During Cesarean Section

Propofol and midazolam are commonly used drugs in procedural sedation. Midazolam is widely used for its five principal pharmacologic effects: anxiolysis, sedation and hypnosis, anticonvulsant actions, spinal cord-mediated skeletal muscle relaxation, and anterograde amnesia. Increased talkativeness, emotional release, excitement, and excessive movement are the common paradoxical reactions to all kinds of benzodiazepines, which are reported since the introduction of chlordiazepoxide (Librium), the first benzodiazepine in 1955. In the United States, sedation with a combination of midazolam with opioids accounts for approximately 75% of routine procedural sedations. Most cases are distinctive. However, some data indicate that these reactions are due to serotonin imbalance, a central cholinergic effect, or a reflection of genetically determined variability in benzodiazepine receptor density or affinity (isoreceptors) throughout the brain. The idea of isoreceptors is comparable to that of isoenzymes like genetic variants of pseudocholinesterase. We report a case in which midazolam administration resulted in paradoxical reactions, which manifested as profound delirium with extrapyramidal symptoms after cessation of propofol sedation in a term parturient during cesarean section. This case report describes paradoxical reactions to benzodiazepines in a term parturient promptly reversed with a small dose of flumazenil. Even though paradoxical reactions to benzodiazepines have low prevalence and are not life-threatening, they have to be treated promptly with flumazenil. Therefore, anesthesiologists performing procedural sedation should be aware of untoward reactions and be prepared to manage them promptly.

Adverse Drug Reaction: Midazolam-Induced Extrapyramidal Symptoms: A Case Report

Midazolam is commonly used for sedation during procedures because of its relative safety and predictability. Still, some rare undesirable medication reactions have been described. We report a case in which midazolam given before a peripheral nerve block caused acute onset dyskinetic extrapyramidal symptoms. These symptoms ultimately resolved following reversal of the midazolam with flumazenil. Given the widespread and multidisciplinary use of midazolam, practitioners should be aware of the potential for rare adverse reactions and be prepared to manage these scenarios.

Efficacy of combination therapy with dexmedetomidine for benzodiazepines-induced disinhibition during endoscopic retrograde cholangiopancreatography

BACKGROUND

Benzodiazepines (BZDs) and analgesics are widely used for conscious sedation during endoscopic ultrasound (EUS) or endoscopic retrograde cholangiopancreatography (ERCP). However, endoscopic procedures are sometimes discontinued because of BZD-induced disinhibitory reactions such as excessive movement. We evaluated the usefulness of dexmedetomidine (DEX) for BZD-induced disinhibition in ERCP.

METHODS

Between February 2018 and August 2019, 22 patients who underwent EUS or ERCP were enrolled. All patients showed BZD-induced excessive movement at the first examination (BZD group) and received DEX at the second examination (DEX group). The initial DEX dose was 6 μg/kg/h for a 10-min loading, followed by 0.4 μg/kg/h during the procedure. BZDs and analgesics were administered before scope insertion. An additional sedative was administered to achieve a Ramsay sedation scale (RSS) of 4-5. Sedative effect, procedure completion rate, and changes in circulatory and respiratory dynamics were evaluated.

RESULTS

Mean RSS scores were significantly higher (p < 0.001) in the DEX (5.1 ± 0.5) compared with the BZD (4.0 ± 0.5) group. The movement score (p < 0.001) and number of additional sedatives required (p < 0.01) were lower in the DEX group. The procedure completion rate was significantly higher in the DEX (95.5%) compared with the BZD group (63.6%; p < 0.05). Significant differences in the frequency of hypotension (p = 1.00), bradycardia (p = 0.22), and respiratory depression (p = 0.68) were not noted between groups.

CONCLUSIONS

The addition of DEX to BZD therapy yielded better sedative efficacy, lower excessive movement, a reduction in BZDs used, and a higher procedure complete rate. DEX may be used as an alternative method for BZD-induced inhibition during ERCP.

Treatment of posttraumatic stress disorder: Focus on pharmacotherapy

Current clinical practice guidelines for the treatment of posttraumatic stress disorder offer varying recommendations regarding the use of pharmacotherapy. Many direct head-to-head comparisons of pharmacotherapy are lacking, and recommendations are based on meta-analyses and small trials. While selective serotonin reuptake inhibitors and serotonin norepinephrine reuptake inhibitors are considered first-line pharmacotherapy, clear distinctions do not exist when considering other classes of psychotropic medications. Ultimately, when selecting an appropriate medication for a patient diagnosed with posttraumatic stress disorder, the clinician needs to consider the current symptomatology being experienced, comorbid conditions, and evidence for efficacy of specific treatments prior to initiating medications.

Factors related to paradoxical reactions during propofol-induced sedated endoscopy

Objective: The factors related to paradoxical excitement during propofol-induced sedation remain unclear. We aimed to investigate this issue during sedated upper endoscopy. Material and methods: Among the health examinees scheduled for sedated upper endoscopy from June 2017 to December 2017, 421 participated in the study. Endoscopists were blinded to the information about the examinees and evaluated the development of paradoxical reactions. Propofol was exclusively used as the sedative agent via intermittent bolus injection. A multiple logistic regression analysis was performed to investigate the factors associated with paradoxical reactions. Results: The incidence of paradoxical reactions was 16.1%. Anxiety (adjusted odds ratio: 2.76; 95% confidence interval: 1.46 - 5.27; p = .002) and age (odds ratio: 0.92; 95% confidence interval: 0.89 - 0.96; p < .001) were significantly associated with paradoxical reactions. Of the nine items of the anxiety questionnaire, four had independent and significant associations with paradoxical reactions (i.e., excess worry, sleeping problems, somatic symptoms, and health concerns; odds ratios: 2.38, 2.71, 2.27 and 2.39, respectively). Conclusion: Propofol-induced paradoxical reactions tend to occur when an individual has anxiety and is of a young age. Further large population-based studies should be performed to confirm this phenomenon.

Benzodiazepines and disinhibition: a review

AIMS AND METHODS

To describe and attempt to quantify the incidence of disinhibitory reactions to benzodiazepines and to identify those at risk. Medline search, 1966–January 2002.

Results

The overall incidence of disinhibitory reactions is small, but those with impulse control problems, neurological disorders, learning disabilities, the under 18s and the over 65s are at significant risk.

Clinical Implications

It is important to be aware of the ability of benzodiazepines to cause behavioural disinhibition and to maintain a high degree of vigilance when these drugs are administered to patients known to be at risk. In patients who have experienced behavioural disinhibition with benzodiazepines, antipsychotic drugs should be used to modify behaviour in any future emergencies.

Behavioral disinhibition and antiepileptic treatment in childhood epilepsy: A retrospective cohort study

OBJECTIVE

To test whether specific classes of antiepileptic drugs increase the risk for behavioral disinhibition, a frequent complication of treatment of childhood epilepsy.

METHODS

In a sample of children with active epilepsy and antiepileptic drug (AED) treatment (n = 146, age 4-17 years), we performed a retrospective chart analysis of the occurrence of symptoms indicating reduced behavioral disinhibition following AED treatment. We used a risk-set approach to analyze whether the presence or recent addition of AED categories defined by their mechanism of action were associated with enhanced risk for behavioral disinhibition symptoms.

RESULTS

Mean duration of follow-up was 2,343 days (range 218-6,292, standard deviation [SD] 1,437). Episodes of behavioral disinhibition were reported in 51 (34.9%) children, with variable latencies between latest change and occurrence of behavioral disinhibition symptoms (mean 67 days, range 2-367). Current use of AEDs targeting gamma-aminobutyric acid (GABA) (odds ratio [OR] 1.8, 95% confidence interval [CI] 1.02-3.29, p = 0.04) and SV2A-mediated neurotransmitter release (SV2A)-mediated (2.0, 1.13-3.60, p = 0.02) neurotransmitter release was associated with increased risk for behavioral disinhibition. Restricting the analysis to the 90 days before behavioral disinhibition episode occurrence revealed that only addition of GABAergic AEDs (OR = 26.88, 95% CI = 6.71-107.76, p < 0.001) was associated with behavioral disinhibition. In contrast to our expectations, seizure control was reported to have improved parallel to most behavioral disinhibition episodes.

SIGNIFICANCE

This exploration of behavioral disinhibition in relation to antiepileptic drug treatment indicates that GABA potentiating drugs are specifically associated with behavioral problems during treatment of childhood epilepsy. Behavioral disinhibition episodes often occurred while seizure control improved, which may have reduced alertness for the consequences of AEDs on interictal symptoms. Our findings may be related to the increasing evidence for a role for excitatory actions of GABA in childhood epilepsy.

Constructivist Simultaneous Treatment of Borderline Personality Disorder, Trauma, and Addiction Comorbidity: A Qualitative Case Study

This qualitative case study explored one client's recovery from borderline personality disorder, trauma, and problem gambling. The client attended 18 months of integrative treatment and was followed for 5 years. The study included 106 data points of both client and therapist data. We identified three phases to treatment. First, alliance formation and normalization appeared as mechanisms, and the client experienced dependence. Second, working alliance and countertransference appeared as mechanisms, and the client experienced reduced gambling and suicidal ideation. Third, external controls and increased opportunity appeared as mechanisms, and "moving into the world" was the client experience. The findings give preliminary support to a phase-based constructivist treatment including trauma assessment to normalize self-feelings, countertransference work to support motivation for restraint, and case management principles to support continuity of change efforts.

Benzodiazepines: Sedation and Agitation

Dental anxiety is common and frequently poses a barrier to necessary dental treatment. The increasing availability of conscious sedation in dental practice has made treatment much more accessible for anxious patients. At present, benzodiazepines are the most commonly used drugs in sedation practice and provide a pleasant experience for most, but not all, patients. An understanding of the mechanism of action of benzodiazepines should inform our practice and deepen our understanding of why and how sedation may fail. CPD/CLINICAL RELEVANCE: As an increasing number of dentists provide sedation for their patients an update on benzodiazepines is timely.

Paradoxical Reaction to Alprazolam in an Elderly Woman with a History of Anxiety, Mood Disorders, and Hypothyroidism

With less than 1% of patients who use benzodiazepines being affected, paradoxical responses to benzodiazepines are rare. In this case report, we outline the course of an 80-year-old female who developed a paradoxical response to benzodiazepines. Significant medical and psychiatric history includes anxiety, mood disorder, hypothyroidism, bilateral mastectomy, goiter removal, and triple bypass. The patient presented with mental status changes, anxiety, motor restlessness, and paranoia. Over time, a temporal relationship between the severity of the patient's motor agitation and intake of alprazolam was observed. As doses of alprazolam were decreased, her motor agitation became less severe. In addition to motor agitation, the patient also demonstrated increased aggressiveness, a subjective feeling of restlessness, and increased talkativeness. As her dose of alprazolam decreased, many of the patient's symptoms were observed to decrease. This case report also discusses theories regarding the pathophysiology of paradoxical reactions to benzodiazepines, known risk factors, and appropriate treatment.

Successful flumazenil reversal of paradoxical reaction to midazolam in a child

BACKGROUND

Greater attention to and management of anxiety and pain in pediatric patients signifies a healthy evolution in the care of children in emergency departments (EDs). Interventions to address such distress may involve unanticipated adverse effects. Midazolam, a benzodiazepine commonly administered to children for anxiolysis, may precipitate paradoxical agitation and delirium, a rare but alarming effect that warrants prompt identification and treatment.

CASE REPORT

The case presented is that of a 4-year-old girl who received oral midazolam and developed a paradoxical reaction, which was reversed successfully with flumazenil. This is the first such case report in an ED involving a child. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Emergency physicians must stay abreast of the adverse and unintended effects of the treatments provided. The literature on benzodiazepine-induced paradoxical reactions is reviewed, and flumazenil as well as other treatment options and anxiolytic alternatives are presented.

Administration of additional analgesics can decrease the incidence of paradoxical reactions in patients under benzodiazepine-induced sedation during endoscopic transpapillary procedures: prospective randomized controlled trial

AIM

The aim of the present study was to evaluate the efficacy and safety of giving pentazocine as an analgesic with benzodiazepine during endoscopic retrograde cholangiopancreatography (ERCP).

METHODS

The paradoxical reactions (PR) incidence was evaluated as an indicator of usefulness. Transcutaneous arterial carbon dioxide tension (PtcCO(2) ) was evaluated as an indicator of safety. A total of 160 patients were enrolled. Subjects were randomly divided into two groups; group 1 sedated with midazolam only and group 2 sedated both with midazolam and pentazocine (7.5 mg).

RESULTS

The initial dosage introduced sedation before procedure was significantly higher in group 1. The occurrence rate of PR's in group 1 was significantly higher compared to that in group 2 (P = 0.0108). Although maximum PtcCO(2) observed during sedation did not differ between the two groups (48.7 ± 7.2, 50.3 ± 7.6 mmHg, respectively),maximum PtcCO(2) during the first 15 min after the start of sedation was significantly higher in group 2 than in group 1 (P = 0.0294). In multivariate analysis, procedure duration (odds ratio [OR] = 1.048) and midazolam dose (OR = 1.221) were predictive factors for PR.

CONCLUSION

The administration of pentazocine is significantly reduced the incidence of PR's in patients under midazolam induced sedation during ERCP.

Effectiveness of Oral Midazolam for Paediatric Dental Care: A retrospective study in two Specialist Centres

AIM

To analyse retrospectively the outcomes for children undergoing oral care under conscious sedation with oral midazolam and local analgesia at Leeds dental Institute, England and Westmead Dental Hospital, Sydney, Australia. Secondly, the study assessed the suitability of oral midazolam for paediatric dental treatment.

STUDY DESIGN

Retrospective study of clinical outcomes based on dental records.

METHODS

All children included in the study had been treated between September 2000 to August 2004 and full dental records were available. The dental records were examined using a standard pro forma sheet and data collected for: age, previous behaviour using the Frankl [1962] scale, units of work planned and achieved using the modified index of O'Sullivan and Curzon [1991], midazolam dosage and treatment outcome.

RESULTS

The study population consisted of 101 children aged 1-11 years in both Leeds (57 children) and Westmead (44 children). There were significant differences between Leeds and Westmead with respect to age (mean +/-SD) in years 5.0+/-1.0 versus 2.9+/-1.6; number of treatment visits 1.7 versus 1.1; sedation dose used 0.5-0.7 mg/kg versus 02.-0.3; type and amount of treatment planned 8.3 units versus 3.3 and achieved 7.5 versus 2.2, for both centres respectively. There was also a difference in overall success rates of rendering the children dentally fit of 65% v. 91%, respectively.

CONCLUSION

Oral midazolam was found to be a useful drug for the management of young children with behaviour problems. It was found, however, not to be effective in all cases and for the provision of all types of paediatric dentistry. The results indicate that, when using oral midazolam in children, the treatment should be restricted to simple restorations and extractions over a maximum of two visits.

Behavioural antecedents to pro re nata psychotropic medication administration on acute psychiatric wards

This study examined the antecedents to administration of pro re nata (PRN) psychotropic medication on acute psychiatric wards, with a particular focus on its use in response to patient aggression and other conflict behaviours. A sample of 522 adult in-patients was recruited from 84 acute psychiatric wards in England. Data were collected from nursing and medical records for the first 2  weeks of admission. Two-thirds of patients received PRN medication during this period, but only 30% of administrations were preceded by patient conflict (usually aggression). Instead, it was typically administered to prevent escalation of patient behaviour and to help patients sleep. Overall, no conflict behaviours or further staff intervention occurred after 61% of PRN administrations. However, a successful outcome was less likely when medication was administered in response to patient aggression. The study concludes that improved monitoring, review procedures, training for nursing staff, and guidelines for the administration of PRN medications are needed.

Tolerance, sensitization and dependence to diazepam in Balb/c mice exposed to a novel open space anxiety test

Balb/c mice were exposed to an elevated platform that is extended on two opposite sides with lowered steep slopes. They were tested for 12min per session in 6 successive days. They received i.p. administration of either saline or one dose of diazepam (DZP 0.5, 1, 3mg/kg) in sessions 1-3, and saline in sessions 4 and 5. All groups of mice received a single dose of DZP (1mg/kg) in session 6. DZP produced inverted U-shaped dose-responses on the number of entries into different areas of the apparatus, with a peak in mean response at 1mg/kg whereas its effect on the duration of entries was mostly comparable between the 3 doses. It increased the number of crossings on the surface of the platform and facilitated entries onto the slopes. DZP-treated mice crossed frequently onto and spent longer time on the slopes in sessions 1-3 whereas saline-treated mice remained on the platform in sessions 1-6. Withdrawal of DZP in sessions 4-5 increased the latency of first entry and decreased the number and duration of entries onto the slopes which was reversed with the administration of 1mg/kg of DZP in the next session. This ON-OFF the drug may be due to the half-life of DZP which is very short in mice and rats ( approximately 0.88h). It also indicates that DZP-treated mice did not benefit from previous experience of entries onto the slopes which suggests a possible "state-dependent" effect. Administration of DZP after repeated exposures to the test did not facilitate entries onto the slopes but instead increased significantly the number of crossings on the surface of the platform; this increase was much higher than that observed in mice initially treated with DZP and exposed to the test. There is no evidence of habituation in saline-treated mice: the number of crossings on the platform was comparable between the first 5 sessions of the test. These results demonstrate that repeated exposures to the same anxiogenic environment resulted in avoidance responses developing tolerance and approach responses developing sensitization. They suggest that tolerance and sensitization are two opposite sides of the habituation process to the same stimulus and may account for the maintained state of anxiety.

Delayed Postoperative Agitation in a Child After Preoperative Midazolam

We present a case report of a 5-year-old boy who had severe agitation after PACU discharge after midazolam premedication for minor otologic surgery. He was treated over several hours in the emergency department with several doses of midazolam and phenobarbital, without resolution of the agitation. Finally, a single dose of flumazenil (0.2 mg) effectively reversed the child's agitation. The incidence and potential mechanisms for postoperative agitation are discussed, with a focus on the potential for midazolam-induced behavioral reactions. This information has nursing implications for postoperative discharge instructions and follow-up.

Clonidine for the prevention of emergence agitation in young children: efficacy and recovery profile

BACKGROUND

Emergence agitation (EA) is a common postoperative problem in young children who have received sevoflurane and isoflurane for general anesthesia. This randomized, double-blinded study evaluated the efficacy of intraoperative clonidine in reducing EA, and describes its recovery profile.

METHODS

With Institutional Review Board approval and informed consent, children undergoing brief, minimally painful procedures were studied. All children received preemptive analgesia with acetaminophen and ketorolac, sevoflurane for induction, and isoflurane for maintenance of anesthesia. Children received either 2 microg.kg(-1) clonidine or placebo intravenously (i.v.) following induction of anesthesia. Children were observed postoperatively for behavior and side effects, and their parents were telephoned the next day to determine postdischarge recovery characteristics.

RESULTS

One hundred and twenty children were included in this study: 59 of whom received clonidine, and 61 placebo; 41% of those in the placebo group exhibited moderate-severe EA compared with only 22% of those in the clonidine group (P < 0.03). Compared with those who received placebo, children who received clonidine awakened more slowly (22 min vs 14 min), had a longer postanesthesia care unit stay (57 min vs 46 min), and experienced sleepiness more frequently after discharge (75% vs 39%; all comparisons significant at P < 0.03). There were no adverse cardiorespiratory events in either group.

CONCLUSIONS

Findings demonstrate that i.v. clonidine administered after induction of anesthesia significantly reduces the incidence of EA in young children, but is associated with sleepiness postoperatively.

Emergency department management of pain and anxiety related to orthopedic fracture care: a guide to analgesic techniques and procedural sedation in children

Orthopedic fractures and joint dislocations are among the most painful pediatric emergencies. Safe and effective management of fracture-related pain and anxiety in the emergency department reduces patient distress during initial evaluation and often allows definitive management of the fracture. No consensus exists on which pharmacologic regimens for procedural sedation/analgesia are safest and most effective. For some children, control of fracture pain is the primary goal, whereas for others, relief from anxiety is an additionally important objective. Furthermore, strategies for the management of fracture pain may vary by fracture location and patient characteristics; thus, no single regimen is likely to provide the best means of analgesia and anxiolysis for all patients. Effective analgesia can be provided by local or regional anesthesia, such as hematoma, Bier, or nerve blocks. Alternatively, induction of deep sedation with analgesic agents such as ketamine or fentanyl, often combined with sedative-anxiolytic agents such as midazolam, may be used to manage distress associated with fracture reduction. A combination of local anesthesia with moderate sedation, for example nitrous oxide, is another attractive option.

Therapeutic potential of kava in the treatment of anxiety disorders

Anxiety disorders are among the most common psychiatric disorders that affect all age groups of the general population. Currently, the preferred treatment is with pharmacological drugs that have antidepressant or anti-anxiety properties. However, these agents have numerous and often serious adverse effects, including sedation, impaired cognition, ataxia, aggression, sexual dysfunction, tolerance and dependence. Withdrawal reactions on termination after long-term administration are also a major limiting factor in the use of these agents. Herbal remedies, including kava (Piper methysticum), have been shown to be effective as alternative treatments, at least in mild to moderate cases of anxiety. Kava is a social and ceremonial herb from the South Pacific. It is available in the west as an over-the-counter preparation. Its biological effects, due to a mixture of compounds called kavalactones, are reported to include sedative, anxiolytic, antistress, analgesic, local anaesthetic, anticonvulsant and neuroprotective properties. The pharmacological properties of kava are postulated to include blockade of voltage-gated sodium ion channels, enhanced ligand binding to gamma-aminobutyric acid (GABA) type A receptors, diminished excitatory neurotransmitter release due to calcium ion channel blockade, reduced neuronal reuptake of noradrenaline (norepinephrine), reversible inhibition of monoamine oxidase B and suppression of the synthesis of the eicosanoid thromboxane A(2), which antagonises GABA(A) receptor function. Clinical studies have shown that kava and kavalactones are effective in the treatment of anxiety at subclinical and clinical levels, anxiety associated with menopause and anxiety due to various medical conditions. Until recently, the adverse effects attributed to kava use were considered mild or negligible, except for the occurrence of a skin lesion. This disorder, called kava dermopathy, occurs only with prolonged use of large amounts of kava and is reversible on reduced intake or cessation. Rare cases of interactions have occurred with pharmaceutical drugs that share one or more mechanisms of action with the kavalactones. In the past few years, about 35 cases of severe liver toxicity associated with kava intake have been reported in Europe and the US. However, a direct causal relationship with kava use has been difficult to establish in the majority of the cases, and there is insufficient evidence to implicate kava as the responsible agent. Nevertheless, until further research clarifies any causality, kava should be used with caution.

Generalised anxiety disorder: treatment options

In recent years generalised anxiety disorder (GAD) has become a much better defined disorder, with specific criteria distinguishing it from the other anxiety disorders; however, it still lacks the same public and scientific interests as some of the other anxiety disorders such as panic and social phobia. Nevertheless, refinement in the treatment of GAD is becoming more evident through the conduct of clinical trials. Up until the mid-1980's, treatment consisted primarily of benzodiazepines. However, as a result of growing characterisation of their abuse potential, other therapeutic options were explored. Benzodiazepines became seen as an effective short-term therapy, and buspirone and some of the newer antidepressants have become the treatment of choice for patients with GAD requiring long-term treatment. Buspirone was the first available alternative to the benzodiazepines in the US; however, the initial excitement over this agent was somewhat dampened because of its mild efficacy combined with a slow onset of action. The antidepressants were seen as beneficial for the treatment of GAD because of the high comorbidity with depression, thus allowing a better outcome for these patients. The antidepressants that offer both a good adverse effect profile and efficacy are the selective serotonin reuptake inhibitors including paroxetine, and the serotonin-norepinephrine reuptake inhibitors such as venlafaxine. Clinicians should also consider the potential benefits of psychotherapy as an adjunct to medication. There are a number of potentially new pharmacotherapies being investigated, including newer serotonin 5-HT1A receptor agonists, cholecystokinin receptor antagonists, neurokinin receptor antagonists, gabapentin and its analogues, and gamma-aminobutyric acid (GABA)A receptor modulators. However, these compounds are all in the early stages of investigation, and there are no new therapies expected to be released in the near future. Nonetheless, in the search for the ideal anxiolytic, a more positive outlook is allowed by imminent future research for new treatment options in patients with GAD.

Rapid tranquillisation: time for a reappraisal of options for parenteral therapy

BACKGROUND

When parenteral treatments are indicated for acutely disturbed behaviour, previous guidelines have recommended droperidol or haloperidol in combination with benzodiazepines. However, there has been recent concern over cardiotoxicity and sudden death associated with some antipsychotic medication and droperidol has now been withdrawn.

AIMS

To ascertain what alternatives can be recommended to replace intramuscular droperidol.

METHOD

Selective review of current guidelines and the literature pertaining to rapid parenteral tranquillisation.

RESULTS

Current guidelines recommend haloperidol as an alternative to droperidol. There is evidence of cardiotoxicity with haloperidol and it has a propensity to cause extrapyramidal side-effects that may exacerbate disturbed behaviour and reduce longer-term compliance. The rapid-acting intramuscular formulations of atypical antipsychotic agents show promise.

CONCLUSIONS

It is recommended that the mainstay of pharmacological rapid tranquillisation should be parenteral benzodiazepines used with due care.

The effects of diazepam (valium) and aggressive disposition on human aggression: an experimental investigation

Sixty male subjects with self-reported high, moderate, and low aggressive dispositions were given the opportunity to aggress, by administering electric shocks, against an increasingly provocative fictitious opponent within the context of a competitive reaction time task. Subjects were randomly assigned to one of two conditions: (1) 10 mg of diazepam or (2) placebo. Results indicated that diazepam-intoxicated subjects aggressed by selecting the highest shock setting (10) more frequently than did nonintoxicated subjects. High hostile subjects were also more influenced by the aggression-enhancing effects of diazepam than moderate and low hostile subjects. Benzodiazepine-facilitated aggression is discussed in the context of individual differences and the importance for physicians to assess a patient's disposition prior to prescribing such medication.

Prolonged recovery and delayed side effects of sedation for diagnostic imaging studies in children

OBJECTIVE

Although sedation-related adverse events in children in the hospital setting have been extensively reported, limited data are available regarding adverse events after discharge home. Despite nationally recommended discharge criteria, in busy outpatient settings, children may be sent home into the care of their parents after a brief recovery from sedation, placing them at risk for adverse events in an unmonitored setting. Previous studies have not addressed issues such as requirement for escalation of care after discharge (ie, emergency department visits or hospitalization), or parental satisfaction with their child's sedation experience. This study was undertaken to evaluate the recovery and delayed adverse events after discharge of children who received sedation for magnetic resonance imaging or computed tomography.

METHODS

With approval from the institutional review board and written informed consent from a parent, children (<18 years old) sedated for magnetic resonance imaging or computerized tomography were studied. Sedative drugs were ordered at the discretion of the radiologist responsible for the procedure in accordance with institutional sedation guidelines and in consideration of the child's health status. Pediatric nurses in the diagnostic areas administered the sedative agent(s) and monitored children according to preestablished institutional guidelines. Demographics, sedative(s) administered, and adverse events including hypoxemia (decrease in SpO(2) by >/=10% of baseline) and sedation events such as inadequate, failed, or excessive sedation, were documented on the institutional quality assurance tool. Children were discharged from the hospital when they met the following preestablished discharge criteria: return to baseline vital signs, level of consciousness close to baseline, and the ability to maintain a patent airway. The following day, parents were telephoned and questioned regarding the child's alertness, side effects, and whether medical follow-up had been sought. Parents also rated their overall satisfaction with the sedation experience.

RESULTS

Three hundred seventy six children comprised the sample. Eighty nine percent of children received chloral hydrate (CH; 64 +/- 13 mg/kg), and 11% midazolam (.15 +/-.13 mg/kg) as the primary sedative. There was an 8% incidence of failed sedation, and a 1.6% incidence of hypoxemia during the procedure. Three children required prolonged monitoring in the postanesthesia care unit before discharge; 1 child attributable to an allergic reaction, a second attributable to wheezing and oxygen desaturation, and the third attributable to prolonged sedation from CH and midazolam. These children were discharged home from the postanesthesia care unit without additional sequelae. Side effects after discharge included: motor imbalance (31%), gastrointestinal effects (23%), agitation (19%), and restlessness (14%). Agitation and restlessness lasted greater than 6 hours in more than one third of children who experienced these effects. CH was more commonly associated with imbalance compared with midazolam, and restlessness and prolonged imbalance were associated with younger age. Medical advice was sought after discharge for 15 (4%) children, 3 of whom required a visit to the emergency department for excessive or prolonged sedation. Each of these children had received CH as a sole sedative in recommended doses (61-77 mg/kg). In 1 of these cases, the procedure had been aborted because of inadequate sedation in the hospital, yet the child became difficult to arouse at home. Only 48% of children returned to baseline activity and behavior within 8 hours of the procedure; however, 89% were back to baseline status within 24 hours. Notably, 5% of all children did not return to baseline activity until the second day after the procedure. Although not statistically significant, infants <12 months old experienced delayed recovery (ie, >/=24 hours) more frequently compared with older c

Plasma concentration of flumazenil following intranasal administration in children

PURPOSE

A pharmacokinetic study in children to determine plasma flumazenil concentrations after the intranasal administration of 40 microg x kg(-1).

METHODS

Following institutional approval and informed written consent, 11 ASA physical status I-II patients, aged two to six years, undergoing general anesthesia for dental surgery were recruited. After induction, 40 microg x kg(-1) flumazenil Anexate, Roche, 0.1 mg x mL(-1) (0.4 mL x kg(-1))) were administered via a syringe as drops, prior to nasal intubation. Venous plasma samples were drawn prior to administration of flumazenil (t = 0), and then at 2, 4, 6, 8, 10, 15, 20, 30, 40, 60, and 120 min thereafter. The plasma samples were immediately processed by the on-site laboratory and then stored at -70 degrees C, before batch analysis via high performance liquid chromatography assay. Pharmacokinetic data calculations were performed using WinNonLin software (Scientific Consulting Inc.).

RESULTS

Eleven patients were studied, but data for one patient were discarded due to insufficient sampling. The median age was 4.3 yr (range 3 to 6), with a median weight of 18.9 kg (range 14.9 to 22.2). There were seven boys and three girls. Mean Cmax was 67.8 ng x mL(-1) (SD 41.9), with Tmax at two minutes. The calculated half-life was 122 min (SD 99).

CONCLUSION

The mean plasma concentrations of flumazenil attained were similar to those reported after intravenous administration, and may be sufficient to antagonize the side-effects of benzodiazepines. This route of administration may be useful when the intravenous route is not readily available.

The "ouchless emergency department". Getting closer: advances in decreasing distress during painful procedures in the emergency department

Painful and frightening injuries and illnesses are frequent reasons for children to seek care in an emergency department. Painful therapeutic procedures are often a necessary part of emergency care and are very distressful for the children, their parents, and healthcare providers. Inadequately relieved pain and distress have acute and long-term consequences, yet methods for pain and anxiety reduction during frightening minor and major procedures are often not used because of lack of detailed knowledge of techniques and fear of adverse effects. This article reviews psychologic and pharmacologic means of safe and effective reduction of anxiety and pain during emergency department procedures.

Adverse events of procedural sedation and analgesia in a pediatric emergency department

STUDY OBJECTIVE

To determine the adverse event and complication rate for the use of procedural sedation and analgesia for painful procedures and diagnostic imaging studies performed in a pediatric emergency department.

METHODS

This prospective case series was conducted in the ED of a large, urban pediatric teaching hospital. Subjects were patients younger than 21 years seen between August 1997 and July 1998, who required intravenous, intramuscular, oral, rectal, intranasal, or inhalational agents for painful procedures or diagnostic imaging. All patients who underwent procedural sedation and analgesia were continually monitored. Adverse events and complications were recorded. The ED controlled substance log was checked weekly and all sedations were reviewed. Adverse events were defined as follows: oxygen desaturation less than 90%, apnea, stridor, laryngospasm, bronchospasm, cardiovascular instability, paradoxical reactions, emergence reactions, emesis, and aspiration. Complications were defined as adverse events that negatively affected outcome or delayed recovery.

RESULTS

Of 1,180 patients who underwent procedural sedation and analgesia in the ED, 27 (2.3%) experienced adverse events, which included oxygen desaturation less than 90% requiring intervention (10 patients) [supplemental oxygen (9), bag-mask ventilation (1)], paradoxical reactions (7), emesis (3), paradoxical reaction and oxygen desaturation requiring supplemental oxygen (2), apnea requiring bag-mask ventilation (1), laryngospasm requiring bag-mask ventilation (1), bradycardia (1), stridor and emesis (1) and oxygen desaturation requiring bag-mask ventilation with subsequent emesis (1). There was no statistically significant difference in mean doses for all procedural sedation and analgesia medication regimens between those children who experienced adverse events and those who did not. No single drug or drug regimen was associated with a higher adverse event rate. In addition, there was no significant difference in the adverse event rate between males and females, among the different ages, or among the different indications for procedural sedation and analgesia. No patient required reversal of sedation with naloxone or flumazenil, endotracheal intubation, or hospital admission because of complications from procedural sedation and analgesia.

CONCLUSION

The adverse event rate for procedural sedation and analgesia performed by pediatric emergency physicians was 2.3% with no serious complications noted.

Psychopharmacologic treatment of pathologic aggression

Several drugs are apparently effective in treating pathologic anger and aggression. Because many of the studies on aggressive populations allowed the use of concomitant medications, it is unclear whether the efficacy of each drug in a particular population is dependent on the presence of other medications, such as antipsychotic agents. Finally, one needs to be circumspect in inferring efficacy of a particular drug in aggressive patients with neuropsychiatric conditions other than the ones in which some efficacy has been established. Lithium appears to be an effective treatment of aggression among nonepileptic prison inmates, mentally retarded and handicapped patients, and among conduct-disordered children with explosive behavior. Certainly, lithium would be the treatment of choice in bipolar patients with excessive irritability and anger outbursts, and it has been shown to be effective in this population. Anticonvulsant medications are the treatment of choice for patients with outbursts of rage and abnormal EEG findings. The efficacy of these drugs in patients without a seizure disorder, however, remains to be established, with the exception perhaps of valproate and carbamazepine. In fact, dyphenylhydantoin did not appear to be effective in treating aggressive behavior in children with temper tantrums and was found to be effective in only a prison population. There is some evidence for the efficacy of carbamazepine and valproate in treating pathologic aggression in patients with dementia, organic brain syndrome, psychosis, and personality disorders. As Yudofsky et al point out in their review of the literature, although traditional antipsychotic drugs have been used widely to treat aggression, there is little evidence for their effectiveness in treating aggression beyond their sedative effect in agitated patients or their antiaggressive effect among patients whose aggression is related to active psychosis. Antipsychotic agents appear to be effective in treating psychotic aggressive patients, conduct-disordered children, and mentally retarded patients, with only modest effects in the management of pathologic aggression in patients with dementia. Furthermore, at least in one study, these drugs were found to be associated with increased aggressiveness in mentally retarded subjects. On the other hand, atypical antipsychotic agents (i.e., clozapine, risperidone, and olanzapine) may be more effective than traditional antipsychotic drugs in aggressive and violent populations, as they have shown efficacy in patients with dementia, brain injury, mental retardation, and personality disorders. Similarly, benzodiazepines can reduce agitation and irritability in elderly and demented populations, but they also can induce behavioral disinhibition. Therefore, one should be careful in using this class of drugs in patients with pathologic aggression. Beta-blockers appear to be effective in many different neuropsychiatric conditions. These drugs seem effective in reducing violent and assaultive behavior in patients with dementia, brain injury, schizophrenia, mental retardation, and organic brain syndrome. As pointed out by Campbell et al in their review of the literature, however, systematic research is lacking, and little is known about the efficacy and safety of beta-blockers in children and adolescents with pathologic aggression. Although widely used in the management of pathologic aggression, the use of this class of drugs has been limited partially by marked hypotension and bradycardia, which are side effects common at the higher doses. The usefulness of the antihypertensive drug clonidine in the treatment of pathologic aggression has not been assessed adequately, and only marginal benefits were observed with this drug in irritable autistic and conduct disorder children. Psychostimulants seem to be effective in reducing aggressiveness in brain-injured patients as well as in violent adolescents with oppositional or conduct disorders, particu

Efficacy of rectal midazolam for the sedation of preschool children undergoing laceration repair

STUDY OBJECTIVE

To determine the efficacy of rectal midazolam as sedation for laceration repair in preschool children in the pediatric emergency department.

DESIGN

Randomized, double-blind, placebo-controlled trial.

PARTICIPANTS

Thirty-four anxious children aged 14 to 51 months with face or scalp lacerations 3 cm or less in length requiring two or more sutures and behavior scores of 3 or more.

INTERVENTIONS

Subjects received 0.45 mg/kg rectal midazolam or saline placebo rectally followed by a topical anesthetic 15 minutes before repair.

RESULTS

Sixteen patients received rectal midazolam, and 18 received placebo. The groups were similar in age, race, gender, laceration length and location, entry behavior score, and entry anxiety score. Ten patients in the rectal midazolam group and 1 in the placebo group achieved adequate sedation (P < .001). Median behavior scores during suturing were more favorable in the rectal midazolam group (P = .003 and P = .08, respectively). Two patients in the rectal midazolam group experienced inconsolable agitation after the repair. None of the patients suffered cardiopulmonary complications.

CONCLUSION

Rectal midazolam is an effective method of sedation for facilitating uncomplicated laceration repair in preschool children. However, physicians must be aware of the possibility of paradoxical reactions when using midazolam in children.

Guidelines for the rational use of benzodiazepines. When and what to use

The main actions of benzodiazepines (hypnotic, anxiolytic, anticonvulsant, myorelaxant and amnesic) confer a therapeutic value in a wide range of conditions. Rational use requires consideration of the large differences in potency and elimination rates between different benzodiazepines, as well as the requirements of individual patients. As hypnotics, benzodiazepines are mainly indicated for transient or short term insomnia, for which prescriptions should if possible be limited to a few days, occasional or intermittent use, or courses not exceeding 2 weeks. Temazepam, loprazolam and lormetazepam, which have a medium duration of action are suitable. Diazepam is also effective in single or intermittent dosage. Potent, short-acting benzodiazepines such as triazolam appear to carry greater risks of adverse effects. As anxiolytics, benzodiazepines should generally be used in conjunction with other measures (psychological treatments, antidepressants, other drugs) although such measures have a slower onset of action. Indications for benzodiazepines include acute stress reactions, episodic anxiety, fluctuations in generalised anxiety, and as initial treatment for severe panic and agoraphobia. Diazepam is usually the drug of choice, given in single doses, very short (1 to 7 days) or short (2 to 4 weeks) courses, and only rarely for longer term treatment. Alprazolam has been widely used, particularly in the US, but is not recommended in the UK, especially for long term use. Benzodiazepines also have uses in epilepsy (diazepam, clonazepam, clobazam), anaesthesia (midazolam), some motor disorders and occasionally in acute psychoses. The major clinical advantages of benzodiazepines are high efficacy, rapid onset of action and low toxicity. Adverse effects include psychomotor impairment, especially in the elderly, and occasionally paradoxical excitement. With long term use, tolerance, dependence and withdrawal effects can become major disadvantages. Unwanted effects can largely be prevented by keeping dosages minimal and courses short (ideally 4 weeks maximum), and by careful patient selection. Long term prescription is occasionally required for certain patients.

Pediatric analgesia and sedation

Sedation and analgesia are essential components of the ED management of pediatric patients. Used appropriately, there are a number of medications and techniques that can be used safely in the emergency care of infants and children. Emergency physicians should be competent in the use of multiple sedatives and analgesics. Adequate equipment and monitoring, staff training, discharge instructions and continuous quality management should be an integral part of the ED use of these agents.

Oral benzodiazepines and conscious sedation: A review

A large number of benzodiazepines have been studied for use as sedatives and for their anxiolytic potential as premedicants for outpatient surgery. Potent, new, orally-administered drugs with short half-lives, rapid onset, and minimal residual effects have been developed. Dose-dependent amnesia is also produced by some of these agents. Advances in understanding receptor physiology have shed light on specific pharmacologic activities and aided the discovery of benzodiazepine antagonists with antidote properties. While these drugs have relatively low toxicity, dose-related oversedation remains a risk in susceptible patients, especially when combined with other sedatives.

Rectal ketamine and midazolam for premedication in pediatric dentistry

Rectally administered midazolam (0.30 mg/kg) and ketamine (5 mg/kg) were compared for preanesthetic medication in children undergoing dental extractions. Sixty patients between the ages 2 and 9 years were randomly allocated to three groups in this double-blind study. In one group of patients who received ketamine rectally, intravenous midazolam (0.05 mg/kg) also was administered immediately after induction of anesthesia. The results from this trial show that 30 minutes after rectal administration of the two drugs, good anxiolysis, sedation, and cooperation were obtained in most patients. Although midazolam appeared to be marginally more efficacious than ketamine in the majority of assessments made and seemed to have less adverse effects, no statistically significant differences could be shown. Ketamine showed a slight decrease and midazolam a slight increase in average blood pressures after premedication. These blood pressure differences were, however, considered to be of little clinical importance.