..

Case PresentationInsomnia

1 55 CC:PI:1PTA PTA PH: MH:FH: 1 SH: Allergy:

Case ScenarioSubjective Data

Dx: Insomnia with Anxiety DisorderRx: Hydroxyzine 25 mg 2X1hs

Objective Data1 ()/2/3/4 /5 /6/7/8/9/10/11/12 /13/14 /15 /5:(Insomnia)1-2 Slow reaction time

Assessment (Adjustment disorders), 1.2. Assessment the duration of symptomsTransient or acuteFew days to 2-4 weeksChronic Persisting for more than 1-3 monthsAssessmentNon-Pharmacological TherapiesCognitive-behavioral therapy(CBT)Stimulus controlCognitive therapySleep restrictionRelaxation training Sleep hygiene

Pharmacological TherapiesBenzodiazepinesLorazepam,Clonazepam,AlprazolamNon-benzodiazepine hypnotics

Melatonin receptor agonist AntidepressantsAntipsychoticsAntihistaminesAssessmentIndicationUS FDA Hydroxyzine Hydroxyzine 50-100 mg PO divided q6hr or 50-100 mg IM divided q4-6hr(Medscape)Assessment

EfficacyMOA: histamine H1 receptor Llorca 334 3 hydroxyzine 50 (12.5 , 50 ) 2 bromazepam ( benzodiazepine) 6 (1.5 , 3 ) 3 3 3 hydroxyzine bromazepam bromazepam (7.9%) hydroxyzine 3.9% 1.8% Assessment Ferreri Darcis 110 hydroxyzine 50 4 hydroxyzine Lader Scotto 4 hydroxyzine Meta Analysis Guaidina Hydroxyzine Hydroxyzine Anxiolytic agents Assessment

SafetySide effect: AssessmentHydroxyzineBenzodiazepinesSSRI/SNRITCA Anticholinergic effects- (Tolerance) (Withdrawal syndrome) (Rebound insomnia) - ( ) - anticholinergic effect - amitriptyline-withdrawal symptoms anticholinergic rebound anticholinergic Adherence antihistamine

AssessmentCost:Hydroxyzine original brand Local made Assessment

Therapeutic plan:1.Hydroxyzine 100mg/dayHydroxyzine(25) 1X4 PC2. Benzodiazepines ,SSRI,SNRI,TCA CaseLorazepam 0.5mg-1mg /dayClonazepam 0.25mg-1mg/dayAlprazolam 0.25mg-0.5mg/dayBeta blockers Somatic anxiety Psychic anxiety Propranolol 30-80mg/day 10-40mg/dose prn

PlanGoals1. 2. 3.

PlanTherapeutic monitoring: Vital sign :BP RR HR BT

Toxicity monitoring:Anticholinergic side effects Drug allergyPlanEducation plan:1. 5 1-2 2. 10 3. 3 304.8-10 Future plan: 2-3 Panic disorder (PD) Generalized anxiety disorders(GAD) Planhttp://www.fda.moph.go.th/ http://drug.fda.moph.go.th:81/nlem.in.th/ National List of Essential MedicinesLlora P, Spadone C, Sol O, Danniau A, Bougerol T, Corruble E, et al. Efficacy and safety of hydroxyzine in the treatment of generalized anxiety disorder: A 3-month double-blind study. J Clin Psychiatry 2002;63:1020-27Ferreri M, Darics T, Burtin B. A multicenter double-blind placebo controlled study investigating the anxiolytic efficacy of hydroxyzine in patients with generalized anxiety. Hum Psychopharmacol 1995;10:181-7References