What is the appropriate action for an Adult-Gerontology Acute Care Nurse Practitioner (AGACNP) regarding a postoperative patient's request to resume alprazolam (Xanax) 0.5 mg orally (PO) every night at bedtime and sertraline (Zoloft) 100 mg PO daily for generalized anxiety disorder after a total hip replacement?

Management of Home Medications After Total Hip Replacement

Restart sertraline only (100 mg PO daily) and avoid restarting alprazolam in the immediate postoperative period. 1

Rationale for Medication Management

Sertraline (Zoloft)

• Sertraline should be continued in the postoperative period as abrupt discontinuation of antidepressants can lead to withdrawal symptoms and potential recurrence of anxiety symptoms 2
• Sertraline is effective for generalized anxiety disorder with significantly greater improvement compared to placebo in clinical trials 3
• SSRIs like sertraline do not cause respiratory depression or significant sedation that would be concerning in the postoperative period 2

Alprazolam (Xanax)

• Alprazolam should not be restarted immediately after surgery due to several important concerns:
  • Benzodiazepines can cause additive central nervous system depression when combined with anesthetics and postoperative pain medications, potentially leading to hypotension, profound sedation, and respiratory depression 1
  • Benzodiazepines increase the risk of delirium, falls, and cognitive impairment in the postoperative setting, especially in patients over 50 years old 1
  • Concurrent use of benzodiazepines with opioid pain medications (commonly used after orthopedic surgery) increases the risk of overdose nearly four-fold 1

Alternative Approaches for Anxiety Management

• For acute anxiety in the postoperative period, non-pharmacological approaches should be attempted first, including:

  • Reassurance and clear communication about recovery expectations 1
  • Ensuring adequate pain control through non-opioid means when possible 1

• If medication is needed for severe anxiety requiring immediate relief:

  • Consider trazodone for nighttime use (option D in the question) as it has less respiratory depression risk than benzodiazepines 4
  • Buspirone could be considered as an alternative anxiolytic that doesn't cause dependence or withdrawal and has minimal sedation effects 4

Long-term Considerations

• After the acute postoperative period (2-4 weeks), reassess the patient's anxiety symptoms 1
• If alprazolam is to be restarted later, it should be done with caution:
  • Start at a lower dose (0.25 mg) in patients recovering from major surgery 5
  • Taper benzodiazepines gradually when discontinuing, reducing by no more than 25% every 1-2 weeks 1

Important Precautions

• Monitor for serotonin syndrome if the patient is receiving medications that increase serotonergic activity (including certain pain medications like tramadol or fentanyl) along with sertraline 1
• Be aware that alprazolam has high misuse liability compared to other benzodiazepines due to its rapid onset of action 6
• Extended-release formulations of alprazolam may be preferable if restarting later due to reduced abuse potential and fewer cognitive side effects 7