What is the most appropriate next step in management for a 57-year-old woman with anxiety and insomnia, taking acetaminophen/butalbital, with a history of breast cancer and normal vital signs, including normotension?

From the Guidelines

The most appropriate next step in management for a 57-year-old woman with anxiety and insomnia, taking acetaminophen/butalbital, with a history of breast cancer and normal vital signs, including normotension, is to offer yoga as a complementary therapy to improve anxiety symptoms.

Key Considerations

• The patient's history of breast cancer and current anxiety symptoms make her a suitable candidate for yoga as a complementary therapy, as recommended by the Society for Integrative Oncology-ASCO guideline 1.
• The evidence suggests that yoga can improve anxiety symptoms in women with breast cancer, with a moderate strength of recommendation and intermediate quality of evidence 1.
• Before initiating yoga, it is essential to rule out any medical causes of anxiety, such as unrelieved symptoms like pain and fatigue, and to assess the patient's current symptomatology level and presence/absence of DSM-V diagnoses 1.
• The patient's current medication, acetaminophen/butalbital, should be reviewed, and consideration should be given to nonpharmacologic interventions or pharmacologic interventions with a favorable adverse effect profile 1.
• A stepped care model should be used to tailor intervention recommendations based on variables such as symptomatology level, functional impairment, and patient preference 1.
• Psychological and psychosocial interventions should be derived from relevant treatment manuals and guided by outcome measures to gauge efficacy and monitor treatment adherence 1.

From the FDA Drug Label

Butalbital, Acetaminophen and Caffeine Capsules should be prescribed with caution in certain special-risk patients, such as the elderly or debilitated, and those with severe impairment of renal or hepatic function, or acute abdominal conditions Butalbital may be habit-forming. Patients should take the drug only for as long as it is prescribed, in the amounts prescribed, and no more frequently than prescribed Because of potential for serious adverse reactions in nursing infants from butalbital, acetaminophen and caffeine, a decision should be made whether to discontinue nursing or to discontinue the drug, taking into account the importance of the drug to the mother.

The most appropriate next step in management for a 57-year-old woman with anxiety and insomnia, taking acetaminophen/butalbital, with a history of breast cancer and normal vital signs, including normotension, is to reassess the need for butalbital and consider alternative treatments for anxiety and insomnia, given the potential for habit-forming and adverse reactions, especially considering her age and history of breast cancer 2 2.

• Monitor renal function and adjust the dose accordingly, as butalbital is substantially excreted by the kidney and the risk of toxic reactions may be greater in patients with impaired renal function.
• Consider alternative treatments for anxiety and insomnia that may be safer and more effective in the long term.

From the Research

Management of Anxiety and Insomnia in a Breast Cancer Survivor

The patient's history of breast cancer and current symptoms of anxiety and insomnia require careful consideration in determining the most appropriate next step in management.

• The patient is currently taking acetaminophen/butalbital, which may be contributing to their insomnia, as butalbital-containing medications have been linked to the chronification of migraine and development of medication-overuse headaches 3.
• A study on the evaluation and management of insomnia in women with breast cancer suggests that non-pharmacologic interventions, such as cognitive behavioral therapy for insomnia (CBT-I), yoga, and mind-body programs, may be effective in addressing insomnia 4.
• Another study on the diagnosis and management of insomnia in older people recommends a step-wise approach, including initial evaluation, determination of crisis, sleep evaluation, and intervention, with non-pharmacological strategies as the mainstay of treatment 5.
• The patient's history of breast cancer and anxiety may also be contributing to their insomnia, as studies have shown that breast cancer survivors are at risk of developing persistent pain, anxiety, and depression 6, 7.
• Considering the patient's normal vital signs, including normotension, and the potential risks associated with butalbital-containing medications, it may be necessary to reassess the patient's medication regimen and consider alternative treatments for their anxiety and insomnia.

Potential Treatment Options

• Non-pharmacologic interventions, such as CBT-I, yoga, and mind-body programs, may be effective in addressing the patient's insomnia 4.
• Alternative medications, such as benzodiazepines with short half-lives or non-benzodiazepines, may be considered for the treatment of insomnia, but their use should be carefully evaluated due to potential risks and side effects 5.
• Exercise and behavioral interventions have been shown to be effective in managing chronic symptoms, including cancer-related fatigue, insomnia, and cognitive impairment, and may be a useful adjunct to other treatments 7.