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

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

• The patient is taking acetaminophen/butalbital, which may be contributing to their insomnia, as barbiturates can disrupt sleep patterns 3.
• Non-pharmacologic interventions, such as cognitive behavioral therapy for insomnia (CBT-I), yoga, and mind-body programs, have been shown to be effective in managing insomnia in patients with breast cancer 3.
• A thorough evaluation of the patient's sleep history and contributing factors, such as pain, discomfort, and fear of recurrence, is necessary to determine the best course of treatment 4.
• Pharmacologic therapies, such as benzodiazepines with short half-lives or nonbenzodiazepines, may be considered for treating insomnia, but their use should be carefully weighed against potential risks and benefits 4.

Consideration of Breast Cancer History

The patient's history of breast cancer is an important factor in determining the next steps in management.

• Breast cancer treatment can contribute to insomnia, and addressing the underlying causes of insomnia is crucial in improving the patient's quality of life 3.
• The patient may be experiencing persistent pain after breast cancer treatment (PPBCT), which can contribute to anxiety and insomnia 5.
• Interventional pain management options, such as botulinum toxin injections and nerve blocks, may be considered to help manage post-mastectomy pain syndrome 6.

Next Steps in Management

Based on the available evidence, the next steps in management for this patient may include:

• A thorough evaluation of the patient's sleep history and contributing factors, including pain, discomfort, and fear of recurrence 4.
• Consideration of non-pharmacologic interventions, such as CBT-I, yoga, and mind-body programs, to manage insomnia 3.
• Evaluation of the patient's pain management regimen and consideration of interventional pain management options, if necessary 6.
• Careful monitoring of the patient's symptoms and adjustment of their treatment plan as needed 3, 4.