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PHRM 845 > 4.6 Pharmacotherapy of anxiety disorders > Flashcards

4.6 Pharmacotherapy of anxiety disorders Flashcards

1
Q

What drugs cause anxiety?

A
  • Albuterol
  • Caffeine (in high doses >800 mg)
  • Decongestants
  • Levothyroxine
  • Steroids
  • Stimulants (ADHD meds)
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2
Q

What is buspirone’s MOA?

A

5HT-1a receptor agonist

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3
Q

What is buspirone used for?

A

Possible 1st line therapy for GAD

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4
Q

What is the dosing of buspirone?

A

Dosed w a target of 10-15 mg 3 times daily (30-45 mg total/day)

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5
Q

How long does it take for buspirone’s effect to start?

A

May take up to 3-4 wks for initial efficacy

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6
Q

What do tx guidelines say about the use of benzos for anxiety?

A
  • Does not support use in routine practice due to misuse potential
  • But effect size for efficacy in anxiety disorders is higher than serotonergic antidepressants
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7
Q

Is long term use of benzos recommended?

A

No

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8
Q

What may withdrawal of benzos cause?

A

Acute withdrawal may lead to life-threatening seizures

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9
Q

What are the warnings associated w benzos?

A
  • Warnings for use of benzos w other CNS depressants and overdose death risk
  • Specific warnings for co-prescribing w opioids
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10
Q

Which benzos have a long-acting active metabolite?

A

Diazepam, clorazepate, chlordiazepoxide

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11
Q

Which benzos do not have an active metabolite?

A

Alprazolam, lorazepam, clonazepam, and oxazepam

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12
Q

What is still a risk (though, not as high) w benzos that doesn’t have an active metabolite?

A

Fall risk

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13
Q

What are the SEs of benzos?

A
  • Sedation
  • Paradoxical excitement
  • Swallowing difficulties
  • Impairment of memory and recall
  • Psychomotor impairment
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14
Q

What is the process of d/c benzos?

A

Slow taper over weeks to months

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15
Q

What pt group are benzos not appropriate in?

A

Elderly

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16
Q

If benzos have to be used in an elderly pt, which ones are preferred?

A

Prefer L-O-T (lorazepam, oxazepam, temazepam)

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17
Q

What is hydroxyzine approved for?

A
  • Hydroxyzine pamoate is FDA approved for tx of GAD
  • Can use HCl salt for lower 10 mg dose
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18
Q

How is hydroxyzine used?

A

Used prn for anxiety or insomnia instead of a benzo

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19
Q

What are the risks associated w hydroxyzine?

A
  • Sedation and anticholinergic SEs are prominent
  • QTc prolongation risk
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20
Q

What pt population should hydroxyzine not be used in and why?

A

Avoid use in elderly due to anticholinergic SEs and fall risk

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21
Q

What is propranolol used for?

A
  • Decrease physiological sxs of acute anxiety (sweating, tachycardia)
  • For non-generalized, performance and situational related SAD
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22
Q

What is the dose of propranolol used for anxiety?

A

10-20 mg 2-3 times daily or LA dosage form

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23
Q

What must be evaluated before a pt can use propranolol?

A

Evaluate for hx/current asthma and CV conditions

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24
Q

What may kava cause and is it recommended?

A
  • May cause hepatotoxicity
  • Not recommended
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25
Q

What is st. john’s wart used for?

A

Anxiety and depression

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26
Q

What is the pharmacological profile of st. john’s wart to evaluate for?

A
  • Strong 3A4 inducer
  • Mild MAO-Bi so increased risk for serotonin syndrome
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27
Q

Is valerian recommended during pregnancy?

A

Avoid use during pregnancy

28
Q

Is passionflower recommended during pregnancy?

A

Avoid in pregnancy due to risk of uterine stimulation induction of early labor

29
Q

What should be avoided if taking chamomile?

A

Blood thinners and ragweed allergy

30
Q

What may gabapentinoids be used for?

A

Considered in a pt w bipolar disorder who has anxiety sxs or comorbid neuropathic pain

31
Q

What does sleep medicine not endorse regarding quetiapine?

A

Quetiapine should not be used for insomnia

32
Q

What is the use of SSRIs/SNRIs?

A

SSRI/SNRIs are 1st line therapy for ALL anxiety disorders

33
Q

While tx guidelines recommended against its use, what are benzos approved for?

A

FDA approved to tx anxiety disorders

34
Q

Are atypical antipsychotics FDA approved for anxiety disorders?

A

No

35
Q

Though atypical antipsychotics are not FDA approved for anxiety disorders, what could they be good for?

A

Clinical evidence suggests efficacy for tx-resistant OCD (aripiprazole and risperidone)

36
Q

What is GAD?

A

Excessive anxiety/worry present for AT LEAST 6 months

37
Q

To be diagnosed w GAD, what sxs must be present?

A

Sxs include at least 3 of the following:
- Restlessness/feeling keyed up or on edge
- Being easily fatigued
- Difficulty concentrating or mind “going blank”
- Irritability
- Muscle tension
- Sleep disturbances

38
Q

What is the 1st line therapy for GAD?

A

1st line maintenance tx are SSRI antidepressants

39
Q

When are SNRIs used for GAD?

A

Useful 1st line if pt ALSO HAS a pain syndrome

40
Q

When are benzos used in GAD?

A

As a “bridge therapy” to cover time until onset of SSRI/SNRI, when appropriate

41
Q

What is social anxiety disorder?

A
  • Persistent fear about social and/or performance situations in which the pt fears embarrassment or humiliation that is unreasonable
  • Specific situations may be avoided that interferes w pt’s normal routine
42
Q

How long must a pt have sxs of social anxiety disorder before it is officially diagnosed?

A

At least 6 months

43
Q

What is 1st line tx for SAD?

A

SSRIs (paroxetine and sertraline)

44
Q

What may be useful for SAD if SSRIs don’t work?

A

SNRIs (venlafaxine is FDA approved for SAD)

45
Q

How is panic disorder defined?

A
  • Recurrent, unexpected panic attacks
  • Abrupt surge of intense fear or discomfort
46
Q

What are the diagnostic criteria for panic disorder?

A
  • At least 4 physical and psychological sxs: sweating, palpitations, nausea, dizziness, fear of losing control, “going crazy, dying
  • At least one attack followed by one month or more of at least the following: persistent concern about more attacks, maladaptive changes to avoid attacks
47
Q

What is 1st line therapy for panic disorder?

A

SSRI

48
Q

Can SNRI be used for panic disorder and if so, which one?

A

Yes, venlafaxine is FDA approved

49
Q

Are benzos considered 1st line for panic disorder?

A

Benzos should not be considered 1st line unless there is inadequate response to serotonergic drugs

50
Q

Which benzos are FDA approved for panic disorder?

A

Clonazepam and alprazolam

51
Q

Define compulsions in obsessive-compulsive disorder.

A
  • Repetitive behaviors or mental acts performed in response to obsession
  • Aimed at reducing or preventing distress
  • Not always connected to the fear
52
Q

What is 1st line tx for OCD?

A

SSRIs

53
Q

What level of sx reduction can we see w SSRIs for OCD?

A

25-50% reduction in sxs can be expected

54
Q

What is considered 2nd line tx for OCD?

A

Clomipramine (tricyclic antidepressant [TCA]), if the pt fails multiple SSRIs

55
Q

What drug class is not FDA approved for OCD, but may be considered?

A
  • Antipsychotics are not FDA approved for OCD
  • May be considered as augmentation w SSRI/SNRIs
56
Q

Which antipsychotics can be used to augment SSRI/SNRIs?

A
  • Risperidone has best data for effectiveness
  • Can also use aripiprazole (inconsistent efficacy)
57
Q

What can cause PTSD?

A

Exposure to real or threatened death, serious injury, or sexual violence

58
Q

What are the cardinal signs of PTSD?

A
  • Flashbacks
  • Re-experiencing
  • Avoidance
  • Hyper-vigilance
  • Negative alterations in mood or cognition
59
Q

What are 1st line tx for PTSD?

A

SSRIs/SNRIs are only FDA approved drug class for PTSD

60
Q

What drug may help w PTSD nightmares?

A

Prazosin

61
Q

Which class is NOT recommended in PTSD and why?

A
  • Benzos
  • May worsen recovery from trauma, potentiate fear response, cause suicidal ideations
62
Q

What is common in PTSD and should be treated concurrently?

A

Substance use

63
Q

What non-pharm therapy may be helpful to tx PTSD?

A
  • Cognitive behavioral therapy
  • Eye movement desensitization reprocessing
64
Q

What can result from use of SSRI/SNRIs for tx of all anxiety disorders?

A

“Jitteriness” syndrome

65
Q

How can jitteriness syndrome of SSRI/SNRIs be avoided?

A

Initial doses should be lower than doses used for depression to minimize this SE

66
Q

How long is the onset of action for SSRI/SNRIs?

A

2-4 wks

67
Q

What are non-pharm tx of anxiety disorders?

A
  • Psychotherapy
  • Cognitive behavioral therapy

PHRM 845 (48 decks)

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