62 - Pharmacotherapy of anxiety

Question 1

drugs that can cause anxiety

Answer 1

albuterol
antipsychotics
bupropion
caffeine
decongestants.
cocaine, meth
levothyroxine
steroids
stiulants
theophylline

Question 2

Buspirone

buspirone is a ___ receptor agonist
approved for ___

often not dosed appropriately for efficacy
- target of ___ - ___ mg ___ time daily (30-45 mg/day)

may take up to ___ - ___ weeks for initial efficacy

Answer 2

5HT-1a
GAD
10-15, TID
3-4

Question 3

BZDs

• ___ -term use is not recommended - dependence/tolerance
• acute withdrawal of BZD may lead to ___ that can be life-threatening
• warning for the use of BZD with other CNS depressants - specific warnings for co-prescribing with opioids

Answer 3

long
seizures

Question 4

BZDs

no active metabolite (4)
- less likely to accumulate
- not as high as a ___ risk

long acting active metabolite (3)
- may lead to ___ and ___ risk, especially in elderly

SE
- sedation
- paradoxical excitement
- swallowing difficulties
- impairment of memory/recall
- psychomotor impairment

d/c requires slow __ over ___ to ___
- depending how long patient has been on BZD and their tolerance

Beer’s criteria - in elderly prefer (3) (LOT)

Answer 4

• alprazolam, loreazepam, clonazepam, oxazepam
• fall
• diazepam, clorazepate, chlordiazepoxide
• hangover, fall
• taper, weeks, months

lorazepam, oxazepam, temazepam

Question 5

hydroxyzine

pamoate: FDA- approved for treatment for ___
- most commonly used ___ for anxiety or insomnia instead if BZD
- sedation and ___ SE are prominennt, QTc prolongation
- avoid use in the ___ ( ___ effects and ___ risk)
- 5HT2A antagonist and H1 receptor antagonists

Answer 5

GAD
- prn
- anticholinergic
- elderly, anticholinergic, fall

Question 6

propranolol

decrease physiological symptoms of acute anxiety
- tachycardia, sweating, flushing

usefil for ___ and situationaly anxiety in prn doses
low doses - 10-20 mg 2-3x daily or LA dosage form

evaluate for asthma/CV conditions

Question 7

natural

kava
st johns wort
passionflower
valerian
chamomile

Question 8

gabapentinoids and quetiapine

may be considered in a patient with ___ disorder wo has anxirty symptoms or comorbid neuropathic pain

quetiapine is somrties prescribed for anxiety and sleep; evidence base is limited fo anxiety and sleep medicine does not endorse the use of quetiapine for insomnia

Question 9

general drug therapy principles

___ and ___ are first line for all anxiety disorders

___ can also be used first line for GAD

BZD FDA-approved but ony use if necessary

atypical antipsychotics are not FDA spproved for anxiety, but clinical evidence suggests efficacy for treatment resistant OCD ( ___ and ___ )

Answer 9

SSRIs, SNRIs
buspirone
risperidone, aripiprazole

Question 10

DSM-5 GAD

excessive anxiety/worry around life events, difficult to control, present for at least ___ months

symptoms include at least 3 of the following
- restlessness
- fatigued
- difficulty concentrating, mind going blank
- irritability
- muscle tension
- sleep disturbances

Answer 10

6

Question 11

GAD treatment

• first line ___ - take 2-4 weeks for initial onset
• SNRIs - useful if patient also has ___
• BZD - ___ therapy to cover time until onset of SSRI/SNRI - MUST ___
• buspirone - good if dosed high enough and patient is aware how long it will take to work
• __ may be useful PRN; SE - anticholinergic and QTc prolongation

Answer 11

SSRI
pain
bridge
taper
hydroxyzine

Question 12

social anxiety disorder

persistent fear about social and or performance situations in whihc the patient fears embarrassemnt or humiliation that is unreasonable
- specific situations may be ___ in a manner tha interferes with the patients normal routine
- durations of symptoms lasts at least ___ month

Answer 12

avoided
6

Question 13

social anxiety disorder treatment

• ___ are first line ( ___ and ___ are FDA approved)
• __ - may be useful is failure ( ___ is FDA approved)
• ___ may be useful for non-generalized performance related SAD

Answer 13

• SSRI, paroxetine, sertraline
• SNRI, venlafaxine
• BBs

Question 14

panic disorder

recurrent, ___ panic attacks
- abrupt surge of intense fear or discomfort
- at least 4 physical and psychological symptoms: sweating, alpitations, nausea, dixxiness, fear of losing control, going crazy, dying

at least one attack has been followed by one ___ or longer of at least one of the following
- persistent concern about additional attacks on their consequences
- significant maladaptive change in behavior releasred to attacks

Answer 14

unexpected
month

Question 15

panic disorder treatment

• ___ are first line
• ____ - ___ is FDA approved
• ___ should not be considered first line maintenance unless inadequate response to ___ drugs

Answer 15

SSRI
SNRI, venlafaxine
BDZ, serotinergic

Question 16

OCD

___ - recurrent intrusive thoughts causing anxiety
___ - repeticitve behaviors or mental acts performed in response to absession

Answer 16

obsessions
compulsions

Question 17

treatment of OCD

• ___are first line
• ___ - ___% reduction in symptoms can be expected
• is patient fails a few trials of differemnt SSRIs, ___ (TCA) is considered 2nd line
• ___ are not FDA approved for OCD, may be considered ___ therapy with SSRI/SNRI - ___ best data, also ___

Answer 17

SSRI
25-50%
clomipramine
antipsychotics, augmentation, risperidone, aripiprazole

Question 18

exposure to real/threatened death, serious injury, or sexual violence
- flashbacks
- re-experiencing
- avoidance
- hyper ___
- ___ alterations in mood/cognition

Answer 18

hypervigilance
negative

Question 19

treatment of PTSD

___ / ___ are first line - only class od srugs FDA approved
- ___ may be helpful for nightmarees
- ___ not recommended in PTSD
- polytherapy common
- substance use is common
- CBT and eye movement desensitization/reprocessing may be helpful

Answer 19

SSRI/SNRI
prazosin
BZD

Question 20

drug therapy issues in anxiety disorders

___ syndrome - can result from the use of SSRI/SNRI
- initial dose should be ___ than depression dosing to minimize this
- onset of action for SSRI/SNRI is ___ - ___ weeks, max response to a specific drug may take ___ - ___ weeks
- evaluate severity of impact of functionality by the disorder befor considering ___ therapy with
- abrubpt d/c of BZD can be ___

Answer 20

jitteriness
lower
2-4, 6-8
bridge, BZD

Question 21

Non-PCOL for anxiety

psychotherapy and CBT

in PTSD - drug therapy more effective in ___ PTSD, non-drug treatment especially useful for veterans

Answer 21

civilians