67. Anxiety Disorders Flashcards
Drugs that cause anxiety
Albuterol (if used too frequently or incorrectly)
Antipsychotics (e.g. aripiprazole, haloperidol)
Bupropion
Caffeine, in high doses
Decongestants (e.g. pseudoephedrine)
Illicit drugs (e.g. cocaine, LSD, methamphetamine)
Levothyroxine (if therapeutic overdose occurs)
Steroids
Stimulants (e.g. amphetamine, methylphenidate)
Theophylline
Natural products used for anxiety and limitations
St. John’s wort - used for depression and anxiety but strong CYP3A4 inducer, causes photosensitivity, and serotonergic
Valerian - used for anxiety and sleep but some products may be contaminated with liver toxins (monitor liver function)
Passionflower
Kava - relaxant, but can cause severe liver damage and is not recommended
First-line treatment for anxiety
SSRIs and SNRIs
Escitalopram (Lexapro)
Fluoxetine (Prozac)
Paroxetine (Paxil)
Sertraline (Zoloft)
Duloxetine (Cymbalta)
Venlafaxine XR (Effexor XR)
Comments about first-line treatment of anxiety with SSRIs and SNRIs
Most drug dosing will start half the initial dose used for depression, titrate slowly to minimize anxiousness/jitteriness
Will not provide immediate relief, takes at least 4 weeks at higher doses for noticeable effect
Other SSRIs/SNRIs may be used off-label for anxiety
Second-line treatments for anxiety
Buspirone - does not provide immediate relief, takes 2-4 weeks for effect
TCAs (amitriptyline, nortriptyline (Pamelor), imipramine) - not FDA-approved, anticholinergic side effects limit use
Hydroxyzine (Vistaril) - sedating antihistamine with anticholinergic activity, FDA approved for anxiety but does not treat underlying condition, should NOT use long-term (only short-term as wneeded as alt to BZDs)
Pregabalin (Lyrica), gabapentin (Neurontin) - not FDA-approved for anxiety but shown benefits in pts with anxiety and neuropathic pain
When is propranolol (Inderal LA, Inderal XL) used in anxiety?
Not FDA approved for anxiety but can reduce symptoms of stage fright or performance anxiety
Dose: 10-40mg 1 hr prior to an event (such as public speech), can cause CNS side effects (e.g. dizziness, confusion)
Buspirone MOA
unknown, but its effects may be d/t its affinity for 5-HT1A and 5-HT2 receptors
Contraindications for buspirone
Do NOT use with MAOi (or within 14 days of use), linezolid, or IV methylene blue
Warnings for buspirone
Serotonin syndrome alone or in combo with other serotonergic drugs
Buspirone and abuse potential
No potential for abuse, tolerance, or phsyiological dependence
When switching from BZD to buspirone, what do you recommend?
BZD must be tapered off slowly
BZDs MOA and place in therapy for anxiety
Enhance GABA (inhibitor NT), causes CNS depression, resulting in anxiolytic, anticonvulsant, sedative and/or muscle relaxant properties
Fast relief of symptoms (antidepressants have longer onset of action) but do not treat underlying cause of anxiety – short-term treatment of acute anxiety (e.g. recent death of a loved one, natural disaster, stressful situation)
D/t risk of dependence with BZDs, they should only be used for ___ for anxiety and d/c. If used for longer, they must be tapered off slowly to prevent withdrawal symptoms.
1-2 weeks
BZDs and Beers Criteria concern
potentially inappropriate in pts ≥65yo
BZDs have high risk of confusion, dizziness, and falls in the elderly – increased if used with other CNS depressants
If BZDs is used in an elderly pt, L-O-T drugs are preferred (lorazepam, oxazepam, temazepam)
Safe use of BZDs: For anxiety
Most anxiety is d/t depression; SSRI/SNRIs are preferred
If BZDs used, consider longer half-life and less risk of abuse (e.g. clonazepam, lorazepam, diazepam)
Safe use of BZDs: For sleep
First-line: non-pharmacologic treatment
Second-line: non-BZD hypnotics like zolpidem (fewer safety issues than BZDs)
If BZD used, consider temazepam
Safe use of BZDs: Elderly pt or pt with liver impairment
If BZD used, consider BZDs that undergo glucuronidation L-O-T drugs (lorazepam, oxazepam, temazepam)
Safe use of BZDs: Seizures
Injectable BZDs or diazepam rectal gel (Diastat AcuDial); diazepam rectal gel can be administered by caregiver at home
Boxed warnings for BZDs
Use with opioids can result in sedation, respiratory depression, coma and death
Risk for abuse, misuse, and additional
Continued use can lead to physical dependence; abrupt d/c can cause withdrawal symptoms (Taper slowly)
Contraindications for BZDs
Severe liver disease (clonazepam, diazepam)
Others: acute narrow-angle glaucoma, sleep apnea, severe respiratory insufficiency, myasthenia gravis (diazepam), not for use in infants < 6 mo of age (diazepam oral), premature infants (lorazepam parenteral products)
Warnings for BZDs
CNS depression, anterograde amnesia, potential for abuse, safety risks in pts age 65 yo and older (impaired cognition, delirium, falls/fractures)
Extravasation with IV use, paradoxical reactions, severe renal or hepatic impairment
Pregnancy: crosses placenta, can cause birth defects and neonatal withdrawal syndrome
Side effects for BZDs
Somnolence, dizziness, ataxia, weakness, lightheadedness
Examples of BZDs used in anxiety
Alprazolam (Xanax)
Clonazepam (Klonopin)
Diazepam (Vallium)
Lorazepam (Ativan)
Others: Chlordiazepoxide, clorazepate (Tranxene), oxazepam
Which BZDs are commonly used for alcohol withdrawal syndrome?
Lorazepam, diazepam, chlordiazepoxide
Antidote for BZDs
flumazenil
Which BZD is contraindicated with strong CYP3A4 inhibitors (e.g. ketoconazole, itraconazole)?
Alprazolam
BZDs have additive effects with CNS depressants such as ___
alcohol, anticonvulsants, antihistamines, antipsychotics, opioids, mirtazapine, skeletal muscle relaxants, trazodone
