Anxiety

Question 1

Define Anxiety

Answer 1

• anticipation of future concern and is more associated with muscle tension
• diagnosis: must be out of proportion with situation and hinders functional ability
• mgmt: 3 classes appropriate for anxiety and NOT for depression, no agent clearly superior

Question 2

SSRI’s (one main drug) for Anxiety

Answer 2

PAROXETINE

• Almost NEVER used when anxiety NOT present
  Indications: GAD, OCD, Panic Disorder, PTSD, SAD
• Causes anticholinergic effects (dry mouth, constipation), highest rate of drowsiness, weight gain and ED, also has many drug interactions
• Contraindication in pregnancy

Other SSRI’s escitalopram, citalopram

Question 3

SNRI’s for Anxiety

Answer 3

Venlafaxine, Duloxetine, Desvenlafaxine

• Helpful in anxious and/or resistant depression
• Depression with psychomotor slowly (duloxetine)
• Also indicated for pain related to depression, fibromyalgia, neuropathy, musculoskeletal pain
• Best for 65yo and younger

AVOID/CAUTION:

• HTN (elevates BP)
• Agitation and Insomnia
• Alcoholism (liver damage)
• SNRI (Serotonin Syndrome) ??
• MAOI’s (Fatal Serotonin Syndrome) ??

Question 4

Buspirone for Anxiety

Answer 4

• Partial 5HT1A Agonist
• Effective ONLY for GAD, not indicated for anxiety subtypes
• Slower onset: 7 - 10 days, Max Effect: 3-4 weeks
• Reasonable for Benzo alternative (for chronic anxiety)
• NOT AN ACUTE DRUG
• Not considered addictive
• Delayed onset and action, not meant for acute anxiety mgmt
• Does not work well if patients have had benzo exposure

Question 5

When to use Benzo’s for Anxiety

Answer 5

Acute anxiety: extremely effective but abuse
- patient acutely fearful (ie planes)

Panic Attacks

• impending doom
• tachy/palps
• diaphoresis
• SOB

Not indicated for anxiety disorders BUT
- are 2nd line option for GAD + panic disorder when appropriate

Use short term until SSRI or SNRI take effect

• may be 1-6 weeks
• or patients that have failed other options

Clonazepam OVER alprazolam to minimize withdrawal and abuse