Anxiety Flashcards
GAD
-AD are the drugs of choice for treatment
-takes 8-12 weeks for meds to work
-diagnosis requires persistent sx for most days for at least 6 months
-avoid stimulants and alcohol
FDA approved drugs fpor GAD
duloxetine, venlafaxine, escitalopram, paroxetine (1st line)
Other drugs used for GAD that aren’t FDA approved
-sertraline, pregabalin (1st line)
-alternatives: duloxetine, buspirone, hydroxyzine, pregabalin, bupropion
Hydroxyzine GAD
-FDA approved
-BEERs list
-2nd line due to anticholinergic SE
-CI: 1st trimester
-Retrolental fibroplasia (can lead to blindness)
Buspirone GAD
-FDA approved
-not for prn use
-takes 2 weeks to see effects
-not a control
-not addictive like BZD
Pregabalin GAD
-not FDA approved
-no withdrawal sx seen when tapered over a week
-produces anxiolysis similar to BZD
-adjust dose if CrCl <60 ml/min
Not approved for GAD treatment
ziprasidone, propranolol, tiagabine
Managing sleep disturbances GAD
Use more sedating agents (pregabalin, hydroxyzine)
GAD management for elderly
-Lexapro, Zoloft
-SNRIs might inc BP
Managing neuropathic pain GAD
Pregabalin
BZD CI
Allergy, SUD, myasthenia gravis, severe hepatic dx, COPD, sleep apnea, pregnancy/breastfeeding, narrow angle glaucoma, BBW w/ opiates
BZD FDA approved for Anxiety
CLAD: Chlordiazepoxide, Clorazepate, lorazepam, alprazolam, diazepam
BZD FDA approved for panic disorder
Clonazepam (Klonopin)
BZD less lipophilic agents
-lorazepam and oxazepam
-slower absorption, slower onset, longer duration (small vd)
-less euphoria
BZD more lipophilic agents
-Diazepam and clorazepate
-faster absorption, faster onet, shorter duration of action (large vd)
-more euphoria
BZD shorter half life
-alprazolam, diazepam, oxazepam
-reach steady state fast w/ minimum accumulation
BZD considerations
-high potency: clonazepam and alprazolam
-d/c of therapy can cause rebound anxiety, recurrence/relapse, withdrawal
-risk of withdrawal seizures inc w/ higher doses, long duration and concomitant med use
BZD d/c strategy
-25% per week until 50% of dose is reached
-Then dec by 1/8 every 4-7 days
-for therapy that was > 8 weeks, taper over 2-3 weeks
-for therapy that was > 6 months, taper for 4-8 weeks
-therapy over a year, taper for 2-4 months
BZD pregnancy
-inc risk for cleft lip/palate
-suicide risk for mother
BZD to use in liver damage or elderly
oxazepam, temazepam, lorazepam
Panic disorder
2 or more agoraphobic situations are now required to distinguish from specific phobia
FDA approved drugs for Panic disorder
-Prozac, Paxil, Zoloft
Not recommended in Panic disorder
buspirone, propranolol, tiagabine, trazodone, bupropion, APS, antihistamines
First line treatment in Panic disorder (not all are FDA approved)
Lexapro, Celexa, Prozac, fluvoxamine, Paxil, Zoloft, venlafaxine XR
BZD Panic disorder
-High potency (xanax and clonazepam) are preferred, but diazepam and lorazepam are possibly effective at higher doses
-Should not be used as mono therapy in those with hx of depression or current depression
-add to AD for 4-6 weeks (short terms)
-optimize before augmenting
Panic Disorder - Specific Phobia
-fear of object or situation
-pt responsive to CBT (cannot use BZD if receiving CBT)
-Evidence that Paxil and BZD can work if CBT fails
First line therapy in SAD
Lexapro, fluoxamine, paxil, zoloft, venlafaxine, pregabalin
-beta blockers are used for sx only
Not recommended for SAD
buspirone, atenolol, imipramine, levetiracetam, quetiapine, propranolol
FDA approved for SAD
sertraline, paroxetine, venlafaxine
SAD treatment resistant
reserve MAOIs and APS (phenelzine and olanzapine)
-if pt fails 2 AD
PTSD
-CBT and eye movement desensitization/reprocessing are most effective nonpharm
-TCA/MAOIs can be used but less effective bc SE
-Bupropion SR not effective
-BZD not effective (can impair CBT effects)
PTSD FDA approved drugs
Zoloft and Paxil
1st line in PTSD
SSRIs and venlafaxine
PTSD with intrusive thought, hypervigilance
augment with risperidone, quetiapine, or olanzapine
PTSD with nightmares
augment with prazosin
PTSD with anger
augment with lamotrigine
PTSD with sleep problems
augment with trazadone
PTSD with anxiety, sleep, nightmares
augment with clonidine
OCD
-can augment with low dose APS
-taper after 1-2 years of treatment
-CBT
-Clomipramine use after failed SSRI due to ADR
-3 AD trail (1 including cloipramine) before augmentation
FDA approved drugs for OCD
Prozac, Paxil, Zoloft, fluvoxamine
