Anxiety Flashcards
Drugs that cause anxiety
Albuterol
caffeine
decongestants
levothyroxine
steroids
stimulants
Buspirone
5HT 1a receptor agonist
approved for generalized anxiety disorder
should be dosed with a target of 10-15mg three times daily or 2 times daily
may take 3-4 weeks to see full efficacy
Benzodiazepines
These are not recommened as first line due to the potential of missuse with them but evidence shows they are more affective than SSRIs
Long term use is not recommened
Acute withdrawal can lead to life threatening seizures
Warning for the use of benzos in combo with other CNS depressants and overdose death risk
what are the benzos without an active metabolite
Alprazolam, lorazepam, clonazepam, and oxazepam
without an active metabolite they are less likely to accumulate while they have a fall ask it is unlikely
Benzos with an active metabolite
Diazepam, clorazepate, and chloridiazepoxide
these long acting metabolies may lead to a hangover feeling and fall risk in elderly
Side effects of benzos
and considerations
sedation, paradoxical excitement, swallowing difficulties, impairment of memory and recall, and psychomotor impairment
Discontinuation requires a slow taper as abrupt discontinuation can lead to deathly stroke
BEERS criteria: may be inappropriate in the elderly
- when thinking of elderly think of LOT (lorazepam, oxazepam, temazepam)
Hydroxyzine
FDA approved for general anxiety disorder
commonly used PRN for anxiety or insomnia instead of benzos
side effects: sedation, anticholinergic side effects are prominent, QTc prolongation risk
AVOID in elderly due to anticholinergic side effects and fall risk
Propranolol
Decrease physiological symptoms of acute anxiety (tachycardia, sweating, flushing)
Used for performance and situational anxiety
low doses 10-20mg TID
Evaluation for history/current asthma and cardiovascular conditions
Natural products
kava - not common due to its hepatotoxicity
st johns wort - 3A4 inducer so can decrease efficacy in antipsychotics
passionflower - avoid in pregnancy
valerian - avoid in pregnancy
chamomile - if allergic to ragweed or pollen avoid as it can cause allergic reaction
Gabepentinoids and quetiapine in anxiety
Really good option if patient is experiencing neuropathic pain and anxiety***
Gabapentinoids can be used for bipolar disorders with anxiety symptoms
evidence shows anxiety and sleep medications does not endorse the use of quetiapine for insomnia
General drug therapy principles for anxiety disorders
- SSRIs and SNRIs are first line therapy for all anxiety disorders
- buspirone is also first line for generalized anxiety disorder
- benzodiazepines are FDA approved to treat anxiety disorders but guidelines suggest using them only if necessary
- atypical antipsychotics are not FDA approved for anxiety disorder but clinical evidence suggest efficacy for treatment resistant OCD (aripiprazole and risperidone)
General anxiety disorder diagnosis
Excessive anxiety/worry around a number of life events for at least 6 months
Must have 3 of the following symptoms
- restlessness, being easily fatigued, difficulty concentrating or mind going “blank”, irritability, muscle tension, sleep disturbance
Treatment of GAD
First line SSRIs antidepressants (takes 2-4 weeks to see full effect)
SNRIs maybe be useful (CAN BE USED FOR PATIENTS with anxiety and also having pain syndrome
Benzos: bridge therapy to cover time until onset of SSRI/SNRI, MUST taper if the patient has been taking long term treatment to avoid withdrawal
Social anxiety disorder
Persistent fear about social and or performance situations in which the patient fears embarrassment or humiliation that is unreasonable
Specific situations may be avoided in manner that interferes with the patients normal routine
duration of symptoms is at least 6 months
Treatment of social anxiety
SSRIs are first line
SNRIs if SSRIs fail
Propranolol can be used as needed to help non generalized performance SAD (sweating, heart rate, flushing)
Panic disorder diagnosis
Abrupt surge of intense fear or discomfort
at least 4 physical and psychological symptoms including sweating, palpitations, nausea, dizziness, fear of losing control, going crazy, or dying
At least one attack has been followed by one month or more of at least one of the following (persistent concern about additional attacks of their consequences)
Treatment of panic disorders
SSRIs are first line treatment
SNRIs- venlafaxine is FDA approved
Benzodiazepines should not be considered first line maintenance therapy unless there is inadequate response to serotonergic drugs
Obsessive compulsive disorder diagnosis
Obsessions: recurrent thoughts or images that are intrusive and cause anxiety; patient attempts to ignore, suppress or neutralize with other thoughts or actions
Compulsions:Repetitive behavior or mental action performed in a response to obsession; aimed at reducing or preventing distress; not always connected in a realistic way to the fear
treatment of OCD
SSRIs are first line and you can expect a 25-50% reduction in symptoms
Clomipramine is considered second line treatment
Antipsychotics can be used as adjunct with SSRIs/SNRIs (risperidone and aripiprazple)
Post traumatic stress disorder diagnosis
Exposure to real or threatened death serious injury or sexual violence
flashbacks
flashbacks, reexperiencing, avoidance, hypervigilance
negative alterations in mood or cognition
Treatment of PTSD
SSRIs/SNRIs are first line treatment, only class of drugs FDA approved for PTSD
Prazosin may be helpful for sleep of nightmares
Polytherapy is common in PTSD
Substance use is common in PTSD
bezodiazepines are not recommended in PTSD
Cognititve behavioral therapy and eye movement desensitization and reprocessing
Selected drug therapy issues in anxiety disorders
Jitteriness syndrome can result from the use of the SSRIs and SNRIs when treating anxiety disorders because of this the initial dose should be lower than doses used for depression to minimize this jitteriness EXAM Q
Onset of action for SSRIs/SNRIs is 2 to 4 weeks
Evaluate the severity of impact on functionality by the anxiety disorder before considering using bridge therapy with beznodiazepines
Abrupt d/c of benzodiazepines can be life threatening
Non-pharmacologic treatment of anxiety disorders
Psychotherapy and cognitive behavioral therapy
In PTSD - drug therapy may be more effective in civilian trauma (usually one time event) versus combat trauma so non-drug treatment are especially useful
