Anxiety Flashcards
What medications can cause anxiety?
-anticonvulsants
-antihypertensives
-BRONCHODILATORS
-dopamine agonists (ILLICIT SUBSTANCES)
-STIMULANTS
-LEVOTHYROXINE
What is first line therapy for generalized anxiety disorder(GAD)?
SSRI/SNRI or anticonvulsants
What SSRIs/SNRIs are FDA approved for the treatment of generalized anxiety disorder(GAD)?
escitalopram, sertraline, paroxetine, venlafaxine, and duloxetine
What are the second line treatment options for generalized anxiety disorder?
-benzodiazepines (good efficacy but 2nd line due to SE and dependence)
-Imipramine (TCA)
-bupropion
-vilazodone and vortioxetine
-quetiapine ER
-buspirone
-hydroxyzine (good efficacy PRN)
What are the recommended follow up guidelines for generalized anxiety disorder?
-assess medication tolerability 1-2 weeks after initiation/change of therapy
-assess efficacy ~4 weeks after patient has been on a stable dosage of medication
What is the first line pharmacotherapy for panic disorder?
SSRI/SNRI
Which anxiety disorder is most likely to experience paradoxical increase in symptoms with initiation of SSRI/SNRIs?
Panic disorder
How can paradoxical increase in anxiety symptoms be managed with SSRIs?
Start with lower doses and titrate slowly or benzodiazepines PRN early on in therapy
Way is the best treatment for PTSD?
Psychotherapy
What is first line pharmacotherapy for PTSD?
SSRI/SNRIs
What PTSD symptoms can be relieved with SSRI/SNRIs?
Re-experiencing, avoidance, hyperarousal
What drugs may be used for sleep disturbances in PTSD?
-mirtazapine= sleep/nightmares
-prazosin (anti adrenergic agents)= sleep/nightmares
-trazodone= sleep/nightmares
What is the second line treatment for PTSD?
-anticonvulsants (not monotherapy)
-antipsychotics
In what anxiety disorders are benzodiazepines highly discouraged due to lack of evidence and even worsening of symptoms?
PTSD & OCD
What is the first line treatment for OCD?
SSRIs= fluoxamine
What is the dosing of SSRIs in OCD?
higher dosing than depression
What are the second line treatment options for OCD?
-clomipramine (TCA)
-venlafaxine XR
-mirtazipine
What are the third line treatment options in OCD?
antipsychotics or anticonvulsants
How long to experience benefit with SSRI/SNRI treatment in anxiety?
2-4 weeks
What antidepressant may worsen anxiety symptoms?
bupropion
What is the dosing of Buspirone?
10-15mg BID-TID (max 60mg/day), best if scheduled and at least BID
What are the common side effects of Buspirone?
dizziness, drowsiness, nausea
What is the place in anxiety therapy for benzodiazepines?
panic disorder or severely distressing situations as “pill-in-pocket” approach- may be used in treatment refractory cases (scheduled with long-acting agents)
What are the side effects of Benzodiazepines?
-sedation
-hypotension
-cognitive/motor impairments
-respiratory depression
What are some pharmacokinetic parameters that are significant to benzodiazepines?
-faster time to peak effect= rapid symptom reduction but also increase euphoria in abuse)
-shorter t1/2= increased potential for withdrawal symptoms
-tolerance can develop
What are the preferred benzodiazepines in hepatic dysfunction?
-lorazepam
-oxazepam
-temazepam
What are the withdrawal symptoms of benzodiazepines?
-increased anxiety
-tremors
-tachycardia
-hallucinations
-seizures
What are the risk factors for withdrawal of benzodiazepines?
long-term use (>4 weeks), high doses, short t1/2
What benzodiazepine is preferred for tapering off strategies?
clonazepam
What anticonvulsants may be used in anxiety disorders?
pregabalin or gabapentin
Why may pregabalin be specifically useful in some patients?
improvement in sleep disturbance or somatic complaints (secondary physical symptoms of anxiety)
What are the common side effects of pregabalin?
dizziness, drowsiness, headache
What is the dosing regimen for hydroxyzine in anxiety disorders?
25-50mg PRN up to 4 times a day
What are the side effects of hydroxyzine?
SEDATION
anticholinergic, blurred vision, confusion
What antipsychotics are FDA approved for anxiety disorders?
none
What is the use of beta-blocker (propranolol) in anxiety disorders?
performance anxiety, helpful for autonomic symptoms (tremors, tachycardia)
