Anxiety Disorders Flashcards
What is the difference between having anxiety and an anxiety disorder?
An anxiety disorder is experiencing chronic and severe symptoms of fear/worry and physical symptoms (tachycardia, palpitations, SOB, upset stomach, chest pain, insomnia/fatigue)
What drugs cause anxiety?
- Albuterol (used too frequently/incorrectly)
- Antipsychotics (haloperidol, aripiprazole)
- Bupropion
- Caffeine (high dose)
- Decongestants (psudoephedrine)
- Illicit drugs (cocaine, LSD, meth)
- Levothyroxine (OD)
- Steroids
- Stimulants
- theophylline
What are lifestyle changes / herbals used to manage anxiety and what are safety concerns?
- cognitive behavioral therapy
- St. John’s wort (strong 3A4 indicer, serotonergic, photosensitivity)
- Valerian ( maybe liver damage, LFTs)
- Passionflower
- Kava (liver damage, monitor LFTs)
What are first line options for anxiety treatment?
- escitalopram (Lexapro)
- fluoxetine (Prozac)
- paroxetine (Paxil)
- sertraline (Zoloft)
- duloxetine (Cymbalta, Drizalma Sprinkle)
- venlafaxine XR (Effexor XR)
How are SSRIs/SNRIs used for anxiety?
- start at half the initial dose for depression and slowly titrate
- will not provide immediate relief; takes at least 4 weeks at higher doses
- other SSRIs/SNRIs can be used off-label for anxiety
What are second line options for anxiety?
- Buspirone (add-on) 2-4 weeks for effects
- TCAs (nortriptyline, amitriptyline, imipramine)
- Hydroxyzine (Vistaril); sedating antihistamine used short-term prn when benzo is not favored
- Pregabalin (Lyrica, Lyrica CR)
- Gabapentin (Neurontin,Gralise)
What drug is used for anxiety in certain situations?
Propranolol (Inderal LA, Inderal XL): not FDA approved but can reduce symptoms of stage fright or performance anxiety
10-40mg take 1 hour prior to event
What is the mechanism of buspirone?
might be due to affinity for 5-HT1A and 5-HT2 receptors
What are CIs with buspirone?
Do not use with MAOi (or within 14 days of D/C), linezolid, or IV methylene blue
What are warnings with busprione?
- Risk of serotonin syndrome alone or in combinations with serotonergic drugs
- Avoid use in severe kidney/liver impairment
What are SEs with buspirone?
- dizziness/drowsiness
- headache
- lightheadedness
- nausea
- excitement
How should someone be switched from a benzo to buspirone?
the benzo must be tapered slowly
What are DIs with buspirone?
- serotonin syndrome increased risk with other drugs
- avoid grapefruit/ grapefruit juice, can increase buspirone levels
- major CYP3A4 substrate; decrease dose if used with inhibitors (erythromicin, diltiazem, verapamil, itraconazole); increase dose with inducers (rifampin)
What is the MOA of benzos?
enhance gamma-aminobutyric acid (GABA) which is an inhibitory neurotransmitter
How should benzos be used for anxiety?
- provide fast symptoms relief; for short term treatment of acute anxiety
- should only be used for 1-2 weeks due to risk of dependence then D/C
- if used regularly for >10 days, taper off to prevent withdrawal
What does the Beers criteria say about benzos?
- potentially inappropriate in patients >/=65 yr
- high risk of confusion, dizziness, falls in elderly
- paradoxical reactions
Which benzos are safer in the elderly?
Benzos that undergo glucaronidation:
Lorazepam (anxiety)
Oxazepam (anxiety)
Temazepam (insomnia)
What benzos have a lower risk of abuse?
Benzos with longer half-life:
Clonazepam
Lorazepam
Diazepam
What are boxed warnings with benzos?
- Used with opioids can result in sedation, respiratory depression, coma, and death
- Risk for abuse, misuse, and addiction can lead to OD/death
- Continued use can lead to physical dependence; abrupt D/C can cause withdrawal symptoms
What are CIs with benzos?
- acute narrow-angle glaucoma
- sleep apnea
- severe respiratory deficiency
- severe liver disease (clonazepam/diazepam)
- myasthenia gravis (diazepam)
- not for use in infant <6 months (diazepam oral)
- premature infants (lorazepam parenteral products)
What are warnings with benzos?
- CNS depression
- Anterograde amnesia
- Abuse potential
- Risks in patients 65+ (impaired cognition, delirium, falls)
- extravasation with IV use
- paradoxical reactions
- severe renal/hepatic impairment
- Pregnancy: crosses placenta and can cause birth defects
- C-IV
What are SEs with benzos?
- Somnolence/dizziness
- Ataxia
- weakness
- lightheadedness
What are important PK effects with diazepam?
lipophilic, fast-onset, long half life, high abuse potential
What are important PK effects with alprazolam?
fast-onset, often abused due to quick actin
What is an antidote for banzos?
flumazenil
What are DIs with benzos?
- Additive effects with CNS depressants
- valproate increases conc of lorazepam
- use caution with CYP3A4 inhibitors (diazepam, clonazepam, clorazepate)
- Alprazolam is CI with strong CYP3A4 inhibitors (azoles)
Which benzos are commonly used for alcohol withdrawal syndrome?
lorazepam
diazepam
chlordiazepoxide
