Anxiety tx Flashcards
Drugs that can cause anxiety
-albuterol
-caffiene (high dose)
-decongestants
-levothyroxine
-steroisa
-stimulants (ADHD meds)
Anxiety med overview
-Buspirone
-Benzos
-SSRIs
-SNRIs
-hydroxyzine
-herbals
Buspirone
-serotonin-1a AGonist
-GAD tx
-may take 3-4 weeks for efficacy
-
Benzodiazepines
-many guidelines say no in routine practice bc abuse
-efficacy is higher than serotonergic antidepressants in soome studies
-not recommended long term
-withdrawal = sz
-warnings for use of benzos w other CNS depressants = OD death risk
Benzos w no active metabolite
-alprazolam
-lorazepam
-clonazepam
-oxazepam
-less likely to accumulate
-slight lower fall risk
Benzos w active metabolite
-diazepam
-clorazepate
-chlordiazepoxide
-long-acting
Benzo side effects
-sedation
-paradoxical excitement
-swallowing issues
-memory probs
-psychomotor impairment
-d/c requires taper
Benzos in elderly
-prob inappropriate
-prefer LOT (lorazepam, oxazepam, temazepam)
Hydroxyzine
-pamoate for GAD tx (HCl salt for lower 10mg)
-PRN for anxiety/insomnia instead of benzo
Hydroxyzine side effects
-sedation
-anticholinergic
-QTc prolongation
-avoid use in elderly (anticholinergic and fall risk)
Propranolol
-dec physical sx of acute anxiety
-performance anxiety tx
-low dose
-evaluate for hx.current asthma and CV conditions
Natural products for anxiety
-Kava (liver toxic)
-St. John’s Wort (3A4 inducer, MAO inhibitor, do not take w other antidepressants= serotonin syndrome)
-Passionflower (avoid in preg= early labor)
-Valerian (avoid in preg)
-Chamomile (avoid w blood thinners and ragweed allergy)
Gabapentinoids
-may be considered in pt w bipolar who has anxiety or comorbid neuropathic pain
Quetiapine
-sleep med
-don’t use in anxiety
General drug therapy principles for GAD
-SSRIs and SNRIs first line
-buspirone can be first line
-benzos only if necessary
-atypical antipsychotics NOT FDA approved but can be used in treatment resistant OCD (aripiprazole and risperidone)
DSM-5, TR GAD
-xs worry for at least 6 months
-3 of the following:
-restlessness/on edge
-easily fatigued
-difficulty concentrating
-irritability
-muscle tension
-sleep disturbances
Treatment of GAD
- SSRI (2-4 weeks)
1a. SSNRI (first line if pt has pain)
-buspirone (takes longer to work)
-Hydroxyzine PRN
-benzos if necessary
Benzo bridge therapy
-cover time until onset of SSRI/SNRI where appropriate
-MUST taper if long-term
DSM-5 Social Anxiety Disorder
-persistent fear in social/performance situations
-fear of unreasonable embarrasment/humiliation
-specific situations may be avoided in a way that interferes w pt normal life
-duration of sx at least 6 months
Tx of social anxiety disorder
-SSRI first line
-BB for non-GAD, performance related anxiety
DSM-5 Panic Disorder
-recurrent, unexpected panic attacks
-at least one attack has been followed by one month or more of at least one of the following:
-concern abt more attacks
-maladaptive change in behavior related to attacks
Panic Disorder tx
-SSRIs first line
-SNRIs (venlafaxine FDA approved)
-no benzos unless SSRI/SNRI failure
DSM-5 OCD
-obsessions: recurrent intrusive thoughts, pt attempts to ignore/supress
-compulsions: repetitive behaviors or metnal acts performed in response to obsession as a way of reducing stress, not always realistically connected to the dear
OCD tx
-SSRI first line (25-50% reduction in sx)
-clomipramine (TCA) second-line
-antipsychotics (risperidone, aripiprazole) as augmentation tx w SSRI/SNRI
DSM-5 PTSD
-exposure to trauma
-flashbacks
-reexperiencing
-avoidance
-hypervigilance
-negative alterations in mood or cognition
PTSD tx
-SSRI/SNRI first line (only class FDA approved for PTSD)
-prazosin may be helpful for sleep/nightmares
-benzos NOT recommended
-polytherapy common
-substance use common
-CBT and EMDS (eye)
Drug therapy issues in anxiety disorders
-jitteriness syndrome from SSRI/SNRI (start at lower dose than depression to minimize)
-onest 2-4 weeks or longer
-evaluate severity before considering “bridge therapy”” w benzos
-dc of benzos can be life threatening
Non-pharma anxiety tx
-psychotherapy and CBT
-non-drug tx especially useful in combat trauma (long-term trauma)
